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North Carolina medical journal [serial]

UNIVERSITY OF NORTH CAROLINA

MAY I 7 1995

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http://www.archive.org/details/ncmed551994janmay

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^North Carolina Medical Journal

For Doctors and their Patients

North Carolina Medical Society's Leadership Symposium:

"Physician Involvement in Health System Reform"

March 10 • 13, Pinehurst Hotel, Pinehurst

J N C - C H H E A LT H, SCIENCES.!,.! BR A R Y

Celiac Sprue

Diagnosis and Diet: Keys to Recovery

Contents

How Would We Manage Your Money? The Same Way We're Managing Our Own.

f:,Pai(ner, private ' .^Investor and philan- i .ttitppist', formerly ■'founder and CEO of ' the Perrniar>'C6rpr . and Basin/lrfCi.r' -^ >"'^

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President/Group,

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North Caroiina. -

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Paffner-arid head ' Portfolio Mart'ager,. - formerly cg-foundef and President of ;. - .MclVlillion Eubanks Capital Management:

Vice Chairman IBM.

William M. Moore, Jr., Partner, President of Trident Financiar^-' Cprpgratipn:,',.,

,• -.'■./'--'//■■ //'' '

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NORTH CAROLINA MEDICAL JOURNAL

For Doctors and their Patients

Published Monthly as the Official Organ of the North Carolina Medical Society

January 1994, Volume 55, Number 1 (ISSN 0029-2559)

EDITOR

Francis A. Neelon, MJ>.

Duiham 919-286-6409

DEPUTY EDITOR

Edward C. Halperin, M.D.

CONSULTING EDFTOR

Eugene A. Stead, Jr., M.D.

ASSOCIATE EDITORS

Eben Alexander, Jr., MJD.

Winslon-Salem William B. Blythe, MX).

Chapel Hill F. Maxton Mauney, Jr., M.D.

Asheville Walter J. Pories, M.D.

Greenville

MANAGING EDfTOR

Jeanne C. Yohn

Durham 919-286-6410, fax: 919-286-9219

EDrrORIAL ASSISTANT

Jane Whalen

SECTION EDITORS

Eugene W. Linfors, M.D. Daniel J. Sexton, M.D.

EDITORIAL BOARD CHAIR

Margaret N. Harkcr, MX).,

Morehead City MEMBERS Jay Arena, M.D.

Durham William B. Blythe, MX).

Chapel Hill Jack Hughes, M.D.

Durham Timothy W. Lane, M.D.

Greensboro Eugene S. Mayer, M.D.

Chapel Hill Walter J. Pories, M.D.

Greenville Robert W. Prichard, M.D.

Winston-Salem Mary J. Raab, M.D.

Greenville

The Society is not to be considered as endorsing the views and opinions advanced by authors of papers delivered at the Annual Meeting or published in the official publication of the Society. — Constitution and Bylaws of the North Carolina Medical Society. Chap. JV, Section 3, pg. 4.

NORTH CAROLINA MEDICAL JOURNAL

Box 3910, Duke University Medical Center, Durham NC 27710, (919-286- 6410/fax: 919-28«-9219). is owned and published by The Nonh Carolina Medical Society under the direction of its Editorial Board. Copyright© 1994 The Nonh Carolina Medical Society. Address manuscripts and communications regarding editorial matters, subscription rates, etc., to the Managing Editor at the Duiham address listed above. Listed in Index Medicus. All advertisements are accepted subject to the approval of the Editorial Board of the North Carolina Medical Journal. The appearance of an advertisement in this publication does not constitute any endorsement of the subject or claims of the advertisement.

Advertising representatives: United Media Associates, Karl Messerrly, 2001 W. Main Sl, Suite 202, Stamford CT 06902; 203-975-0606; and Den French, Box 2093, Cary NC 27511; 919^67-8515.

Printing: The Ovid BeU Press, Inc., 1201-05 Bluff St.. Fulton MO 65251 .

Annual subscription (12 issues): $17 (plus 6% tax in NC = $18.02). Single copies: $2. Second-class postage paid at Raleigh NC 27601 . and at additiorul mailing offices. POSTMASTER: SEND ADDRESS CHANGES TO THE NORTH CAROUNA MEDICAL SOCIETY, 222 N. PERSON ST., RALEIGH NC 27601.

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NCMJ / January 1994, Volume 55 Number I

orth Carolina Medical Journal

FOR DOCTORS AND THEIR PATIENTS

Contents / January 1994, Volume 55, Number 1

On the cover: Capsule intestinal biopsy devices, like the Crosby capsule on the left, formerly were used to help diagnose celiac sprue. At right, an abdominal x-ray shows the capsule in position in the small bowel near the ligament of Treitz. Photo courtesy of Glaxo Corporation , Research Triangle Park. Used with permission. See article on celiac sprue on page 32.

VIEWS FROM THE PODIUM

10 Valedictory Address 15 Inaugural Address

F. Maxton Mauney, Jr., MD. Elizabeth P. Kanof, M.D.

THE STATE OF OUR HEALTH

18 Conjoint Report: To the North Carolina Medical Society and the North Carolina Commission for Health Services

Ronald H. Levine, M.D.. M.PM.

MEDICINE IN THE MARKETPLACE

22 Physician/Hospital Organizations: Integrating the Delivery of Health Care Arlene J. Diosegy and Steven D. Simpson

HEALTH WATCH

27 Alzheimer's Disease: An Overview

North Carolina Medical Society

THE SPECTRUM OF DISEASE

32 CeUac Sprue: Diagnosis and Diet — Keys to Recovery

Stephen M. Schutz. MD., J. Stroebel, MB., E.M. Schutz, R.D., L. Leaseburge, R.D., and J. Baillie, M.B. Ch£.

SCREENING FOR DISEASE

37 Screening for Lung Cancer: It Doesn't Make a Difference

Jeffrey G. Wong, MD., and John R. Feussner, M.D.

COMMENTARY

41 Doctors vs. Lawyers: A Robert Bums Analysis

Erie E. Peacock, Jr., MD., J.D.

MEDICAL EDUCATION

45 Sowing the Seeds of Primary Care Medicine: The Early Commtinity Experience in Medical Education

Craig H. Steffee, MD.

BULLETIN BOARD

4 Instructions for Authors 5-8 Letters to the Editor

8 "Pearl of the Month" 14 Subscription Form 48 Carolina Physician's Bookshelf

50 Continuing Medical Education

5 1 Classified Advertisements

52 New Members

56 Aphorisms of the Month

56 Index to Advertisers

2 NCMJ/ January 1994,Volume 55 Number I

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Instructions for Authors

The North Carolina Medical Journal is a medium for com- munication with and by members of the medical community of this state. The Journal will consider for publication ar- ticles relating to and illuminating medical science, practice, and history; editorials and opinion pieces; letters; personal accounts; poetry and whimsical musings; and photographs and drawings. Papers that relate to the present, past, or future practice of the health professions in North Carolina are especially pertinent, but manuscripts reflecting other per- spectives or topics are welcomed. Prospective authors should feel free to discuss potential articles with the editors.

Manuscript Preparation

Authors should submit papers prepared according to the "Uniform Requirements for Manuscripts Submitted to Bio- medicalJoumals" (NEngl J Med 1991;324:424-8) with the following exceptions: 1) no abstract is needed for an article; 2) no running title is needed; and 3) measurements must be reported in metric units, but use of the International System of Units (SI) is optional.

To summarize major elements: Submit two copies of text (including Letters to the Editor), double-spaced typed with one-inch margins, on one side of each sheet of paper. Title page should include addresses, and telephone and facsimile numbers of the corresponding author. Authors may submit a cover letter and a 3 1/2- or 5 1/4-inch floppy computer disc containing the text written in MS DOS com- patible format (WordPerfect, Microsoft Word, Display write, or ASCII).

Submit illustrations, in duplicate, in the form of high- quality color 35mm slides or 5-by-7-inch or 8-by-lO-inch glossy photographs, or as black-and-white glossy prints (5- by-7-inch or 8-by-lO-inch). Label all illustrations with author's name, number them sequentially according to their position in the text, and indicate the orientation of the images, if necessary. Do not write directly on the backs of prints. This can damage them.

Type figure legends, double-spaced, on a separate sheet of paper. Tables should be typed, double-spaced, one to a single sheet of paper. All tables must have titles and consecu- tive Arabic numbers.

Keep references to a minimum (no more than 15, preferably 10 or fewer), retaining those that document

important points. The "Uniform Requirements" id above contain the format for references. Authors are r»onsible for the accuracy and pertinence of all citations.

Avoid abbreviations entirely if possible; keepem to a minimum if not When used, completely define abbiiations at the first point of usage in the text.

Manuscript Review and Editing

A medically qualified editor reads all manuscripts id, in most instances, sends them out for further review byne or more other members of the North Carolina Medical S:iety. Authors' cover letters should include a line that stat that their submitted manuscripts are not under consideratii for publication elsewhere. Decisions to pubhsh or not areiade by the editors, advised by the peer reviewers.

We encourage a relatively informal writing style nee we believe this improves communication. Imagine yoiself talking with your unseen audience — as long as this docn't lead you to scientific or linguistic inaccuracy. Be brief, c^ar, simple, and precise.

We edit accepted manuscripts for clarity, style, jid conciseness. Except for letters, authors receive a copy of he edited manuscript for their review and approval before publication. Manuscripts not accepted will not be returned.

Authors retain copyright to articles published in the North Carolina Medical Journal, but the North Carolir.i Medical Society copyrights the contents of each entire issue. Requests for permission to reprint all or any part of a published article must be submitted in writing to theac'dres;. below and negotiated with the author and editor jondy. Reprinted material must carry a credit line identifying th. t it appeared in the North Carolina Medical Journal.

Submissions

Address manuscripts and all other correspondence to:

Editor, North Carolina Medical Journal Box 3910, DUMC Durham, NC 27710 Telephone 9191286-6410 Fax 919/286-9219

NCMJ/ January 1994. Volume 55 Number I

Letters to the Editor

^

A Question of Validity To the Editor:

The article 'The Reinvention of Tra- ditional Medicine in Western North Caro- lina" (NC Med J 1993;54:550-2) empha- sizes Cherokee healing practices and how they may be of value in healing non- Cherokees. Having cultivated a close personal friendship over many years with the most senior medicine person (one of three) of the eastern band of the Cherokee tribe, I have some familiarity with Chero- kee healing beliefs and practices.

I am disturbed by statements about Cherokee spiritual and healing practices and beliefs that are simply not true. The beliefs described in this article as "Chero- kee" would more closely be identified as "new age," which often tries to link itself to native American beliefs. Some of the sources quoted by these authors includ- ing "D. Ywahoo" and the person de- scribed in the article as "a Cherokee sha- man named Beautiful Painted Arrow, one of the last remaining shamans of south- eastern America," are not only not Chero- kee medicine people, but they are not even Cherokee Indians. I cannot com- ment on the value of these people 's teach- ings, but they are not what they represent themselves to be. The validity of these practices are not to be found in their antiquity, since these are not the beliefs of the ancients.

I expect a higher degree of care and research than exhibited in this article, especially by authors from academic de- partments at our state universities here in North CaroUna.

Steven J. Stafford, M.D. Central Carolina Urology Associates

3320 Wake Forest Road, Suite 100 Raleigh, NC 27609

The Authors Respond:

We appreciate Dr. Stafford's inter- est in our article and his concern about accurate representation of Cherokee cul- ture. We would like, however, to clarify the point that our article is not about Cherokee medicine but rather about the reinterpreiation of Cherokee healing practices by urban , non-Cherokee people. We were asked to write an article about folk medicine that would be helpful for physicians who treat patients who use alternative medical therapies. We do think it is useful for physicians to know some- thing about how patients who use folk medicine interpret their illness experi- ences and respond to physician recom- mendations. In addressing our subject, we felt that it would be particularly useful to examine some examples of what is popularly referred to as "New Age heal- ing," that is, the reinvention by partici- pants of "traditional" practices and their incorporation into new systems of heal- ing. These practices are an increasingly important phenomenon in American so- ciety today and it is precisely from their invocation of "tradition" that they draw their popularity.

The point of our article was to dem- onstrate how "Cherokee traditions" have been reinterpreted in new healing sys- tems in western North Carolina, of how participants in these new healing systems have recreated the notion of what Chero- kee culture is. Participants in the Earth Center, the healing group described in the article, perceive Beautiful Painted Arrow as a Cherokee shaman, and describe him as "one of the last remaining shamans of southeastern America" in order to con- firm his authority and hence the authority of the healing rituals that they have cre-

ated. Dr. Stafford comments that "the validity of these practices is not to be found in their antiquity since these are not the beliefs of the ancients." We do not argue that these rituals are authentic an- cient Cherokee rituals. The point of our article is that the people who participate in these rituals believe them to be ancient traditions and that in their perceived an- tiquity rests the power of these rituals.

As anthropologists, we believe it is critical to respect the integrity of all Na- tive American cultures. As anthropolo- gists, we also believe it is critical to examine our own culture as an object of study. Clearly, "reinvented" traditional healing practices are becomingmorecom- mon in our culture. These practices are valid objects of study and, given their increasing popular appeal, cannot be ig- nored by either medical anthropologists or medical practitioners.

Heidi Kelley, Ph.D.

Catherine O 'Sullivan

Joan Reed, B.A.

Jean Sexton

Department of Sociology

University of North Carolina

at Asheville

One University Heights

Asheville, NC 28804-3299

Inmates' Right to Health Care

To the Editor:

Dr. Rosemarie Tong's discussion of the philosophical considerations of the "right" to health care (NC Med J 1993; 54:590-5) was particularly intriguing to me since all of my patients already have a legally established "right" to health care. I am medical director of a jail health service. Dr. Tong enumerated all of the potential justifications for such a right.

NCM J / January 1 994, Volume 55 Number 1 5

i.e. moral, political, economic, and per- sonal, but omitted the one under which we function. Thatjustification is judicial.

The Supreme Court decided nearly two decades ago that inmates in jails and prisons, whether serving sentences or awaiting adjudication, had the right to adequate health care. It further declared indifference to that right to be grounds for lawsuit A series of federal class action suits have since expanded and defined that right The jail population has qua- drupled during this same interval. It is a population that by its very definition is familiar with the legal system and cogni- zant of its rights. Lawsuits brought by inmates mean that most of the nation's correctional facilities currently operate under consent orders. The name of this game is to balance the risk of litigation with available resources.

It would be an interesting experi- ment to see if a managed health care system could serve the incarcerated popu- lation— those with a clearly defined right to adequate health care. If Dr. Tong wants to see a demonstration project of such a population I invite her to come and see me. H. Strawcutter, M.D., Medical Director

Robeson County Detention Center

2316 Sanchez Drive

Lumberton, NC 28358

Dr. Tong Replies:

Dr. Strawcutter offers us the oppor- tunity to see if a managed health care system can be developed to deliver health care goods and services to one segment of the population that does indeed have a right to health care: the prison popula- tion. In view of the fact that health care resources are no more available in pris- ons than they are in the larger society, his hope is to avoid litigation by prisoners insistent on having their rights honored. Although I fully appreciate why the Su- preme Court deemed that prisoners have a right to health care — they are, after all, a group of people toward whom the larger society feels little, if any, sense of obliga- tion— I nevertheless wish that it had not done so. Not only is it difficult for prison authorities to dispense what they do not

have, it is simply too difficult for the average U.S. citizen to understand why in Seattle, Washington, for example, mur- derers receive liver transplants, while the hard-working, but relatively poor rela- tives of their victims most probably go unaided.

Rosemarie Tong, Ph.D.

Thatcher Professor

in Medical Humanities,

Professor of Philosophy

Davidson College

P.O.Box 1719

Davidson, NC 28036

Cover Kudos To the Editor:

I want to express my gratitude to the /ourna/ editorial staff for using my draw- ing, "Southern Railroad Depot," on the cover of the November 1993 issue of the North Carolina Medical Journal. I sin- cerely appreciate the beautiful way in which the drawing was displayed and the inclusion of the short historical perspec- tive (NC Med J 1993;54:566).

I have always enjoyed reading the North Carolina Medical Journal. It is extremely well done and provides me with a very important perspective of medi- cine in North Carolina. Many thanks to you and your staff for an outstanding job with the publication.

Joseph F. Nicastro, M.D.

Associate Professor

of Orthopedic Surgery

Bowman Gray School of Medicine

Medical Center Boulevard

Winston-Salem, NC 27157

The Need for Tort Reform To the Editor:

I enjoyed Dr. Councell's letter in the November issue of the North Carolina Medical JournaKNCMod J 1993;54:564- 5). I agree with the several other physi- cians who commented that this letter sum- marizes key negative aspects of the cur- rent malpractice situation and demon- strates the urgent need for significant tort reform.

To the points made by Dr. Councell, I would add two others:

1) Physicians suffer a significant

emotional toll because of greed-rooted frivolous lawsuits, supported by unscru- pulous attorneys. Physicians must deal with enough patient care-related stress and strain without having the biu'den of non-meritorious suits. What a terrible waste of resources! 2) There is a Kafkaesque contradiction in promoting managed care while maintaining the cur- rent malpractice situation without tort reform. What a cruel and insulting joke on people who have dedicated a signifi- cant portion of their lives to acquiring skills and knowledge to help otherpeople! I agree thoroughly with Dr. Councell that tort reform is urgently necessary.

Obviously, lobbyists for lawyers are not going to support tort reform. A recent Wall Street Journal article stated that tort reform is not on the immediate horizon because itcontradicts the interestsof law- yers' lobbyists. Nevertheless, logical and rational people should support the very urgent need for tort reform, knowing the fact that it may be "a long time coming." Georgia L. Newsom, M.D. 101 Asheville Highway Sylva, NC 28779

Cases in Court: A Malpractice Lawyer's Viewpoint

To the Editor:

The "sitting duck" returns. Maybe the responses to my article (NC Med J 1993;54:352-4) are so vituperative be- cause the respondents feel that lawyers never admit the possibility of frivolous lawsuits, just like doctors never admit the possibility of medical negligence. Let me give, as examples of meritorious cases, two that we settled during 1993:

Case I: A 24-year-old patient, recover- ing from a head injury, fell 17 feet from an unsecured window to a concrete pad, receiving a second serious head injury. During the day he had alarmed nursing personnel by packing his suitcase, strik- ing out at a nurse during blood draw, and running up three flights of stairs. He was diagnosed by his physician as confused and agitated. A doctor's order for "be- havior precautions, Haldol, andrestraints as necessary" was neither seen nor com-

NCMJ /January 1994, Volume 55 Number 1

plied with by nursing personnel. This fact was uncontested.

The neuropsychiatrist who was treat- ing him testified that the standard of care in agitated coma recovery cases when there is demonstrated intent to wander (as in this case) requires a safe environment, medication, and sometimes one-on-one supervision. In fact, this patient was left alone in a day room for one hour.

Other testimony came from a non- treating expert physiatrist who does in- spections for the Commission for the Accreditation of Rehabilitation Facilities and from a head injury specialist from the NTH. Each expert had served as medical director of a reputable head injury center. It was not hard to come by experts, even local ones, experienced at all levels of head injury health care. Obviously, this was a complex case. There were issues of premises liability and a problem with disentangling the effects of the second head injury upon the first. Anyone in the field would recognize the integrity and expertise of the doctors who testified for the plaintiff

The NIH expert looked at the patient's rate of recovery after both inju- ries, his present inabihty to live indepen- dently five years after the second, and determined that the damages resulting from the fall were severe and lifelong. This case ended with a structured settle- ment that provides monthly payments for life. The money is held in a trust, admin- istered by a bank and the patient's court- appointed guardian, to pay for the patient' s medical care, which costs approximately $70,000 per year.

Case 2: A baby was bom with cerebral palsy, severe mental retardation, cortical blindness, and seizures. During delivery, profound and marked cardiac slowing resulting in hypoxia was fully documented on the fetal heart monitor strip. The doc- tor who deUvered the baby testified that a nurse failed to recognize the danger of decreased heart rate, failed to notify the doctor (in fact, told the doctor that the strip was fme), failed to administer oxy- gen per protocol, failed to start an IV, failed to turn the mother on her side and

otherwise deviated from the standard of care. In fact, the mother was left alone to labor for three hours. At one point, the fetal monitor strip paper ran out and the husband had to find a nurse to insert another roll.

The neonatal course met NIH crite- ria for hypoxic ischemic encephalopathy. The baby weighed more than nine pounds at birth, there was no intrauterine growth retardation, no evidence of viral infec- tion, no genetic problem, and no evi- dence of a prior hypoxic incident. We investigated this case for a full two years before filing suit, knowing that only 6% of cerebral palsy is caused by birth injury. One of our experts was a Duke University medical school graduate, former resident, and perinatal fellow. Another of our ex- perts teaches maternal-fetal medicine; the third is in full-time clinical practice in Atlanta. There is no doubt about the in- tegrity and expertise of the doctors who testified for the plaintiff

This case settled for a significant sum, although less than the expected ex- penses, because the estimated cost of care for this baby, even with his shortened life expectancy, exceeds any amount ever awarded by a North Carolina jury. The parents are fast approaching the $1 mil- lion lifetime cap on their insurance cov- erage. They will need every cent to care for their child.

In the face of a vigorous and well- financed insurance defense, we might have lost either of these cases despite their merit One of your respondents sug- gests that plaintiffs who lose should pay the insurance company's attorney's fees. Imagine the injustice to the wife of a head-injured breadwinner or the parents of a handicapped child were this the law.

Repeatedly, your respondents ignore the issue that it is their patient who is dissatisfied and other physicians who tell the lawyer and the jury what the standard of care requires.

Tracy K. Lischer, J.D., Ph.D.

Pulley, Watson & King

BrighUeaf Square, P.O. Drawer 3600

Durham, NC 27702

Editor's note: For more on the continu-

ing debate between doctors and lawyers, see pages 41-43.

The Value of PSA Screening To the Editor:

Drs. Wong and Feussner admirably analyzed the dilemmas we face with pros- tate cancer (NC Med J 1993;54:568-71). From their perspective, one positive bi- opsy and three negative ones rate an ex- clamation point. From the patient's perspective, a negative biopsy is a true delight.

Their article states: "But the value of the PSA as a screening test falls short of our basic criteria," but they do not tell us what their criteria are.

The difficulties with radical prostatectomy focus on the lifestyle prob- lems of impotence and urinary inconti- nence.

It is crucial to the analysis of whether or not to use PSA to consider its sequen- tial use in the same patient. A single PSA for "Susan's father, Sydney Smith, age 63" is one value. If Mr. Smith had had a PSA each year from age 50 we might interpret the value at age 63 quite differ- ently.

John R. Dykers, Jr., M.D.

P.O. Box 565

Siler City, NC 27344

Drs. Wong and Feussner Reply:

We are pleased that Dr. Dykers found our article thought-provoking and offer these comments in reply.

Each of the questions we posed to the reader (NC Med J 1993;54:218-21) and subsequently discuss in our analyses are the important criteria by which we judge the usefulness (or uselessness) of any screening strategy. We applied this method to the PSA determination and concluded that it fell short of the criteria when used as a screening test

We do agree that the "true delight" of a "negative biopsy" may be very helpful in the therapeutic management of some patients. However, getting a benign patho- logical result for a patient that did not require a biopsy in the first place is not often helpful. Furthermore, falsely "nega- tive biopsies" can and do occur. What

NCMJ / January 1994, Volume 55 Number I

"true delight" would a patient have with a "negative biopsy" report only lo de- velop symptomatic prostate cancer later on?

Dr. Dykers has identified some im- portant problems associated with radical prostatectomy. Another crucial problem includes the potential of fatal outcomes from this procedure.' This underscores the need for proof that this procedure actually improves and prolongs life for

our male patients, a point that is still contended.^

Finally, the data regarding useful- ness of serial PSA determinations for prostate cancer screening are incomplete and suffer from the same limited predic- tive value that the single PSA test does. Our analysis of the available data would not suggest that 13 PSA detenninations for Mr. Smith (one each since age 50), or 13,000 PSA tests for 1,000 Mr. Smiths,

would be a wise use of our health care resources.

References

1 Lu-YaoGL, McL.erran D, WassonJ.Wennberg, JE, and ihe Prostate Patient Outcomes Research Team. An assessment of radical prostatectomy: time trends, geographic variation, and outcomes. JAMA 1993;269:2633-6.

2 Johansson JE, Adami HO, Andersson S, et al. High 10-year survival rate in patients with early, untreated prostate concer. JAMA 1992;267:2191- 6.

Pearl of the Month: "New Year's Resolution"

Let's resolve to give shots that are relatively painless. Most of the nerve endings are in the skin — a few are deep in the muscle.

1 . Lay the patient on the exam table — both buttocks exposed.

2. Slap both cheeks sort of hard. Swab both cheeks quickly.

3. Before feeling nerve endings reorganize pop the needle in deep where you want it. (Going slow hurts the skin nerve endings badly.)

4. With your thumb on the plunger, make the plunger stay still and with two fingers retract the syringe barrel over the plunger. This puts the drug in a long narrow track instead of a 1 cc pool, which has to tear muscle fibers to make a 1 cc space.

5. When finished, snatch the syringe out and hide it quickly.

6. Ask the patient, "Are you ready?" You will be surprised how many will say, "Yeah, go ahead."

7. If you took over six seconds total to administer the shot, you need practice, and the pain was worse.

— Bruce B. Blackmon, M.D., Buies Creek

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VIEW FROM THE PODIUM

Valedictory Address

By 1993 NCMS President R Maxton Mauney, Jr., M.D.

Edrtor's note: The following essay Is based on a speech given by Dr. Mauney, an Asheville cardlothoracic surgeon and 1 993 president of the North Carolina Medical Society, which he delivered to the Society's House of Delegates at the Annual Meeting held in Charlotte in November 1993.

By tradition, I owe an accounting of my year of stewardship.

I am proud to report that my fellow officers have been keenly aware of their responsibilities, serious about their oaths of office and totally dedicated in responding lo the business of this organization. No one has said, "Heck, let the next admin- istration tackle that one." This has been a year of tumultuous upheaval and focused debate about the future of medical care and, in parallel, the future of the North Carolina Medical Society. I hope that the investment of considerable time, much energy, and a lot of emotion will, over time, better prepare this Society for the important tasks ahead.

One of the reasons I sought the office of president was to help organized medicine continue as a strong voice for my two sons who have chosen medicine as a career and for all the other young physicians. If "positioning" is the current buzzword, then the Society is, in my view, "repositioned" and "well positioned" for continued improvement in its effectiveness.

Last year, I highlighted concerns that I believed important. Foremost was my fum conviction that our Society needed to become stronger, tougher, and more responsive than ever before. I emphasized the need to improve communication with members, the public, and allied organizations. I indicated my special interest in doing all that could be done to strengthen, and if necessary, reorganize our Department of Governmental Af- fairs and our legislative/lobbying effort. Finally, I pledged that the staff and officers would spare no effort to build stronger bridges and closer working relationships with large and small component societies statewide and with allied organizations.

We began with a self-assessment study of our headquarters operation and an analysis of the relationship of our staff with committee chairs, councilors, commissioners, and officers. We have continued throughout the year to '■rilically examine of)era- tional decisions and the governing process. I must share a conversation I had some time ago with an Episcopal priest friend of mine who explained that there really was no difference

between the various denominations of churches that had "dea- cons," "elders," or "vestry members." He went on to say that all these groups had the same primary mission — to protect the eight sacred words of their respective organizations. These eight words, in case you are interested, are: "But we've never done it that way before." Believe me, I heard these words more than once during the past year. I emphasized that no operational policy was too sacred to be asked the basic question: "Can we do it better?"

I have strived for more openness, for more sharing of responsibility, and for more effective partnerships, internally and externally. I believe that we have built a new sense of trust and respect between individual members of the staff, between the staff and officers, and between the members and officers. Most importantly, we have reached out to our allied organiza- tions in a genuine effort to rebuild old and valuable linkages, because the ultimate task of president is to build a consensus among all of the diverse specialty groups that are woven into the fabric of this organization. I am proud that the House of Medicine in North Carolina has not broken down into a bunch of self-interest splinter groups but remains focused on quality care for our patients and preservation of our great heritage as practitioners of medicine.

Staffing Changes

At this time, I stand before you as president of a Medical Society whose executive vice president's resignation became effective October 12, 1993; a society whose director of Governmental Affairs asked for and received reassignment to health poUcy director; a Society whose entire legislative and lobbying pro- gram is in the process of critical review, evaluation, and probably, reorganization. I offer no apology for this state of affairs — on the contrary, I believe the Society has an unparal-

10

NCMJ / January 1994, Volume 55 Number 1

leled opportunity to become more flexible and more responsive to membership needs than we have in a long time.

On a personal note, let me digress a moment to publicly express our appreciation to George E. Moore, former executive VP, for the many contributions he made to the operation of this organization over the course of a decade. His dedication to his work was evident 24 hours a day, seven days of every week. He wanted to be involved personally in almost every facet of day- to-day operations, and to a considerable extent he was. George will be missed by me and the many other friends he came to know in this organization. I join you in wishing him the very best his future endeavors.

A committee has been appointed to search for a new executive vice president The committee was appointed with consideration to geographic, age, gender, and leadership repre- senta tion.The members are Joe Jenkins, urologistofFayetteville, John Daniels, general surgeon of Durham, C.K. Rust, internist of Wilmington, Jeff Runge, emergency room physician of Charlotte,Liz Kanof, dermatologist of Raleigh, Bill Costenbader, ENT surgeon and hospital medical director from Asheville, John Fagg, speaker of the Medical Society, and chaired by Carolyn Ferree, secretary-treasurer. The committee will have the necessary fiscal resources and will take the necessary time to select from a very strong group of applicants the very best qualified person for this Soci- ^^^^

ety. I am confident that the Society will be well served and well directed by an indi- vidual with the experience and team-building skills the posi- tion demands.

"We spent an inordinate amount ot

time and energy on alternative medicine issues last year, and I am afraid that it is not a dead issue."

Year in Review

With no significance in order or presentation, here is an over- view of important activities accomplished this year.

Tim Pittman, our new director of Communications, ar- ranged a series of statewide visits by officers and regional medical leaders to major newspaper editors, editorial staff, publishers, and recognized medical reporters. This proactive engagement has and will continue to help us get our message out His new publication, "Component Chronicles," helps us share AMA, North Carolina Medical Society, and regional news across the state. He arranged the largest press conference ever in our headquarters building the day after President Clinton presented his health care reform plan to Congress. Health care reform briefing books explaining our position have been pre- pared for officers, members of our Legislature, and members of Congress. The Communications Department staff will get more closely involved and coordinated with our lobbying program before and during sessions of the Legislature.

Our Third Party Relations Committee, led by Phil Sellers with the strong staff support of Peggy Boughers, has done a yeoman's job this year. The HCFA-mandated Carrier Advisor

Committee (CAC) is now implemented in all 50 states, and coordinated nationally by the AMA. It has met every quarter, is maturing rapidly, and the almost 70 specialty representatives on the CAC have begun to understand how to work with our carrier and the system.

Ann Hale has compiled an excellent report and summary of the vital work of our Legislative Committee. It was an inordi- nately long legislative session that considered hundreds of bills of interest to organized medicine. Dr. Joe Jenkins has agreed to continue as chair of the Legislation Committee. With his concurrence, I appointed a group of seven to serve as the North Carolina Medical Society Legislative Executive Cabinet. This group met frequently and worked closely with Dr. Jenkins, Ann Hale, Elizabeth Bailey, and our two lobbyists. This smaller group was able to better define strategy and deploy our limited resources in the most effective way. We spent an inordinate amount of time and energy on alternative medicine issues last year, and I am afraid that it is not a dead issue. Karen Gottovi, wife of Dr. Dan Gottovi, is one of five House members appointed to the North Carolina Health Planning Commission, and we are glad to have someone with her intellect and insight on this Commission. On August 5, 1993, 1 appointed an ad hoc committee on Governmental Affairs Operation to carefully review oiu" principal lobbying needs. The committee looked in ^^^^ detail at our Governmental

Affairs budget, current organi- zation and staff responsibili- ties, our lobbying effective- ness, and our past and possible future relationship with the law firm of Smith, Anderson. Rec- ommendations of the group have been presented to the Executive Committee and negotia- tions are under way to see that we deploy the most effective program we can assemble next year. It is a must for the Society. Dr. Gene Mayer has agreed to chair a task force on the governance of the North Carolina Medical Society. Gene has considerable insight and experience with this subject since he chaired our initial governance study group in 1987. The Execu- tive Committee has strongly recommended, and I agree, that we should have another look at our governance and change it if we can find a better way. The "concept" of 1 8 districts, nine "rural" and nine "urban," is not working as well as we hoped it would. In fact we may have put in place an idea ahead of its time.

We have reassessed the marketing strategy for our newly introduced health benefits insurance program offered by Blue Cross/Blue Shield through the Medical Mutual InsuranceCom- pany. Your Executive Committee mandated that we had to make this program available to all our members. That means marketing the plan in Buncombe, Mecklenburg, and Pitt coun- ties where existing proprietary health insurance products are already offered by those component societies. We have com- municated with these organizations and will try to introduce our product without direct solicitation of subscribers in pre-existing programs. The Member Benefits and Services Committee is

NCMJ / January 1994, Volume 55 Number 1 1 1

developing a means of sharing revenue with component societ- ies who co-endorse and help promote our many endorsed programs. I hope this can be worked out, as it will be a carrot/ carrot opportunity that will help all of us with non-dues revenue support. It is yet another example of how state and component organizations can thrive in a synergistic relationship.

I applaud this House for approving making affiliate mem- bership available to physician assistants. As someone closely involved with the PA movement from its inception at Duke in 1966, 1 am proud to announce that we now have more than 125 dues-paying PA members in this organization.

I have had to expend less time and energy with the North Carolina Medical Society Alliance than with any other of our closely allied organizations. This was not by design, but dic- tated by circumstance and the fact that we clearly have always had a strong bond and a very effective linkage with their leadership that just gets better every year. The work of the Alliance also gets better as indicated in the annual report delivered by Alliance President Gay Bowman.

Earlier this year, we had a very useful meeting with the North Carolina Hospital Association president and selected board members. Dr. Kanof is trying to schedule a follow-up meeting. We disagree with the Hospital Association on some issues, but the two organizations have much to gain by working jointly on common concerns ^^^^—

that are threatening the health care delivery system. I am extremely pleased that Ed McCauley, president of the North Carolina Hospital As- sociation, was able to attend our meeting this year, and I

extend to him a warm wel-

come. I hope his presence is symbolic of future potential collaboration between our respective organizations.

responsibility for this project She very much deserves our appreciation for seeing this through some hard times, as does Don Lucey whose dedication and consensus-building have created this excellent report. Some may argue that the method- ology is "not pure," some may object to the various rankings, but no one can question the importance of starting to allocate our finite health care resources. The question of whether health care or health care access is a basic right becomes somewhat moot when you finally admit that there are simply not enough resources out there to give everything to every living person on demand.

Board of Medical Examiners

I met twice with the Board of Medical Examiners, the last time in executive session with the entire Board in September 1993. The Board and our Society each benefit from better understand- ing of our mutual concerns. The Board and its executive secretary agreed with my proposal to establish a Data Collec- tion Task Force, to better address the manpower data needs of the North Carolina Medical Society, AHEC, the Sheps Center in Chapel Hill, the North Carolina Academy of Family Practice, and others including possibly the General Assembly Commis- sion on Health Care Reform.

". . .the (Medical Society and the North Carolina Hospital Association) have

much to gain by working jointly on common concerns that are threatening

the health care delivery system."

Essential Benefits Model

Two years of hard work by Dr. Donald Lucey and the more than 60 hard-working specialist members of his Essential Benefits Task Force have given us their report. Supported by a grant from the Kate B. Reynolds Health Care Trust, this monumental work may become a national model and is gaining a lot of favorable review and acknowledgment across the country, even before its full completion and review by this House. The psychiatric portion needs more refinement, but the fact that "essential," "desirable," and "optional" psychiatric diagnostic and treatment pairs are to be incorporated in this document is noteworthy. It parallels the fact that the AMA formally incor- porated a psychiatric coverage benefits package last June.

I am very proud to have supported and encouraged the progress of this task force and am delighted to have its report reach the House at this time. It is a dynamic and ongoing piece of work. Margaret Woodcock has been untiring in her staff

Accurate, timely, and manda- tory medical manpower data collection is becoming more crucial. This collaborative en- deavor is a giant step forward from the recent past.

Our Board of Medical

Examiners is facing a fiscal

crisis by December 1 994 unless we help them with all available resources to get the bi-annual registration fee raised. The vital role of the BME in credentialing physicians, investigating complaints, and in salvaging careers rather than destroying them deserves our unwavering support. The BME is working hard to become more user friendly. Leaders of both the Board and the Society have agreed to meet informally but regularly at intervals throughout the coming year.

Tobacco Legislation

Critics took us to task on the issue of lobbying tobacco legisla- tion, accusing the North Carolina leadership of rolling over, of abandoning the high moral ground, of not fully supporting our Tobacco Task Force and our Cancer Committee's hard work. Our Legislative Cabinet would see it differently. Like good tacticians, we reserved our troops to fight again at a time and place where we could achieve a victory. That opportunity came when Dr. Ron Levine, State health director, and I coordinated a letter-writing campaign to all component society leaders and to county health department directors urging passage of local

12

NCM J / January 1994, Volume 55 Number 1

smoking control rules before the October 15 expiration date of the state statutes relating to this issue. As of November 1993, 3 1 counties have community- wide smoking regulations and 25 additional counties have restricted smoking in county and city buildings. This effort was such a huge success that the Tobacco Institute of Washington is considering a lawsuit in several eastern counties.

Conclusion

I come to my final comment. In general, organizations are greater than the sum of their parts. 1 learned this the hard way when precipitously confronted with a critical and life-threaten- ing illness 10 years ago. My hospitaUzed post-op heart patients were cared for with great skill and concern by my partners and nursing staff, bills were paid, my children took over additional responsibilities. I would like to believe I came out of the experience as a "kinder, gentler" man. I was humbled by the realization that I was not so indispensable and enlightened by the realization that all truly good work continues.

Two months ago we were suddenly without an executive vice president and yet, the good work of the Society goes on as it has for 144 years. It does so because of the excellent work of

you, the members, who serve with extraordinary dedication as committee members, chairs, councilors, commissioners, and officers. I am deeply grateful to so many who have helped and given me their support. It continues because the headquarters staff, with a new sense of empowerment and responsibility, has stepped in and done their work better than ever.

In my last "President's Newsletter," I said this has been a year of myriad feelings and emotions. There have been major low jx)ints and some terrific highs. There have been a few successes, somedisappointments,occasional aggravations, and some frustrations. I have a scrapbook with several hundred letters — some critical and a few appreciative ones — a lot of frequent Hyer miles, and enough good memories and new friendships to last a lifetime. Overall it has been a challenging and satisfying year, and, although hectic, it's been fun.

The days ahead will be challenging. This society will be ready and capable to meet those challenges. Many of you are tired of the hassle, upset about inadequate reimbursement, and worried as to how you will survive in the as yet undefined "managed competition" environment There will be change. More than ever we must expand the membership of the North Carolina Medical Society, the AMA, the political action com- mittees. More than ever we must hang tough, hang together, and hang on to this great profession. □

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1 4 NCMJ / January 1994. Volume 55 Number 1

VIEW FROM THE PODIUM

Inaugural Address

By 1994 NCMS President Elizabeth P. Kanof, M.D.

Ed/fof's note; The following essay Is based on a speech given by Dr. Kanof, a Raleigh dermatologist and 1 994 president of the North Carolina Medical Society, which she delivered to the Society's House of Delegates at the Annual Meeting held in Charlotte in November 1993.

On October 23, 1993, 1 saw on CBS News a colleague of ours in family practice being interviewed about the hassles of medical practice and their impact upon his effectiveness as a physician. Before the interview was over, this physician, sev- eral years my senior and looking very tired, was in tears and rubbing his forehead in desperation. That disturbing image will shadow me during this year in which you have entrusted to me the leadership of our Society. I pledge to make every effort to strengthen and inspire the family of medicine in this state by encouraging our sticking together, serving together, and shar- ing together.

Sticking Together

We need to crystallize the central core beliefs of North Carolina physicians about health system reform so that we can speak with a unified, effective voice in the ongoing debate. To do this we must better understand the issues. Last year our Society sponsored seminars on health system reform and how to adapt to the legal, regulatory, and structural changes facing us. These seminars will continue under the leadership of Dr. Larry Cutchin, our first vice president and Lisa Jemigan, our executive assis- tant for Business Services. We have already scheduled semi- nars on: Managed Care, CUnics Without Walls, Health Alli- ances, Medicare Update 1994, Coding Seminars, Improving Office Productivity and Performance, How to Conduct an Internal Audit, Medical-Legal Updates, and Relating to the Media.

We have just initiated a new project, the formation of a network to assist certified medical assistants in finding employ- ment. Updated listings will be distributed to component societ- ies monthly and to members requesting them in the hope of expediting the filling of staff vacancies.

Gene Mayer, our Communications Committee chair, Tim Pittman, our Communications director, and the Communica- tions Committee will continue to strengthen internal and exter- nal communications. The "Component Chronicle," a compila- tion of timely and important health information, is provided weekly to component society presidents and executives and has already enabled us to communicate more rapidly. Our first forum for the public on health system reform was held in Raleigh on October 25, 1993, and was a great success. Six more are scheduled across the state; the staff would be happy to assist in sponsoring one in your community.

As president, Mac Mauney initiated an Executive Commit- tee of county executives that allows them to work more closely with the Medical Society leadership; that approach will con- tinue this year. Feelings of being overwhelmed vanish when I meet with them and our staff at headquarters. Their dedication and hard work makes it possible to fulfill our objectives.

It doesn't happen often that the president of the North Carolina Medical Society is also a member of the NCMS Alliance, our closest ally. My hope is that the Society and the AlUance will work more closely than ever before on issues such as adolescent health, family violence, and the health of you, the doctor, and the medical family.

With Thad Wester as our president-elect, I look for a renewed sense of warmth and cooperation between the public and private sectors for the betterment of all that we do to promote good health in North Carolina. As an example, our combined efforts in sending a sample smoking control statute to local boards of health, county commissioners, and county society presidents was met by a gratifying response: 32 counties responded by passing city-wide smoking restriction ordinances and 24 by limiting smoking in public buildings. We are a more effective force when we work with all of our alUes than when we work alone.

NCMJ / January 1 994, Volume 55 Number 1 15

We also plan to work closely with the Hospital Association to address common ground issues including legislative goals, tort reform, problems with organ procurement, and lo discuss ethical concerns such as futile care.

Serving Together

We need to encourage more physicians to serve on community boards, councils, and commissions, and to be more active in local and state politics. We intend to forge closer relationships with business and industry, with the North Carolina Bar Asso- ciation, with the North Carolina Academy of Trial Lawyers, and with the North CaroUna Coalition Against Domestic Vio- lence, which will sponsor with us a conference next spring that will address the serious problem of battering in our state.

Within our own organization. Gene Mayer will chair a task force on Society governance to explore the role of the council- ors, the district system, the feasibility of granting commission- ers voting privileges on the Executive Council, and other issues. Society members can participate in this process by sending suggestions and by contacting me, the officers, or the commit- tee chairs with your ideas.

Assad Meymandi will chair a new task force on domestic violence, which will work closely with the legal profession, public health officials, the Alli- ance, and those civic orga- nizations that see violence as a public health issue and

"We need to encourage more physicians

to serve on community boards, councils,

and commissions, and to be more active

in local and state politics."

are committed to discovering together an effective treatment. Members of the Old North State Medical Society have graciously agreed to serve as consultants on many of our committees this year. I hope that, under the leadership of Grimes Byerly, chair of the Membership Committee, we can work out affiUate memberships between our organizations and visibly increase membership in the NCMS and the Alliance.

Sharing Together

We need to share more equitably the responsibility of caring for those patients who are underserved throughout the state, par- ticularly patients with AIDS and sexually transmitted diseases. We need to share the responsibility of caring for our senior citizens, especially the real difficulties that Medicare patients confront in finding a physician. Darlene Menscer, our second vice president, will spearhead our efforts at grappling with these problems.

We will share our intellectual and scientific strengths through the formation of a Science and Technology Committee. This committee will consist of a faculty member from each of our four medical schools, one member each from the School of

PubUc Health and the public health sector of state government and, as on all of our committees, a student and resident member. Under the leadership of Harvey Estes, this committee will receive scientific information from many sources and will report on what is relevant and important for transmission to the Society. In addition, the committee will serve as a resource on technical and medical matters for the news media, governmen- tal agencies, organizations, and others who need authoritative, science-based information to guide policies and decisions.

Sharing also means your support of the North Carohna Medical Society Foundation, created in 1966 as a non-profit corporation and organized exclusively for charitable, educa- tional, and scientific purposes. The Foundation manages the Kate B. Reynolds Community Practitioners Program, which not only recruits medical personnel desperately needed in underserved areas, but also organizes locum tenens support by staff from family medicine residency programs so that our colleagues in these areas can have time off for educational or recreational leave. Furthermore, the involvement of lay persons on the Foundation's Board of Trustees is a superb opportunity for us to reach beyond ourselves to others in our communities. The Foundation served as the fiscal intermediary for the Physicians Health and Effectiveness Program, which has been

so successful in identify- ing and rehabilitating im- paired physicians. The suc- cess of PHEP is such that it will soon become a sepa- rate organization of its own. For me, the Founda- tion symbolizes the essence of medicine as a profes- sion. Those past presidents of our Society who have endowed lectureships for the Spring Conference have dedicated their personal energies and a significant part of their financial re- sources to ensure that our generation and future generations of North Carolina physicians will, on an annual basis, be privi- leged to hear and exchange views with the best minds in the country. Those of you who contribute to the Foundation help enormously to fulfill the goals of the Society and to promote new programs without expending dues dollars.

My Challenge

I see the challenge of my year ahead, and I now feel ready to abandon the "funky shoes" that Reporter Tinker Ready man- aged to notice when she interviewed me for the Raleigh News and Observer's 'Tarheel of the Week." Remember Kate Tho- mas' statementon women's capabilities? — "Ginger Rogers did everything that Fred Astaire did but she had to do it backwards and in high heels." I stand before you today in my medium heels. With your continued friendship and active participation, and with the love and support of my husband and family I hope to be standing before you a year from now in my high heels. □

16

NCMJ / January 1994, Volume 55 Number 1

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THE STATE OF OUR HEALTH

Conjoint Report

To the North Carolina Medical Society and the North Carolina Commission for Health Services

Ronald H. Levine, M.D., M.P.H.

Editor's note: Dr. Levine, North Carolina's state health director, delivered the following message at the Medical Society's Annual Meeting in Charlotte in November 1993.

I write again to brief you on public health issues of importance, courtesy of the leg- islator who, years ago, convinced our General Assembly to place this obliga- tion of the State Health Director squarely within North Carolina's General Stat- utes. I hope that my comments on these topics, including a public health perspec- tive on the health system reform debate, will be of interest to you.

Sexually Transmitted Diseases and AIDS

After North Carolina had achieved the dubious distinction of ranking second among the states in primary and second- ary syphilis morbidity, we feel we may have turned a comer in the perennial battle that we, along with the other South- em states and major urban areas, wage against this and other sexually transmit- ted diseases. During the first two-thirds of this year, the stepped-up efforts of our field epidemiology staff has yielded a 24% decrease in cases. At the same time, the incidence of that most horrific of

preventable diseases, congenital syphi- lis, is beginning to wane although we are likely to tally as many as 50 cases before the end of 1993. We hope this trend continues so that, with the help of a high index of suspicion and a commitment to repeated prenatal serology testing by the state's doctors, we can once again elimi- nate congenital syphiUs as a problem in our state.

It is very difficult to interpret the slope of the epidemic curve for AIDS in North Carolina. The recently liberalized definition of AIDS has led to cases being reported that would not have been in- cluded under the old definition. Never- theless, what we do know gives scant comfort; indeed it is rather alarming. AIDS is now the number one killer of young men in this state and ranks eighth for young women. The seropositivity rate for HIV among non-white pregnant women in some of our metropolitan coun- ties approaches 1%. Many of the babies bom to these women will die from pedi- atric AIDS. In fact, our minority commu- nity is facing a crisis of huge dimensions; more than 75% of new HIV infections

occur in people of color. We desperately need resources for both community- wide and targeted prevention and education programs. We hope and pray that the need will be recognized by those in both the public and private sectors who have the ability to lend a hand.

Speaking of lending a hand, I ask the practicing physicians and dentists of this state to help shoulder the burden of pri- mary care for those suffering from AIDS. Our tertiary care centers are literally stag- gering under the load of patients who come long distances at great inconve- nience and expense, patients who could quite effectively be cared for in their own or neighboring communities until their disease becomes so complex, demand- ing, and difficult that the expertise of the AIDS specialist is required. I am very proud of the primary care physicians of Asheville who have worked out an ar- rangement to share this burden equitably among themselves so that no one physi- cian is unduly burdened. I am asking the leadership of the Society to join with me, our superb medical centers, and our state ' s excellent AIDS training institute to de-

FromtheStateofNorthCarolinaDepartmentof Environment, Health and Natural Resources, P.O. Box 27687, Raleigh 2761 1-7687.

18

NCMJ / January 1994, Volume 55 Number 1

velop a program that will provide quality, compassionate care close to home for just as long as that is in the patient's best interests.

Immunization of Children

We will also be joining the Medical Soci- ety in what promises to be a colossal effort to raise the percentage of our young children who are immunized. A major public awareness campaign, an effort to make local health departments and other clinics more "user-friendly," a statewide computerized immunization registry that will reach right into our practicing physi- cians' offices, greater availability of free vaccine wherever infants and young chil- dren go for their care, relaxed consent and confidentiality laws and rules — all of these as well as a host of additional mea- sures will enable us to meet the goal of having 90% of our two-year-olds up to date on immunizations by the year 2000. I am very optimistic that this public/ private collaboration will be one of the most successful in our history.

Rabies in North Carolina

Last year I warned you that our previ- ously rabies-free state was being threat- ened on three sides by the incursion of wildlife-borne rabies. I must report to you that the epidemic is here, placing our pets and domestic animals and, more importantly, our families at serious risk. Before the end of 1993, we will have had more than 100 cases of rabies in our state. We have had reports of rabid cats literally chasing and attacking their owners.

Physician knowledge of this disease and its prevention is critical. There have been no treatment failures in the U.S. when appropriate post-exposure patient management procedures are followed. The greatest risk to humans occurs when exposure to rabies goes unattended. Once symptoms appear, the illness is almost always fatal. Thus it is crucial that physi- cians abide by the recommendations of

the Advisory Committee on Immuniza- tion: treat the wound, administer rabies- immune globulin, and vaccinate with five doses of human diploid cell vaccine.

Infant Mortality and Maternal Health

I am particularly pleased to report a fur- ther decHne in North CaroUna's infant mortality rate from 10.6 deaths per 1 ,000 live births in 1991 to 9.2 per 1,000 in 1992. This is the lowest infant mortality rate in the history of our state. In order to maintain this trend, our service deUvery system has expanded its efforts to reach women at risk for poor pregnancy out-

"I am particularly pleased

to report a further

decline h North

Carolina's infant

mortality rate from

10.6 deaths per 1,000 live

births in 1991 to

9.2 per 1,000 in 1992. This

is the lowest infant

mortality rate in the

history of our state,"

comes. During 1993 almost40,000 high- risk pregnant women received maternity care coordination services from nurses and social workers assigned to assist these women in obtaining proper and timely medical and community support services. Our studies have firmly established that both infant mortality and low- and very low-birth weight births were significantly reduced among women receiving these outreach services.

I am also happy to report that in 1 992 there was a 5% decline in the rate of adolescent pregnancy. This represents an 11% decline since 1989. This is good news, but far too many adolescents in this state still opt to take on the onerous bur- den of parenthood before their time. Ac-

cording to the Center for Population Op- tions, 25% of all teen mothers go on welfare, and two-thirds of children younger than age six in families begun by a teen birth live in poverty. We still have much to do to deal with the problem of children having children.

Public Health: Present and Future

1 want to close with a few thoughts from the public health family regarding health system reform. I am pleased that I don't have to exhort you (as I did in 1992) to get off the sidelines and into the action. 1 had the pleasure of attending one of the Society's public forums on this subject and it was obvious to me that the Society is taking very seriously the obligation to educate and inform its members and the public as well.

I am more than pleased that the re- curring themes of my past reports — on ensuring timely mammograms. Pap smears, smoking cessation, and so on — are reflected in the strong support of organized medicine for cUnical preven- tive medicine. And for preventive prac- tices that are adequately emphasized and reimbursed.

I do have two more concerns to share with you. I request your understanding and, I hope, your advocacy. The first has to do with the purpose of this entire monu- mental effort to restructure the manner in which health services are financed and delivered. Over and over we hear that the goals of restructuring are: 1) To provide universal access to quality health care; 2) To constrain out-of-control health care costs. To quote the incomparable Peggy Lee, "Is that all there is?" Are we really going to subject providers and patients to such wrenching reformulation of roles, responsibilities, and relationships with- out setting as a third and possibly more important objective: "To achieve im- proved health status?"

We must not be concerned just with the level of expenditures on health care in this country and the resulting impact on our ability to remain competitive in the

NCMJ / January 1994, Volume 55 Number 1

19

global marketplace; we must recognize and do something about the fact that, in spile of these expenditures, our great na- tion ranks so low among the developed nations in so many measures of health status. I ask that as you consider and participate in a renewed emphasis on beneficial outcomes for individual pa- tients, please think also of outcome mea- sures for all of our people, for North Carolinians, for Native Americans, for premature babies and so on. Help us ensure that systems are in place to quan- tify these outcomes and more importantly, to assure that a healthier America re- mains our goal.

And, finally, I ask you to do all you can as individuals, as community leaders and as members of the North Carolina Medical Society to see that your public health clinics are adequately supported until the arrival of the health reform mil- lennium . Then we may have the privately

operated, accountable health care plans to care for all, and we will truly have one system of care, and the distinctions be- tween public/private may at last be erased. Those of us in the public health system.

"I ask you to do all you

can. . .to see that your

public health clinics

are adequately supported until the arrival of the health reform millennium."

particularly in the South with its longstanding major commiunent to clini- cal services for the underserved and the difficult-to-serve, are concerned that there

exists the belief that we can "close up shop" in anticipation of the new era. You and I know better. We will continue to assist you in your care for those who need assistance and encouragement, whose priorities revolve around putting a meal on the table and rather than on continuing comprehensive care, who can't speak English, who need the services of the nutritionist, the outreach worker and the public health nurse.

I ask you to advocate, during this interim as we wait to see what reform will do for us, for your public health system and, I might add, for your migrant, rural, and community health clinics so that ac- cess to care does not actually become less during the transition. I ask this in the knowledge that private practitioners and public health practitioners in the Tarheel State have bonded long ago and will continue to work together for what is best for the people of North Carolina. □

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20 NCMJ / January 1994, Volume 55 Number 1

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Physician/Hospital Organizations

Integrating the Delivery of Health Care

Arlene J. Diosegy and Steven D. Simpson

The health care industry has changed dramatically in the past 10 years. Hospitals and physicians have already adapted to Medicare's implementation of a Prospective Payment System (PPS) and a Resource-Based Relative Value Scale schedule for physician's fees. Now doctors and hospitals are becoming more interdependent as they respond to increasing competition, cost control pressures from third-party payers, the rapid emergence of managed care programs, and greater governmental scrutiny and intervention. Washington's rush to health care reform, and the trend toward "managed care" and "managed competition," have led to greater cooperation among hospitals and their medical staffs. We are beginning to see the emergence of physician/hospital organizations (PHOs). Their rapid spread has come to North Carolina.

No doubt, the rising costs of health care and the rhetoric of the "health care crisis" will spur additional profound, structural changes in our health care system. The various proposals for health care reform rely to some extent on integrated health care delivery, managed care, or both to provide efficient, high- quality health services to all Americans. We discuss the factors that have led to the creation of PHOs (a partially integrated delivery system): the legacy of prospective payment, the growth of managed care, and health care reform proposals.

The Need for PHOs

Prospective payment. Implementation of prospective payment by Medicare in 1983 introduced new incentives to the health care system. Instead of rewarding hospitals with higher pay- ments to reimburse costs of additional services, the PPS re- warded hospitals for quicker and more efficient diagnosis, treatment, and discharge. Even commercial insurance carriers are now considering PPS-type reimbursement systems. Inno- vative hospitals and health care systems recognized the incen- tives inherent in PPS and responded by the development of PHOs in which:

1. Diagnosis can occur before hospitalization by using comprehensive outpatient diagnostic and ancillary service cen- ters such as freestanding imaging centers or cardiac catheteriza- tion centers.

2. Hospitalization can sometimes be avoided by using alternative treatment centers or programs such as ambulatory surgery centers or freestanding radiation therapy centers.

3. Hospital patients can be discharged more quickly to the care of "down stream" alternative providers like comprehen- sive outpatient rehabilitation facilities, home health agencies, home intravenous therapy providers, and nursing facilities.

Health care reform. In 1990, 36 million Americans reportedly had no health insurance. Access to affordable health care has become an important feature of the domestic policy agenda. Despite the need for more services, in 1992 the U.S. spent $838.5 billion on health care, an increase of 1 1 .5% over 1991; in 1993, the U.S. will spend more than $939.9 biUion, a further increase of 12. 1 % over 1992. Health care spending is forecasted to increase annually by as much as 15%. Because of these figures, the Clinton Administration, the state General Assem- bly, and health care policy groups have discussed initiatives for reforming health care access and financing. Most proposals fall into one of four categories based on philosophical policy differences: mandated benefits (play or pay), single payer, market reform, or managed competition. The Clinton Admin- istration appears to favor the managed competition approach.

The Emergence of PHOs

PHOs may play an important role as North Carolina health care providers structure their response to the external factors that effect the climate of medical practice. There are four currently prevalent types of organizations:

7 . The management service organization. Under this struc- ture a hospital supplies office administration services, billing or

This article is not intended to provide legal advice. For questions, contact your attorney. For more information, contact the authors at Health Care Practice Group, Maupin Taylor Ellis & Adams, PA, P.O. Drawer 19764, Raleigh 27619, 919/981-4000.

22

NCMJ / January 1994, Volume 55 Number 1

computer services, and the like to physicians whose time is thereby freed to provide medical services to patients. This type of PHO can be established simply by the participants entering into appropriate contractual arrangements.

2. The "clinic wilhoul walls." Physicians in unrelated medical groups and specialties, often as part of a preferred provider agreement, create a practice to provide medical ser- vices to patients. This type of organization may avoid violating antitrust laws, and also may alleviate Medicare scrutiny regard- ing fraud and abuse. A clinic without walls may stand alone as a physician organization or be organized with a PHO.

3. The medical foundation. In cooperation or affiliation with a local hospital, a tax-exempt organization is created to directly provide professional medical and perhaps hospital services to patients. At present, this entity is primarily a West Coast phenomenon.

4. The integrated health care delivery system. The IDS is a variation of the medical foundation model. It involves the creation of a tax-exempt organization, frequently a medical foundation, to purchase professional medical practices. The foundation contracts with the staff physicians for provision of medical services to patients. Representatives of the affiliated hospital and IDS physicians serve on the board of the medical foundation. Contractual arrangements between hospital and foundation establish the medical services that will be offered and delineate the rights and responsibilities of each party in terms of billing, insurance coverage, and similar matters.

Objectives of PHOs

The goal of a PHO is to allow the hospital and physician members to act as a cohesive health care entity. In starting a PHO, one must consider these management and practice items:

• The balance of hospital and physician interests in terms of control, governance, program opportunities, and internal incentives offered to physicians.

• Tax status of the PHO; Medicare fraud and abuse concerns.

^ How to minimize change and still provide new, innova- tive programs that meet competition and seize opportu- nities.

»/ How to maintain the independence of the physicians' medical practice and the autonomy of the hospital.

i/ How to reduce potential conflict between the hospital and the medical staff by making sure that new programs are joint initiatives rather than unilateral changes, and that the economic and professional tensions of prospec- tive payment, managed care, and other cost-containing measures are addressed.

\/ How to improve the PHO's competitive posture by adopting tools that organized health plans and large systems use to efficiently provide quality care: effec- tiveness review, strategic planning, advanced market- ing, vertical integration, and private capital financing.

Hospital

Physician entity

PHO Central

Health plan (HMO/PPO)

Facility/service ventures

Financing ventures

Fig. 1: Physician/hospital organization

• How to be flexible about the "form" in which third party payers reimburse for services; prepayment, prospective payment, and fee-for-service are not mutually exclu- sive.

• How to create new, selective, health care risk pools rather than relying solely on others to create such pools of patients.

• Recognizing that competition between the hospital and physicians may be self-defeating in the long run. Selling traditional hospital services in competition with the physicians may reduce hospital volume (and revenues), cause cost increases in the short run, and perhaps curtail hospital services in the long run. Similarly, competition by physicians for patient referrals may merely undercut the hospital's traditional referral network.

Design of a PHO. The PHO uses the straightforward device of creating a new, freestanding entity to avoid the common pitfalls of working directly through existing hospital or medical staff structures. Figure 1 , above, shows a general schematic diagram for a PHO. The concept is quite simple and very flexible although the number of options created by that flexibility sometimes obscures its simplicity.

The hub of the PHO is PHO Central, an entity created by the hospital and the physicians. It has three purposes:

1 . To provide a forum for estabUshing joint px)licy and strategic plans through a governing board comprised of hospital and physician representatives.

2. To identify, evaluate, and develop health care venture op- portunities of mutual interest and benefit to the hospital and physicians. PHO Central may own or control these ventures.

3 . To develop and provide each PHO venture with the manage- ment tools necessary to operate. The management costs are spread over a number of activities or ventures.

PHO Central can be a partnership, a for-profit, or a non- profit corporation depending on legal analysis of the specific objectives of the parties, state and federal and corporate and tax

NCMJ / January 1994. Volume 55 Number 1

23

laws, and the method by which new ventures are to be financed (equity contributions, taxable debt financing, or tax-exempt bond financing, as may be applicable).

PHO Central is controlled by the hospital and a physician entity composed of the physicians on the active medical staff at the hospital who individually participate in the PHO. The board of directors includes representatives of both the hospital and physicians.

PHO Central allows the hospital and a group of physicians to undertake one or more specific ventures. Physician members can pick and choose among PHO ventures; they need not participate in all or, in fact, any. There are numerous potential PHO ventures. Anything that effects hospitals or physicians can be considered as long as physician ownership or involvement is consistent with state and federal law. There are three major PHO venture types:

Competitive health plan ventures: These include any com- petitive plan that markets the services of physicians and the hospital as a combined package of health care benefits. In- cluded are HMOs, preferred provider organizations, and other approaches, such as an exclusive provider organization.

Innovative health facility/ service ventures: A PHO can sponsor many of the health facility/service ventures currently being pursued independently by hospitals, physicians, and non- provider entrepreneurs (imaging centers, urgent care centers, ambulatory surgery centers, etc.). PHO sponsorship removes a measure of the animosity and inu-amural competition often attached to these projects when pursued independently.

Financing opportunities: From time to time, both the hospital and the various PHO ventures will need to acquire capital assets. Financing the lease or purchase of expensive equipment involves PHO Central in both cash flow analysis and an examination of the tax burdens or benefits to be derived.

A Formalized PHO: The IDS

An integrated health care delivery system is perhaps the most formal of the four common types of PHO. The formation of an IDS involves the creation of a tax-exempt organization to contract with participating physicians for professional medical services. The organization may purchase the assets of private medical practices or clinics formerly maintained by the partici- pating physicians. Professional service contracts are structured to fit within one or more of the legal "safe harbors" promulgated by the Office of Inspector General of the Department of Health and Human Services and thereby avoid any concerns of fraud or abuse arising from the organization's payment of profes- sional fees to the physicians.

Since an IDS is a new, formal legal entity, its structure is often more complicated than that of management service orga- nizations, clinics without walls, or medical foundations (Figure 2, right, shows the delivery of systems). The IDS typically provides the following:

i/ Physician primary care and specialty care

*/ Outpatient diagnostic and ancillary services such as freestanding imaging centers or cardiac catheterization centers

• Alternative treatment centers such as ambulatory sur- gery centers and freestanding radiation therapy centers

• Acute care hospitals

i^ Post-acute care providers such as comprehensive outpa- tient rehabilitation facilities, nursing facilities, home health agencies, durable medical equipment suppliers, and home intravenous therapy

• Insurance, HMOs, or managed care programs

Organization of an IDS

Vertical integration is a primary thrust of today's health care marketplace, but there is no single organizational model for an IDS. The variety of existing models reflects more the time period in which a given system emerged or the local political factors of a given health care community than it does any quintessential corporate organizational planning. A review of the various corporate models suggests that the basic premises of an IDS should be simplicity a.x\A flexibility.

That said, it appears that the Internal Revenue Service (IRS) currently favors the Section 501(c)(3) tax-exempt orga- nization as the structure for an IDS and for the subsequent conduct of its health care services. The IRS recently granted exemption to two organizations qualifying as medical founda- tions operating an IDS. The IRS specifically allowed the lax-

Em pioyer/pat lent

Insurance, HMO, or managed care product

Primary care physicians

Specialists

Diagnostic & ancillary service providers

Alternative providers

Acute care hospital(s)

Post-acute care providers

Fig. 2: An IDS model

24

NCMJ / January 1994, Volume 55 Number 1

exempt medical foundations to purchase the tangible and intan- gible assets of physicians' practices or multispecialty group clinics, specifically including patient records as items to which part of the purchase price was allocated.

The IRS also allowed foundations and selling physicians to enter into professional service agreements for the provision of future medical services in return for reasonable compensation. Medical foundations can arrange for the provision of profes- sional medical services through contracts with physicians, but such contracts should not require or anticipate that patients be referred to a particular hospital, whether or not it is operated by the medical foundation. The medical foundation itself need not operate a hospital in order to qualify for exemption.

Recent IRS rulings indicate that physicians should make up no more than 20% of the board of directors of an IDS medical foundation. The 20% limitation may not be appropriate in all cases, and the IRS may be willing to consider facts and circum- stances in determining whether an organization qualifies for exemption as a Section 501(c)(3) charitable organization.

The IRS will allow a Section 501(c)(3) medical foundation to purchase the assets of a private medical practice or clinic and allow it to execute appropriate contracts with the selling physi- cians to provide future medical services. Due to the developing area of the law on this issue, we recommend obtaining advance IRS approval of any proposed IDS.

Recommendations for Forming a PHO

North Carolina hospitals and physicians who want to create a PHO might proceed as follows:

1 . Obtain the firm support of key hospital management and board members toward the PHO concept.

2. Once there is hospital interest, explore the creation of a PHO with a representative panel of key physician leaders. Do not proceed further without strong physician interest.

3. Given mutual interest by physicians and hospital leaders, form a PHO task force comprised of physicians, hospital administrators, and board members. The task force must undertake the necessary legal research, develop a busi- ness plan for one or more initial PHO ventures, roughly assess feasibility of the proposed PHO, and make a formal recommendation for board and physician action. The task force needs a defined deadline for completing its efforts (minimum 90 days), the authority to incur costs ($10,000 to $100,000, depending on the nature of the selected PHO ventures), and authority to retain manage- ment consultants (if desired) and legal counsel experi- enced in PHO formation and development.

4. The task force should deal first with selecting initial PHO ventures that reflect concrete needs or opportunities and generate broad interest within the medical staff.

5. Once initial PHO ventures are selected, the task force should turn the business plan development and feasibility assessment over to its staff. The task force then can focus

on PHO organization, control, and structure and each of the proposed PHO ventures. The task force will need legal counsel, and the hospital and the physicians may need separate legal advice.

6. After the organizational design, business plans, and fea- sibility estimates are complete, the physician task force members should present the salient features at a staff meeung. No formal action is necessary (or desirable), but the physician members of the task force need to assess carefully the degree of support from their colleagues.

7. The task force should present its formal assessment and recommendations to the hospital board and ask for a commiunent to form the PHO, contingent on appropriate physician participation.

8. If the board's response is positive, PHO Central would be created. Task force members could act as the incorpora- tors and interim governing board of PHO Central.

9. PHO Central must then solicit physician participaUon by a direct mailing to eligible members of the medical staff, allowing 30 to 60 days for response.

10. If the level of physician participation meets previous specifications, the hospital board ratifies its commitment to the PHO, votes the necessary funds, and selects its representatives to the PHO Central governing board.

1 1 . Participating physicians then elect directly, or through a physician entity, representatives to the PHO Central governing board.

Other Ways to Develop an IDS

A PHO is not an absolute prerequisite to the development of an IDS. Some hospitals have established partial IDSs by helping their medical staff create individual practice associations that facilitate patient entry into managed care. Others have helped establish alternative diagnostic and ancillary care centers or providers of post-acute care within the hospital system.

Given the changes in payment systems, the growth of managed care, and other factors in the health care marketplace, many physicians seek the security of employment by group practices, HMOs, and hospitals. North Carolina hospitals have begun to establish affiliated group practices, sometimes con- trolling those practices by limiting enrollment to hospital staff physicians or through a non-profit corporation over which the hospital has effective control. By bringing the hospital and physicians together under hospital management, the nucleus of an IDS is established. It can be fleshed out by creating the complementary diagnostic and ancillary providers, alternative care providers, post-acute care providers, and managed care products within the hospital system.

Proposed health care reforms focus public and media attention on the health care industry, which is under intense pressure to limit or curtail costs while continuing to provide quality care. The PHO may be an important component of the health care industry's response to these external pressures. Q

NCMJ / January 1994, Volume 55 Number 1

25

Business Owners Fight Back! Discover The 10 Tax Saving Secrets The IRS and Congress Didn't Want Them to Know

Raldgh, NC — John was really mad now. "I can't believe I'm getting nailed this bad. I seem to be supporting the national debt myself!" he thought to himself.

Once again, he had to write a big check with his tax return. Once again he had been told by his "tax advisor" that, "There is nothing you can do about it. You know that we're doing all that we can. Besides, your business is cash flowing nicely, and paying taxes ("Your Fair Share") is a good problem to have."

Somehow John knew that his accountant had to be working for the IRS . "He must be. Why would he be so willing to roll over and play dead for the government?" This same accountant had advised him to change tax status to an S-Corp in 1987 under the promise of lower taxes forever. And now, after Clinton's new lax bill, this same advice would have him paying federal taxes at 39.6%, slate taxes at 7%, and social security payroll taxes of 7.65% (times 2) in 1993 and beyond.

As John painfully substracted the amount of the check made payable to the IRS from his checkbook he was staring at a pile of unread newspapers and fmancial reports on his desk. A headline in yesterday's financial newspaper caught his attention, "Business cWners Face 50% Marginal Tax Rates Once Again! New Tax Bills Pending in Congress to Raise Taxes Further and Cut Pension Benefits for Business Owners."

John started to get anxious. He read the article and began to feel helpless. The reporter explained how small business owners were catching the brunt of all the new taxes, and how Congress felt everyone should pay more, and 50% taxes on business owners should not be a burden.

The story went on to warn of Hilliary's health care proposal and how S-income would be subject to FICA taxes for business owners, how popular age-based profit sharing plans would be repealed, and so on. The story ended by staling that while new taxes were inevitable, many creative strategies still existed to reduce laxes legally and most business owners were ignorant or had poor advisors who were unaware of me tax saving secrets the IRS and Congress preferred Small Business didn't know about. "If business owners only knew the many ways to legally reduce taxes they wouldn't complain so loudly, the article ended.

John had had enough. "I'm going to fight back legally! I'll never again be a patsy!" He knew that starting tomorrow he was going to stop complaining and take action.

As he picked up the telephone , he vowed that he was going to learn "The 10 Tax Saving Secrets The IRS and Congress Didn't want him to Know." A copy of this FREE REPORT is available by calling the 24 hour toll-free recorded message line listed below.

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Health Watch

VOLUME 55 / NUMBER 1 / JANUARY 1994

Alzheimer's Disease

AN OVERVIEW

What is Alzheimer's Disease?

Alzheimer's Disease is a progressive degenerative disease that attacks the brain and results in impaired memory, think- ing and behavior. It affects an estimated 2.5 million Ameri- can adults. It usually has a gradual onset Problems remem- bering recent events and difficulty performing familiar tasks are early symptoms. Additionally, the Alzheimer patient also may experience confusion, personality change, behavior change, impaired judgment, and difficulty finding words, finishing thoughts or following directions. How quickly these changes occur will vary from person to person, but the disease eventually leaves its victims totally unable to care for themselves.

Risk Factors

The primary risk factor for Alzheimer's Disease is age. As our population ages — which it is doing rapidly, thanks to

North Carolina Medical Society, PO Box 27167, Raleigh, NC 27611.

medical advances and better health habits — more people will have Alzheimer's Disease because there will be more aged people. At present, over 4% of people over 65 and about 15% of people over 85 have Alzheimer's Disease. That's over 2 million people in the United States.

Another major risk factor is gender since most studies find a preponderance of women with Alzheimer's Disease. However, the aged population contains more women than men anyway, and women are more likely to see a physician, so the preponderance in women may not actually be that great

There may be a genetic link to Alzheimer's Disease: Down's syndrome is a clear risk factor. Down's syndrome results in mental retardation and other birth defects. People with Down's syndrome have an extra chromosome 21. If they survive into middle age, these individuals frequently develop changes in the brain that are identical to those in Alzheimer's Disease. The similarities between premature aging of the brain in Down's syndrome patients and the Alzheimer brain have been the basis of several important research efforts.

Geography may be a risk factor, but no true patterns have yet been found. Alzheimer's Disease is more prevalent in blacks than in whites, so race may also be a risk factor. One

NCMJ / January 1994, Volume 55, Number 1

27

study found that Alzheimer's Disease patients were more likely to have suffered past head trauma. So far, that's the only preventable possible risk factor.

Several risk factors have been examined and eliminated: thyroid disease, low socioeconomic status, and aluminum exposure.

History

Dr. Alois Alzheimer, a German neurologist, described the first Alzheimer's Disease patient in 1906. She was 51 years old, was experiencing psychiatric and behavioral problems, including a persistent but untrue belief that her husband was unfaithful to her. Her disease progressed rapidly and she encountered memory problems and increased language dif- ficulties. She became unable to write, speak or communicate at all and she developed profound intellectual deficits, incon- tinence and seizures. In five years she was dead.

Diagnosis

There is no specific diagnostic test for Alzheimer's Disease. The diagnosis is chnical and is confirmed only after death because there is no way to biopsy the brain to examine the cells for the typical cellular changes that are characteristic of Alzheimer's.

Arriving at the Diagnosis

The typical basic evaluation of the suspected Alzheimer's Disease patient will usually include the following:

1) A social and medical history given by both the patient and a relative or close friend.

2) A complete physical examination.

3) A neuropsychological examination testing sensory and motor functions, mental status and verbal, intellectual and reasoning abiUties.

4) A face-hand test in which a person closes his or her eyes and tells the examiner where he or she feels a touch.

5) A mental status questionnaire which tests mental alert- ness. It asks such questions as "Who is the President?" "When is your Birthday?"

6) A test of memory for digits. This tests a person's ability to remember numbers and repeat them.

7) A "misplaced objects" test during which a person is asked to place pictures of familiar objects in correct places, such as kitchens and bedrooms.

8) Pencil and paper tests used by psychologists to deter- mine a person's mental condition.

9) A clinical interview by a psychologist or psychiatrist to determine emotional status.

10) A CAT scan to see if there is obvious brain damage over time.

11) A PET scan which measures the brain's use of glucose. A person with Alzheimer's Disease uses less glucose than normal people.

12) An EEG which measures electrical activity in the brain.

13) A lumbar puncture or spinal tap.

14) A blood test which may pinpoint possible causes of the memory impairment but cannot diagnose Alzheimer's Disease.

In the end, biopsy of the brain is the final proof, arrived at only after the death of the Alzheimer's Disease patient.

'\ \^'

28

NCMJ / January 1994, Volume 55, Number 1

The Phases of Alzheimer's Disease

Alzheimer's Disease has four specific phases. In the first phase, a person may seem tired, lacking energy or initiative. There may be a tendency to shun new places or to meet new people; in other words, the familiar is much preferred. But this stage is so insidious that family members may not even react or notice chances in the person. In the second stage the losses become noticeable. Speech slows, balancing a check- book becomes impossible, so financial embarrassment may occur unpaid bills or an overdrawn account. At this stage the person continues to function, but supervision becomes im- portant.

...learn about the illness, about community resources, about finding legal and financial advice, about how to handle the person.

Disability is the catchword of the third phase. The person becomes disoriented to time and place. He or she fails to recognize people or recall recent events. There is lethargy, a need for frequently repeated instructions and directions. The person makes up new words, behaves strangely, but may have an astonishingly clear remembrance of the remote past

By the fourth state the persons wanders, needs near constant assistance with ordinary activities, loses even more of the recent memory and begins to lose remote memory as well. Words and phrases are repeated. Recognition of self and others disappears. Depression, delusion or delirium may occur. Institutionalization looms on the horizon.

Treatment

At the moment there is much exciting research into treat- ments for Alzheimer's Disease, searching for a means to eradicate the troublesome symptoms in the brain. These include experimental brain cell implants which have report- edly had some success in patients with Parkinson's Disease in Mexico.

For the present, however, treatments aim to alleviate such symptoms as anxiety, sleep disturbance and depression. While these are extremely important for both the person and the caregiver, they are only temporary stop-gap measures. The progression of Alzheimer's Disease is inexorable.

The average Alzheimer's Disease patient lives nine years after diagnosis, but there is great variability within the range. Patients may live months to years imable to walk or speak, incontinent of bladder and bowel, totally dependent on others, but usually just one: The caregiver.

Coping

Once the diagnosis is made and accepted, the burden falls directly, though relatively briefly, on the patient. It falls simultaneously and awfully on the caregiver. This is the other victim and he or she will have important needs to be met in coming months and years:

1 ) Emotional support is essential. Giving care to an erratic, demanding Alzheimer's Disease person is an emotional rollercoaster. The burden must be shared.

2) Information. The caregiver must learn about the illness, about community resources, about finding legal and financial advice, about how to handle the person.

3) Psychological understanding. The caregiver must learn to analyze the person's actions, to understand non-verbal communication, to discuss the phases of grief and the diffusion of anger.

4) Relationships. It is sad but true that dealing with friend- ships that end is important, because people stop coming by, and yoimger family members sometime react inap- propriately to the person's behavior.

5) Self-Care. Caregivers cannot neglect themselves, men- tally or physically. When both the person and caregiver are ill and unable to cope, there could be serious trouble.

6) Outlook. It is important for the spouse to develop a new philosophy of life. He or she will need help to escape a tendency to depression, loss of hope and disillusion- ment

7) Logistics of caregiving. It sounds simple but it isn't Someone must get the person fed, dressed, and out for a walk or drive.

8) Grieving. At some point the relationship between the Alzheimer's Disease person and the caregiver ends. Depending on the cause of the separation, the caregiver may experience grieving at death, often with remorse and guilt or may encounter intense loneliness when the patient enters a nursing home, also accompanied by great guilt.

Alzheimer's Disease is a family problem. The biggest burden in the family usually falls to the spouse, often when that person is older, maybe in not so good health. Children play an important role as well — usually female children — ^by relieving or replacing an overwrought or absent caregiver.

But some other important issues must be dealt with as Alzheimer'sDisease progresses. Included here are healthcare, legal and financial decisions.

NCMJ / January 1994, Volume 55, Number 1

29

Healthcare issues are increasingly cost-dependent and cost-driven. Medicare unfortunately is of little to no help with Alzheimer's Disease. Medicare is designed for acute care, but Alzheimer's Disease is a chronic condition. Be- cause of the length of time patients with Alzheimer's Disease tend to live, the disease becomes an incredible economic burden. The answer for the spouse often is to "spend down," to become eligible for Medicaid in order to place the pa- tient— at Medicaid expense — in an appropriate facility, if possible.

One of the hallmarks of medical care — the confidential- ity and inviolability of the doctor-patient relationship — comes into question when the patient's diagnosis is Alzheimer's Disease. Soon the patient will be unable to discuss symptoms and make treatment choices. To whom does the physician turn fcK the needed information and decisions? Often the appropriate response is to the caregiver who has arranged legal transfer of guardianship to himself or herself, including the right to make healthcare decisions for the patient. In this circumstance the caregiver can also make other legal decisions: to sell a house or stock, for example. The legal activities must be done early enough, while the patient is still capable of agreeing with them.

Another healthcare fact to be confronted is the right to die or not to continue to live if a threatening illness befalls the

patient with Alzheimer's Disease. North Carolina has a right to a natural death law, and living wills are legal. It is up to the person and caregiver to be certain the physician and all others involved in the patient's care are aware of — and concur with — their feelings on the question of prolonging dying.

Another legal issue is a will. While the person's will must be updated and legally signed during his or her relative health, the caregiver's will must not be forgotten. If the caregiver dies, little should be left to the person who cannot enjoy the gifts and whose eUgibility for federal assistance might be delayed or jeopardized if there were a sudden financial windfall. Estate and inheritance taxes can be minimized with good legal and financial advice.

For specific legal and financial and other assistance, the best possible source of information is a support group. Comprised of others who know firsthand the frustrations and complexities of caring for someone with Alzheimer's Dis- ease, support groups are immensely helpful to the caregiver. Members will know of available respite caregivers, of the best nursing homes, of the federal assistance plans that work and are accessible. Most importantly, they can empathize — they've been there or they are there.

ADRDA, the Alzheimer's Disease and Related Disor- ders Association, has a toll-free number: (800) 621-0379. Call them for more information and local help. Q

Glossary of Terms

Dementia

This is not a disease in itself but a group of symptoms that characterize certain diseases and conditions. The major symptoms involve a decline in intellectual functioning that is severe enough to interfere with routine activities. Alzheimer's Disease is the most common form of dementia.

Senility

This label often was used to describe an individual 65 years or older with dementia Senility used to be considered a normal part of aging. Today, physicians recognize that dementia is not a normal part of aging but the result of a disease such as Alzheimer's Disease.

Senile dementia/pre-senile dementia

Senile dementia is a label that used to apply to patients whose symptoms of dementia appeared after age 65. Pre-senile dementia is a label that used to apply to dementia victims who were younger than age 65. These distinctions have largely been eliminated. Today, most cases of dementia in both groups of patients are diagnosed as Alzheimer's Disease.

Chronic organic brain syndrome

This label is sometimes given to patients with a collection of symptoms such as memory loss, disorienta- tion, confusion, personality changes and inability to carry out normal daily activities. The preferred term for these symptoms is dementia or dementing illness.

Hardening of the arteries

The correct medical term is arteriosclerosis. The dementia symptoms associated with arteriosclerosis result only when multiple cerebral infarcts (strokes) have occurred. This condition is called muW-infarct dementia.

30

NCMT / January 1994, Volume 55, Number 1

YOCON*

YOHIMBINE HCI

Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohlmbine-16a-car- boxylic acid methyl ester. The alkaloid is found in Rubaceae and related trees. Also in RauwoKia 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 mydriatnc. It 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 tor 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 shoukl 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))iockade. These include, anti-diuresis, a general picture of central excitation includirig 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 dmg.^2 Also dizziness, headache, skin flushing reported when used orally. 13 Dosage and Administration: Experimental dosage reported in treatment of erectile impotence. ' ■3'' 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 'A tablet 3 times a day, followed by gradual increases to 1 tablet 3 times a day. Reported therapy not more than 1 0 weeks . 3 How siippiied: Oral tablets of Yocon« 1/12 gr. 5.4 mg in bottles of 100's NDC 53159-001-01 and 1000's NDC 53159-001-10. References:

1. A. Morales et al.. New England Journal of fWedi- 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.,TheJoumal of Urology 128: 45-47, 1982.

Rev. 1/85

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THE SPECTRUM OF DISEASE

Celiac Sprue

Diagnosis and Diet: Keys to Recovery

Stephen M. Schutz, M.D.; J. Stroebel, M.D.; E.M. Schutz, R.D.,^ L. Leaseburge, R.D.,^ and J. Baillie, M.B. Ch.B.'

Our Division of Gastroenterology recently hosted the first meeting of a new chapter of the American Celiac Society. Patients with celiac sprue (CS) from the Triangle area (and beyond) met to share their ex- periences and to discuss their disease. A recurrent theme these patients raised was the feeling that they were "on their own" once the diagnosis of CS was made. In- deed, several participants reported that they had had to see a number of doctors before the diagnosis was established. And even after that they got little information about the special diet and other treat- ments available to help them. It struck us that a review of this disorder would be timely and would raise the level of aware- ness of health professionals in North Caro- lina regarding this debilitating, but clearly treatable disorder.

CS is a relatively uncommon but nevertheless important diseaseof interest to gastroenterologists and all physicians. Also called celiac disease, gluten-sensi- tive enteropathy, idiopathic steatorrhea, non-tropical sprue, and "celiac passion," it was for many years thought to be a disease of children until clinicians real- ized that a variety of adult disorders actu- ally represented manifestations of celiac sprue, and the long list of names was shortened. "

From the 'Department of Internal Medi- cine, Division of Gastroenterology, and the ^Department of Nutritional Medicine, Duke University Medical Center, Durham 27710. "Gluten-free" symbol in back- ground used courtesy of Glaxo Corp. ©Gower Medical Publishing Ltd.

CS causes significant morbidity and even death if not recognized and treated. A high level of clinical suspicion is usu- ally necessary to make the diagnosis. Fortunately, diagnosis is worthwhile be- cause CS usually responds well to treat- ment. There are four essential features of the disorder:

1) It is activated by ingestion of gluten, a protein found in wheat and other grains.

2) There is a characteristic, but non-spe- cific, histological lesion of small bowel mucosa.

3) There is malabsorption of nutrients across the damaged mucosa.

4) There is prompt clinical improvement following withdrawal of gluten from the diet.

History

In 1888 Samuel Gee published a land- mark paper describing "the coeliac af- fliction" in children suffering from wast- ing, pallor, weakness, growth retarda- tion, and a "doughy" abdomen. Gee noted an association with certain foods such as rice, com flour, and other starches. He concluded, "If the patient can be cured at all it must be by means of diet." In 1932 Thaysen first described the condition in adults.

In 1953 Dicke' reported on the inci- dence of CS in the Netherlands before and during World War II. During the war, when grain products were in short sup- ply, there was a decreased incidence of CS, and previously diagnosed patients

reported improvement in their symptoms. After the war, the incidence returned to pre-war levels. Dicke suggested that ce- real grains somehow harmed patients with CS. Subsequently, van de Kamer, Dicke, and others showed that the wheat protein gluten caused the small bowel mucosal damage in CS.

Epidemiology

Celiac sprue is found worldwide, but is most common in Caucasians, particu- larly northern Europeans.^ The preva- lence in Europe is 5 to 20 per 10,000 population; in western Ireland it is 33/ 10,000; in the United States it is less 5/ 10,000. The disorder is unusual in those of African and Asian descent. There is a slight excess of incidence in females.

Pathogenesis

The essential element of CS is injury of the small bowel mucosa by exposure to gluten. Gluten is a water-insoluble, high molecular weight protein found in wheat, rye, barley, and oats. There are two com- ponents of gluten, glutenin and gliadin. Glutenin is not toxic , but gliadin is. It has four subtypes, all of which damage small bowel mucosa in vitro.

The mechanism of gluten toxicity is unknown, and attempts to study the mechanism are hampered by the lack of an animal model. Circumstantial evidence suggests that the mucosal injury isimmu-

32

NCMJ / January 1994, Volume 55 Number 1

nologically mediated. Large numbers of immunologically active cells infiltrate the small bowel mucosa in active CS, and there is an increased local production of antigliadin antibodies in the mucosa after exposure to gliadin.

Genetic factors may also be involved. Susceptibility to CS is closely associated with certain major histocompatibility antigens, notably HLA-B8, DR-3, and DQ-W2. One or more of these HLA sub- types is present in 60% to 90% of CS patients compared with less than 20% of controls.

Early investigators postulated that a mucosal enzyme deficiency resulted in an accumulation of toxic gluten metabo- lites. In fact, patients with untreated CS do have multiple mucosal enzyme defi- ciencies but these are secondary to glu- ten-induced mucosal injury and resolve as the mucosa recovers with treatment. They are not thought to be involved in the pathogenesis of the disease.

The "viral trigger" theory is a rela- tively new concept advanced by Kagnoff and coworkers,^ who discovered that a subtype of human adenovirus shares a sequence of 12 amino acids with alpha- gliadin. These authors found that 89% of Uieir celiac patients had serologic evi- dence of prior infection with this particu- lar adenovirus compared to 17% of con- trols. They suggested that infection with the virus sensitizes genetically predis- posed individuals to produce antibodies against gliadin antigens resembling those on the virus coat. According to this theory, the immune response that follows expo- sure to gliadin antigens then causes the small bowel mucosal injury.

Pathology

Celiac sprue is basically a mucosal le- sion. The degree of mucosal involvement varies widely, generally corresponding with the level of symptoms. Except in severe cases, the small bowel is more involved proximally than distally. This explains why vitamin B12 and bile salts are absorbed normally (in the distal small bowel) until relatively late in the disease. CS often has a patchy distribution.

Figure 1: Left — Crosby capsule intestinal biopsy device. Right — Abdominal x-ray showing Crosby capsule in position in the small bowel near the ligament of Treitz. (Courtesy of Glaxo Corporation, Research Triangle Park. Used with permission.)

with some areas of the small bowel rela- tively spared, so it is important to select biopsy sites with care. In the past, biop- sies were taken distal to the duodeno- jejunal junction using a suction biopsy device such as the Crosby capsule (Fig- ure 1). The devices were swallowed and carried by peristalsis beyond the liga- ment of Treitz, where they were "fired." Capsule biopsy devices are seldom used today because the technique is time con- suming, uncomfortable for the patient, requires fluoroscopy, and has a 5% to 10% failure rate. They have been re- placed by flexible endoscopy, which is simple, safe, rapid, and allows direct ex- amination of the bowel wall and precise selection of the biopsy site with virtually 100% success." This is now the preferred technique, especially since multiple bi- opsies can be taken from various loca- tions in the duodenum, increasing the diagnostic yield.

The histologic diagnosis of CS de- pends on four findings: 1) villus shorten- ing, 2) crypt hyperplasia, 3) transforma- tion of the normal columnar lining cells of the mucosa, and 4) infiltration of the lamina propria with large numbers of inflammatory cells. The villi are short or even flat in CS , but the actual thickness of the mucosa is unchanged because the crypts are hypertrophied and elongated.

Normally the crypt: villus ratio is approxi- mately 2:5; in severe CS it can approach 10:1. The columnar absorptive cells that normally line the small bowel lose their characteristic shape and become cuboi- dal or even squamous in appearance. Usually there is a significant increase in the number of inflammatory cells (lym- phocytes, plasma cells, eosinophils, and mast cells) in the mucosa.^

Clinical Features

Celiac sprue is well described in adults, but it remains primarily a disease of chil- dren. There is an early peak of incidence during infancy when cereals are first in- troduced into the diet. Curiously, the clini- cal manifestations frequently remit dur- ing adolescence. They sometimes return in adulthood, usually during the third and fourth decades of life, although carefully documented cases have been reported in patients as old as 84.^

The clinical features of CS are highly variable and non-specific. At one end of the spectrum we find individuals with minimal malabsorption of nutrients who may present with iron deficiency anemia, weakness, or lethargy but no other mani- festations. At the other extreme lie pa- tients with frank steatorrhea, osteo-

NCMJ / January 1994, Volume 55 Number 1

33

malacia, protein deficiency , and profound weightless. Most patients fall somewhere in the middle of the spectrum. The sever- ity of an individual's symptoms depends largely on the severity and extent of mu- cosal damage since the more extensive the mucosal injury, the less the capacity for absorbing essential nutrients.

Many patients first become symp- tomatic as adults. This may represent primary CS or the unmasking of "latent" disease. By "latent" we refer to asymp- tomatic sprue, which becomes apparent only after a clinical "challenge." Thus sprue may appear in adults in response to an abrupt increase in the rate of delivery of gluten to the small bowel, such as after peptic ulcer surgery that increases the rate of gastric emptying, or after changes in diet One remarkable case involved a member of the U.S . military sent to Saudi Arabia during Operation Desert Storm in 1 99 1 . This man developed severe malab- sorption shortly after arriving in the desert and had to be sent back to the U.S . Duode- nal biopsy was consistent with CS, and his symptoms resolved with a gluten-free diet. The ubiquitous military "meals- ready-to-eat" (MRE) contain unusually high levels of gluten.

Gastrointestinal Manifestations

Table 1 shows the clinical features of celiac sprue. Diarrhea is the most com- mon symptom.^ It can have several causes, all related to the underlying intestinal malabsorption that results in a markedly increased delivery of fluid and osmoti- cally active substances to the colon. Fluid

Table 1. Clinical features of celiac sprue

Children

Adults

Poor growth

Diarrhea

Diarrhea

Anemia

Irritability

Weight loss

Delayed dentition

Hypoproteinemia

Muscle wasting

Nutritional deficiencies

Protuberant abdomen

Bone pain

Tetany

Night blindness

delivery is increased because injured small bowel mucosa secretes water and elec- trolytes into the intestinal lumen; when the distal small bowel is involved, the malabsorption of bile salts traps free wa- ter in the colon. Chronic diarrhea in turn causes dehydration, electrolyte abnor- malities, and protein and fat malabsorp- tion with their own complications. Weight loss, sometimes profound, is common and, as nutritional compromise contin- ues, there are frequent complaints of weakness. Flatus due to fermentation of unabsorbed carbohydrates can be a sig- nificant problem,^ but patients are often embarrassed to volunteer this informa- tion, which should be requested.

Other Manifestations

Anemia can be an important feature, even the first sign of the disease, especially in the elderly. Iron and folate deficiencies are well described in CS, but vitamin B 12 deficiency israre. Iron deficiency anemia in the absence of blood loss or folate deficiency in a patient without the usual risk factors should both raise the possibil- ity of occult CS.

Malabsorption of vitamin K can cause coagulopathy with prolonged pro- thrombin time. An elevated platelelcount can result from the impaired spleen func- tion (hyposplenism) characteristic of ad- vanced CS.' Osteopenia, due to inad- equate calcium and vitamin D absorp- tion, predisposes to compression frac- tures and pain. Hypomagnesemia and hypocalcemia may be severe enough to cause tetany, muscle cramps, and ileus. Neurologic abnormalities such as ataxia, weakness, and paresthesias have been associated with CS , but their cause remains a mystery. They are not related to vitamin B 12 deficiency and usually revert after institution of a gluten-free diet. Follicular hyperkera- tosis can be an early manifestation of vita- min A deficiency that

can even result in night blindness if un- treated.

There is a very close association between CS and dermatitis herpetiformis, an intensely pruritic, chronic papuloves- icular eruption symmetrically distributed on extensor surfaces such as elbows, knees, and buttocks. More than 90% of patients with dermatitis herpetiformis have changes in the small bowel mucosa identical to those seen with CS, even when they have no sprue-like symptoms.' Like CS, dermatitis herpetiformis is as- sociated with histocompatibility antigens HLA B8 and DR 3, but most patients with CS do not develop dermatitis herpeti- formis.

Laboratory Assessment

Laboratory abnormalities, like physical findings, tend to reflect the degree of intestinal malabsorption (Table 2). Antigliadin antibodies are present in the serum of more than 90% of patients with CS, but the presence of these antibodies is not a good diagnostic test for CS be- cause they can be found in other disorders that affect the small bowel mucosa, such as Crohn's disease. Radiographic studies of the small bowel may be normal, even in severe CS, or they may demonstrate dilation of the intestinal lumen, a rapid transit time through the bowel, or oblit- eration of mucosal folds. "Flocculation" of barium in small bowel loops, once regarded as pathognomonic of CS, is rarely seen with modem contrast media.

The "gold standard" for diagnosis of CS is small bowel biopsy. The histologi- cal appearance on biopsy and the absorp- tion of ingested D-xylose are normal in many of the diseases that may mimic CS by causing intraluminal maldigestion and malabsorption (e.g., pancreatic insuffi- ciency, chronic liver disease, bacterial overgrowth). Abdominal CT scan, endo- scopic retrograde cholangiopancreato- graphy (FRCP), liver biopsy, or dynamic tests of bacterial metabolism are usually needed to confirm other diagnoses.

Diseases that do alter small bowel mucosa and cause malabsorption include tropical sprue, lymphoma, Whipple'sdis-

34

NCMJ / January 1994, Volume 55 Number 1

Table 2. Common laboratory abnormalities of CS

Abnormality Cause

Anemia Iron, folate deficiency Prolonged prothrombin time Malabsorption of vitamin Increased platelet count Hyposplenism Hypocalcemia Malabsorption of vitamin

K D

Table 3. Basic principles of a gluten-free diet

• Eliminate wheat, rye, oats, and barley.

• Use rice, buckwheat, potato, corn, or soybean flours.

• Choose fresh milk products, meat, fish, and poultry.

• Avoid processed foods; read labels carefully.

• Speak with the chef or cook when dining out.

• Avoid fast food restaurants.

ease, hypogammaglobulinemia, and eosi- nophilic gastroenteritis. These disorders cannot always be distinguished from CS histologically, but they can usually be differentiated by history, physical exam, and lack of response lo a gluten-free diet.

Treatment

Patients with severe CS-related compli- cations— dehydration, electrolyte abnor- malities, vitamin deficiencies — must have these problems addressed as a first step. This is particularly important when ane- mia, osteomalacia, or tetany are present. Thereafter, one should move quickly to address the underlying problem of gluten intolerance.

As Samuel Gee predicted, the main- stay of treauiient is a special, gluten-free diet (Table 3). Foods that contain wheat, barley, rye, and oats should be strictly avoided, which can be a challenge to patients. In addition to being a basic in- gredient in breads, cereals, and pastas, gluten may be present as an additive in other, ostensibly non-gluten-containing foods such as pudding, ice cream, and ketchup. To make matters even more difficult, pharmaceutical manufacturers

often use gluten asanexcipientor filler in capsules ortablets. Adher- ing to the diet is difficult, but nec- essary because the most com- mon cause of symptom relapse is dietary non- compliance. Newly diagnosed patients with CS should review their diet with a dietitian at least twice a year early in their course. Many patients find membership in the American Celiac Society (ACS) or simi- lar support groups to be quite helpful in maintaining compliance.

Most patients improve within two to three weeks of beginning a gluten-free diet, but some take longer. It is important to follow patients closely and monitor their progress. In general, if patients have not responded by four to six weeks after gluten withdrawal, a trial of glucocorti- coids is appropriate. Only 5% of patients are refractory to dietary treatment, and they generally respond to glucocorti- coids.' The rare patients who fail to re- spond even to glucocorticoids may ben- efit from immunosuppressive drugs such as Imuran, Cytoxan, or cyclosporine.'

Complications

Patients with CS appear to have an in- creased risk of developing a malignancy, perhaps as high as 11% to 13% over a lifetime.'" CS-related malignancies usu- ally occur in older patients who have had CS for many years. The most common malignancy is small bowel lymphoma (in one series of 235 patients with CS and a malignancy, approximately 50% had lym-

phoma"), but other tumors include small bowel adenocarcinoma and squamous cell carcinoma of the esophagus. It is still not clear whether a gluten-free diet alters the risk of malignancy, but at least one study suggests that it does,'^ and this is one more reason to encourage patients to pay close attention to what they eat.

A search for malignancy should be undertaken only if there is cause for sus- picion. For example, patients who have done well for long periods on a gluten- free diet should be investigated if they begin to experience symptoms again. So should patients who fail initial dietary treatment and continue to lose weight or otherwise do poorly. There is no indica- tion for routine screening of CS patients for malignancy.

An unusual but potentially devastat- ing complication of CS is ulcerative enteritis. The resultant ulcers and stric- tures of the small bowel can result in perforation or obstruction, which often require surgery with a high mortality risk — up to 75% in the case of perfora- tion. Ulcerative enteritis is the leading cause of premature death in young pa- tients with CS.

Summary

Celiac sprue is a devastating disease that can have fatal consequences if untreated. Fortunately, if diagnosed correctly and promptly, it can be effectively treated with very satisfactory outcomes. A care- ful history will often suggest the diagno- sis, but definitive diagnosis requires find- ing the typical lesion on small bowel biopsy and clinical improvement with a gluten-free diet If symptoms and mu- cosal abnormalities persist, glucocorti- coids should be tried. Malignancy is a rarecomplicationoflongstandingCSthat should be looked for if there is no re- sponse to gluten withdrawal or if symp- toms relapse despite adherence to diet. □

References

1 Dicke WK, Weijers HA, van de Kamer JH. Coeliac disease: II. The presence in wheat of a factor having a deleterious

effect in cases of coeliac disease. Acta Paediatr 1953;42:34-40. 2 Cooke WT, Holmes GKT. Coeliac Dis-

ease. Edinburgh: Churchill Livingstone, 1984. 3 KagnoffMF, Austin RK, Hubert JJ.etal.

}^CM} / January J 994. Volume 55 Number 1

35

Evidence for the role of a human intestinal adenovirus in the pathogenesis of ceUac disease. Gut 1987;28:995-1001.

4 Jabbari M, Wild G, Goresky CA, et al. Scalloped valvulae conniventes: an endoscopic marker of celiac sprue. Gastroenterol- ogy 1988;95:1518-22.

5 Marsh MN, Hinde J. Inflammatory component of celiac sprue mucosa: I. Mast cells, basophils and eosinophils. Gastroenterol- ogy 1985;89:92-101.

6 O'Grady JG, Stevens FM, Harding B, et al. Hyposplenism and gluten-sensitive enteropathy: natural history, incidence, and rela- tionship to diet and small bowel morphology. Gastroenterology 1984;87:1326-30.

7 Katz SI, Hall RP, Lawley TI, Stober W. Dermatitis herpetiformis: the skin and the gut. Ann Intern Med 1980;93:857-74.

8 Wall A, Douglas A, Booth C, Pearse A. Response of the jejunal mucosa in adult coeliac disease to oral prednisolone. Gutl970;ll:7- 14.

9 Bernstein EF, Whitington PF. Successful treatment of atypical sprue in an infant with cyclosporine. Gastroenterology 1988;95:199-204.

10 Cooper BT, Holmes GKT, Cooke WT. Lymphoma risk in coeliac disease of later life. Digestion 1982;23:89-92.

1 1 Swinson CM, Slavin G, Coles EC, Booth CC. Coeliac disease and malignancy. Lancet 1983;1:111-5.

12 Holmes GKT, Prior P, Lane MR, et al. Malignancy in coeliac disease— effect of a gluten-free diet. Gut 1989;30:333-8.

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NCMJ / January 1994, Volume 55 Number 1

SCREENING FOR DISEASE

Screening for Lung Cancer

It Doesn't Make a Difference

Jeffrey G. Wong, M.D., and John R. Feussner, M.D.

"Mr. Jones is a 57-year-old man who has worked in the textile mills most of his life, Up until

three years ago, he smoked one to two packs of cigarettes per day and had since his

late teens. He quit because it seemed he hod 'pneumonia all the time' and he was tired

of coughing and being short of breath. He gained 20 pounds following smoking cessation,

and he has mild hypertension, controlled well with medication. He has come in for his

annual check-up and inquires about a chest x-ray to screen him for lung cancer."

Should we order a chest x-ray for Mr. Jones? In the first article in this series on health care screening of asymptomatic patients by primary care practitioners (NC Med J 1993;54:218-21) we addressed general considerations for deciding whether and how to screen asymptomatic patients for disease. In this article we formulate a recommendation for Mr. Jones, by applying the six guidelines pro- vided in our first article to his question. We review each guideline in order to arrive at a reasonable therapeutic plan.

Target Disease Considerations

1. Is the disease common or serious enough to warrant screening? Yes. Lung cancer is the most common causeof cancer-related death in thiscoun- try. In 1993, there were 170,000 new cases of lung cancer and 49,000 deaths.' Although mortality from lung cancer is great in men, there has been an alarming increase in the incidence and mortality rate of lung cancer in women — more women now die from lung cancer than

from breast cancer.' The incidence rates for lung cancer increase with age begin- ning at age 40 and peak at about age 70 to 75. Patients who die from lung cancer lose, on average, 15 years of life.^

2. Is there a presymptomatic phase in the natural history of the disease during which time a test can detect it?

Possibly yes, but. . . Lung cancer can be detected at an early stage by plain chest radiograms or other radiological tests (computerized tomography scans, mag- netic resonance imaging scans). Cyto- logical investigation of sputum can de- tect occult lung cancer — cancer that is not seen radiographically. Practically speaking, however, the discovery of "si- lent" lung cancer by any method is usu- ally serendipitous, occurring during the investigation of a patient's non-specific complaints (cough, fatigue, weight loss, etc.). In addition, the poor accuracy of all tests (see section on test characteristics) adversely affects this screening criterion.

3. Are there effective treatments for the disease available to use after early de- tection?

In few instances, yes. For therapeutic reasons, lung cancer is grouped into two categories: small cell lung cancer (for- merly called oat-cell), and non-small cell lung cancer (squamous cell carcinoma, adenocarcinoma, large cell carcinoma, and anaplastic carcinoma). Establishing the histological cell type is important in selecting appropriate treatment, but de- tecting the cancer at a limited stage is critical for survival.

Advanced stage non-small cell can- cer (Stage 111 or IV) has a dismal progno- sis. Overall, less than 13% of all non- small cell lung cancer patients survive more than the five years.' However, pa- tients with very limited stage non-small cell lung cancer (Stage I — small tumor, no regional lymph node involvement), may have five-year survival rates as high as 70% following surgical resection." Surgical resection of Stage II disease (small tumor with localized peribronchial or ipsilateral lymph nodes only) gives only modest improvement over baseline survival.' Nevertheless, surgery is the ow/y u^eaunent that produces any improve- ment in mortality for limited non-small cell lung cancer. The presence of occult

From the Division of General internal Medicine, Box 3375, Duke University Medical Center, Durham 27710.

NCMJ / January 1994, Volume 55 Number 1 37

metastases in apparently "limited" dis- ease accounts for lack of complete cure. Radiation therapy and cytotoxic chemo- therapy have httle effect on survival re- gardless of chnical stage and are consid- ered palliative therapies.

Small cell lung cancer represents about 20% to 25% of all cases of lung cancer. It has a very poor prognosis. Un- treated, patients with small cell lung can- cer live on average less than nine months. Almost all have extrathoracic metastases (Stage IV disease) at presentation al- though the degree of tumor burden varies from patient to patient. In most instances, there is an initial favorable response to treatment with cytotoxic chemotherapy or radiation therapy or both. Following remission, the cancer usually relapses and even in the best cases, the two-year survival rate following treatment is less than 25%.^

Screening Test Considerations

/. Are there screening tests with accept- able sensitivity and specificity available to detect the target disease?

Probably not. Clinicians use two main strategies to screen for lung cancer: the plain chest radiograph and cytological evaluation of sputum. With both there are significant problems in performance of the test and in interpretation of the re- sults. These problems undermine the over- all accuracy and diminish the usefulness of the tests.

The screening chest radiograph has three main problems in detecting lung cancer. First, important performance vari- ables, including the amount of exposure, radiographic technique, patient position, and cooperation must be controlled in order to get a "good film." Secondly, once obtained, there are inherent difficul- ties in interpreting the radiograph. A le- sion considered suspicious for cancer by one radiologist may not be so interpreted by another — in fact, significant disagree- ment occurs often.' Thirdly, even lesions that, by consensus, have a radiographic appearance of lung cancer can never be diagnosed with certainty without the "gold

standard" of tissue biopsy.

Similarly, the use of sputum cytol- ogy is limited by difficulties of obtaining adequate sputum samples to study, the problems of cytopathological interpreta- tion, and the ultimate need for "gold standard" comparison between cytology and tissue pathology.

Acknowledging the inherent prob- lems, it is clear that determining sensitiv- ity and specificity of screening tests for lung cancer is very difficult. Mathemati- cal models give an estimated sensitivity of chest x-ray in discovering Stage I tu- mors at around 16%.^ Values for speci- ficity have not even been estimated.

Few studies have looked at the effec- tiveness of these tests in screening aver- age risk populations; randomized trials have targeted high-risk populations for their study cohorts. Case control studies in Germany' and Japan' utilized patients in tuberculosis screening programs. There was no reduction of mortality in the case population in the German study; the Japa- nese study did show a trend for improved survival in the screened population at one year of follow-up (p = 0.07).

In 1971, randomized studies per- formed under the auspices of the Na- tional Cancer Institute were initiated at Johns Hopkins Hospital,'" at Memorial Sloan-Kettering Hospital," and at the Mayo Clinic.'^ All three trials studied middle-aged to older male smokers.

At Memorial Sloan-Kettering, the study subjects (n=10,000) were random- ized into a screened population who had yearly chest x-rays and sputum cytology every four months and a "control group" who only had yearly chest x-rays. The trial at Johns Hopkins was identically designed and had a total of 10,400 par- ticipants. In both of these trials, the vol- unteers were followed for six years and there were no differences in the survival rates between the screened and control populations.

The Mayo CUnic trial had a different design but similar results. Volunteers (n= 10,900) all had an initial chest radio- graph and sputum cytological evalua- tion. All subjects who did not have cancer and were otherwise suitable were then randomized into a screened population

that received chest radiographs and spu- tum cytological tests every four months for six years or into a control population whose members were advised at the be- ginning of the study to get yearly chest x- rays and sputum cytological tests, but this advice was not repeated. About 50% of the control group got chest x-rays. More cancers were discovered in the screened group; there were more deaths due to cancer in the screened population; and there was no significant difference in mortality rates between the two groups.

In Czechoslovakia," 6,364 male smokers were initially evaluated with chest radiographs and sputum cytology and those with cancer (n=19) were ex- cluded from the analysis. The remaining 6,345 subjects were randomized into screened and control groups. The screened group received chest x-rays and sputum cytology every six months for three years; the control group received no studies unless they developed symptoms. Can- cers discovered during the three-year du- ration of the study were labeled "screen- detected" cases. After three years, both groups received yearly chest radiographs, and any cancers discovered during this time were labeled "interval" cases. More lung cancers were diagnosed in the screened group. "Screen-detected" cases had a five-year survival rate of 25% com- pared to the corresponding "interval" case five-year survival rate of 8.2% (p<0.00 1 ). However, during the entire study period, there was no differences in survival rates. Screening detected cancers earlier and before symptoms appeared, but this did not improve survival (lead-time bias).

In summary, several trials have dem- onstrated that intensive screening (chest x-ray every four to six months) is no better than occasional or annual screen- ing and that sputum cytological evalua- tion adds no screening benefit. Some experts believe that asymptomatic, high- risk individuals should be screened,'* but the available data do not support this position.

2. Can an appropriate population of high-risk patients be identified to un- dergo screening?

Yes. A number of risk factors for lung

38

NCMJ / January 1994, Volume 55 Number 1

cancer have been identified but none are more important than cigarette smoking. The risk of lung cancer dramatically in- creases with the number of cigarettes and the number of years smoked.'' The risk of lung cancer is higher in men than in women but that difference is narrowing, probably due to the increased amount of smoking by women. Several occupational and environmental factors also increase lung cancer risk: asbestos,'* radon gas (found in mines), and several environ- mental agents (chromate, nickel, polyhydrocarbons, and alkylating com- pounds)."

3. Do the benefits of screening justify the costs of the screening strategy?

Probably not. Since we have no estimates

of screening test sensitivity and specific- ity, any cost-benefitanalysis isextremely difficult. There certainly arc no data to support the screening of populations at average risk, and the studies performed in high-risk populations have shown no improvement in mortality rates with screening. Since the benefits of screening are so few (if any), the costs (for evalua- tion of false-positive tests) associated with overdiagnosis in the high-risk popula- tions take on greater importance in policy decisions."

Recommendations

Virtually all organizations (American Cancer Society, National Cancer Insti-

tute, U.S . Prevent! ve Services Task Force, American College of Physicians, and the Canadian Task Force) concur that screen- ing for lung cancer is not justified. These conclusions are based on available evi- dence demonstrating that there is no ben- efit for screening. It appears that our ability to detect lung cancer, whether symptomatic or asymptomatic, does not appreciably change the natural history of the disease. Not surprisingly , experts have focused on preventing lung cancer occur- rence by altering the greatest risk factor in our society, cigarette smoking. We would recommend that Mr. Jones not smoke, but not recommend that he get a chest x-ray. Q

Next in our series on screening strategies for disease, we will discuss the following:

Mr. Jones has listened to your explanation about the lack of benefit of a chest x-ray for him. He states that he will continue to abstain from cigarettes and is interested in improving his overall health. He is worried that his uncle, also a cigarette smoker, died of "mouth cancer." Mr. Jones wonders if there are any tests that can assure him that he isn ' t developing mouth cancer.

What should we tell him?

References

1 Boring CC, Squires TS.TongT. Cancer statistics, 1993. CA Cancer J Clin 1993;43:7-19.

2 HormJW.SondikEJ. Person-years of life lost due to cancer in the United States, 1970 and 1984. Am J Public Health 1989;79:1490-3.

3 American Cancer Society. Cancer statis- tics, 1989;39:3-20.

4 Flehinger B J, Kimmel M, Melamed MR. The effect of surgical treatment on the survival from early lung cancer: implica- tions for screening. Chest 1992; 10 1:101 3- 8.

5 Ihde DC. Approaches to the management of lung cancers. In: Kelley WM, ed. Text- book of Internal Medicine. Phildelphia: JP Lippincott Company. 1989:1244-50.

6 Herman PG,GersonDE,HesselSJ,etal. Disagreements in chest roentgen inter- pretation. Chest 1975;68:278-82.

7 Flehinger BJ.KLmmelM. Natural history of adenocarcinoma-large cell carcinoma of lung: conclusions from screening pro-

grams in New York and B altimore. J Natl Cancer Inst 1988;80:337-44.

8 Ebeling K, Nischan P. Screening for lung cancer: results from a case-control study. Int J Cancer 1987;40:141-4.

9 Sobue T, Suzuki T, Naruke T, and the Japanese Lung-Cancer Screening Re- search Group. A case-control study for evaluating lung-cancer screening in Ja- pan. Int J Cancer 1992;50:230-7.

10 TockmanMS.Survivalandmortalityfrom lung cancer in a screened population: the Johns Hopkins study. Chest 1986; 89:324S-325S.

11 Melemed MR, Flehinger B J, Zaman MB, at al. Screening for early lung cancer: results of the Memorial Sloan -Kettering study in New York. Chest 1984;86:44- 53.

12 Fontana RS, Sanderson DR,WoolnerLS, et al. Screening for lung cancer: a critique of the Mayo Lung Project. Cancer 1991;67:1155-64.

13 Kubik A, Parkin DM, KhlatM.etal. Lack

of benefit from semi-annual screening for cancer of the lung: follow-up report of a randomized controlled trial on a popula- tion of high-risk males in Czechoslova- kia. Int J Cancer 1990;45:26-33.

14 Flehinger B J, Kimmel, M, Melemed MR. The effect of surgical treatment on sur- vival from early limg cancer. Implica- tions for screening. Chest 1992;101 : 1013- 8.

15 The Surgeon General's 1989 report on reducing the health consequences of smok- ing: 25 years of progress. MM WR 1989;38 (suppl2):l-32.

16 Hammond EC, Selikoff IJ, Seidman H. Asbestos exposure, cigarette smoking and death rates. Arm NY Acad Sci 1979; 330:473-90.

17 RoscoeRJ, SteenlandK, Halperin WE, et al. Lung cancer mortality among non- smoking uranium miners exposed to ra- don daughters. JAMA 1989;262:629-33.

18 Eddy DM. Screening for lung cancer. Aim Intern Med 1989;111:232-7.

NCMJ / January 1994, Volume 55 Number 1

39

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COMMENTARY

Doctors vs. Lawyers

A Robert Burns Analysis

Erie E. Peacock, Jr., M.D., J.D.

"Oh wad some power the giftie gie us

To see oursels as others see us!

It wad frae monie a blunder free us,

An' foolish notion."

—Robert Burns, To a Louse (1 786), st. 8

I am a life member of the North Carolina Medical Society. I recently read for the second timeTracy Lischer'spresentation intheNorthCarolinaMedicalJournalof what she perceives to be mydis that di- vide the medical and legal professions.' The editor tells me he hoped that publica- tion of Ms. Lischer's ideas would be the beginning of a better understanding be- tween doctors and lawyers. That hope may or may not have been realized de- pending on one's point of view or defini- tion of "understanding." The reaction of most physicians was, I suspect, the same as my own and that of the several corre- spondents whose letters the Journal sub- sequently published, namely, that all we really achieved was a better understand- ing of the worst kind of misunderstand- ing. The nature of the misunderstanding became more clear in Ms. Lischer's re- sponse^ to the correspondents' letters than it was in the original article, although there it was clear enough.

I am also a member of the North Carolina Bar Association and a practic- ing attorney in the field of malpractice defense. On the same day that I reviewed Ms. Lischer's article and letters to the editor, I experienced an equally clear demonstration of why attorneys see phy-

sicians as arrogant and unapproachable. I had detected what appeared to be an error in the report of an autopsy performed by the State Medical Examiner's office. I called the prosector at home and asked if I could see him to discuss my finding. He instructed me to call his office the next day because he did not know his sched- ule. The next day I went directly to the Medical Examiner's office because, in any case, I wanted to examine the records. I encountered the pathologist in the hall and introduced myself. The introduction was followed by an expression of dis- pleasure that I had not called before mak- ing an appearance; he then announced that if I wanted to talk to him, it would cost me $ 1 50 an hour. Instead I examined the records alone, then asked to speak to the Associate Medical Examiner. His re- ceptionist relayed to me the message that 1 could only speak with the good doctor by appointment and that he also charged $150 an hour, even to speak to another physician.

Several days later, I discussed the matter with the Chief Medical Examiner who went over the case with me, an- swered my questions, and excused his subordinates' actions by saying that they must not have understood my request. I

agree that they did not understand what I wanted — but apparently they did not un- derstand because they simply would not listen.

Attorneys tend to generalize about physicians in the same way that physi- cians generalize about lawyers. Lawyers feel that doctors often are arrogant, some- times pompous, and much of the time simply won't listen! Even though I know better, my reaction to a State employee in a State office about a public document generated by a member of a medical specialty customarily having the last word, led me — at least at first — to characterize my medical colleagues the same way my attorney colleagues categorize them. In one day, I saw, I heard, and I experienced all I needed to realize that the division between lawyers and doctors is real and that feelings run deep on both sides.

Points to Ponder

I agree that clarifying positions is an important first step to understanding, even when it means we must clearly illuminate the worst problems causing division. Because of my many years as a physician and now as an attorney in a firm special-

From Patterson, Dilthey, Clay & Bryson, Suite 550, 4020 WestChase Blvd., Raleigh 27607.

NCMJ / January 1994, Volume 55 Number 1 41

izing in defense of health care providers, I have access to various points of view and some first-hand observations that may help analyze the reasons for the gulf be- tween the two professions. In fact, my dual careers have given me a more fer- vent desire to reduce misunderstanding and promote cooperative effort between lawyers and doctors than most members of the professions. I am pleased, there- fore, to offer comments that I presented to the Durham-Orange County Medical Society at its October 1993 meeting:

1. Do doctors and lawyers appre- ciate the division between them equally? My answer is no! In my experi- ence, most lawyers do not despise doc- tors in the same way that most physicians distrust, and, in some instances, actually despise attorneys. It is true that lawyers are commonly jealous about the income that physicians enjoy. And I have found lawyers irritated and frustrated by trying to work with physicians, but I have not encountered the universal condemnation of a profession by lawyers that I fre- quently hear from doctors. Basically, there are two reasons for this. Probably the most obvious is that lawyers hold a power over physicians that is not reciprocated. You simply do not feel comfortable when another profession holds power over you, and sometimes exercises that power in a way that seems frivolous or greedy. And, although good lawyers are not guilty of abusing the legal process, some not-so- good lawyers do and they inflict pain and damage to brand the profession in the eyes of victims and their sympathizers.

2. The two professions analyze and solve problems in different ways. Al- though the differences are significant, it is in this area that I believe we have the best opportunity to be achieve better un- derstanding. For instance, we could ask how each profession seeks truth. Through the ages the medical profession has learned to rely on the scientific method and to hold learned authority in high regard or respect. The legal profession, in marked contrast, often has little under- standing of the scientific method and has virtually no respect for authority. Law-

yers search for truth through analytic and synthetic logic; they are trained intensely to find and present truth as a by-product of rational thought and reason. The ulti- mate criterion of truth for physicians is the reproducibility of observations upon testing and use. The ultimate test of truth for lawyers is that a jury is persuaded by presentation of evidence.

There is a vast difference between these two approaches in the search for truth, and some of the division between law and medicine would be reduced if each understood how "truth" is found and presented by the other. Neither is neces- sarily right; neither is necessarily wrong, but there surely are differences in the fundamental intellectual processes by which the two professions proceed.

3. Lawyers and doctors differ be- cause of their respective ignorance about specialized fields of knowledge:

the Rules of Evidence in law and the Calculation of Risk in medicine. I have found that the ignorance of each profes- sion regarding the requirements of the other in these areas is very destructive. Doctors simply do not understand how and why the Rules of Evidence are criti- cal to the legal resolution of disputes, and lawyers seldom understand or appreciate the comparative risks involved in manag- ing human ailments. In my judgment, significant distrust between the two pro- fessions often results from ignorance about these basic principles. Some law- yers seem to live in a world governed by the ethereal specter of the "reasonable, prudent person" who foresees (or ought to have foreseen) every possible conse- quence of every possible action. Doctors cannot and do not live by this standard and they resent being held liable for not doing so. For their part, doctors seem to live as though their world is (or ought to be) above the law, as though the rules for settling disputes that have evolved over centuries from the best legal minds of the English-speaking world simply should not apply to them. Neither of these states of ignorance is helpful and only a more sympathetic understanding by the pro- fessions of how each other works and thinks can begin to improve things.

Why Doctors Need Lawyers

Let us look for a moment at the question of whether there is any real need to reduce the division between the legal and medi- cal professions. If I were asked to give an answer on behalf of the medical profes- sion, I would say emphatically, "Yes!" In fact, that is why I wanted to study law. In my judgment, physicians of the future are going to have to work more closely with lawyers than $ver before. And medical malpractice is only the tip of the iceberg. With every governmental reform in health care delivery, there will be more check- ing (often by lay people) for "quality assurance" (as perceived by lay people). More and more, physicians are going to be working for and at the direction of non-physicians because this previous vio- lation of common law has been strikingly reversed through establishment of HMO statutes, etc. Doctors are not organized and do not have the legal power of collec- tive bargaining that is available to other similarly treated groups. The result, al- ready painfully obvious, can be frank denial of constitutionally protected rights for every American citizen, regardless of occupation.

Even more dangerous, in my opin- ion, is what physicians are doing to each other. An oversupply of physicians, par- ticularly of highly compensated special- ists, has brought about ugly, economi- cally motivated attempts to eliminate competition. Peer review (and the only partially correct perception that peer re- viewers have legal immunity for their actions) provides a method of discourag- ing or eliminating competition, in direct violation of the Clayton and Sherman Anti-Trust Acts. Physicians need more than just help with malpractice defense; they need a different kind of legal help to defend themselves in these new areas.

Of course, doctors will still need help in the malpractice arena. No hope is more misplaced, in my judgment, than the fervent faith that tort reform will solve the abuse of medical malpractice litigation. Significant tort reform is prob- ably not going to happen for a number of reasons, including the fact that compen-

42

NCMJ / January 1994, Volume 55 Number 1

sation caps, the very heart of tort reform, will certainly face state and national con- stitutional challenge. The U.S. Supreme Court has not ruled on this question but nine state courts have been divided in their decisions.' In Idaho, Illinois, Kan- sas, North Dakota, and Texas, compensa- tion caps have been struck down; in Ne- braska, the Supreme Court divided evenly on the issue which let the cap remain in place; in three states, Indiana, Louisiana, and Virginia, caps have been upheld.

There are many other facets of phy- sician-lawyer relations that cry for im- provement. For example, the problem of AIDS has shown that, in some cases, a lawyer can do more for the patient than a doctor can — if the lawyer has coopera- tion from a doctor in doing so. What else can we expect when any procedure or treatment can require legal interpretation and, thus, become a "federal case?"

Another example involves the prob- lems of contract law. Every day, unsus- pecting and relatively naive physicians sign contracts with HMOs, PPOs, insur- ance companies, or hospitals. These con- tracts are drawn up by superb lawyers who protect with zeal the needs of the institutions that hired them. But such contracts are often formed at the expense of, even the outright oppression of, par- ticipating physicians. Doctors simply need to work more closely and more coopera- tively with lawyers, first for the good of our patients, secondly for ourselves, and finally for the good of our country during its coming struggle to provide universal health care without breaking the law or the bank. Q

References

1 Lischer, TK. Doctors, lawyers, and per- sona] injury: separating myth from fact. NC Med J 1993;54:352-4.

2 Lischer, TK. Letter to the editor. NC Med J 1993;54:433.

3 Knidelbaugh WW. Comf>ensa:ion caps for medical malpractice. ACS Bulletin 1993:78:27.

Law and Medicine

Separate Domains, Separate Dominions

Francis A. Neelon, Editor

I have had quite an education from our long and arduous correspondence by and about lawyers and doctors. Readers have called me and we have published a number of letters and responses to letters. Now I would like to comment.

I had no idea what repercussions would follow our naive and innocent publication of an advertisement from a law firm soliciting referrals of individuals who had been injured and sought compensation (NC Med J 1 992;53:21 1 ). We might have anticipated the Vesuvius of indignation and wrath that erupted — but we did not, and the editor's learning curve was expanded as a result. Tracy Lischer, a Durham attorney, read the initial letters and was appalled at the vehemence of doctors' responses; at my request she wrote a little piece reflecting her views on why relationships between doctors and lawyers are so adversarial and acrimonious and why this is bad (NC Med J 1 993;54:352-4). The response to her article was incendiary and, as her letter in this issue (see page 5) confirms, she feels battered and vilified, but not heard. After all, from her perspective she was upholding the American way: the riglit, the legal and constitutional right, of for anyone who has been injured, or who believes himself or herself to have been injured, to seek redress through the courts. Since lawyers honor and serve this constitutionally guaranteed process, should doctors not better understand and appreciate what lawyers do?

Of course, the psychology of this whole business is vastly more complex and less Olympian than that. But lawyers (God help me for saying this) do have points to make, and doctors need to listen to them as Erie Peacock (M.D. and now, after a long and successful career as professor of surgery at the University of North Carolina at Chapel Hill, the University of Arizona, and Tulane University, J.D.) points out in his article adjacent.

I must say that the crux of the seemingly irresolvable antipathy arises from the vastly different world-views of doctors and lawyers. Doctors see themselves as living in a world of pragmatic reality, their job as making decisions based on nebulous probabilities. The doctors' world has nocertitude, only varying degrees of likelihood. And no matter which decision doctor and patient make, if things turn out badly, the same patient (accompanied by a lawyer who was not around when the going got tough) can claim that any other decision would have been a better one — and they can find some doctor, somewhere, to agree. Doctors feel that this is unfair and often, but not always, it is.

Lawyers, on the other hand, live in quite a different world — a thought-world of logical argument, of hypothetical explanations and, eventually, of absolute decisions. When judge and jury finally rule, their decision determines the way things were. One is guilty or not, not 51% guilty and 49% innocent. After the verdict the doctor's shades of gray become the lawyer's black or white. From the doctor's perspective, lawyers live in a virtual reality, a world of how things ought to have been. They hold doctors to a standard of perfection in thought and action that surpasses human capacity and endurance. Lawyers need to get some lived experience in the reality of clinical decisions so that they might appreciate and sympathize with what doctors have known from the beginning: that "experience is treacherous, decision difficult." □

NCMJ / January 1994, Volume 55 Number 1

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MEDICAL EDUCATION

Sowing the Seeds of Primary Care IViedicine

The Early Community Experience in Medical Education

Craig H. Steffee, M.D.

Given our increasingly urgent need for physicians who can provide comprehen- sive primary care, undergraduate medi- cal education must take steps to foster interest in general internal medicine, fam- ily practice, and general pediatrics. One commonly used method is to provide an experience in community medicine, of- ten in the form of a four- week rotation in the final year of medical school — after the student has already made a solid choice of a career path. Occasionally the pri- mary care experience occurs early in medical education (even in the first year), when it can profoundly influence the sub- sequent years of training and encourage a primary care career path in many cases. Early primary care experiences do not, it seems to me, so much recruit future prac- titioners, as they enrich the learning pro- cess for all students; they remind frus- trated preclinical students that the prac- tice of medicine is a patient-centered ac- tivity and they enhance subsequent basic science and clinical learning by provid- ing a context of real clinical experience. Students' selection of clinical spe- cialties is dramatically influenced by their clinical experiences in the chosen disci- pline.'"^ Rabinowitz" and others have documented that more students enter fam- ily medicine residencies if they have had

From the Department of Pathology, Bow- man Gray School of Medicine, Medical Center Boulevard, Winston-Salem 27157.

required experience in family medicine. Cauthen et al^ found a sharp drop (from 36% to 9% of students) in interest in family medicine as a career between the end of the second year and the end of the third year of medical school. They attrib- uted the decline in interest, in part, to a lack of direct exposure to primary care during the third-year curriculum.

Furthermore, some investigators*' have observed a direct relationship be- tween the year in which students under- take their primary care exj)erience and the year in which they finalize their deci- sion to enter primary care. It is character- istic of many medical schools nationwide that first-year students are initially enthu- siastic about primary care, but subse- quently "defect" to subspecialties. This pattern suggests a need to capitaUze on the period of intense interest by provid- ing an early comprehensive care precep- torship.'

Early Clinical Experiences

As a student at the Bowman Gray School of Medicine, 1 enrolled in the problem- based curriculum track (Parallel Curricu- lum). In the spring of my first year I spent eight weeks at the general internal medi- cine practice of Randy Long, M.D., in Lexington, North Carolina. This was not only an opportunity to observe, but also a

daily challenge to apply my nascent his- tory taking, physical examination, and chnical reasoning skills. I interviewed and examined clinic patients and wrote up the history and physical examination findings on those admitted to Lexington Memorial Hospital. In my case this early chnical experience did not deflect me from my prematriculation career choice of pathology, but it did expand my inter- est in comprehensive care issues and pro- vided a foundation for my remaining ba- sic science studies.

Students' humanitarian motives, per- ceptions of medicine as a patient-ori- ented profession, and self confidence in treating patients all decUne during medi- cal school.' Early clinical experiences can help to forestall the cynicism that grows during the process of medical edu- cation. They can also help to preserve in medical students the empathy, optimism, and self-confidence that are such valued attributes of comprehensive primary care providers.

I found it highly motivating, as an aspiring physician, to speak with and examine ill individuals, to participate in the evaluation of the illness, to see treat- ment initialed and to be present for the follow-up visit when symptoms had abated or improved. I did not see such continuity of care in the teaching centers where I and other medical students spend most of our chnical training, yet it is the basis of effective primary care and the

NCMJ / January 1994, Volume 55 Number I

45

source of greatest satisfaction to its prac- titioners.

Direct contact with patients in a phy- sician office environment is crucial to the effectiveness of early primary care expe- riences; lectures about the cognitive as- pects of the discipline, even when given by primary care practitioners, are insuffi- cient alternatives.' Bruhn and Naughton'" found that, whereas clinical case presen- tations are indeed useful to first-year stu- dents, the students themselves viewed such maneuvers as a "frustrating substi- tute" for an actual patient. The authors described a clinically oriented first-year medicine course that consisted of bed- side rounds in small groups (60% of class time) correlated with didactic basic sci- ence sessions. Students judged bedside rounds to be the most effective teaching method in the course, and they responded to their early clinical exposure by show- ing an increased interest in common dis- eases and diagnostic challenges (as op- posed to unusual diseases and therapeu- tic challenges). For students, the benefit of integrating basic science with clinical experience is clear, and the mere expo- sure to patients attracts preclinical stu- dents to study the disease processes that are most frequently encountered in pri- mary care.

I find it disappointing that students, confined to tertiary care centers for the greater part of their cUnical years, see so few cases of the disorders that, in the absence of complications or concomitant illness, are treated in community hospi- tals or as outpatients. To the first- or second-year medical student, meeting a patient who has community-acquired

pneumonia provides exactly the incen- tive to stimulate dedicated study of the microbiological and pharmacologic is- sues presented by common infections. Such a patient usually has a clinical his- tory and physical findings that tremen- dously expand the experience base and reinforce the confidence of novice exam- iners.

In my own early community rota- tion, I saw patients with empyema, chronic active hepatitis, diverticulitis, dissemi- nated gonococcal infection, acute myo- cardial infarction, delirium tremens, he- patic encephalopathy , pernicious anem ia, and newly diagnosed ulcerative colitis. I remember the details of their presenta- tions and their clinical courses vividly. As I revisited the basic science issues relevant to these disease processes dur- ing the second year of medical school, my reading was firmly anchored by the clinical correlation I drew from my own experiences.

Beyond Basic Science

Students who are immersed in the didac- tic seaof facts that we call "basic science" (and designate as a prelude to clinical medicine) may not fully realize that a patient does not walk into the physician 's office carrying a multiple-choice list of potential diagnoses and therapeutic op- tions. Primary care experiences intro- duce students to the uncertainty of clini- cal diagnosis and theraj)eutics, to the bal- ancing of costs and benefits, and to the logistical obstacles that many patients face in obtaining health care. Patients

with hypertension, for example, clearly illustrate these points by virtue of the sheer variety of pharmacologic and non- pharmacologic therapies that can be em- ployed.

As physicians, we must encourage medical schools as they explore innova- tive ways to introduce early comprehen- sive care experiences into their curricula. These may be half-day visits in the imme- diate community or extended preceptor- ships in remote locales. I call upon com- munity practitioners to contact our medi- cal schools and find out how they can participate in community-based student teaching.

The primary care preceptor benefits, too, in ways that go beyond the satisfac- tion of teaching and the continuing edu- cation stimulated by student questions. Recruiting future physicians to rural and underserved areas is facilitated by the flux of students to the practice site and, furthermore, patients hold their doctors in higher esteem when they perceive him or her as a mentor.

In the present climate of health care introspection and reform, early commu- nity experiences may help to answer the call of the American Association of Medi- cal Colleges and of the Clinton Adminis- tration for a new emphasis on compre- hensive primary care. But regardless of whether these experiences will blossom into greater numbers of students entering primary care, they will introduce a new synergy between basic science and clini- cal learning and will refresh the altruistic motives that most students bring to their medical training. We will be cultivating better health care providers. □

References

1 Markert RJ. Change in specialty choice during medical school. J Fam Piact 1983;17:295-300.

2 Eagleson BK, Tobolic T. A survey of students who chose family practice resi- dencies. J Fam Pract 1978;6:111-8.

3 Brearley WD, Simpson W, Baker RM. Family practice as a specialty choice: effect of premedical and medical educa- tion. J Med Ed 1982;57:449-54.

4 RabinowitzHK. The relationship between medical student career choice and a re- quired third-year family practice clerk-

ship. Fam Med 1988;20:118-21.

5 CauthenDB, Adams RL,DeLaRoseR,et al. Medical students and family practice: a prospective study. Texas Medicine 1980;76:57-60.

6 Black RR.SchmittlingG.StemTL. Char- acteristics and practice patterns of family practice residency graduates in the United States. J Fam Pract 1980;1 1:767-78.

7 Rabinowitz HK. The change in specialty preference by medical students over time: an analysis of students who prefer family medicine. Fam Med 1990;22:62-3.

8 Ernst RL, Yett DE. Physician Location and Specialty Choice. Ann Arbor: Health Administration Press, Univ. of Michigan, 1985, p. 109.

9 AllenSS, Sherman MB, Bland CJ,Fiola JA. Effect of early exposure to family medicine on students' attitudes toward the specialty. J Med Ed 1987;62:911-7.

10 BruhnJG.Naughton J. Effects of a course in internal medicine on attitudes of first- year medical students. J Med Ed 1969;44:504-9.

46

HCMJ / January 1994. Volume 55 Number 1

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BOOK REVIEWS

Carolina Physician's Booicsheif

Edward C. Halperin, M.D., Deputy Editor

Huff, O. The Window of Childhood: Glimpses of

Wonder and Courage. Louisville: Westminster/John

Knox Press, 1990, $9.99, ISBN O-664-25094-7.

Andrews, Billy F. Ideals and Inspiration. New York: Vantage Press, 1993, $14.95, ISBN O-553-10286-3.

Ripoll, Ignacio. Ethical Health Care Reform: Person- Focused Reorganization. Norfolk: Hampton Roads Publishing Co., 1993, $8.95, ISBN 1-878901-53-2.

Stacey, James. Inside the New Temple: The High

Cost of Mistaking Medicine for Religion. Winnetka:

Conversation Press, 1993, $12.95, ISBN O-9634395-1-0.

Reviewed by Edward C. Halperin, M£>., Book Review Editor

I take full blame for the book review column of the North Carolina MedicalJournal. I proposed publishing book reviews to the former editor, Dr. Eugene Stead, a few years ago. He gave me the go-ahead and I was off. The concept, initially, seemed simple. 1 would pick the books for review, cajole the medical publishing houses to let me have free "review copies," and then distribute the titles for evaluation. For the most part, that is how it has worked.

I fully expected to end up on mailing lists for the commer- cial medical publishing houses. I envisioned myself happily requesting $150 elegantly bound tomes from Saunders, Lippincott, Raven, and McGraw-Hill. For the most part, things haven't worked out that way. A few of the publishing houses do provide me with regular notification of their new volumes. Some even cheerfully provide me with free review copies. Some have politely told me to go jump in the lake when I have asked for review copies. Most have ignored me.

From the Division of Radiation Oncology, Box 3085, Dul<e University Medical Center, Durham 27710.

Something I hadn't banked on was the deluge of unsolic- ited books. It seems that every month brings with it another paperback or small, hard-bound volume from some publishing house. Some of the books are accompanied by glossy "press packets," breezily informing me of the crucial information and deathless prose to be found in the touted volume. "Book Review Editor!" the press releases often cry, "Don't miss this litde gem!" When four unsolicited new books piled up on my desk, and didn't seem to be going anywhere else voluntarily, it was clearly time to take action. They all got packed off into the mini- van along with one spouse, three children, eight bathing suits, and a few stuffed animals for a trip to the beach. Everybody returned in relaxed and fine condition. 1 got through the books. My oldest daughter lost one of her bathing suits. (I am always amazed how children seem to be able to manage to lose clothes. This is a talent that we seem to lose as adults. How can you lose a garment that you spend most of the day wearing? Is it not like an umbrella or pen that you always seem to be putting down some place and forgetting. But this is a subject for another day.)

The stand-out of the lot is Dr. Olson Huff's book. Dr. Huff is a pediatrician from Black Mountain, North Carolina. He and his publishing house certainly did a good job of attempting to scare me off before I began the book. Nothing strikes fear in the heart of a medical journal book review editor like a title that the company bills as "inspirational," i.e., appropriate for religious bookstores. I don't scare easily, however, so I plunged in.

Dr. Huff has provided his readers with 134 pages of pleasant short stories. Each recounts a scene from the life of the pediatrician: a discussion with a parent, a late night in the emergency room, and a series of conversations with a child. Some of the stories give you that "God is in heaven and all is right with the world" feeling that qualifies the book as "inspi- rational;" some of the stories are heart-warming in the James Herriott vein; and some are poignant. Dr. Huff's book is a light, easy, and pleasant read. This would make a good "gift book" for a medical student contemplating a career in Pediatrics, a Pedi- atric house officer in need of uplifting, or your favorite pedia- trician.

Dr. Billy Andrews' hook, Idealsandlnspiration, has been served up by Vantage Press. Readers of this column have

48

NCMJ / January 1994, Volume 55 Number I

encountered this publisher before — a so-called "vanity press." Vantage runs advertisements in magazines. I am sure you have seen them: "Authors, in search of a publisher?" They invite you to send your manuscript in and will, for a fee, publish and distribute your book. People in the commercial publishing business turn their nose up at vanity publishers. They will be quick to point out that books pubhshed by vanity press "haven't cut it" with editors in the for-profit sector. I am sure this is, to some extent true; although die criticism is a bit self-serving.

Dr. Andrews is a pediatrician at the University of Louis- ville. He received his undergraduate degree from Wake Forest and his medical degree from Duke. Ideals and Inspiration is a collection of his poetry. The poems begin with boyhood poems written to honor mother, flowers, and the wonders of nature. Dr. Andrews' mother, it appears, faithfully saved her son's first efforts at poetry. Now, many years later, he has chosen to publish them. The poems of Dr. Andrews' adult life deal with problems of medicine, faith, and Ufe. There are also some poems written in homage to professional colleagues and friends.

Dr. Andrews is a devotee of the rhyming couplet. He seems to find rhymes in the most extraordinary places. Consider, for example, a selection from his poem, "To My Departed Friend, Virginia Apgar." Dr. Apgar is memorialized, of course, in the "Apgar score" given to newborns atone and five minutes of life:

To teach us how to make others breathe Was a great legacy for you to leave.

And, also to enlighten us with the Apgar score For selection of the newborn who needs us more.

You were the champion of each infant with a birth defect. The leader the national foundation did so wisely select.

To establish in many locations a birth-defect center Where each needy infant and child could enter.

Rous, Stephen M. The Prostate Book: Sound

Advice on Symptoms and Treatment. W.W. Norton

& Co., 1992, $22.95, ISBN O-393-02592-6.

Reviewed by Raymond E. Joyner, Associates, Durham.

M.D., Durham Urology

The Prostate Book is an improved edition of a title originally published in 1988. Rous provides his readers with a thorough review of the anatomy and physiology of the prostate gland. The text has been updated with a new final chapter thataddresses the problem of prostate cancer including diagnosis and treatment. Although the text is directed primarily at lay persons, the prose is appropriate only for fairly sophisticated readers. In my view the text provides a bit too much information and will over- whelm a large segment of the patient population. At more than 200 pages long, not including the glossary, there is probably more detail to be found in The Prostate Book than most patients are seeking.

Nonetheless, Dr. Rous' book is well-written and contains extensive information about the prostate. The chapter concern- ing prostate cancer, in particular, addresses the current clinical dilemma of dealing with prostate-specific antigens (PSA) and discusses prostate cancer treatment choices. In fact, the chapter might be appropriate for non-specialist physicians seeking a reasonable review concerning PSAs and prostate cancer.

The Prostate Book provides an in-depth discussion of problems related to the prostate gland. It has become available at a time when the prostate seems to be the subject of a great deal of public concern and discussion. The book will serve as a fine resource for educated lay persons and many physicians inter- ested in the topic, and it will be suitable for the occasional patient who has extensive questions and a desire to study the prostate in depth. The text, however, is not suitable as general waiting room literature. □

Most of my knowledge of poetry comes from those anthologies that students are obligated to plow through in high school and college. I don't claim to be any great judge of poems. Frankly, most of the poetry that appears in The New Yorker, The A tlantic, and The New York Review of Books mystifies me. I am wilUng to say about poetry, as I feel about modem an, that I know what I like and I don't like. I wish Dr. Andrews well with his avocation of poetry . As a poet, in my humble opinion, I think he is a good pediatrician.

Mr. Stacey and Dr. Ripoll's books are the start, I suppose, of a trend. Now that health care reform is on everyone' s political agenda, the publishing industry will respond by providing us with book after book containing prescriptions forreform. There is so much available in medical periodicals and in the popular press, both of hard data and opinion concerning health care reform, that neither of these two opinionated books engaged my attention for long. □

Lucente, F.E. Sobol, S.M. Essentials of Otolaryngology. Raven Press, $27.50, ISBN 0-88167-369-2.

Reviewed by Harold C. Pillsbury, M.D., Professor and Chief, Otolaryngology, Head and Neck Surgery, UNC-Chapel Hill.

Essentials of Otolaryngology is an outstanding introduction to otolaryngology for medical students. It is superbly written, with a broad scope of descriptive cases, as well as useful tables and diagnostic gems. The writing is clear and concise. Each chapter includes references appropriate for further study. I highly recommend this text for all medical students who are rotating on the otolaryngology service. □

NCM J / January 1994. Volume 55 Number 1

49

Continuing i\1edicai Education

January 29

2nd Annual Hyperbaric

Medicine Symposium

Place: Searle Center, Duke University Credit 8.5 hours Category I, AMA Fee: $40 physicians ($20 residents/

others) — by Jan. 14 Info: Carmen Hurst, Box 3823

DUMC, Durham 27710,

919/684-3305

February 17-18

Youth and Families of Color:

"What's Going On?"

Place: Chapel Hill

Fee: $50 (students, UNC faculty/staff

& seniors — over 60 are free) Info: Phylliss Woody, Office of CME,

UNC School of Public Health,

Chapel Hill 27599-8165,

919/966-4032

February 25

The Rafael C. Sanchez Family

Medicine Annual Update:

Current Concepts in Family Medicine

Place: Greenville Credit: 7 hours Category I, AMA Info: Office of CME, ECU School of Medicine, 919/816-5208

February 28-March 3

The Alton D. Brashear Postgraduate

Course in Head and Neck Anatomy

Place: Richmond, VA Credit: 44 hours Category I, AMA Info: Dr. Hugo R. Seibel, DepL of Anatomy, Box 709, Medical College of VA, Richmond, VA 23298, 804/786-9624

March 3-4

ACLS Provider Course

Place: Raleigh

Credit 16 hours, AAFP

Fee: $150

Info: Helen Creech, RN, Course Co-

ordinator, Rex Hospital, 4420 Lake Boone Trail, Raleigh 27607,919/783-3161

March 4-5

The Duke Dysphagia Symposium:

Current Clinical Challenges

Place: Durham

Credit 1 1 hours Category 1, AMA Info: Duke CME Office, 1-800/222-9984

March 4-5

2nd Annual Neurology

for the Non-Neurologist

Place: Winston-Salem Credit 1 1 hours Category I, AMA Info: Sarah Franklin, Div. of CME, Bowman Gray School of Medi- cine, Medical Center Blvd., Winston-Salem 27157, 919/748^204

March 8-9 Practical Pediatrics

Place: Winston-Salem Credit 9 hours Category I, AMA Info: Sarah Franklin, Div. of CME, Bowman Gray School of Medi- cine, Medical Center Blvd., Winston-Salem 27157, 919/748^204

March 16

5th Annual Risk

Management Symposium

Place: Greenville Credit 17 hours Category I, AMA Info: Office of CME, ECU School of Medicine, 919/816-5208

March 24-26

6th Annual Physician's

Office Laboratory Symposium

Place: Winston-Salem

Credit 20 hours Category I, AMA

Info: Sarah Franklin, Div. of CME,

Bowman Gray School of Medi- cine, Medical Center Blvd., Winston-Salem 27157, 919/748-4204

March 25-26

7th Annual Surgical

Symposium and Hightower Lecture

Place: Winston-Salem Credit 8 hours Category I, AMA Info: Sarah Frankhn, Div. of CME, Bowman Gray School of Medi- cine, Medical Center Blvd., Winston-Salem 27157, 919/748^204

March 30-31

18th Annual UNC Lineberger

Comprehensive Cancer

Center Symposium: Viral

Pathways to Cancer

Place: Chapel Hill

Info: Sarah Rimmer, 9 19/966-3036

April 22 Pediatrics Day

Place: Greenville Credit 7 hours Category I, AMA Info: Office of CME, ECU School of Medicine, 919/816-5208

April 25-26

International Symposium on

Inherited Epidemolysis Bullosa

Place: Chapel Hill

Info: Jo-David Fine, M.D., Depart- ment of Dermatology, UNC, 137 NCMH, CB# 7600, Chapel HiU 27514, 919/966-3321

April 29

6th Annual Down-East

Dermatology Day

Place: Greenville Credit 7 hours Category I, AMA Info: Office of CME, ECU School of Medicine, 919/816-5208

50

NCMJ / January 1994, Volume 55 Number 1

Classified Advertisements

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CAROLINA!: Have you ever consid- ered moving to beautiful Charlotte, North Carolina? Our practice is grow- ing, dynamic, and focused on devel- oping programs to meet the medical needs of the 90s. Our practice empha- sizes general neurology, inpatient gen- eral medical rehabilitation and neurorehabilitation, and comprehen- sive pain management We are in need of an energetic, motivated, and cre- ative neurologist who enjoys hard work, feels compassion for his or her patients, and strives always to main- tain the highest level of professional service. Send your CV to Ronald C. Demas, M.D., 2219 E. 7th Sl, Char- lotte, NC 28204. We look forward to hearing from you.

CHARLOTTE, NC: Outstanding op- portunity now available for board-cer- tified internist to serve as Assistant Director of Medical Clinic at Caroli- nas Medical Center, an 843-bed Level I trauma center. The Medical Center is one of five academic teaching centers in NC. Responsibilities include ad- ministration, resident supervision, and clinical research. Please send CV to: Mary Baucom, M.D., Department of Medicine, Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28232.

CHIEF MEDICAL OFFICER: Seek- ing licensed MD to manage the public health programs of the multi-jurisdic- tional Southside Health District. Also provides clinical services. Headquar- tered in Mecklenburg County, the dis- trict also includes Halifax and Brunswick counties; located near re- sort communities. Ideal candidate will possess knowledge of public health along with management and supervi- sory experience. Must also demon- strateabihty toeffectively interact with state and local governing officials, public, and staff. Travel required. Pre- fer board certification in Preventive Medicine. Apply lo#1420. Completed Virginia state application with refer- enced position tide and/or number must be received by 5 p.m. on February 25, 1994, at the Virginia Department of Health, Division of Employment Ser- vices, Main Street Station, P.O. Box 2448, Richmond, VA 23218. Minori- ties, females, and disabled are encour- aged to apply. Equal opportunity/af- firmative action employer.

NORTH CAROLINA: A diversified, expanding Occupational Medical/In- dustrial Hygiene practice is looking for an energetic physician to staff a clinic with established clientele. Good clinical skills essential. Experience very helpful. Occupational or family medicine boards/eligibility a plus, but not essential. Experience or a strong interest in musculoskeletal problems a definite plus. Salary would be com- petitive with excellent chance for ad- vancement Send CV to Code #25, North Carolina Medical Journal, Box 3910, DUMC, Durham, NC 27710.

NORTH CAROLINA STATE UNI- VERSITY: Student Health Service desires BC/BE physician in FP, IM, or PED. Attractive benefits (CME, mal- practice, retirement, health inisurance, 26 days annual leave, etc.). Student Health has eight physicians, four NPs, lab/x-ray, and pharmacy. Send letter of interest, CV, name, address, and phone number for three references to AdministraUve Director, Student Health Service, NCSU, Box 7304, Raleigh, NC 27695.

OXFORD: Need FP to replace retiring partner, one weekday off/week. Two out of three weekends off. Call for details.E.D.Day,M.D., 919/693-8126 (days), 919/693-1715 (nights and weekends).

POSITION AVAILABLE— NASH- VILLE, TENNESSEE: Two fuU- time BE/BC physicians are needed to staff one of Baptist Convenient Care's five urgent care centers. Schedules will be arranged in 1 3-hour shifts with a minimum of 40 hours per week. We offer a competitive salary and benefits package that includes $70 an hour, two weeks paid vacation, 40 hours paid CME, malpractice coverage 2M/ 4M, health insurance, and profit shar- ing. For more information, contact Sylvia Parker, Vice President of Op- erations, or Robert Hutton, M.D., FACEP, Medical Director, at 2601P Elm Hill Pike, Nashville, TN 37214, or call 614/883-7790.

Continued on page 55

NCMJ / January 1994, Volume 55 Number 1 51

New Members

Editor's note: To familiarize students with the Medical Society and promote membership, the NCMS recently gave first-year medical students at Bowman Gray/Wake Forest University, Duke University, East Carolina University, and the University of North Carolina at Chapel Hill a free one-year membership. We publish here, and in our next issue, listings of the new members.

Mark Phillip Albright (STUDENT), 1904-C

Falcon Pointe Drive, Winston-Salem 27127 Carlin Ann Alleyne (STUDENT), 1640 NW

Blvd. #8, Winston-Salem 27104 Elaine Christine Atos-Radzion (N), 100-18

Melville Loop, Chapel Hill 27514 Timothy Andrew Barker (STUDENT), 917

BeUview Sl, Winston-Salem 27103 AnjaU Bhatt (STUDENT), MS 2591 Bowman

Gray Sch. of Med, Winston-Salem 27157 David Forrest Black (STUDENT), 244 Oak wood

Court, Winston-Salem 27103 Susanna Moseley B utler (STUDENT), 624 West

End Blvd., Apt A5, Winston- Salem 27101 Sheri D. Campbell (STUDENT), 222 Glen Eagles

Drive, Winston-Salem 27101 Richard C'teen Chang (STUDENT), 245 Co- rona Sl, ApL #3, Winston-Salem 27103 Ashish Chandu Chaudhari (STUDENT), 1811

Ehzabeth Ave., Winston-Salem 27103 Marc Eric Dalton (STUDENT), 3826-A Coun- try Club Road, Winston-Salem 27104 Ernesto Esteban de la Tone (STUDENT), 444

Lockland Ave., Winston-Salem 27103 Reinaldo De Los Heros (P), P.O. Box 670,

Edenton 27932 Douglas Lewis Decker, 345-5 Carolina Pines

Blvd., New Bern 28560 Gerald Clarence Dey, Jr. (STUDENT), 390-B

Glendare Drive, Winston-Salem 27104 Charles Derek Dickens (STUDENT), 237 N.

Sunset Drive, #6, Winston-Salem 27101 Megan K. Dishop (STUDENT), 129 N. Sunset

Drive, #D-1, Winston-Salem 27101 Michael McDonald Dunn (STUDENT), 1632

W. First Sl, #2, Winston-Salem 27103 Carol Jean Finicky (STUDENT), 109 N. Sunset,

ApL B, Winston-Salem 27101 Kendall Evans (STUDENT), 1620 W. First Sl,

ApL #31, Winston-Salem 27104 CUnton Alexander Ewing (STUDENT), 2831

SL George Road, Winston-Salem 27106 Deborah Lynn Fantz (STUDENT), A3 -624 West

End Blvd., Winston-Salem 27101 David Wilson Fisher (STUDENT), 135

Creekwood Drive, Advance 27006 Kyle Lee Gamer (STUDENT), 857 Lockland

Ave., Winston-Salem 27103 Melissa Jane Garretson, 4600 University Drive,

#105, Durham 27707

Roberto Adrian Gonzalez (STUDENT), 1608 Northwest Blvd., ApL L, Winston-Salem 27104

Philip Gary Goodman (R), Box 3808 DUMC, Durham 27710

Rick Gorman (STUDENT), 1138 West End Blvd., Winston-Salem 27101

William Alexander Graham, IV (STUDENT), 253 1-D Miller Park Circle, Winston-Salem 27103

Lafaine Grant (STUDENT), 1426 Glade SL, ApL #3, Winston-Salem 27101

Hans Christian Hansen (AN), 3408 Pinehurst Road, StatesvUle 28677

LauraC. Hanson (GER),UNC,CB #71 10, Chapel Hill 27599

David Hardesty (STUDENT), 1600 Academy Sl, Winston-Salem 27103

Hans Leighton Hinson (STUDENT), 363 N. Stratford Road, Winston-Salem 27104

Larry Array HoUar, Jr. (STUDENT), 2365-B Ardmore Terrace, Winston-Salem 27103

Howard David Homesley (STUDENT), 2601 Club Park Road, Winston-Salem 27104

Christopher Haricer Hunt (STUDENT), 713-B Avalon Road, Winston-Salem 27107

Susan Cragin Ireton (PC), 303 Aberdeen Ter- race, Greensboro 27403

Jason Daniel Jones (STUDENT), 2831 St. George's Road, Winston-Salem 27106

Timothy Royal Jones (STUDENT), Bowman Gray Sch. of Med., Winston-Salem 27157

Mark Kenneth Jordan (STUDENT), 1514 Acad- emy Sl, Winston-Salem 27103

Morton Shawn Kahlenberg, 54 13 Penrith Drive, Durham 27713

Darin Neal Kennedy (STUDENT), 138 N. Sun- set Drive, ApL #4, Winston-Salem 27101

Eugene Jacob Kim (STUDENT), 420 Irving Sl, Winston-Salem 27103

James RobertLarosea (STUDENT), 130-B Pied- mont Ave., Winston-Salem 27101

Hyoseon LindaLee (STUDENT), 2500-B Miller Park Circle, Winston-Salem 27103

Ehzabeth Simmons Long (STUDENT). 1143 Hawthorne Road, Winston-Salem 27103

Scott Alfred Luking (FP), 520 Maple Ave., Ste. B, ReidsviUe 27320

William Stephen Luking (FP), 520 Maple Ave., ReidsviUe 27320

Scott Geoffrey Mann (STUDENT), 930 West

End Blvd., ApL A, Winston-Salem 27101 Weeza Matthias, MAHEC Family Practice Cen- ter, AshevUle 28801 Philip Douglas Mayo (IM), 2307-G Norwood

Ave., Goldsboro 27534 John Matthew McDonald (STUDENT), 2203

Gaston Sl, Winston-Salem 27103 Kirk Patrick McNagny (STUDENT), 854 Brent

SL, Winston-Salem 27103 Kimberly Anne Mebust (N), 4100 Five Oaks

Drive, #10, Durham 27707 Michelle Melisko (STUDENT), 636 S. Sunset

Drive, Winston-Salem 27103 WilUam Anthony Mercanti, Jr. (STUDENT),

291 -A Dalewood Drive, Winston-Salem

27104 Kshitij Pankaj Mistry (STUDENT), 1811 Eliza- beth Ave., Winston-Salem 27103 Nermine Morcos (STUDENT), 320-R Glendare

Drive, Winston-Salem 27104 Mark Wayne Morgan (STUDENT), 1 138 West

End Blvd., Winston-Salem 27101 Bryant Armond Murphy (STUDENT), 3826-A

Country Club Road, Winston-Salem 27104 Leticia Shawn Myers (STUDENT), 2980-J

Walnut Forest Coiut, Winston-Salem 27103 Keith Hunter Nelson (STUDENT), 224 Oakwood

Court, Winston-Salem 27103 Michael John Noud (STUDENT), 1407 Seneca

Sl ApL #C, Winston-Salem 27103 Michael E. O'Keeffe (STUDENT), 713-B N.

Avelone Road, Winston-Salem 27109 Heather Noelle Paddock (STUDENT), 134

LobloUy Lane, Chapel Hill 27516 Melanie Jean Parham (STUDENT), 5211 Old

Oak Drive, B2, Winston-Salem 27106 Melinda J. Peterson (STUDENT), M.S. Box

2669, Winston-Salem 27157 Kristen Aline Powell (STUDENT), 2315

Cloverdale Ave., ApL D, Winston-Salem

27103 Kenneth Owen Price (STUDENT), 708 Fenimore

Sl, Winston-Salem 27103 Victor F. Randolph, 3867-B Sweeten CreekRoad,

Arden 28704 Robert Arnold Reeg (STUDENT), 1407-B Sen- eca Sl, Winston-Salem 27103 Robert Paul Rieker, Jr. (STUDENT), 420 Irving

Sl, Winston-Salem 27103

52

NCM J / January 1994, Volume 55 Number 1

Daiyl Alan Rosenbaum (STUDENT), 420 Irv- ing St., Winston-Salem 27103 John Wallis Rusher (STUDENT), 1703 Dare

Sl, Raleigh 27608 Wm. Madison Sattenvhite, 111 (STUDENT), 525

Hedgewood Place, Winston-Salem 27104 Stephen Loren Sgan (STUDENT), 9 1 7 Bellview

St., Winston-Salem 27103 Michele Jedlica Shaw (STUDENT), 715

Fenimore Sl, Winston-Salem 27103 William P. Silver (STUDENT), 132 Piedmont

Ave., #B, Winston-Salem 27101 Margareta J. Smith (STUDENT), 486 Avalon

Road, Winston-Salem 27104 Jeffery Davis Stone (STUDENT), 1336 W. First

Sl, Winston-Salem 27101 Lara Jean Teal (STUDENT), 1937 1/2 Gaston

Sl, Winston-Salem 27103 David Caii Thomas (STUDENT), 216 Corona

SL, Winston-Salem 27103 Giaco Murriyankanenkal Thomas (STUDENT),

22 S. Folsom Drive, Brick, NJ 08724 Jason William White Thomason (STUDENT),

2203 Gaston SL, Winston- Salem 27103 Jason Alexander Walker (STUDENT), 2353-C

Salem Court, Winston-Salem 27103 Kwame L. White (STUDENT), Bowman Gray

Sch. of Med., Diamond Bar, CA 27157 Jeremy Demetri Williams (STUDENT), 1632-

A W. First Sl, Winston-Salem 27104

Buncombe

David Michael Cypcar (PD), 21 0 Asheland Ave. ,

Asheville 28801 James Brian Hoer (IM), 445 Biltmore Ctr., Ste.

407, Asheville 28801 Christopher Todd Lechner, 20 McDowell Sl,

Asheville 28801 Jennifer Seaber Moore (OBG), 60 Livingston

Sl, Ste. 100, Asheville 28801

Davidson

Martin Augustus Allen (OBG), 244-C Fairview Ave., Lexington 27292

Durham-Orange

Todd J. Adams (STUDENT), Rl #7, Box 104,

Chapel HiU 27514 Amy Marie Allshouse (STUDENT), 3612 Cot- tonwood Drive, Durham 27707 Angela Denise Ballance (STUDENT), 336

Summerwalk Circle, Chapel Hill 27514 IbiezRafiqBanoukwala(STUDENT), 300 Chase

Ave., Chapel Hill 27514 Andrew William Bazemore (STUDENT), ApL

#21, Hwy. 54 Bypass, Chapel Hill 27516 Kimberly Lorraine Beavers (STUDENT), 605

Jones Ferry Road, ApL CC8, Carrboro 275 1 0 Keturah Chesbrough BeU (STUDENT), 9P

Kingswood Apts., Chapel Hill 27516 Mark Leekley Bland (STUDENT), 201 HoweU

Sl, ApL 2C, Chapel Hill 27514 George Moore Brinson (STUDENT), 8 1 1 Kings

Mill Road, Chapel Hill 27514 Donna Marie Brock (STUDENT), 398

Summerwalk Circle, Chapel Hill 27514 Brian Daniel Brown (STUDENT), 1521 E.

FrankHn SL, Chapel HiU 27514 Debbie Ann Brown (STUDENT), 404 Jones

Ferry Road, ApL D-2, Carrboro 27510 Michael B. Brumback (STUDENT), 104-K

Shadowood Drive, Chapel ffill 27514 Richard Catoe Bumgardner (STUDENT), 100

Rock Haven Road, ApL G104, Carrboro

27510 Brett HoUingsworth Cannon (STUDENT), #4

Merritt Apts., Chapel Hill 27514 Sheri Lynn Carroll (STUDENT), 33-C

Westminster Drive, Chapel Hill 27514 Mark David Charlson (STUDENT), 501 Jones

Ferry Road, ApL BB3, Carrboro 27510 Stephen Victor Chiavetta (STUDENT), 140

BPW Qub A-24, Carrboro 27510 Kathy N. Chism (STUDENT), 4-A Kingswood

Apts., Chapel Hill 27516 Elizabeth Charlotte Clark (STUDENT), 216

Branson Sl, #B, Chapel Hill 27514 Joseph Brian Clark (STUDENT), 605 Jones

Ferry Road, ApL 779, Carrboro 27510 Uura Anne Clark (STUDENT), 1 1 1-B HoweU

Sl, Chapel Hill 27514 Michael Todd Cross (STUDENT), 502 Ferguson

Sl, Chapel Hill 27516 Lance Lee Davis (STUDENT), 205-1 Sunrise

Lane, Chapel Hill 27514 Wesley Boyd Davis (STUDENT), 10-B Poplar

Sl, Chapel Hill 27516 Andrea Lynn Decsi (STUDENT), 10418 Fair- way Ridge Road, Charlotte 28277 Marta Lynn Derieg (STUDENT), 203 Angier

Drive, #3, Chapel HiU 27514 Carrie Ann Dow (STUDENT), 101-E2 Thomas

Lane, Carrboro 27510 Mark Thomas Dransfield (STUDENT), 112-D

Purefoy Road, Chapel HiU 27514 Nathan Judson Elder (STUDENT), 5639 Chapel

HiU Road, ApL 709, Durham 27707 Eric Douglas Ervin (STUDENT), 423 Rocky

Ford Sl, Morganton 28655 CharUe Weichin Fang (STUDENT), 331 Rose- mary Sl, #2, Chapel HiU 27516 Paul Marcus Flanagan (STUDENT), 9 EUen

Place, Chapel HiU 27514 CharUe H. Foster, Jr. (STUDENT), 1 100 High- way 54 Bypass, Chapel HUl 27516 Sarah Frank (STUDENT), 737-B Edwards SL,

Chapel HUl 27516 Arthur D. Fu (STUDENT), 230 Kirkwood Drive,

Chapel HUl 27514 Joseph Edwin Gadzia (STUDENT), 1521 E.

FrankUn Sl, ApL C206, Chapel HiU 27514 JuUe Gale (STUDENT), 1521 E. FrankUn Sl,

ApL CI 13, Chapel HiU 27514 Thomas WUUam Gansman (STUDENT), 119

Barclay Road, Chapel HiU 27516 Thomas J. Geigerman (STUDENT), 906 Shady

Lane, Chapel HUl 27514 Nancy Lynn Georgitis (STUDENT), 201

Westbrook Drive, ApL B- 1 3 , Carrboro 275 1 0 Chandra Sekhar Ghosh (STUDENT), 300 Chase

Ave., Chapel HUl 27514 Anna Marlet Gibson (STUDENT), 353 Cobble- stone Court, Chapel HUl 27514 Michael GUI (STUDENT), 4932 Pine Cone

Drive, Durham 27707 Leigh Barden Goodwin (STUDENT), 1 00 Rock

Haven Road, ApL K-205, Carrboro 27510 Christine Jacquelene Gorman (STUDENT), 143

Old Forest Creek Drive, Chapel HUl 27514 MauraLynnHamrick (STUDENT), 1203Seaton

Road, T-104, Durham 27713 Heather Marie Henderson (STUDENT), 124

Basnight Lane, Chapel HUl 27516 Anne EUzabeth HUlman (STUDENT), 220 EUza-

beth Sl, #A-17, Chapel HUl 27514 Thomas W. Hodgin,Jr (STUDENT), 1000 Smith

Level Road, Carrboro 27510 John Patrick Hunt (STUDENT), 218 Pittsboro

Sl, Chapel HiU 27516 Daciana loana lancu (STUDENT), 737-B

Edwards Sl, Chapel HiU 27514 Srikant Iyer (STUDENT), 300 Chase Ave.,

Chapel HiU 27514 Harold Albert Johnson (STUDENT), RR #12,

Box 40, Chapel HiU 27514 Kenneth Lee Johnson (STUDENT), 243

Summerwalk Circle, Chapel HiU 27514 Monique Delana Johnson (STUDENT), 401

Highway 54 ApL C-10, Cairboxo 27510 Andrew Lee Katz (STUDENT), 705 Snowcrest

Trail, Durham 27707 Richard Calhoun Kelsey (STUDENT), 1800

WUUamsburg Road, #14- A, Durham 27707 Rohit Mohan Khanna (STUDENT), 34 HoUand

Drive, Chapel HUl 27514 Bobbie Alyse Khosh (STUDENT), 400 E. Rowan

Sl, Raleigh 27609 Nelson CUfford Klaus, HI (STUDENT), N-202

Ramsgate Apts., Carrboro 27510 KaUierine Tyson Kobza (STUDENT), 3621

Abercromby Drive, Durham 27713 Amy Leigh Kosobucki (STUDENT), 21 1 Schultz

Sl, Chapel HUl 27514 Sarita Kumar (STUDENT), 1 14 Purefoy Road,

Chapel HiU 27514 Herbert Stanley Lambert, m (STUDENT), 104-

A Misty Wood Circle, Chapel HiU 27514 Eric Tyler Landis (STUDENT), 741 1/2 E.

FrankUn Sl, Chapel HiU 27514 Stephen Roderick Lavine (STUDENT), 224-A

Vance Sl, Chapel HiU 27516 Kathryn Ann Lee (STUDENT), 215-A Vance

Sl, Chapel HUl 27514 Kevin Marks (STUDENT), 413-B E. Patterson

Place, Chapel HUl 27514 Jessica Dawn McAdoo (STUDENT), 102

Pinegate Circle #2, Chapel HUl 27514 Sean Edward McLean (STUDENT), 105 Jones

Ferry Road, ApL J- 12, Carrboro 27510 MeUnda Menezes-Sanchez (STUDENT), 603

W. Spring Sl, HUlsborough 27278 Roben Christopher MiUer (STUDENT), 1-4

Kingswood Apts., Chapel HiU 27514 Dawson A. Mims, lU (STUDENT), 1 03-A Pleas- ant Drive, Carrboro 27510

NCMJ / January 1994, Volume 55 Number 1 53

Jerry Wayne MitcheU, Jr. (STUDENT). M-303 Ramsgate Apts., Carrboro 27510

Dean Scott Morrell (STUDENT). 15 WiUow Spring Place. Chapel Hill 27514

Thomas Christopher Morris (STUDENT), 1 Davie Circle, Chapel HUl 27514

Julia Kathryn Nelson (STUDENT). 500 N. Duke St.. 56-307. Durham 27701

Mark Andrew Nugent (STUDENT). 501 High- way 54 Bypass. #10N, Carrboro 27510

Timothy Andrew O 'DonneU. 5801 -28 Tattersall Drive, Durham 27713

Thomas Danell Owens (STUDENT), 140 BPW Club Road, Apt 84, Carrboio 27510

Namrata Pai (STUDENT), 502 Ferguson Road. Chapel Hill 27514

James Anthony Palermo (STUDENT). 402 Summerwalk Circle, Chapel Hill 27514

John Charles Parker (STUDENT). 220 Eliza- beth St. Apt. B-1, Chapel HiU 27514

Steven Andrew Patemo (STUDENT), Berkshire Manor, ApL F-8, Carrboro 27510

Measha Peterson (STUDENT), Highland HiUs #M-9, Carrboro 27510

William Gibbs Pittman, HI (STUDENT), 300 Chase Ave., Chapel HiU 27514

Rajivi Pothiraj (STUDENT), 1250 Ephesus Church Rd., Apt E3, Chapel Hill 27514

Jennifer Eve Rhodes (STUDENT), 808-B9 Park Ridge Road, Durham 27713

Lindwood Robinson (STUDENT), 404 Jones Ferry Road, F-13, Carrboro 27501

Noralea Elizabeth Rose (STUDENT), 250 S. Estes Drive, #61, Chapel Hill 27514

Janel. Ruman (STUDENT), 502 Ferguson Road, Chapel HiU 27516

Scott Salam(STUDENT), 100 Rock Haven Road, Apt. K102, Carrboro 27510

Nancy Lenhardt Schafstedde (STUDENT), 106 Cameron Glen, Chapel Hill 27514

Karen E. Schetzina (STUDENT), 8 19 S. Colum- bia Sl, Chapel Hill 27514

Betsy Schmerler (STUDENT), 103 Timber Hol- low Court, #123, Chapel HiU 27514

Krista Schwabacher (STUDENT), 601 Jones Ferry Road, Apt NIO. Carrboro 27510

Amar Setty (STUDENT). 23, 506, N. Greens- boro St, Carrboro 27510

Sherene Katherine Shakib (STUDENT), 819 S. Columbia St, Apt B, Chapel HUl 27514

Scott Stephen Shapin (STUDENT), Box K102 Rock Haven, Carrboro 27510

Leena Shrivastava (STUDENT), 1000 Smith Level Road, Apt F13, Carrboro 27510

Vincent Charles Smith (STUDENT), 606 Coolidge St, Chapel Hill 27516

Jennifer Lynne SmuUen (STUDENT), 3707-C Highgate Drive, Durham 27713

John Ruan Stephens (STUDENT), 220 Eliza- beth St, Apt Bl, Chapel HUl 27514

Jennifer K. Stoddard (STUDENT), 737-B Edwanis St, Chapel Hill 27516

Geeta Krishna Swamy (STUDENT). 124 Basnight Lane. Chapel Hill 27516

Enoch Tetteh (STUDENT), 501 Highway 54

Bypass, #D-8, Carrboro 27510 Alesia Dawn Thrift (STUDENT), 1501 Ford

Road, Chapel HiU 27516 Scott Kenneth Trufant (STUDENT), M-303

Ramsgate Apts., Carrboro 27510 Amy M. Ursano (STUDENT), Old WeU Y7,

Carrboro 27510 Ralph Nelson Vick (STUDENT), 106-X

Shadowood Drive, Chapel HiU 27514 Deepak Pathe Vivekananthan (STUDENT), 34

HoUand Road, Chapel HiU 27514 Andrew Wackett (STUDENT), 1 10-G W. Carr

St, Carrboro 27510 Lauren Wagner (STUDENT). 100 Rock Haven

Rod, K-304, Carrboro 27510 Lydia Ward (STUDENT), 124 Basnight Lane,

Chapel HiU 27516 Anne Boat Waters (STUDENT), 1 206 The Oaks,

Chapel Hill 27514 Harry Peter Weber (STUDENT), Ramsgate

Apts.. #N202. Carrboro 27510 Marsha Elaine Wells (STUDENT), P.O. Box

4821, Chapel Jmi 27515 Daniel Edward Wessell (STUDENT), #9 Hol- land Drive, Chapel Hill 27514 Kimberiy Paige Whalen (STUDENT), 3401

Cottage Place, Greensboro 27401 lUya Lamar Wilkerson (STUDENT). 501 Jones

Ferry Road. Apt D-9. Carrboro 27510 Cameron Michael WoodUef (STUDENT). 605

Jones Ferry Road. Apt 553. Carrboro 27510 AdamZolotor (STUDENT). 200 Barnes St. #5E.

Carrboro 27510

Forsyth -Stokes-Davie

Hubert Francis Bonfib (OM), RJR-401 N. Main

St, Winston-Salem 27102 John W. Cory (STUDENT). 1100-7 Barbara

Ann Circle. Winston-Salem 27103 Peter M. Cram (STUDENT). 2030 Academy St.

Winston-Salem 27103 Harlan Beaver Daubert (ORS). 1 425 Plaza Drive.

Winston-Salem 27114 David Michael Ferriss (STUDENT). 371-0

Glendare Drive. Winston-Salem 27104 Rebecca Love Foster (STUDENT). 619 Jersey

Ave., Winston-Salem 27101 Laura Frances Giordano (STUDENT), 223-C

New Drive, Winston-Salem 27103 Frank R. Glatz, III (STUDENT), 1811 Hawthorne

Court Apts.. Winston-Salem 27103 Maxwell Paisley Hendrix (STUDENT), 2352-C

Cloverdale Ave., Winston-Salem 27103 StephenLesherLeighton (FP), 3983 Old Greens- boro Road. Winston-Salem 27101 Joanne Bik-Sahn Lim (STUDENT). 7 1 2 Watson

Ave.. Winston-Salem 27103 James Francis Linnane, Jr. (GE), Hawthorne

Medical Plaza, Winston-Salem 27103 James Andrew Lovette (STUDENT), 2080

Queen St, Winston-Salem 27103 Amy Olsen (STUDENT), 5390 Palisade Drive,

Pfafftown 27040 Michael Chfford Ott (STUDENT), 857 Lockland

Ave., Winston-Salem 27103

John Christopher Paschold (STUDENT), 1 123 West End Blvd., Apt #3, Winston-Salem 27101

Barry Robert Seltzer (IM), Winston-Salem HealUi Care, Winston-Salem 27103

Siegfried Shyu (STUDENT), 1608-M North- west Blvd., Winston-Salem 27104

Richard Dana Siira (STUDENT), 1515 Bolton St, Winston-Salem 27103

Leslie Anne Webb (STUDENT), 1730 Aber- deen Terraxx, Winston-Salem 27103

Charles E. WiUiams (STUDENT). 2006 S. Main St. Winston-Salem 27127

David Alexander Zvara (AN). 1116 Claverton Court, Winston-Salem 27104

Gaston

William Lee SUkstone (PD), 1839 E. Garrison, Gastonia 28054

Granville

Philip Karl Lind (GS), 1026 College St, Oxford 27565

Greensboro ""

Stuart AUan Kossover GM), 520 N. Elam Ave..

Greensboro 27403 Kevin Mark Supple (ORS). 1401 BenjarrrinPark-

way. Greensboro 27408

High Point

Keshavpal Gunna Reddy (P). Triad Psy. Coun- seUng Ctr., PA. High Point 27262

Roscoe V. Robinson (AN), 401 Femdale Blvd., High Point 27262

Mecklenburg

Roberta Samelson Bracken (IM), 125 Baldwin

Ave., Charlotte 28204 Thomas Kern Carlton, 111 (PM), 1641 Provi- dence Road, Charlotte 28207 David Alan Cox (IM), 1718 E. 4th St, #501,

Charlotte 28204 Michael WUson Craig (PD), 1340 MatUiews

Township Pkwy., Matthews 28105 Steven Ralph Gold (OTO). 1 350 S. Kings Drive.

Charlotte 28207 Carol Anne Rupe (FP). 3201 MUl Pond Road,

Charlotte 28226 Edwin James Selx)ld (ORS), 120 Providence

Road, Chariotte 28207 David Corydon Shaver (OBG), 1718 E. 4th St,

Ste. 604, Charlotte 28204

New Hanover-Pender

Cyrus A. Kotwall (GS), Coastal AHEC, WUmington 28402

Pitt

George Edward Adcock. Ill (STUDENT). 330 Lindsay Drive, Apt G-8, Greenville 27834

Mary Helen Alien (STUDENT), 113 Asbury Road, Greenville 27858

Kodi Azari (STUDENT), 141-F Victoria Court, GreenviUe 27834

54

NCMJ / January 1994, Volume 55 Number 1

Michael Sein Baker (STUDENT), 114-A

Huntingridge Road, Greenville 27834 Jennifer Lynn Barger (STUDENT), Rownetree

Townhomes, Greenville 27834 Bethany Michele Beigamo (STUDENT), 1642

Treybrooke Circle, Greenville 27834 StacieJillBoyer(STUDENT), 105 Bishop Drive,

Winterville 28590 Melanie Anne Chesson (STUDENT), 1608

Treybrooke Circle, Greenville 27834 Christopher Yan-Chi Chow (STUDENT), 326

Haven Drive, #0-3, Greenville 27834 Cynthia Rae Christiano (STUDENT), 2907-A

Cedar Creek Road, Greenville 27858 John Kerry ColUns, Jr. (STUDENT), J-7 Doctor's

Park Apts., Greenville 27834 Emest Cudjoe (STUDENT), 1574-K Bridle

Circle, Greenville 27834 Kendall Couger (STUDENT), M-9 Doctors Park

Apts., Greenville 27834 Randolph Eugene Edwards (STUDENT), 239

Sl James Court, Wilmington 28409 Kristi Lynne English (STUDENT), 41 Golden

Road, Greenville 27858 David Lovell Fairbiother (STUDENT), 1113

Grovemont Drive #G-7, Greenville 27834 Joseph Andrew Franklin (STUDENT), G-5

Doctor's Park, GreenviUe 27834 Tarsha Valencia Garland (STUDENT), 3203

Brasswood Court, Apt. #8, Greenville 27834 Brenda Lynn Gibbs (STUDENT), 209-A River

Bluff Road, Greenville 27858 Peggy Ellen Goodman (EM), ECU School of

Medicine, Greenville 27858 John Louis Guglielmetti, Jr. (STUDENT),

Doctor's Park Apts. # 16D, Greenville 27834 Jennifer Grae Hancock (STUDENT), 303 1/2 S.

Harding Sl, Greenville 27858 Rachel Dianne Harris (STUDENT), 2907-A

Cedar Creek Road, Greenville 27858 Bobby Evans Harrison (STUDENT), 901-22

Treybnx)ke Circle, Greenville 27834 Wallace Haywood (STUDENT), 314 Undsay

Drive Apt 2A, Greenville 27834 Roselyn Marie Hicks (STUDENT), 1620

Treybrooke Circle, Greenville 27834 Laura Anne Hines (STUDENT), C-3 Doctors

Park, Greenville 27834 Joseph Kevin Hunter (STUDENT), 706 Patton

Circle, Apt. 32, Winterville 28690 SheUey Lynne Janssen (STUDENT), T-4 Doc- tors Park Apts., Greenville 27834 Kenneth Lee Johnson, II (STUDENT), 1501

Treybrooke Circle, Greenville 27834 WiUiam Thomas Kendrick (STUDENT), Route

1, Box 38A-1, Greenville 27834 Richard Stewart Lewis (STUDENT), 1 22 Gates

Drive, Winterville 28590 Barbara Diane Lippard (STUDENT), 1329

Treybrooke Circle, Greenville 27834 James Eugene Long (STUDENT), 106 Scales

Place, L-Z, Greenville 27834 Rita Kay Mabine (STUDENT), U-5 Doctor's

Park Apts., Greenville 27834 Julie Ann Means (STUDENT), Route #2, Box

216, Grimesland 27837

Monica Earlette Miller (STUDENT), 3212 Brasswood Court 12, Greenville 27834

Jason Allan Mutch (STUDENT), 1002-B Westover Drive, Greenville 27834

Deborah Denise Proctor (GE), Pitt Co. Mem. Hosp., GreenvUle 27858

Margaret Anne Query (STUDENT), 3362 To- bacco Road, Apt. 19, GreenviUe 27858

Christopher Scott Reid (STUDENT), 308-F Horseshoe Drive, GreenvUle 27834

Kim A. Reynolds (STUDENT), Q-4 Doctors Park Apts., GreenviUe 27834

Rachel Marie Rogers (STUDENT), 208 N. East- em Sl, Greenville 27858

Rebecca Rowland (STUDENT), 3 West HiUs Townhomes, GreenvUle 27834

Grady Van Shue, Jr. (STUDENT), 2904-B Mul- berry Lane, GreenviUe 27835

Timothy Milton SUver (STUDENT), 326 Lind- say Drive, 10-E, GreenviUe 27834

Janet EUzabeth Simmons (STUDENT), L-1 Doctors Park Apts., Greenville 27834

Wickham Bryant Simonds (STUDENT), K-1 Doctors Park Apts., GreenvUle 27834

Gagan Singh (STUDENT), 635 Cotanche SL, ApL 812, GreenviUe 27858

Brenda Pearl Smith (STUDENT), Route 2, Box 320, GreenvUle 27858

Robert Mark Steffens (STUDENT), M-2 Beasley Drive, GreenvUle 27834

David Andrew Stokes (STUDENT), G-5 Doc- tors Park Apts., Greenville 27834

Robert Kevin Talton (STUDENT), L-2 Doctors Park Apts., GreenvUle 27834

Johnna Sue Thomas (STUDENT), D-6 Doctors Apts., GreenvUle 27834

Lawrence WaUace (STUDENT), G-6 Doctors Park Apts., GreenvUle 27834

SheUy Lorraine West (STUDENT), 107 ShUoh Drive, ApL 1, Greenville 27834

Neil Evans Whicker (STUDENT), 28-C Courtney Square Apts., GreenvUle 27858

Heather Anne Wilfong (STUDENT), 1242 Treybrooke Circle, GreenvUle 27834

Kelcey Louis Williams (STUDENT), Pecan Grove ApL B-9, GreenvUle 27834

Rae Lynn Yates-Britt (STUDENT), D-5 1107 Grovemont Drive, GreenvUle 27834

Rowan

PeterGerald Vanoosten (OBG), 315 Mocks vUle Road, Salisbury 28144

Wake

Deepak Pasi (CD), 3324 Six Forks Road, Ra- leigh 27609

NeU Bradford Perlman (IM), 7609 Tylerton Drive, Raleigh 27613

Wayne

Kevin James KerUn (RO), 801 MUl Road, Goldsboro 27534

Classified Advertisements

continued from page 51

PRIMARY CARE PHYSICIAN: free- standing clinic: Urgent Care/Occupa- tional Medicine: Immediate opening in the Piedmont area of North Caro- lina for aggressive primary care phy- sician interested in long-term career commitment. Excellent salary, fringes plus a progressive profit-sharing plan. Call or send CV to Dr. Jeffrey A. Smith, 613 E. Roosevelt Blvd., Mon- roe, NC 28112. Phone 7(M/283-8193.

RALEIGH, NC: Practice opportunity. Join three pediatrician-group in edu- cational, cultural city. Teaching op- portunities, consultations at nearby medical centers. Inquire Oberlin Road Pediatrics, 1321 OberUn Road, Ra- leigh, NC 27608, or call Mary Anne Clark at 919/828-4747.

WILMINGTON, NC: Approximately 2,800 square feet within walking dis- tance of Regional Hospital, two (2) basic suites — $326,000. Laney Real Estate Co. 1-800/733-1428 (day) or 910/392-9030(night). Ask specifically for Dr. Pete Camak, agent.

Classifed rates & information

For members of the North Carolina Medi- cal Society— $1 5 for the first 25 words, 25 cents for each additional word; for non- members — $25 for the first 25 words, 25 cents for each additional word. Copy must be submitted at least one month prior to publication. Please indicate the number of months ad should run. There is no Classified ad column in the March Roster edition of the Journal. Pre-payment or purchase orders are not required. Con- tact: North Carolina Medical Journal, Box 3910, DUMC, Durham, NC 27710; 919/ 286-6412, fax: 919/286-9219.

NCMJ / January 1994, Volume 55 Number 1 55

Aphorisms of the Month

Daniel J. Sexton, M.D., Editor

Random Thoughts on

Money, Prosperity,

and Judges

When a fellow says it hain't the money but the prin- ciple o' the thing, it th' money. — Kin Hubbard

Money can be translated into the beauty of living, a support of misfortune, an education, or future security. It also can be translated into a source of bitterness.

— Sylvia Porter

There is an old time toast which is golden for its beauty. "When you ascend the hill of prosf)erity may you not meet a friend." — Mark Twain

Prosperity is the surest breeder of insolence I know.

— Mark Twain

There is no such thing as justice — in or out of court.

— Clarence Darrow

We mustremember that we have to make judges out of men, and that by being made judges their prejudices are not diminished and their intelligence is not in- creased. — Robert G. Ingersoll

Judge — a law student who marks his own examination papers. — HL. Mencken

Judging from the main portions of the history of the world, so far justice is always in jeopardy.

— Walt Whitman

Our judges have been, on the whole, both able and upright public servants. . . . But their whole training and the aloofness of their position on the bench prevent their having, as a rule, any real knowledge of, or understanding sympathy with, the Uves and needs of the ordinary hard-working toiler.

— Theodore Roosevelt

Index to Advertisers

Auto Brokers, International

47

Baron Benefits

26

CompHealth

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56

NCMJ / January 1994, Volume 55 Number 1

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The

Official Journal

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North Carolina

Medical Society

February 1994

Volume 55

Slumber 2

|^^iVERSiTY_ORiORTHJ^

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North Carolina Medical Journal

For Doctors and their Patients

HEALTH SCI£NCESL1BR.«1

Sekh-Met

First Goddess of Medicine

By Dennis A. Greene, MD

Also in this issue:

Black Widow Spider Poisoning

Foreign Body Aspiration

Intrapartum Liver Rupture

Organ Donation Screening for Oral Cancer

NCMS Spring Leadership Conference:

"Physician Involvement

in Health System Reform"

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NORTH CAROLINA MEDICAL JOURNAL

For Doctors and their Patients

Published Monthly as the Official Organ of the North Carolina Medical Society

February 1994, Volume 55, Number 2 (ISSN 0029-2559)

EDITOR

Francis A. Neelon, MJ).

Duiham 919-286-6409

DEPLTTY EDITOR

Edward C. Halperin, M.D.

CONSULTING EDITOR

Eugene A. Stead, Jr., M.D.

ASSOCIATE EDrrORS

Ebcn Alexander, Jr., MX).

Winston-Sal cm WUliam B. Blythe, MX).

Chapel Hill F. Maxton Mauney, Jr., M.D.

Asheville Walter J. Pories, M.D.

Greenville

MANAGING EDfTOR

Jeanne C. Yohn

Durham 919-286-6410, fax: 919-286-9219

EDITORIAL ASSISTANT

Jane Whalen

SECTION EDITORS

Eugene W. Linfors, M.D. Daniel J. Sexton, M.D.

ACTING

BUSINESS MANAGER

Donald R. Wall

EDITORIAL BOARD CHAIR

Margaret N. Marker, MX).,

Morehead City MEMBERS Jay Arena, M.D.

Durham William B. Blythe, MX).

Chapel Hill Jack Hughes, M.D.

Durham Timothy W. Lane, M.D.

Greensboro Eugene S. Mayer, MX).

Chapel Hill Walter J. Pories, M.D.

Greenville Robert W. Prichard, M.D.

Winston-Salem Mary J. Raab, M.D.

Greenville

The Society is not to be considered as endorsing the views and opinions advanced by authors of papers delivered at the Annual Meeting or published in the official publication of the Society. — Constitution and Bylaws of the North Carolina Medical Society. Chap. IV, Section 3, pg. 4.

NORTH CAROLINA MEDICAL JOURNAL Box 3910, Duke University Medical Center, Durham NC 27710, (919-286- 6410/rax: 919-286-9219). is owned and published by The Nonh Carolina MedicalSocietyunderlhcdirecLionof its Editorial Board. Copyright© 1994 The North Carolina Medical Society. Address manuscripts and communications regarding editorial matters, subscription rates, etc. , to the Managing Editor at the Durham address listed above. Listed in Index Medicus. All advertisements are accepted subject to the approval of the Editorial Board of the North Carolina Medical Journal. The appearance of an advertisement in this publication does not constitute any endorsement of the subject or claims of the advertisement

Advertising representatives: United Media Associates, Kari Messerrly, 2001 W. Main St. Suite 202, Stamford CT 06902; 203-975-0606; and Don French, Box 2093, Cary NC 2751 1; 919-467-8515.

Printing: The Ovid BeU Press, Inc., 1201-05 Bluff St., Fulton MO 65251.

Annual subscription (12 Issues): $17 (plus 6% tax in NC = $18.02). Single copies; $2. Second-class postage paid at Raleigh NC 27601 , and at additional mailing offices. POSTMASTER: SEND ADDRESS CHANGES TO THE NORTH CAROUNA MEDICAL SOCIETY, 222 N. PERSON ST^ RALEIGH NC 27601.

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Contents / February 1994, Volume 55, Number 2

Cover." The war goddess Sekh-met (Egyptian, Dynasty XVin, 1570 B.C.- 13 14 B.C.) has been associated with healing and healers, as Dr. Dennis A. Greene explains on page 94. The 3,500-year-old bust was discovered in England in 1982 being used as a support for a garden bench. It is now the property of the North Carolina Museum of Art in Raleigh, a gift of Mr. and Mrs. Gordon Hanes. Used with permission.

SCREENING FOR DISEASE

65 Screening for Oral Cancer: It Takes More Than Just a Look

Jeffrey G. Wong, MD, and John R. Feussner, MD

REFLECTING ON RESEARCH

68 Eureka! : It' s a Negative S tudy !

Edward C. Halperin, MD

MODERN MEDICINE

70 Organ Donation: Rescuing Triumph From Tragedy

Thomas V. Clancy, MD

REPRODUCTIVE HEALTH

72 Spontaneous Intrapartum Rupture of the Liver: A Life-Threatening Complication of Pregnancy

Philip H. Pearce, MD. FACOG 76 Difficulty Finding and Removing a Norplant* System Capsule

Takey Crist, MD, FACOG, MJi. Barnes, MD, FAFP, and W.C. Whitehurst, MD

HEALTH WATCH

77 Back Pain: Lift It Safe

North Carolina Medical Society

PEDIATRIC HEALTH

83 Foreign Body Aspiration in North Carolina Children

Amelia F. Drake, MD, Timothy L. Smith, MD, and Newton D. Fischer, MD

TOXIC ENCOUNTERS

86 Will the Defendant Please Rise?: Black Widow Spider Poisoning

Ronald B. Mack, MD

THE NAMES AND FACES OF MEDICINE

90 Mary Frances Shuford, MD: One North Carolina Physician Who Made a Difference Will Durham

THE HISTORY OF MEDICINE

94 Sekh-Met: First Goddess of Medicine

Dennis A. Greene, MD

BULLETIN BOARD

60 Letters to the Editor

64 Instructions for Authors

82 Continuing Medical Education

89 The Journal's Reviewers: The Ties That Bind

93 Subscription Form

95 Change-of-Address Form

96 New Members

99 Classified Advertisements

100 Aphorisms of the Mondi: Surgeons

100 Index to Advertisers

58 NC AJ / February 1994, Volume 55 Number 2

We've been defending doctors since these were the state of the art.

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Letters to the Editor

^

December NCMJ: Thoughts on Dr. Stead's Article and More To the Editor:

I thank Dr. Stead for his article in the December Journal (NC Med J 1993;54: 645-50) in which he expressed his insight about teaching. I hope that others will absorb his philosophy. Unfortunately, my teaching days are long gone, but certainly not forgotten.

I hope that my residents absorbed some of my thoughts but I know they were inferior to Dr. Stead's. Surely I learned more from his article, as I always learned more from my residents than was conveyed to them.

Everett I. Bugg, Jr., MD

Route 2, Box 143

Pittsboro,NC 27312

To the Editor:

I was so moved by Dr. S tead ' s Lecocq Lecture (NC Med J 1993;54:645-50) that I felt compelled to send the article to all of our orthopaedic staff from the bottom up. I thank Dr. Stead for guiding me more than 30 years ago. How vividly I remem- ber those precious moments of learning. James R. Urbaniak, MD Professor and Chief Division of Orthopaedic Surgery Box 2912, Duke Univ. Medical Center Durham, NC 27710

To the Editor:

I have read Dr. Stead's "four talks" as recorded in the Journal (NC Med J 1993;54:645-50). I think it's only fitting that I tell him what I have intended for some time. As he was 40 years ago, he remains a great inspiration in my per- sonal as well as professional life. Early on I aspired to become wise, as I per- ceived him to be. Even though I have fallen short of my aspirations, I did not suffer from lack of direction from him.

This is not meant to be maudlin, but

rather, an expression of my admiration

for Dr. Stead and appreciation for the

opportunity to have shared his wisdom.

John C. Ayers, Jr., MD

Eastern Carolina Internal Medicine

P.O. Box 12933

New Bern, NC 28561

To the Editor:

I enjoyed Dr. Stead's piece (NC Med J 1993;54:645-50). There is much wis- dom about education in it that will go completely unobserved by the institution he served so well — not to mention all other medical schools.

But, unless I am mistaken. Dr. Green- field didn't get the message clearly ei- ther. In his commentary (NC Med J 1993;54:650) he points out that it is im- portant for doc tors to become confident — and cites this as a reason for not doing the "politically correct" thing of changing their training to an ambulatory setting. Dr. Stead, unless I am mistaken, was not touting inpatient services because they are inpatient services. He was talking about how important it is for a young doctor to be inundated by terribly sick patients during his or her training. He mentioned Grady, Boston City, and Cin- cinnati General hospitals. I understand what he means; I trained at Bellevue. Are the wards at North Carolina hospitals filled with the terribly sick, hopeless and helpless, down and out, and soon to be dead? I doubt it. If they aren't, they don't meet Dr. Stead's criteria. And if they aren't in that league, and if Dr. Stead is correct about the effect of such training, then Dr. Greenfield shouldn't (like all the other chiefs in the country) merely pro- tect his turf — he should figure out how to provide Stead's kind of experience. The hospital population in New York doesn't cut Dr. Stead's mustard either. Bellevue is an exception because of AIDS, the homeless, the poor, and the down and

out. But the students don't want to go there, the dummies, because there's "too much AIDS."

Maybe we have to take young physi- cians, give them one year on the ward at a U.S. hospital, then ship them to Zaire, Thailand, or Bangladesh for one year of heart-breaking work among the really sick. Then we would bring them back to the wards and ambulatory setting of the world of the clean and neat. I'm not kidding. After all, we're not talking about every doctor, but only those whose lives will be devoted to the care of the sick.

The other documents that speak to the education of students in much the same way that Dr. Stead talks about house officersare Ludwig Eichna's papers about medical education published more than 10 years ago. Eichna was chair of the Department of Medicine at Downstate Medical School and Kings County Hos- pital (which has the "right kind" of pa- tients). When he retired, he went back to medical school as a fully matriculated medical student! After it was over he wrote three papers about his conclusions.'" ' They are quite rich, but somewhat cryp- tic. Nevertheless, they are diamonds, worth finding and reading. He was a crusty man — no less so as he aged — but he, like Stead, had something to say...

When I am the Czar... (I'll be even richer than the Czar. Because I'll be the Czar and I'll have a small practice on the side.)

Eric J. Cassell, MD

28 Old Fulton St.

Brooklyn, NY 11201

References

1 Eichna LW. Medical-school education, 1975- 1979: a student's perspective. N Engl J Med 1980;303;727-34.

2 Eichna LW. A medical-school curriculum for the 1980s. N Engl J Med 1983;308:18-21.

3 Eichna LW. Medical school education for whom, student or patient. Bull NY Acad Med 1991;67:151-61.

60

NCMJ / February 1994, Volume 55 Number 2

To the Editor:

I recently read Dr. Stead's article in ti\QNorthCarolinaMedicalJournal(NC Med J 1993;54:645-50). He never ceases to amaze me — Congratulations!

William G. Anlyan, MD

Chancellor Emeritus, Duke University

2200 W. Main St., Suite 1066

Durham, NC 27705

To the Editor:

I was a member of the Duke School of Medicine Class of 1965. 1 was very stimulated by Dr. Stead's piece in the Journal (NC Med J 1993;54:645-50).

Although my children, like those of Dr. Stead's parents, were also bright, 1 am confident that I was quite different from his mother and father — I was pretty dumb. Nevertheless, only one of my chil- dren has followed me into medicine. 1 can't decide whether my children made their decisions because I influenced them positively or negatively. In any case, 1 am sending each of my children a copy of Dr. Stead's Lecocq Lecture because 1 think it will be as interesting and as thought- provoking for them as it was for me.

The curriculum I was exposed to as a medical student was a little different than that of most of my classmates: 1 spent a year in Duke's Research Training Program and ultimately Professor Robert Hill's biochemistry laboratory. I think Dr. Hill is still embarrassed that someone he devoted so much time to ended up being a neurosurgeon. Nevertheless, the experience was really important to me. 1 learned discipline in that lab and methods of thinking and communicating that have been important for me in my professional life. And I don't think he required me to memorize anything. Dr. Stead's advice points medical education to the right track.

Dr. Stead retired when I was on Duke's siu-gical house staff. I viewed him as an old man back then. Now I am rapidly becoming an old man myself, and he sounds like a very young one. Con- gratulations!

Larry A. Rogers, MD

Neurological Surgery

Eastover Medical Park

271 1 Randolph Road, Suite 207

Charlotte, NC 28207

Read Me! To the Editor:

I accepted your challenge, as I have in almost all issues of \he North Carolina Medical Journal, to read every word in each issue, and I enjoyed reading your repeated challenge in the December issue (NC Med J 1993;54:618). This was a better issue than most of the many good ones, particularly the educational article "Gold, Frankincense, Myrrh, and Medi- cine" by Dennis A. Greene, MD (NC Med J 1993;54:620-2) about the early history of the Bible and a number of things about Israel.

The article by Leslie Newton and Nicholas Stratas, MD, about the actions of the N. C. Board of Medical Examiners (NCMedJ 1993;54:625-32) was particu- larly meaningful for me, a former chair of the Board. Dr. Stratas has had a distin- guished career with the Board, and I think the analysis that he and Ms. Newton made of the disciplinary actions of the Board and how it goes about them is a real education to all those who are puzzled by what the Board has to do.

But nothing quite compares to the article "Gene Stead Looks at Doctoring" (NCMedJ 1993;54:645-50). I have been a "studier of Stead" ever since I was a surgical intern at Peter Bent Brigham Hospital when Dr. Stead came there with Soma Weiss. I have enjoyed him at every opportunity, and I particularly enjoyed this frank article, which I hope will not be his last (though he threatens it will). I was flattered when he asked me to participate with him as associate editor of the Jour- nal, and I have enjoyed that association with you as well.

Dr. Stead madealotof contributions to the lives of many people, and although it is not difficult to disagree with him about a lot of things, it is very difficult to defend oneself in such a disagreement.

Thank you for running such a good

journal. I hope that North Carolina will

continue to have its own journal for the

state Medical Society because of its great

importance to the physicians of this state,

to students, and to historians of the future.

Eben Alexander, Jr., MD

Professor Emeritus

Department of Neurosurgery

Bowman Gray School of Medicine

Medical Center Boulevard

Winston-Salem, NC 27157-1029

To the Editor:

The December issue of the Journal was superb and timely. I enjoyed your editorial and hope that you get many responses. Gene Stead's article was in- teresting, and, as usual provocative. Dr. Carteras' "Four-E" model (NC Med J 1993;54:652-3) was also provocative. I would prefer the "Threc-A" model for the complete physician: astuteness, affa- bility, and most of all availability.

I have been on the editorial board of a number of medical journals over the years and the two that I have enjoyed most are the North Carolina Medical Journal, for its homey and local/state orientation — it's really a state journal, and Emergency Medicine, where my friend Harry Atkins is editor. This journal always has a good mix of curtent chnical articles, brief and well illustrated and presented. Reading it has always been a learning experience for me.

Jay M. Arena, MD

Professor Emeritus

Department of Pediatrics

Box 3024, Duke Univ. Medical Center

Durham, NC 27710

Dr. Neelon comments:

I much appreciate the comments of Drs. Alexander and Arena. Both of them touch on the thing that makes me most proud to be editor of the North Carolina Medical Journal, but Dr. Arena said it most clearly: "It's really a ^raie journal." Many state medical journals look to me like poor imitations of national journals (or like newsletters from the society of- fice). North Carolina's does not. In part that's because we are blessed with the felicitous combination of responsive and enlightened leadership in Raleigh and an articulate, communicative membership — one that writes to and for ihe Journal, that enlightens and entertains and educates us all. My thanks to all our cortespondents and my prayer that all of you will con- tinue to read what we print and to send your thoughts to us.

NCMJ / February 1994, Volume 55 Number 2 61

Board Review: Sustaining Quality Medical Practice To the Editor:

It is with great pleasure that I antici- pate each month's Journal. Not simply because you publish material that I for- ward to you but because of the increas- ingly interesting nature of the Journal itself.

Regarding my article in the Decem- ber issue about the North Carolina Board of Medical Examiners (NC Med J 1993; 54:625-32), I welcome the comments of Dr. John Dees who has made significant contributions to medicine both clinically and organizationally in his distinguished career. Our article provokes many ques- tions, and I hope they will be asked.

Although I am no longer on the Board, I hope that each medical specialty will identify a small committee or repre- sentative group that can engage with the Board in reviewing the Board's experi-

ence with that specialty. Out of this pro- cess we can hope to gain insights regard- ing the steps we must take to sustain and increase the quality of medical practice. The special needs of the primary care physician must be attended to, par- ticularly in light of developing health care reform. However, attention to other specialties will be necessary as well, and can only serve to further improve our care.

Nicholas E. Stratas, MD

Past President (1992-93)

N. C. Board of Medical Examiners

3900 Browning Place, Suite 201

Raleigh, NC 27609

Health Watch: On Alzheimer's Disease To the Editor:

I'm writing concerning the Health Watch section on Alzheimer's disease that appeared in the January Journal (NC

MedJ 1994;55:27-30). I take itthatmuch of this four-page enclosure was obtained from the Alzheimer's Disease and Re- lated Disorders Association and, to my knowledge, this has not been reviewed by the North Carolina Neurological Society. Certainly, the bulk of this material presented is true and factual. Of concern is the absence of reference to other medi- cal conditions that may mimic Alzheimer's disease, (e.g. pernicious ane- mia or depression). Also of alarm is the absence of reference to COGNEX (Tac- rine HCL). This drug was approved in 1993 for the therapy of Alzheimer's dis- ease. Although this agent is not curative, widespread neurological experience has shown that up to 60% of Alzheimer pa- tients may benefit and that 20% may have significant and sometimes spectacular improvement in their cognitive function.

Continued on page 98

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62

NCMJ / February 1994, Volume 55 Number 2

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Instructions for Authors

Manuscript Preparation

Prepare papers according to the "Uniform Requirements for Manuscripts Submitted to Biomedical Journals" (N Engl J Med 1991;324:424-8) with these exceptions: 1) no abstract, 2) no running title, and 3) report measurements in metric units; use of the International System of Units (SI) is optional.

Text (including Letters to the Editor) should be typed with one-inch margins and double-spaced. Title page should include address, and phone and fax numbers of the corresponding author. Submit two copies or a cover letter and a 3 1/2- or 5 1/4-inch computer disc with text written in MS IX)S compatible format (WordPerfect, Microsoft Word, Displaywrite, or ASCII).

Submit illustrations, in duplicate, in the form of color 35mm slides or glossy photographs, or as black-and-white glossy pho- tographs. Label them with author's name, note their position in the text, and indicate image orientation, if necessary. Do not write on the backs of prints. This can damage them. Type legends separately. Tables should be typed, double-spaced, one to a page. Tables must have titles and consecutive Arabic numbers.

Minimize references (no more than 15 if possible, prefer- ably 10 or fewer). The "Uniform Requirements" cited above contain the format for references. Authors are responsible for the accuracy and pertinence of all citations. Avoid abbreviations entirely if possible, or keep them to a minimum. When used, completely define abbreviations at the first usage in the text.

Manuscript Review and Editing

A medically qualified editor reads all manuscripts, and most are also reviewed by members of the North Carolina Medical Soci- ety. Submitted manuscripts must not be under consideration for publication elsewhere. Decisions to publish or not are made by the editors, advised by peer reviewers.

We encourage a relatively informal writing style since we believe this improves communication. Imagine yourself talking with your audience — as long as this doesn't lead you to scientific or linguistic inaccuracy. Be brief, clear, simple, and precise.

We edit accepted manuscripts for clarity, style, and concise- ness. Except for letters, authors receive a copy of the edited manuscript for approval before publication.

Authors retain copyright to articles published in the North Carolina MedicalJournal, but the North Carolina Medical Soci- ety copyrights the contents of each issue. Requests for permission to reprint all or part of an article must be submitted in writing to the address below and negotiated with the author and editor jointly. Reprinted material must carry a credit line identifying that it appeared in the North Carolina Medical Journal. Address manuscripts and correspondence to: Editor, North Carolina MedicalJournal Box 3910, DUMC Durham, NC 27710 Telephone 9191286-6410 Fax 9191286-9219

64

NCMJ / February 1994, Volume 55 Number 2

SCREENING FOR DISEASE

Screening for Oral Cancer

It Takes More Than Just a Look

Jeffrey G. Wong, MD, and John R. Feussner, MD

"Mr. Jones has listened to your explanation about the lack of benefit of a chest x-ray. He states he will continue to abstain from cigarettes and is interested in improving his overall health.

He is worried that his uncle, also a cigarette smoker, died of 'mouth cancer.' Mr. Jones wonders if there are any tests that can assure him that he isn't developing mouth cancer."

What should we tell Mr. Jones? Using the six guidelines provided in our first article on health care screening (NC Med J 1993;54:218-21), we will formulate a recommendation for him, reviewing each guidehne individually in order to arrive at a reasonable therapeutic plan.

Target Disease Considerations

1. Is the disease common or serious enough to warrant screening?

Yes. Cancers of the mouth and oral cavity represent about 6% of all cancers diag- nosed each year in the U.S. This year, about 30,000 new cases will be discov- ered and some 7,700 deaths will be attrib- uted to this disease.' It is only one-fifth as common as cancers of the breast, colon, or lung but it is more than twice as com- mon as cervical cancer.^ Since most oral cancers develop in patients over 40, the incidence rate is expected to rise as the population ages; one study in Connecti- cut has already demonstrated this trend.'

2. Is there a presymptomatic phase in the natural history of the disease during which time a test can detect it?

Yes. Oral cancer usually starts as a lesion in the mouth, on the palate, or under the tongue. Early, localized oral cancers are often asymptomatic and symptoms only appear when regional or distant disease is present." Unfortunately, even when a- symptomatic lesions are seen, patients and doctors may mistake them for "can- ker sores" or other minor, transient ab- normalities.

The test used to detect oral cancer is a careful physical examination of the oral cavity and biopsy of any suspicious le- sions. In one of the earliest papers look- ing at oral cancer, Mashberg and Meyers described the anatomic location and size of asymptomatic squamous cell carcino- mas; they recommended biopsy of all persistent (present for 14 days or more) mucosal abnormalities.'

3. Are there effective treatments for the disease available to use after early de- tection?

Possibly yes. Oral cancer is clinically staged as follows: Stage I — tumor 2 cm or less in diameter and no evidence of lymph node involvement; Stage II — tu- mor 2 cm to 4 cm in diameter but with no lymph node involvement; Stage III — tumor greater than 4 cm in size or a tumor

of any size with an ipsilateral lymph node less than 3 cm in diameter; Stage IV — a large lesion with deep invasion, or the presence of a lymph node larger than 3 cm in diameter, or evidence of distant metastases.' The standard treatment of oral cancer consists of surgical removal and adjuvant radiotherapy as indicated. The natural history of oral cancer is not known, but some data suggest that patients with early-stage oral cancer have a better prognosis than those with ad- vanced disease at the time of diagnosis. A Canadian study demonstrated a five-year survival rate of 63% in patients with localized disease compared to 17% in patients with distant metastases.' How- ever, these results may be misleading due to lead-time and length-time biases (see NC Med J 1993;54:438-40).

Screening Test Considerations

I. Are there screening tests with accept- able sensitivity and specificity available to detect the target disease?

Who knows? There are two methods by which we can screen for oral cancer: inspection and palpation of the mouth

Drs. Wong and Feussner are faculty members with the Division of General Internal Medicine, Box 3375, Duke University Medical Center, Durham 27710.

NCMJ / February 1994. Volume 55 Number 2 65

and adjacent structures, and the use of tolonium chloride oral rinses. Examina- tion should include careful visual inspec- tion, but many cancers occur on the ven- tral and lateral aspects of the tongue and on the soft palate, places not easily seen. Therefore, the recommended examina- tion also involves the use of a gloved hand and gauze pad to fully palpate the oral cavity including the area beneath the tongue, the floor of the mouth, and along all buccal surfaces.' There is, unfortu- nately, little information on the sensitiv- ity of this detailed examination and no data on the accuracy of this procedure (compared to the reference standard of tissue biopsy). In one study, dentists were better at evaluating the oral cavity than were medical physicians, and regular check-ups by a dentist led to diagnosis of a greater proportion of early-stage can- cers (70% in Stage I or II) compared to the group that did not have such regular check-ups (40% in Stage I or II).'

Population-based oral cancer and precancer detection programs have been reported from Sri Lanka' and from rural Virginia,' and the results are mixed. In Sri Lanka, more than 87,000 patients were screened and roughly 6% referred for biopsy. The true positive rate of biopsied lesions ranged from 62%-80%. In Vir- ginia, more than 10,000 patients were screened and, again, about 6% sent for biopsy. In contrast to the results from Sri Lanka, however, the true positive rate in Virginia (that is , the percentage of lesions thatweremalignantorpremalignant) was only 31%. Both of these studies em- ployed a fairly extensive oral examina- tion that may be impractical for a busy clinician to use on each patient.

The dye tolonium chloride (TCI), also known as toluidine blue, selectively stains acidic tissue components such as

exposed DN A or RN A . It has been used as a mouth rinse or applied directly to suspicious lesions. Normal tissues do not stain with TCI but neoplastic tis- sues do. Unfortunately, other inflamma- tory, non-cancerous lesions stain too, lead- ing to a relatively high false positive rate. In addition, lesions with limited dyspla- sia or atypia may not stain consistently and therefore give false negative results. '° A meta-analysis indicated that use of TCI by oral surgeons gave an estimated sensi- tivity of 93%-98% and a specificity of 73%-93% in an extremely high-risk pa- tient population . " No prospective studies evaluate the efficacy of this test in mass screening programs.

2. Can an appropriate population of high-risk patients be identified to un- dergo screening?

Yes. Major risk factors for the develop- ment of oral cancer have been identified (Table 1). This is a disease of the eldedy with an average age at diagnosis of 65 years.' The use of tobacco (of all kinds, but especially chewing tobacco) and ex- cessive alcohol consumption have been linked to higher rates of oral cancer. It has been postulated that the use of tobacco and alcohol together exerts a synergistic effect on carcinogenesis.'^ Other risk fac- tors that may increase the risk of oral cancer include poor dental hygiene, mal- nutrition, the Plummer-Vinson Syn- drome, and excessive mouthwash use.'''''

3. Do the benefits of screening justify the costs of the screening strategy?

Who knows? Without data on sensitivity and specificity it is very difficult to per- form cost/benefit analyses. The costs of screening include the cost of the

Table 1. Major risk factors for oral cancer

1. Advanced age (average age at diagnosis = 65 years).

2. Tobacco use, especially chewing tobacco.

3. Excessive alcohol use, especially with tobacco use.

physician's time spent performing an extensive oral evaluation, the costs of the biopsy and of the histopathological ex- amination of identified lesions, the costs of the TCI dye (if used), and the costs of treatment for positive findings. Other, harder to quantitate costs include the pain experienced by an asymptomatic patient who undergoes biopsy and the "chagrin factor" related to patients who are cleared by a "normal" examination only to later develop oral cancer. And finally, the evi- dence that early detection of oral cancer significantly improves patient outcomes is weak and based on indirect findings.

Recommendations

The National Cancer Institute'^ and the American Cancer Society" recommend that an oral examination (inspection and palpation) be included in the periodic health evaluation. The Canadian Task Force" recommends an annual visual in- spection of the mouth for cancer in males and in all smokers. The U.S. Preventive Services Task Force'* docs not recom- mend full oral examinations for asymp- tomatic persons but states that it may be prudent to offer such an examination to high-risk patients and that everyone over 65 receive regular dental check-ups.

Mr. Jones is at somewhat higher risk for oral cancer because he had been a cigarette smoker. Having carefully in- spected his mouth as part of our routine clinical examination, we would still strongly recommend that he also be seen by his dentist. □

Next in our series on screening strategies for disease, we will discuss the following:

Carol Jones, the 22-year-old daughter of Mr. Jones, comes to the office for periodic examination. She is a senior in college, does not smoke cigarettes, has no significant medical history but has a severe sunburn from her recent spring break trip to the beach. She says that she usually "gels a little burned each year," but that this is the worst she has ever had despite using over-the-counter sunburn cream, and she is still very uncomfortable. On physical exam, she has red hair and even redder skin with an underlying fair complexion. On examination you find no worrisome skin lesions.

What should you tell her about the dangers of sun exposure, the need to regularly use sunscreens, and her risk for skin cancer? How should you plan to follow her?

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NCMJ / February 1994, Volume 55 Number 2

References

1 Boring CC, Squires TS, Tong T. Cancer statistics, 1993. CA Cancer J Clin 1993; 43:7-26.

2 Fedele DJ, Jones JA, Niessen LC. Oral cancer screening in the elderly. J Am Ger Soc 1991;39:920-5.

3 Chen JK, Katz RV, Krutchkoff DJ. Intraoral squamous cell carcinoma: epi- demiologic patterns in Connecticut from 1935 to 1985. Cancer 1990;66:1288-96.

4 Mashberg A, Samit AM. Early detection, diagnosis and management of oral and oropharyngeal cancer. Cancer 1989;39: 69-88.

5 Mashberg A, Meyers H. Anatomic site and size of 222 early asymptomatic oral squamous ceU carcinomas: a continuing prospective study of oral cancer II . Can- cer 1976;37:2149-57.

6 Elwood JM, Gallagher RP. Factors influ- encing early diagnosis of cancer of the oral cavity. Can Med Assoc J 1985; 133: 651-6.

7 Fedele DJ, Jones JA, Niessen LC. Oral

cancer screening in the elderly. J Am Ger Soc 1991;39:920-5.

8 Wamakulasuriya KAAS, Nanayakkara BG. Reproducibility of an oral cancer and precancer detection program using a pri- mary health care model in Sri Lanka. Cancer Del Prev 1991;15:33M.

9 Kaugars GE, Bums JC. An educational program for oral cancer detection. J Can- cer Education 1989;4:175-7.

10 Mashberg A. Final evaluation of tolonium chloride rinse for screening of high-risk patients with asymptomatic squamous car- cinoma. J Am Dent Assoc 1983;106:319- 23.

1 1 Rosenberg D, Cretin S . Use of meta-analy- sis to evaluate tolonium chloride in oral cancer screening. Oral Surg Oral Med Oral Pathol 1989;67:621-7.

12 Blot WJ, McLaughlin JK, Winn DM, etal. Smoking and drinking in relation to oral and pharyngeal cancer. Cancer Res 1988;48:3282-7.

13 Myers EN, Cunningham MJ. Treatment

of choice for early carcinoma of the oral cavity. Oncology 1988;2:18-24.

14 Winn DM, Blot WJ, McLaughlin JK, et al. Mouthwash use and oral conditions in the risk of oral and pharyngeal cancer. Can- cer Res 1991;51:3044-7.

1 5 National Cancer Institute. Working guide- lines for early cancer detection: rationale and supporting ev idence to decrease mor- tality. Bethesda, MD: National Cancer Institute, 1987.

16 American Cancer Society. Guidelines for the cancer -related check-up: recommen- dations and rationale. CA 1980;30:194- 240.

Canadian Task Force on the Periodic Health Examination. The periodic health examination. Can Med Assoc J 1979; 121 : 1193-1254.

US Preventive Services Task Force. Screening for oral cancer. In: Fisher M, ed. Guide to Clinical Preventive Services. Baltimore MD: Williams and Wilkins, 1989:91^.

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NCMJ / February 1994, Volume 55 Number 2 67

REFLECTING ON RESEARCH

Eureka!

It's a Negative Study!

Edward C. Halperin, MD, Deputy Editor

The figure of the solitary researcher, succeeding against over- whelming odds because of a flash of genius, is one of our enduring cultural icons. Like most other schoolchildren, 1 was taught the story of Archimedes (287 B.C.-212 B.C.) — the famous Greek philosopher/scientist. Trying to find a way to determine whether the king's crown was pure gold or was adulterated with silver, Archimedes plopped into the bathtub to think things over. When the water ran over the sides of the tub, he realized that his own body mass had displaced the water. Convinced that one could ascertain density by displacement of a fluid, he ran through the streets of Syracuse shouting his discovery, "Eureka! Eureka!" ("I have found it, 1 have found it"). Of course, he neglected to put on his Christian Dior bathrobe before charging through the streets. Thus, a principle of physics and streaking were discovered simultaneously.

The Myth of the Big Breakthrough

The notion of the solitary scientist winning by virtue of making the "big breakthrough" was reinforced, for me, on the Saturday afternoons of my childhood. When the New York Yankees were rained out, the local television station would fill the void in programming with "Rain-Out Theater." To this constant fare of ancient and honorable black-and-white cinema was added my favorite Sunday afternoon television occupation, "Picture for a Sunday Afternoon." Who can forget Alexander Graham Bell (played by Don Ameche) working tirelessly in his attic to invent the telephone (and, incidentally, win the heart of Loretta Young)? Remember Spencer Tracy's Thomas Edison, sketch- ing out the prototype of the phonograph on a piece of scrap paper and then, within three minutes, demonstrating his success by reciting "Mary Had a Little Lamb" into the device — all while heroic music in the background swelled to a climax?

Dr. Halperin is Professor, Department of Radiation Oncology, Box 3085, Duke University Medical Center, Durham 27710.

Far be it for me to denounce happy childhood memories. It is important to note, however, that the myth of the solitary scientist lives on and with some unpleasant consequences for modem medicine. Recent studies published in the Journal of the American Medical Association (1990;263:1385 and 1991 ;266: 1824) point out that the popular press is biased toward reporting "positive" rather than "negative" medical studies. Your local newspaper or television news shows are far more likely to comment on a clinical trial that appears to offer some "positive" results for the public than to offer a report of a negative study. Thus, the public is much more likely to hear shouts of "Eureka!" about the treatment of cancer, multiple sclerosis, or arthritis than they are to hear about the follow-up trials that show that some earlier "breakthrough" wasn't much of a breakthrough at all. I suppose the press can't be faulted. Nobody wants to hear how many cats didn't climb up a tree yesterday. On the other hand, think of how often a patient comes into your office clutching a newspaper clipping touting some new "breakthrough" reported yesterday and wanting to know whether or not the treatment is appropriate for them or for a loved one.

The Slow Mill of Science

The truth about science, of course, is not to be found in mythical descriptions of Archimedes, Alexander Graham Bell, or Tho- mas Edison. In fact most science is halting: one step forward and three steps back. Just as important as positive trials are the negative trials that show paths that ought not be taken. The benefit of our system of peer-reviewed research publications is that fraud, statistical variation, and unusual circumstances of luck will, eventually, be found out when other people try and fail to reproduce the results of earlier work. We ought to be just as grateful to those whose labor shows what doesn't work as we are to those who find out what does.

I ran up against a similar problem myself in my work as a

68

NCMJ / February 1994, Volume 55 Number 2

radiation oncologist. I have always been fascinated by the number of patients who ingest vitamins or swab various vita- min-laden emollients over themselves in the hopes of prevent- ing cancer, treating cancer, or avoiding the side effects of conventional anti-cancer therapy. Among the most popular nostrums are various forms of vitamin C. A few years ago some colleagues and I investigated whether topical vitamin C could prevent radiation-induced der- matitis. In a randomized, pro- spective, double-blind trial, we found that topical vitamin C was no help. I fired the result- ant manuscript of f to a journal only to have it promptly re- turned. The managing editor said that the study was well- designed, well-performed, and

the science was good, but that

they couldn't publish my paper because "of course, it is a negative trial." I responded with a discussion of bias against reporting negative trials. Eventually, my paper was published (Int J Rad Oncol Biol Phys 1993;26:413), but I was stung.

Recently I had a call from a representative of the Raleigh News & Observer. They were looking for a quote about a new "breakthrough" in the treatment of AIDS. The story was famil- iar to me from the Saturday afternoons of my childhood: A hard-

"Unequivocal breakthroughs are

rare and,...wher^ actually

accomplished the researcher

often hasn't the slightest idea of

what was being broken through."

working medical student, in the face of great odds, had discov- ered that three-drug therapy was a superior way to treat AIDS. Those of you who followed the story in the popular press know, of course, that the results were shortly found by other investi- gators to be less than they were cracked up to be. The story, however, was almost too good not to be true — ^another solitary, heroic researcher succeeding against the odds.

Most biomedical science is collaborative, derivative, slow, and subject to many false starts and dead ends. Unequi- vocal breakthroughs are rare and, as medical historian Rich- ard Gordon points out, when actually accomplished the re- searcher often hasn ' t the slight-

est idea of what was being

broken through. Unfortu- nately, this scenario is just not the stuff of successful screen- plays. Nonetheless, the truth about research and the value of negative trials should keep clinicians from prematurely accept- ing "new" therapies. We can hope for more restrained reporting about science that will diminish the cycle of raised, then dashed, expectations of the public about what research can deliver. Doctors, asa species, shout "Eureka!" more often than it's war- ranted. □

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NCMJ / February 1994. Volume 55 Number 2 69

MODERN MEDICINE

Organ Donation

Rescuing Triumph From Tragedy

Thomas V. Clancy, MD

Not long ago, an experienced nurse devoted to the care of diabetic patients — many of whom are on dialysis — asked me if I would write an editorial that would focus on the importance of caring for donors and on the unique relationship that develops between doctors and the families of donors. Although we are all familiar with the benefits of transplantation and are aware of the great need for donor organs, other less recognized issues emerge from this situation.

As the 20th century comes to a close, science fiction fantasies have now become part of our daily medical practice. Medical research has opened doors for survival to thousands of people — young and old — previously doomed to premature death from irreversible organ disease. That physicians and surgeons can prolong life through the transplantation of internal organs from one human being to another represents an unprec- edented giant step into future medicine.

The Difficulties of Decision

Accompanying such advances are new and complex life situa- tions with which patients, families, and doctors must grapple. Although media coverage of personal tragedy seems endless, one cannot prepare for the experience of visiting the hospital bedside of a child, spouse, or close relative who suddenly becomes a "donor candidate." Under duress, family members first hear the question, "Do you want to have the organs donated?" Federal law mandates the organ request.

One's immediate environment may influence the answer. Today, many hospitals have on their staffs dedicated physi- cians, nurses, members of the clergy, patient representatives, and personnel from organ procurement agencies who assist, educate, and counsel families confronting the crisis. These individuals are committed to the care of potential or consented

donors. The patient remains the center of medical attention until a decision is made to either donate or terminate care.

The Magnitude of the Problem

Two thousand potential recipients of organ transplants died in 1990 while awaiting the ultimate match of their lives; 15,000 others received suitable organs and continued to live. Atpresent, more than 30,000 people await organ transplantation and more than 200,000 people await the donation of specialized tissues. Unfortunately, the number of organ donors has not increased during the past five years. The discrepancy between the number of organs donated and the number of patients awaiting trans- plantation continues to grow. Our potential to reduce the anxiety and despair caused by the anticipation of "dying in the waiting line" lies in our ability to learn from those families who have already made the commitment.

The Triumph of Organ Donation

Among the greatest rewards of organ donation is the sense of purpose and fulfillment that comes to those who make such a donation. Unconditional generosity becomes the answered prayer for multiple others — strangers — still clinging to life. Gifts of such magnitude defy measurement. A profound beUef in the preciousness of life allows people to look beyond their own crisis and consider the plight of others similarly compro- mised by fate. We hold in utmost regard those who, at a time when focusing on others does not come naturally, provide this miraculous opportunity. Their decision to donate is a decision for life. It represents the rescue of triumph from tragedy. □

Dr. Clancy is Assistant Professor of Surgery at the University of North Carolina at Chapel Hill, and Chief, Trauma Service, New Hanover Regional Medical Center and Coastal Area Health Education Center, P.O. Box 9025, Wilmington 28402-9025.

70

NCMJ / February 1994, Volume 55 Number 2

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REPRODUCTIVE HEALTH

Spontaneous Intrapartum Rupture of the Liver

A Life-Threatening Complication of Pregnancy

Philip H. Pearce, MD, FACOG

Spontaneous hepatic rupture is a very uncommon but catastrophic and poten- tially life-threatening complication of pregnancy. It occurs most often in asso- ciation with severe preeclampsia or the HELLP syndrome (Hemolysis, Elevated Liver enzymes. Low Platelets).''^ I used Medline to search the literature from 1976 through 199 1 and found only 65 reported cases plus eight other anecdotally re- corded cases.

I add here my jjersonal experience with a 66th case because it alerts all physicians to the possible pitfalls of a condition (pregnancy) that is usually con- sidered more an altered but normal physi- ological state than a pathological one. There can be no doubt that spontaneous hepatic rupture is a frightfully lethal dis- ease. Since 1976 maternal survival has improved from 41% to 62%, but fetal survival remains low and unchanged at 38% to 40%. The results in my case and my perusal of the literature allow me to summarize current methods of diagnos- ing and managing this disorder.

My Patient

Admission: A 27-year-old black woman, pregnant for the first time, was admitted at 40 weeks' gestation because of nausea.

vomiting, and epigastric pain. Her blood pressure was 225/1 1 8; the tendon reflexes were hyperactive; there was no edema. Urine gave a strong reaction for protein. The fetal heart rate was 1 10 to 1 20; there was no uterine or epigastric tenderness and no evidence of labor; the cervix was closed and thick, the vertex high. She was considered to be preeclamptic and mag- nesium sulfate was given.

She gave a history of hypertension associated with migraine headaches as a teenager, but had no recent symptoms; she was chronically obese. Her prenatal course had been uneventful until the 37ih week of gestation when her BP was found to be 130/98 but there was no proteinuria, her reflexes were normal, the uterine fun- dus measured 35 cms, and there was no edema. Thereafter, she was seen every three to four days. BP remained in the range of 132-150/90-100, but came to normal with resting. Urine protein was trace to 1+. She was asked to remain at bed rest but did not follow this advice. Five days before admission, laboratory studies showed normal blood cell counts, platelet count, bilirubin, uric acid, and liver function test results.

Hospital course: Two hours after admission, we decided to proceed with operative delivery because of mild fetal bradycardia, an unfavorable cervix, and

because laboratory results on admission showed evidenceof the HELLPsyndrome (the bilirubin had increased from its ear- lier value of 0.5 to 0.9; there was marked elevation of the lactate dehydrogenase (LDH) at 1635 (normal 118-242), the alanine aminotransferase (ALT) at 1563 (normal 0-40), and the aspartate ami- notfansferase (AST) 981 (normal 0-45); and theplateletcounthad fallen lo87,000). Immediately after adminisuation of epi- dural anesthesia the BP fell to 70/30, and the fetal heart rate to 80.

Operation: Five hundred cc of intra- peritoneal blood were noted when the abdomen was opened. A low u-ansverse Cesarean section resulted in 300 cc of blood loss from the uterus. There was marked oligohydramnios and meconium. The liver was exposed and noted to be a mottled brown color but there was no active bleeding. A flap or defect was palpable in the anterior right lobe of the liver. BP was 120/50 at the end of sur- gery. The female infant weighed 2030 gm; the pH of the cord blood was 6.72; Apgar scores were 1,5, and 7. Subse- quent growth and development were nor- mal.

Post-operative course: The patient's hematocrit fell from 40 to 22 and her plateletcountto32,000; prothrombin time was 15.3 (normal 11.3-12.7); partial

Dr. Pearce is Assistant Consulting Professor at Duke University Medical Center and in private practice at Durham Women's Clinic, PA, 209 East Carver St., Durham 27704.

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NCMJ / February 1994, Volume 55 Number 2

thromboplastin time, 39 (nor- mal 20.4-30.4); fibrinogen, 210 (normal 173-240); fibrin split products, >40 (normal <10), and the concentration of the D-dimer of fibrinogen was increased. These data were compatible with dis- seminated intravascular co- agulation (consumptive coagulopathy). Her liver function worsened with a bi- lirubin rising to 3.9, LDH to 2305, AST to 2190, and ALT to 1450. Computerized tomo- graphic (CT) scans of the ab- domen on the day of delivery (Fig. 1 ) and the third postpar- tum day revealed hepatic ne- crosis, as well as evidence of subcapsular hematoma and free fluid in the peritoneal cavity. Proteinuria cleared rapidly after delivery and uri- nary output was good.

She was treated with pro- phylactic antibiotics and nifedipine. She received four units of packed red blood cells, four units of fresh frozen plasma, two units of Plasmanate, and eight units of platelets. She was seen by general surgery and hematology consultants, and transferred for six days to Duke Univer- sity Medical Center in case she would need immediate specialized U ver surgery. Fortunately, the patient did well with supportive care and no surgery was re- quired. All laboratory tests returned to normal by six weeks postpartum. Nifedipine was discontinued 12 weeks postpartum and the patient remained nor- motensive.

She was placed on oral contracep- tives, but despite this became pregnant. She requested interruption of pregnancy and sterilization, which was performed six months after her delivery. At laparoscopy the appearance of the liver was entirely normal except for minor adhesions near the site of the laceration previously described. To my knowledge this is the first time that laparoscopic inspection of the liver has documented complete heaUng in a patient managed conservatively for liver rupture.

Fig 1 : CTscan on the day of delivery showing necrosis and subcapsular hematoma in the right lobe of the liver.

Discussion

Abercrombie first described hepatic rup- ture during pregnancy in 1 844 .' A review in 1976" cited 91 cases and quoted a maternal mortality of 59% and a fetal mortality of 62%. My Medline search disclosed 65 additional cases plus the case reported here, and eight other re- ported anecdotally.' The maternal mor- tality in these 74 recent cases had fallen to 38%, but the fetal mortality had not im- proved (3 1 % were stillborn and 3 1 % died posmatally).

All practitioners who care for preg- nant women need to be aware of the hepatic response to eclamptic syndromes. A triad of findings strongly suggests liver hematoma, necrosis, or rupture: toxemia (preeclampsia, eclampsia, or HELL? syn- drome), pain (right upper quadrant or epigastric), and shock. Usually the earli- est laboratory abnormality is an acute drop in the platelet count, followed shortly by a rapid rise in liver enzymes (espe- cially AST and ALT). Hemolysis may occur, leading to an increase in bilirubin and LDH and changes in the peripheral blood smear.

Disseminated intravascularcoagulo- pathy is often seen and can be considered present if one has any three of the follow- ing findings: prolongation of the pro- thrombin time or the partial thrombo- plastin time or both, hypofibrinogenemia, increase in the degradation products of fibrin (the most specific of which is D- dimer), or thrombocytopenia.

The sequence of events is thought to be as follows: Hepatic necrosis and asso- ciated clotting abnormalities lead to intrahepatic and subcapsular hemorrage; the intrahepatic hematoma may then spon- taneously rupture its contents into the peritoneum. Intraperitoneal bleeding can be detected at surgery as in our case or by paracentesis, ultrasound, or CTscan. Liver hematoma without rupture can only be detected by an imaging procedure such as CT, ultrasound, liver-spleen scan, or he- patic arteriography. Patients with liver hematoma, with or without rupture, should be delivered promptly by Cesarean sec- tion in order to avoid the trauma of vagi- nal delivery and to improve the survival rate of the mother and fetus.'' Postpar- tum patients who are hemodynamically stable may be managed conservatively

NCMJ / February 1994, Volume 55 Number 2

73

by giving blood products as appropriate for their clinical condition.'-'"" Hemo- dynamically stable patients may need embolization of the hepatic artery'''*"" if there is evidence of an enlarging hema- toma or small rupture of the liver or when surgery gives only partial hemosta-sis. Patients who are unstable, or who do not respond to conservative management, require surgery to drain the hematoma and acquire hemostasis by suture, use of topical hemostatic agents, hepatic artery ligation, or packing the liver. Hepatic resection should be used only when the surgeon is unable to control life-threaten- ing hemorrhage by any other means, since the underlying hepatic damage of tox- emia is diffuse, but is reversible after delivery."

The causes of the 25 deaths noted since 1976 were: exsanguination in six; sepsis in six; renal failure in five; dis-

seminated intravascular coagulation in four; adult respiratory distress syndrome in two; hepatic failure in one; and cardiac arrest in one. No cause was reported in 10. (The numbers do not add because some list multiple causes of death.)

One issue I have not seen addressed in the literature relates to the risk of subsequent pregnancy in patients who have previously experienced toxemia- related liver rupture. In my review I found reports of only five other patients who had become pregnant after a liver rup- ture. Two delivered without complica- tions" and one was delivered prema- turely by Cesarean section but without liver function abnormality." Two other reports each men tioned a subsequent preg- nancy with normal BP at six to eight weeks of pregnancy but no outcome.''''^ Since the HELLP syndrome occurs in 4% to 12%of patients with severe preeclamp-

sia or eclampsia, and is reported to recur in 4% to 25% of subsequent pregnan- cies,^' the prior presence of this syn- drome would imply that a subsequent pregnancy poses substantial risk.

If we are to reduce the severe mor- bidity and mortality of liver rupture as a complication of pregnancy-induced hy- pertension, physicians must be alert to the symptoms and the laboratory data that aid in the diagnosis and management of this dreadful disorder. Early recogni- tion and an aggressive multidisciplinary approach (utilizing advice from radiol- ogy, anesthesiology, surgery, hematol- ogy, nephrology, and cardiology consult- ants) should improve survival. Early rec- ognition may also lead to successful reso- lution without surgery, since in 15 of the 66 cases I reviewed, patients survived with non-operative management of the liver rupture. Q

References

1 Killam AP, Dillard SH, Patton RC, Pederson PR. Pregnancy induced hyper- tension complicated by acute liver dis- ease and disseminated intravascular co- agulation. Am J Obstet Gynecol 1975; 123:823-8.

2 Weinstein L. Syndrome of hemolysis, elevated liver enzymes and low platelet count: a severe consequence of hyperten- sion in pregnancy. Am J Obstet Gynecol 1982;142:159-67.

3 AmbercrombieJ.Hemorrhageoftheliver. London Medical Gazette 1844;34:7924. [Quoted by Bis & Waxman (Ref #4)].

4 Bis KA, Waxman B. Rupture of the liver associated with pregnancy: a review of the literature and report of two cases. Obstet Gynecol Surv 1976;31:763-73.

5 Merrell D, Koch M. Management of 7 of 8 cases of rupture of liver capsule without surgery. University of Witwaterstand, South Africa. Report at Fourth World Congress of the International Society of Hypertension in Pregnancy. [Reported byGoodlin(ll)].

6 HennyC, Lim A.BrummelkampW.etal. A review of the importance of acute multidisciplinary treatment following spontaneous rupture of the liver capsule during pregnancy. Surg Gynecol Obstet 1983;156:593-8.

7 Herbert W, Brermer W. Improving sur- vival with liver rupture complicating preg - nancy. Am J Obstet Gynecol 1982; 142:5304.

8 Manas KJ. Welsh JD, Rankin RA, Miller DD. Hepatic hemorrhage without rupture in preeclampsia. N Engl J Med 1985; 312:424-6.

9 Neerhof M, Zelman W, Sullivan T. He- patic rupture in pregnancy. Obstet Gynecol Surv 1989;44:407-9.

10 Ekberg H, Leyon J, Jeppson B, et al. Hepatic rupture secondary to preeclamp- sia: report of a case treated conserva- tively. Ann Chir Gynecol 1984;73:350-3.

1 1 Goodlin R, Anderson J, Hodgson P. Con- servative treatment of liver hematoma in the postpartum period: a report of two cases. J Reprod Med 1985;30:368-70.

12 Hibbard L. Spontaneous rupture of liver associated with pregnancy: report of eight cases. Am J Obs Gyn 1976;126:334-8.

13 Woodhouse DR. Conservative manage- ment of spontaneous rupture of the liver in pregnancy: a case report. Br J Obs Gyn 1986;93:1097-9.

14 Loevinger E, Vujic I, Lee W, Anderson M. Hepatic rupture associated with preg- nancy: treatment with transcatheter embolotherapy. Obstet Gynecol 1985; 65:281-4.

15 Minuk G, Lui R, Kelly J. Rupture of the liver associated with acute fatty liver of

pregnancy. Am J Gastroenterol;82:457- 60.

16 Terasaki K, Quinn M, Landell C, et al. Spontaneous hepatic hemorrhage in preeclampsia: treatment with hepatic anterial embolization. Radiology; 174:1039-41.

17 Smith L, Moise K, Dildy G, Carpenter R. Spontaneous rupture of liver during preg- nancy. Obstet Gynecol 1991;77:171-5.

18 RoopnarinesinghS,JankeyN,Gopeesingh T. Rupture of the liver as a complication of preeclampsia: case report and review of the literature, hit Surg 1981 ;66: 169- 70.

19 Cathcart RS, Buxton JT, Principe RF, et al. Spontaneous rupture of the liver in pregnancy. J SC Med Assoc 1977;73:420- 2.

20 ParekhD,Sathianathan,I,WachaD. Sf)on- taneous rupture of the liver during preg- nancy. Med J Zambia 1982;16:10-3.

21 Sibai B, Taslimi M, El-Nazer A, et al. Maternal-perinatal outcome associated with syndrome of hemolysis, elevated liver enzymes and low platelets in severe preeclampsia/eclampsia. Am J Obstet Gynecol 1986;155:501-9.

Additional references derived from Medline search are available from the author on re- quest.

74

NCMJ / February 1994, Volume 55 Number 2

YOCON*

YOHIMBINE HCI

Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-16a-car- boxylic acid methyl ester. The all<aloid is found in Rubaceae and related trees . Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolalkylamine all(aloid with chemical similarity to reserpine. It is a crystalline powder, odorless. Each compressed tablet contains (1/12 gr.) 5.4 mg of Yohimbine Hydrochloride.

ActliMi: 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 m 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 mydriatnc. It may have activity as an aphrodisiac.

Contraindications: Renal diseases, and patient's sensitive to the drug. In view of the limited and inadequate informahon at hand, no precise tabulation can be offered of additional contraindications. Warnii^: 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 shouW it be used in conjunction with mood-modifying drugs such as antidepressants, or in psychiatric patients in general. Adverse Reactions: Yohimbine readily penetrates the (CMS) and produces a complex pattern of responses in lower doses than required to produce periph- eral a-adrenergjc-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 dnjg.''^ Also dizziness, headache, skin flushing reported when used orally.i'3 Dosage and Adminisfration: Experimental dosage reported In treatment of erectile impotence. ^'3.4 1 tablet (5.4 mg) 3 times a day, to adutt 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.^ How Skipplied: Oral tablets of Yocon® 1/12 gr. 5.4 mg in bottles of 100's NDC 53159-001-01 and 1000's NDC 53159-001-10. References:

1. A.-Morales et at,. 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 et al. , The Journal of Urology 128: 45-47, 1982.

Rev. 1/85

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Difficulty Finding and Removing a Norplant® System Capsule

Takey Crist, MD, FACOG, FACS, M.R. Barnes, MD, FAFP, and W.C. Whitehurst, MD

Norplant® is a long-acting, reversible hormone contraceptive for women that the U.S. Food and Drug Administration recently approved for use. It has been tested for 20 years in 46 countries, and more than 500,000 women have used it as a contraceptive method. Sixteen countries other than the U.S. also permit its use.

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Several months ago, one of our patients came to the of- fice requesting the removal of six Norplant® capsules. Her ob- stetrician made a surgical inci- sion in the medial aspect of her upper right arm and easily re- moved five of the capsules, but could not locate the sixth one by digital probing. We referred the patient to the Radiology Department at Onslow Me- morial Hospital in Jacksonville where the sixth capsule was faintly visualized

on plain radiographs using soft-tissue technique.

The patient then underwent real-time sonography in hopes of a more precise localization, but the capsule could not be

visualized, probably because of interfer- ing soft tissue edema and air left by the earlier incision. The patient was taken to the computed tomography suite, and multiple thin (3 mm) slices were ob-

tained, but the capsule could not be iden- tified, again probably due to the edema and air in the incision site.

We did not actually subject the pa- tient to magnetic resonance imaging but we wanted to determine whether or not that technique could be helpful. We placed an identical Norplant* capsule on a water phantom and obtained multiple Tl -weighted and T2- weighted images, but again the capsule could not be seen.

Finally, using intermit- tent fluoroscopy and persistent digital probing, the obstetrician , was able to localize and re- move the sixth capsule. Never- theless, our experience with this patient has demonstrated to us that a Norplant* capsule can be very difficult to precisely lo- calize— even in a modem radi- ology department — when the capsule is surrounded by sub- cutaneous edema and air. We believe that the manufacturers of the Norplant* capsules and similar devices should modify their prod- ucts so that they can be more easily local- ized by sonography or fluoroscopy when the devices cannot be located by palpa- tion and probing. □

Drs. Crist and Barnes are physicians at the Crist Clinic for Women, Surgical Ambulatory Care Center, 200 Memorial Drive, Jacksonville 28546. Dr. Whitehurst is chief radiologist at Onslow Memorial Hospital, Jacksonville 28546. (Computer graphic redrawn from Norplant® System prescribing information, Wyeth-Ayerst Laboratories, 12/90)

76

NCMJ / February 1994, Volume 55 Number 2

.:^^^

o^

? ^ NORTH CAROLINA MEDICAL SOCIETY

Health Watch

LIFT IT SAFE

The American Academy of Orthopaedic Surgeons has launched a nationwide public education program on preven- tion of back pain — Lift It Safe. The program is aimed at professional health care workers and home caregivers — persons caring for an injured or ill family member at home — as well as industrial and business workers. The following is information provided by this program. Anyone interested in obtaining more information can contact the Communica- tions Department of the American Academy of Orthopaedic Surgeons at 6300 N. River Rd., Rosemont. IL 60018.

More people see doctors for back pain than for any other medical ailment except colds and upper respiratory com- plaints. Over six million persons a year see their doctor for this aliment, often because they did not use the proper methods of lifting and moving an object.

Back pain is common not only among laborers and warehouse workers, but also caregivers. Studies show that nurses rank second only to heavy industry workers in the number of persons suffering back pain. If you are caring for

North Carolina Medical Society, PO Box 27167, Raleigh, NC 27611.

an ill or injured family member at home, you are at risk of suffering back pain or injury unless you use the proper methods of Ufting and moving the person.

If Ufting is part of your job, it is important to do it correctly.

Back Pain is Costly

Most back pain lasts only a few days, but about one in six persons have experienced severe back pain that lasts at least two weeks sometime during their Ufe. The cost of treatment, lost wages, and rehabilitation of all sufferers of back pain is unknown, but it is beheved to be enormous. Just the direct costs of insurance-compensated medical bills and payment for lost wages related to low back pain are estimated at more than $11.5 billion a year. Indirect costs of lost production time, training unskilled replacements for disabled workers, administrative costs, etc., are difficult to determine, but significantly increase the total cost.

Back pain caused by hfting can be prevented if you use proper lifting techniques and exercise regularly to improve your muscle strength and overall physical condition. To Lift It Safe:

NCMJ / February 1994, Volume 55, Number 2

77

Plan ahead what you want to do and don't be in a huny.

Separate your feet shoulder- width apart to give you a solid

base of support.

Bend at the knees.

Tighten your stomach muscles.

Position the person or object close to your body before

lifting.

Lift with your legs.

Avoid twisting your body; instead, point your toes in the

direction you want to move and pivot in that direction.

Maintain the natural curve of your spine; don ' t bend at your

waist.

Do not try to lift by yourself an object that is too heavy or

an awkward shape. Get help.

Lifting Techniques for Home Caregivers

If you are taking care of a family member at home, you are at greatest risk for back pain when you are:

• pulling a person who is reclining in bed into a sitting position

• transferring a person from a bed to a chair

• leaning over a person for long periods of time

Sitting up in bed

To move a person lying in bed to a wheelchair, put the chair close to the bed and lock the wheels. If the person is not strong enough to push up with his or her hands to a sitting position, place one of your arms under the person's legs and your other arm under his or her back. Move the person's legs over the edge of the bed while pivoting his or her body so the person ends up sitting on the edge of the bed. Keep your feet shoulder-width apart, your knees bent and your back in a natural straight position.

Standing up

If the person, who is sitting, needs assistance getting into a chair, face the patient, spread your feet shoulder-width apart, and bend your knees. Position the person's feet firmly on the floor and slightly apart. The person's hands should be on the

bed or armchair or on your shoulders. Place your arms around the person's back and clasp your hands together or use a transfer belt which fits around the person's waist and pro- vides a secure handhold. Hold the person close to you, lean back, and shift your weight as you lift the person to an upright position.

s"^"

Caring

Caregivers who assist seated or reclining persons for long periods of time should stand with their knees bent and their back in a natural straight position. Don't bend at your waist.

Preventing Bacic Pain at Woric and at Home

When lifting objects at home or at work you need to take precautions that will prevent injury to your back.

• Plan ahead what you want to do and don't be in a hurry. Position yourself close to the object you want to lift. Separate your feet shoulder-width apart to give you a solid base of support. Bend at the knees. Tighten you stom- ach muscles. Lift with your leg muscles as you stand up. Do not bend at your waisL Don't try to lift by yourself an object that is too heavy or an

awkward shape. Get help.

• While you are holding an object, keep your knees slightly bent to maintain your balance. If you have to move the object to one side, avoid twisting your body. Point your toes in the direction you want to move and pivot in than direction. Keep the object close to you when moving.

78

NCMJ / February 1994, Volume 55. Number 2

• If you must place an object on a shelf, move as close as possible to the shelf. Spread your feet in a wide stance, positioning one foot in front of the other, to give you a solid base of support Do not lean forward and do not fully extend your arms while holding the object in your hands.

• If the shelf is chest high, move close to the shelf and place your feet apart and one foot forward. Lift the object chest high, keep your elbows at your side and posi- tion your hands so you can push the object up and on to the shelf. Remember to lighten your stom- ach muscles before lifting.

Exercise to Lessen Problems with Bacl< Pain

You can minimize problems with back pain with exercises that make the muscles in your back, stomach, hips and thighs strong and flexible. Some people keep in good physical condition by being active in recreational activities like run- ning, walking, bike riding and swimming. In addition to these conditioning activities, there are specific exercises that are directed toward strengthening and stretching your back, stomach, hip and thigh muscles.

Before beginning any exercise program, you should dis- cuss the program with your doctor and follow the doctor's advice. It is important to exercise regularly, every other day. Before exercising you should warm up with slow, rhythmic exercises; if you haven't exercised in some time, you can warm up by walking. Inhale deeply before each repetition of an exercise and exhale when performing each repetition of an exercise.

Exercises to strengthen your muscles

Wall slides to strengthen back, hip and leg muscles.

Stand with your back against a wall and feet shoulder- width apart. Slide down into a crouch with knees bent to about 90 degrees. Count to five and slide back up the wall. Repeat five times.

Leg raises to strengthen back and hip muscles.

Lie on your stomach. Tighten the muscles in one leg and raise it from the floor. Hold your leg up for a count of 10 and return it to the floor. Do the same with the other leg. Repeat five times with each leg.

Leg raises to strengthen stomach and hip muscles.

Lie on your back with your arms at your sides. Liftoneleg off the floor. Hold your leg up for a count of 1 0 and return it to the floor. Do the same with the other leg. Repeat five times with each leg. If that is too difficult, keep one knee bent and the foot flat on the ground while raising the other leg.

Partial sit-ups (crunches) to strengthen stomach muscles.

Lie on you back with knees bent and feet flat on floor. S lowly raise your head and shoulders off the floor and reach with both hands to- ward your knees. Count to 10. Repeat five times.

Back leg swings to strengthen hip and back muscles.

Stand behind a chair with your hands on the back of the chair. Lift one leg back and up while keeping the knee straight. Re- turn slowly. Raise the other leg and return. Repeat five times with each leg.

NCMJ / February 1994. Volume 55. Number 2

79

Exercises to decrease the strain on your bacic

Lie on your back with your knees bent and feet flat on your bed or floor. Raise your knees toward your chest. Place both hands under your knees and gen- tly pull your knees as close to your chest as possible. Do not raise your head. Do not straighten your legs as you lower them. Start with five repetitions, several times a day.

Lie on your stomach. Place your hands un- der your shoulders with your elbows bent and push up. Raise the top half of your body as high as possible, al- lowing your hips and legs to remain flat on the be or floor. Hold the position for one or two seconds. Repeat 10 times, several times a day.

Stand with your feet slightly apart. Place your hands in the small of your back. Keep your knees straight Bend back- wards at the waist as far as possible and hold the position for one or two seconds.

Are You at Risk?

You are most at risk for back pain if:

• your job requires frequent bending and hfting

• you must twist your body when lifting and carrying an object

• you must lift and carry in a hurry

• you are overweight

• you do not exercise regularly or do not engage in recre- ational activities

• you smoke

How to Prevent Back Pain

• Use the correct lifting and moving techniques. Get help if an object is too heavy or an awkward size.

• Exercise regularly to keep the muscles that support your back strong and flexible.

• Don't slouch; poor posture puts a strain on your lower back.

• Maintain your proper body weight. Being overweight puts a strain on your back muscles.

• Keep a positive attitude about your job and homelife; studies show that persons who are unhappy at work or home tend to have more back problems and take longer to recover than persons who have a positive attitude.

What to Do if You Get Acute Back Pain

Lie down on your back and relax for 20 to 30 minutes. Ice packs help reduce the initial pain and swelUng. Most back pain disappears in a few days. Your treatment may begin with a short period of rest in bed. Depending on the source of the back pain, your orthopaedist may suggest medication. Your treatment will eventually involve exercises to prevent recur- rence of back pain.

While surgery is uncommon, operative treatment may be recommended for problems that are not responsive to other therapies. Q

80

NCMJ / February 1994, Volume 55, Number 2

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32

NCMJ / February 1994, Volume 55 Number 2

PEDIATRIC HEALTH

Foreign Body Aspiration in Nortii Carolina Children

Amelia F. Drake, MD, Timothy L. Smitii, MD, and Newton D. Fischer, MD

The sound of a child choking creates anxiety in all who realize the potential complications that follow foreign body aspiration. Fortunately, most "choking spells" are self Umited, and the foreign body is cleared from the airway by cough and gag reflexes. However, when aspira- tion occurs despite these defense mecha- nisms, early diagnosis and prompt treat- ment of this potentially lethal problem are essential.

We present here a complicated, but successfully managed, case of foreign body aspiration and review the nature of this problem in North Carolina and throughout the world.

Our Patient

A 16-month-old Hispanic boy experi- enced a "choking episode" while eating candied peanuts. The child was taken to an emergency departmentanddischarged after no evidence was found of airway foreign body. The child's mother returned with him to the emergency department five times because he continued to cough and wheeze. Ten days after the initial event, the child was referred to us.

On physical examination, he was afebrile; respirations were 24/minute and unlabored. On auscultation, mild inspira-

From the Division of Ololaryngology/Head and Neck Surgery, UNC Hospitals, CB# 7070, Chapel Hill, NC 27599.

tory and expiratory upperairway wheezes were heard on the right. Anteroposterior and lateral chest radiographs demon- strated right middle lobe atelectasis (Fig.

1).

He was taken to the operating suite where visualization using the rigid bronchoscope revealed diffuse inflam- mation and edema of the right mainstem bronchus. Fragments of peanut were re- moved piecemeal from the right mainstem bronchus and multiple mucous plugs were removed by suctioning. The procedure was tech- nically difficult because of the diffuse inflamma- tory response initiated by the foreign body. The pa- tient was kept overnight in the pediatric intensive care unit; he developed wheezing which respond- ed to inhaled albuterol. He was discharged to home the following day.

The patient returned, as scheduled, five days later. Chest radiograph re- vealed persistent right middle lobe atelectasis. The patient was returned to the operating room where rigid bronchoscopy revealed multiple small fragments ofpeanut in the distal right main bronchi- oles. These were removed

using a combination of rigid and flexible bronchoscopes and foreign body forceps. A few small peanut fragments could be seen in, but not removed from, distal subsegmental bronchi. The patient was again observed overnight and discharged to home.

At the return appointment 10 days later, the patient's mother stated that the child had coughed up at least one small piece of peanut. Chest radiographs were normal.

Fig 1 : Chest radiograph demonstrating patchy infiltrate of the right lung secondary to foreign bodies (pieces of peanut) in the right mainstem bronchus.

NCMJ / February 1994, Volume 55 Number 2

83

Discussion

Accidental deaths are one of the great tragedies of childhood, the more so be- cause they often result from preventable causes. One such problem is foreign body aspiration. Fortunately the number of deaths from this cause is small, but the morbidity can be severe, especially when the diagnosis is delayed, as in our case. Table 1 shows that 52 North Caro- lina children died from aspiration of food substances and 36 from aspiration of other foreign bodies during the 1 1 -year period, 1980 through 1991. This means an aver- age of 4.7 deaths each year from food aspiration and 3.3 from aspiration of other objects. By way of comparison, from 1980 to 1985, aspiration of food caused only 180 deaths (and aspiration of other items, 144 deaths) in children aged 0 to

Table 1 . Number of children who died In North Carolina because of Inhaled foreign bodies, 1980-1991*

Age of child <1 year 1-4 years 5-14 years

Nature of aspirated

foreign body

Food Other objects

26 19

21 11

5 6

*Data from Baker SP, Waller AE. In: Child- hood injuries state by state mortality facts. Johns Hopkins Injury Prevention Center pam- phlet, 1/89.

14 years' throughout the entire U.S. (giv- ing rates for the entire country of 36 and 28.8 deaths per year, respectively). These data suggest a greater problem in North Carolina, which has about 3% of the nation 's population but about 1 2% of the childhood aspiration deaths. One reason may be our large African American popu- lation. The death rate for aspiration inju- ries to African American and Native American children is two or more times higher than the death rate for white chil- dren. Childhood mortality in North Caro- lina is related to socioeconomic class.^

A Distillation of the World's Literature

It is hard to estimate the number of non- fatal aspiration injuries that occur since these are not reported. A re- view of the literature reveals large series of cases from many medical centers all over the world. All reports show data consistent with the following summary:

1) Foreign body aspiration is unusual in children less than six months old.

2) Foreign body aspiration has a peak incidence in children aged one to two years.

3) Foreign body aspiration

Table 2. Correlation of symptoms and site of obstruction after foreign body aspiration*

Clinical presentation

Larynx

Site of obstruction Trachea Bronchus

Total

Wheeze only

Cough only

Wheeze and cough

Hemoptysis

Stridor

Threatened asphyxia

No symptoms

0 0 2 0 15 4 2

7 2

0

1 0 1 2

99 51 17 12 0 7 11

106 53 19 13 15 12 15

Number of patientsf

20

13

197

230

'Data from Pyman"

tNote: The numbers do not always add up because

some patients had more than one symptom.

decreases remarkably after three years of age.

4) More than half of the objects aspi- rated are food materials (usually nuts or seeds) and more than half of these are peanuts.

5) Most foreign bodies lodge in the right main bronchus.

6) Boys aspirate 1 .2 to 2.0 times more often than girls.

7) Often the choking episode is ob- served; if the child is less than two years old, the episode is often wit- nessed by a responsible adult.

8) About 30% of patients do not obtain care until three or more days after the original episode; 50% of pa- tients who seek care late do so be- cause of parental negligence.

9) About 1% to 2% of patients cough up objects spontaneously.

10) Some patients have no symptoms,

and the classic triad — cough, wheez- ing, and decreased breath sounds — is not always present.

11) Chest x-rays are useful but may be negative. Antero-posterior and lat- eral films in inspiration and expira- tion are more helpful than comput- erized tomographic scans.

12) A death rate of 1% to 2% is reported for bronchoscopic removal (under general anesthesia).

The problem of aspiration exists worldwide. We have found reports from England (40 patients),' from China (400 patients),"'"" two from Germany (94 patients' and 224 patients'), two from the U.S. (143 patients^ and 331 patients*), from Israel (200 patients),' from Greece (90 patients),'" from Turkey (500 pa- tients)," from Canada (202 patients),'^ and from Australia (230 patients)." The papers from China describe in detail the overall data," radiologic findings,'" and causes and complications of late diagno- sis (greater than three days)." The report from Turkey" details the four types of bronchial obstruction that can occur

1) Acheckvalve — air can be inhaled but

not completely expelled.

2) A stop valve — complete obstruction.

3) A ball valve — the foreign body dis- lodges during expiration and reimpacts during inspiration.

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NCMJ / February 1994, Volume 55 Number 2

4) A by-pass valve — there is partial

obstruction of a bronchiole leading

to atelectasis.

The report by Pyman from Austra- lia'' is especially helpful because it cor- relates six broad types of clinical pre- sentation with the location of the for- eign body in the respiratory tract. Table 2 summarizes the data from that paper.

Our patient's case illustrates the complexity of managing patients with foreign body aspiration. This child made six trips to the emergency room — and two to the operating room — before his problem was resolved. Foreign body aspiration is potentially life-threaten- ing, and the surgical expertise required to remove a distally located foreign body is considerable. Each aspirated foreign body is unique in location, con- sistency, length of time that it has been present, and amount of surrounding tis- sue reaction (Fig. 2 shows some of the various objects we have removed from the airways of children over the years).

Although some authors consider foreign body aspiration to be a form of child abuse or neglect," the most urgent

thing for a physician caring for a child who has had a "choking" episode is that he or she recognize the sometimes subtle findings, know the potentially disastrous consequences, and arrange or provide the careful evaluation and follow-up that are needed. □

Fig 2: A collection of aspirated foreign bodies removed at UNC Hospitals (clock- wise from top left: a jack, a metal cap of Cfiristmas tree ornament, a piece of Lego, and a portion of a paper clip.

References

1 Waller AE, Baker SP, Szocka A. Child- hood injury deaths: national analysis and geographic variations. Am JPublic Health 1989;79:310-5.

2 NelsonMD Jr. Socioeconomic status and childhood mortality in North Carolina. Am J Public Health 1992;82:1131-3.

3 Davis CM. Inhaled foreign bodies in chil- dren. Arch Dis Child 1966;41:402-6.

4 Mu L, He P, Sun D. Inhalation of foreign bodies in Chinese children: a review of 400 cases. Laryngoscope 1991;101:657- 60.

5 SteenKH.ZimmermannT. Tracheobron- chial aspiration of foreign bodies in chil- dren: a study of 94 cases. Laryngoscope 1990;100:525-30.

6 Mantel K.Butenandtl. Tracheobronchial foreign body aspiration in childhood: a report of 224 cases. Eur J Pediatr 1986; 145:211-6.

7 CohenSR, Herbert WI, Lewis GB.Geller KA. Foreign bodies in the airway: five- year retrospective study with special ref- erence to management. Ann Otol Rhinol Laryngol 1980;89:437-42.

8 Catch G, Myre L, Black RE. Foreign body aspiration in children: causes, diag- nosis, and prevention. AORN J 1987; 46:850-61.

9 Blazer S, Naveh Y, Friedman S. Foreign body in the airway: areview of 200 cases. Am J Dis Child 1980;134:68-71.

10 Daniilidis J, Symeonidis B, Triaridis K, Kouloulas A. Foreign body in the air- ways: a review of 90 cases. Arch Otolaryngol 1977;103:570-3.

1 1 Aytac A, Yurdakul Y, Ikizler C, et al. Inhalation of foreign bodies in children: report of 500 cases. J Thorac Cardiovasc Surg 1977;74:145-51.

12 KimIG,BrummiuWM,HumphryS,etal. Foreign body in the airway: a review of 202 cases. Laryngoscope 1973;83:347- 54.

13 Pyman C. Inhaled foreign bodies in child- hood: a review of 230 cases. Med J Aust 1971;62-8.

14 Mu LC, Sun DQ, He P. Radiological diag- nosis of aspirated foreign bodies in chil- dren: review of 343 cases. J Laryngol Otol 1990;104:778-82.

15 Mu L, He P, Sun D. The causes and complications of late diagnosis of foreign body aspiration in children: report of 210 cases. Arch Otolaryngol Head Neck Surg 1991;117:876-9.

16 Friedman EM. Caustic ingestions and for- eign bodies in the aerodigestive tract of children. Pediatr Clin North Am 1989; 36:1403-10.

NCMJ / February 1994. Volume 55 Number 2

85

TOXICENCOUNTERS

Will the Defendant Please Rise?

Black Widow Spider Poisoning

Ronald B. Mack, MD

When my brother and I were young, our father would regale us with stories about our cousins from his side of the family. We rarely met them, even though we lived in the same big city. Times were bad, money was hard to come by (le- gally), and people did what they could to survive. Our paternal figure ran a "speak- easy" in a "blind pig" and we did reason- ably well considering we lived in an apart- ment, had no automobile, and prayed that Prohibition would never be repealed. The Volstead Act and the 18th Amendment to the U.S. Constitution became our tickets to "three hots and a cot" (see Glossary). Our male cousins. Dad would tell us, were rarely able to buy new suits. When

they did he would slyly ask us, "What were the first words they heard when they wore the suits for the first time?" Playing along with our loved one, we would not answer, even though we knew the correct reply. Then Dad would say, "Will the defendant please rise!" as the bailiff of the court would say when the judge pre- pared to pass sentence on members of our extended family.

And so the clinician-manager must think of the black widow spider in a similar way: as the guilty perpetrator in patients unlucky enough to have been bitten and then suffer acute onset of muscle pain and cramping with board-like rigid- ity of the abdomen.

Glossary

blind pig

illegal liquor establishment

18th Amendment

Ratified 1/16/19. Prohibited the manufacture, sale, or transportation of intoxicating liquors within the U.S.; also banned the import and export of such beverages. (The 19th Amendment, ratified on 12/5/33, repealed the 18th Amendment.)

speakeasy

a place where alcoholic beverages were illegally sold

three hots and a cot

three meals a day and a bed to sleep in

Volstead Act

provided the means to investigate and punish violators of the 18th Amendment

The Ubiquitous Arachnid

Spiders are, allegedly, the most numer- ous, widespread, and varied of all of the animals on earth.' (Oh really? 1 thought lawyers were.) To date, more than 1(X),000 species have been identified; they can be found on land, in the air, and on and under water — lite rally anywhere on earth where life prevails. Almostall species of spiders produce a venom, obviously to help them trap, kill, and eat prey, but very few are poisonous to us. The two potentially most dangerous spiders in this country are the Latrodectus sjjecies (the black widow and her friend) and the Loxosceles (the brown recluse and its relatives). For a discussion of the brown recluse spider, see my article, "The Bite of the Spider Woman: Loxosceles reclusa [The Brown Recluse]" NC Med J 1992;53:200-3.

Black widow spiders are members of the genus Latrodectus ("robber-biter" or "murderer"). Only the lady form of this genus is dangerous to human beings. Because 1 am politically correct I will not comment on this gender disparity in wreaking havoc but 1 can think about it, silently, to myself These animals are small, eight-legged varmints, divided into two parts: a cephalolhorax and a large bag-like abdomen. The chelicera (a.k.a. fangs) can be readily apparent or loo small to be seen. They spend their entire lives trapping and eating flies, mosqui-

Dr. Mack is a faculty member with the Department of Pediatrics, Bowman Gray School of Medicine, Medical Center Boulevard, Winston-Salem 27157.

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NCMJ / February 1994, Volume 55 Number 2

toes, and various other insects. The ma- ture lady black widow can be quite attrac- tive with a glossy black, gray, or brown color complete with a red, orange, or yellow hourglass marking on the ventral surface of the abdomen (the tummy, dummy !).Mtisabout the sizeofaquarter, i.e. 1 to 1-1/2 inches long, when the legs are extended. The "prepubertal," as it were, immature female black widow spi- ders have red, brown, or cream markings on their dorsal and cream -colored hour- glass markings on their ventral surfaces. As with very young girls everywhere, their bites are not dangerous.

In order to be able to spend their entire existence catching and eating bugs, black widows exert a fair amount of en- ergy constructing webs to catch their prey (Remember, it's "Won't you come into my parlor?" said the spider to the fly, not "What is your sign?" "Haven't we met before?" or "What's a pretty fly like you doing in a dump like this?"). Black wid- ows like to hang out in warm dry areas, dimly lit and surrounded by flies. Out- houses were at one time the classic loca- tion where black widow spiders could bite and yell, "Gotcha!" particularly if they attacked a male and his netherparts (for this the spider could earn points for the Arachnid Hall of Infamy). The out- door privy has largely disappeared, of course, except in our part of the continen- tal U.S.

Now these shy, allegedly non-vio- lent critters spin their webs in trash dumps, hollow tree stumps, under wood piles, in stone walls and garages, in bams and stables, as well as indoors in storage sheds, closets, basements, clothes boxes, and trunks. The webs are typically irregu- lar, located in comers and generally un- disturbed areas.

You can find Latrodectus species all over the world but they are most preva- lent in tropical climes. They can be found throughout most of the U.S. but are most common in the southwestern and south- eastem states and in California.^ There are more than 20 species although the clinical adversities they produce are qui te similar. In the U.S. there are only five species of Latrodectus; remember only the females are dangerous to people.

Black Widow Bites

Black widow spider bites are the leading cause of death from arthropod envenom- ations in the U.S. Most fatalities occur in very young children and senior citizens. The morbidity and mortality result from systemic envenomation. On a volume- per-volume basis, the neurotoxic venom of Latrodectus mactans is more potent than that of pit vipers such as a cotton- mouth or rattlesnake.'" Fortunately, the spider's venom glands, located in its cephalothorax, contain less than 0.2 mg of venom. These glands have walls com- posed of striated muscle that control the delivery of venom. Mean lethal doses, in humans, range from .(X)5 to 1.0 mg/kg." The venom adversely affects the motor end-plates of neuromuscular synaptic membranes by binding gangliosides and glycoproteins at the synapses.' This bind- ing keeps the channels for sodium influx open regardless of normal action poten- tial properties. There is a pathophysi- ological release of acetylcholine and nore- pinephrine into the synapse and inhibi- tion of re-uptake. All of this biochemical interplay results in excessive stimulation of the motor end-plate. The really bad actor in this spider's venom is a peptide known as d-latrotoxin, which is respon- sible for the systemic effects of this type of spider bite.'

The clinical effects resulting from a black widow spider bite can be divided into local and systemic. The most imme- diate effect may be a sensation of pinprick or pinching, but there may be no initial painful sensation. If pain does occur, it usually subsides in a matter of minutes and is replaced by a dull ache or sensation of numbness that appears 20 to 40 min- utes later, accompanied by swelling, erythema, and pruritus.^ Inspection of the area involved may reveal two red punc- ture marks flanked by an area of blanch- ing. This is surrounded by an outer blue- red border, referred to as a "target" or "halo" lesion.' The puncture marks are 1 to 2 mm apart. Most bites occur on the distal extremities, buttocks, or genital areas ." B lack widow venom does not pro- duce tissue necrosis as does that from Loxosceles (brown recluse) spiders.

The worrisome effects of a black widow spider bile to the patient and the doctor are the systemic manifestations. The clinical adversities that can ensue from a small amount of this potent toxin include muscle cramping, tachycardia, hypertension, local or generalized dia- phoresis, salivation, lacrimation, and bronchorrhea.^ These cholinergic effects can mimic organophosphate or carbam- ate insecticide poisoning. Here is where a very careful history can lead you down the correct diagnostic path.

The unfortunate victim of a black widow attack can experience severe pain and spasms of large muscle groups that typically begin as early as 30 to 60 min- utes after the bite. This discomfort peaks in one to six hours, although other symp- toms may continue to increase for 24 hours. The pain itself can persist for sev- eral days. The classical board-like rigid- ity of the abdomen that is often seen is more often associated with bites on the lower extremities. This scary abdominal rigidity can be very confusing, especially if the history of a bite is not evident, since it may suggest other kinds of catastrophe such as acute appendicitis, peritonitis, renal