Pharmacopeia, which appears to be the latest edition, is not a book of standards and specifications in the sense
that the United States Pharmor
copeia and the National Formulary are. There are no tests for identity, purity, quality, or potency. It is more
reminiscent of an herbal of several centuries back rather than a compen¬ dium of modern drugs. It is not at all comforting that "the bill assures that future homeopathic preparations will be processed through the monograph system." This presumably suggests that all new homeopathic prepara¬ tions will be subjected to the rigorous tests for safety and efficacy that are now required of drug products used in allopathic medicine. With the excep¬ tionally large number of homeopathic preparations currently listed as avail¬ able and with the dearth of meaning¬ ful research in this area, it is unlikely that any new homeopathic prepara¬ tions will emerge. The analysis report further notes "that homeopathic drugs have never been fully subjected to the require¬ ments of the current FD&C Act, and should be distinguished from allo¬ pathic drugs under the Drug Regula¬ tion Reform Act. Any other approach would probably not be cost-effective in protecting the public health, given the present role of homeopathic medi¬ cine in the United States." This does not appear to be adequate justifica¬ tion for continuing the official status of the Homeopathic Pharmacopeia. Martin I. Blake, PhD, RPh University of Illinois at the Medical Center
Chicago 1.
Section-by-Section Analysis, Drug Regulation form Act of 1978. US Dept of Health, Education, Welfare, 1978, pp 122-125.
Cost of Medical Care To the Editor.\p=m-\DrMarkle's
(239:1629, 1978)
on
cost
Reand
thoughts
awareness more
reiterate those of a slightly formal survey recently published.1 It is not that physicians in the private sector forget incurred costs with the pressure of day-to-day patient care. The fact that residents in training performed equally poorly reflects the lack of fiscal responsibility inherent in the educational process.
Third-party sources are presently attempting to engage public awareness. Yearly physician Medicare collections have been published by the Department of Health, Education, and Welfare, and Blue Cross patients receive an itemized account of all reimbursements on their behalf. A more productive approach is directed
cost-awareness training during the formative educational experiences of those soon to wield the technological imperative. The recent explosion of funding for cost-containment teaching programs has been noted (Am Med News 21:22-23, April 21, 1978). At my clinic we have made an overt attempt to recognize the financial aspect in terms of the stress it can create in the psychosocial area of patient care. Our fiduciary role is made evident from day 1 of the internship in that the trainee bills for services and laboratory tests within the family practice model unit. This is done by means of a master billing sheet that describes the charges directly alongside of the service rendered. The physician fills this out and gives a copy to the patient at the time of visit. Even with the recent
Frequently that just is not so, but then older physicians, who should know better, are pressured into simi¬ lar practices, since all this extrava¬ gance is becoming the norm. Programs such as Dr Rodney describes are most commendable. They should be carried through to the practicing physicians. A copy of each patient's hospital bill should have to be initialed by his physician after discharge. Either the utilization com¬ mittee or the appropriate appraisal committee should also see the total figures. Where there are noticeable deviations from the average, those charts should be pulled and reviewed. Where a physician consistently runs up higher total bills than those of his colleagues, he should be asked to justify those high bills to the commit¬
emphasis on cost, our program re¬ mains unique within this university center in this approach for costawareness training. Although longi¬
up bills less than average, his work should be reviewed to see how
tudinal studies of retention of aware¬ ness remain to be done, the thrust for removal of the presently artificial separation between trainee physi¬ cians and the cost they incur is one that holds promise for improvement of the present fiduciary failure of the medical
profession.
William MacMillan Rodney, MD University of California, Los Angeles
Family Practice Center Los Angeles 1. Kelly S: Physician's knowledge of hospital costs. J Fam Pract 6:171, 1978.
In Reply.\p=m-\I am extremely gratified that there is an increasing number of physicians like Dr Rodney who are not only concerned about the costs of health care, but who are doing something about them. I thoroughly agree that traditional training in our medical educational institutions is biased toward extravagant use of expensive technology, more costly medications and therapies, and overuse of hospitals and medical personnel. Residents in training and those physicians who have recently finished their training may be quicker to use pulmonary function studies than their stethoscopes, intravenous aminoglycosides instead of oral penicillin, or an operating room instead of the office for a minor
procedure. Fear of malpractice suits has something to do with this of course, but in many cases the young physicians just have never been shown how to practice in any other way. They appear to believe that anything that is more expensive, more time-consuming, and more difficult simply has to be better.
Downloaded From: http://jama.jamanetwork.com/ by a University of Manitoba User on 06/15/2015
tee.
Where
a
physician consistently
runs
by neglecting his patients or by superior efficiency. he does it, whether
George B. Markle IV, MD Medical Center
Guadaloupe
Carlsbad, NM
Commentary on a Commentary Improving the Public Health To the Editor.\p=m-\CharlesD. Aring, MD, is a highly intelligent physician who uses his intelligence. His COMMENTARY, however, needs a commentary, because it clearly blames physicians for not preventing enough disease (239:2557, 1978). Ivan Illich, Ren\l=e'\Dubos, Thomas McKeown, and A
on
Michael Wilson are all cited as authorities for what is made to seem a new idea that people should take more responsibility for their own health, and that since they do not, physicians are at fault. It is made to appear that if doctors could do less doctoring and more educating, all would be well. Congress and Senator Kennedy vociferously concur. Free enterprise is obviously a failure. Charitably overlooking the end-to\x=req-\ end clich\l=e'\s,the message is clear that we physicians had better do something about it or else the government, committees, and an assortment of humanitarians will. No physician I have ever known denies that preventive medicine is preferable to curative medicine, but by the same token, they have learned how obdurate people are. Have you tried lately to tell your children that they dare not smoke, eat junk foods, and be sexually promiscuous? Have all the social workers in India headed off the catastrophic population in-
crease? Just how effective is your own voice in convincing business to stop selling mouthwash to prevent colds? And incidentally, how do you prevent colds? What about telling a person suffering from angina that if he could only keep calm and not get upset, he would get along just fine? Just leave your diseases alone, live right, avoid physician dependence, and all will be well. I hate to say it, but all the extreme preventive medicine advocates need to do is teach us how to do all these things and I guarantee medicine will change overnight, as it always has when a way has been found to prevent disease. Prevention of rheumatic fev¬ er is an example. In the meantime, we have enough troubles to deal with, many of which are soluble, without holding out illusive promises that we simply cannot honor. Our hearts are in the right place, as witness the American Medical Association sup¬ port of the Kennedy Health Preven¬ tion Bill (S 3115). Irvine H. Page, MD
Cleveland Clinic Cleveland
Cardiac Exercise Program To the Editor.\p=m-\Thereport "Ventricular Fibrillation in a Medically Supervised Cardiac Exercise Program: Clinical, Angiographic, and Surgical Correlations" by Fletcher and Cantwell (238:2627, 1977) brings out some pertinent information. It would be valuable to know the most important predictor of arrhythmia during exertion: the smoking history. Three of the five patients exercised in excess of their prescribed heart rates. The precise mode of exercise
prescription was not given, although completion of a 1.6-km jog was mentioned for one of the subjects.
This suggests that short bursts of anaerobic activity are being used. If these episodes of arrhythmia have occurred in smokers in oxygen debt, correction of these two factors should take precedence over bypass surgery. The study of Tilkian et al1 shows that "coronary surgery improves exercise capacity without decreasing associated ventricular arrhythmia." Three of the five patients had myocardial revascularization and were presumably able to continue the program. Patient 5 refused surgery and was not allowed to continue the exercise program. It is reasonable to assume that patient 5 would get as much benefit in the program as those patients who underwent surgery and
with the same possibility of the devel¬ opment of arrhythmia. The authors' reluctance "to grad¬ uate" patients makes the whole con¬ cept of cardiac rehabilitation seem fruitless. Structured and monitored programs should be reserved for the early phases of cardiac rehabilitation and thereafter for selected high-risk groups. I think that the morbidity and mortality of the majority of the patients are low enough to give grad¬ uated cardiac patients the feeling of freedom and enjoyment of the fun associated with free exercise in a nonstructured program. Frank P. Cardello, MD Torrance, Calif
1. Tilkian AG, Pheifer JF, Barry WH, et al: The effect of coronary bypass surgery on exercise-induced ventricular arrhythmias. Am Heart J 92:707-714, 1976.
Reply.\p=m-\Only one patient of our (patient 5) continued to smoke cigarettes despite our repeated urging
In
group to
stop. After reversible ventricular
fibrillation, he had
coronary arteri-
ography and had noticeable lesions that were deemed operable. He
refused surgery, however, and we thought that he should not exercise. With regard to types of anaerobic activities, we do use "short bursts" of such in our session. The patient's program is gradually increased from a
walking program to a jogging always setting the target
program,
heart rate at 75% to 85% of the maximum tolerated heart rate on his treadmill testing. With regard to graduation of patients, we do think that some patients can leave a supervised exercised program. Many exercise programs now have an initial therapeutic phase of exercise that is medically supervised and usually entails the first 12 weeks after the cardiac event. After this, certain patients can be graduated to a nonsupervised maintenance program but continue to have exercise testing and follow-up by their physician. Coronary atheroscle¬ rotic occlusive disease is a progressive problem, and we do believe that medi¬ cal supervision in the therapeutic phase is most important. The physi¬ cian should be knowledgeable in the disease and help determine when the patient should have coronary arteriography, when drug changes or initia¬ tion of medication should be made, and when the patient's exercise pre¬ scription should be changed; he should place continuing emphasis on multiple risk-factor modification in addition to exercise. Exercise, of course, in all patients should be individually prescribed, and
Downloaded From: http://jama.jamanetwork.com/ by a University of Manitoba User on 06/15/2015
this determines the time of change from a therapeutic supervised pro¬ gram to a nonsupervised maintenance program of long-term duration. Gerald F. Fletcher, MD John D. Cantwell, MD
Emory University School of Medicine Atlanta
Regimen for Alkalinization of Urine
To the Editor.\p=m-\InQUESTIONS AND (239:2385, 1978) Donald R. Bennett, MD, PhD, described the recommended daily dosage for a healthy 70-kg adult of sodium bicarbonate taken daily as a urine alkalinizer. He mentioned the usual dosage range of 325 mg to 2 g, one to four times daily, with a maximum total daily dosage of 16 g. He very properly specified great caution with these dosages in patients with "edematous sodium-retaining states." In many years of alkalinizing the urine of patients with lymphoma (in ANSWERS
pre-allopurinol days) undergoing lympholytic chemotherapy with attendant hyperuricemia and hyperuricuria, I have successfully followed the dosage plan recommended by Dr Bennett with the exception that acetazolamide, 0.5 to 1.0 g, is prescribed at bedtime. Through inhibition of carbonic anhydrase, this leads to renal secretion of the sodium ion
that has been administered during the day, thus achieving sodium balance and alkalinization of the urine at the same time. Daniel S. J. Choy, MD New York
Gustatory Sweating To the Editor.\p=m-\In"Recurrent Severe Facial Perspiration and Redness" (239:2701, 1978), I believe the answer
to the question was incorrect. This patient has gustatory sweating, also called Frey's syndrome. The patient perspires profusely in the region innervated by the auriculotemporal nerve. Usually, no treatment is needed unless symptoms are severe. If symptoms are severe, it may then help to resect the tympanic plexus in the middle ear, since it is through this pathway that parasympathetic motor fibers from the petrosal ganglion reach the otic ganglion and finally the auriculotemporal branch of the mandibular nerve.
given
Gerald T. Schultz, MD Fort Lauderdale, Fla
that the United States Pharmor
copeia and the National Formulary are. There are no tests for identity, purity, quality, or potency. It is more
reminiscent of an herbal of several centuries back rather than a compen¬ dium of modern drugs. It is not at all comforting that "the bill assures that future homeopathic preparations will be processed through the monograph system." This presumably suggests that all new homeopathic prepara¬ tions will be subjected to the rigorous tests for safety and efficacy that are now required of drug products used in allopathic medicine. With the excep¬ tionally large number of homeopathic preparations currently listed as avail¬ able and with the dearth of meaning¬ ful research in this area, it is unlikely that any new homeopathic prepara¬ tions will emerge. The analysis report further notes "that homeopathic drugs have never been fully subjected to the require¬ ments of the current FD&C Act, and should be distinguished from allo¬ pathic drugs under the Drug Regula¬ tion Reform Act. Any other approach would probably not be cost-effective in protecting the public health, given the present role of homeopathic medi¬ cine in the United States." This does not appear to be adequate justifica¬ tion for continuing the official status of the Homeopathic Pharmacopeia. Martin I. Blake, PhD, RPh University of Illinois at the Medical Center
Chicago 1.
Section-by-Section Analysis, Drug Regulation form Act of 1978. US Dept of Health, Education, Welfare, 1978, pp 122-125.
Cost of Medical Care To the Editor.\p=m-\DrMarkle's
(239:1629, 1978)
on
cost
Reand
thoughts
awareness more
reiterate those of a slightly formal survey recently published.1 It is not that physicians in the private sector forget incurred costs with the pressure of day-to-day patient care. The fact that residents in training performed equally poorly reflects the lack of fiscal responsibility inherent in the educational process.
Third-party sources are presently attempting to engage public awareness. Yearly physician Medicare collections have been published by the Department of Health, Education, and Welfare, and Blue Cross patients receive an itemized account of all reimbursements on their behalf. A more productive approach is directed
cost-awareness training during the formative educational experiences of those soon to wield the technological imperative. The recent explosion of funding for cost-containment teaching programs has been noted (Am Med News 21:22-23, April 21, 1978). At my clinic we have made an overt attempt to recognize the financial aspect in terms of the stress it can create in the psychosocial area of patient care. Our fiduciary role is made evident from day 1 of the internship in that the trainee bills for services and laboratory tests within the family practice model unit. This is done by means of a master billing sheet that describes the charges directly alongside of the service rendered. The physician fills this out and gives a copy to the patient at the time of visit. Even with the recent
Frequently that just is not so, but then older physicians, who should know better, are pressured into simi¬ lar practices, since all this extrava¬ gance is becoming the norm. Programs such as Dr Rodney describes are most commendable. They should be carried through to the practicing physicians. A copy of each patient's hospital bill should have to be initialed by his physician after discharge. Either the utilization com¬ mittee or the appropriate appraisal committee should also see the total figures. Where there are noticeable deviations from the average, those charts should be pulled and reviewed. Where a physician consistently runs up higher total bills than those of his colleagues, he should be asked to justify those high bills to the commit¬
emphasis on cost, our program re¬ mains unique within this university center in this approach for costawareness training. Although longi¬
up bills less than average, his work should be reviewed to see how
tudinal studies of retention of aware¬ ness remain to be done, the thrust for removal of the presently artificial separation between trainee physi¬ cians and the cost they incur is one that holds promise for improvement of the present fiduciary failure of the medical
profession.
William MacMillan Rodney, MD University of California, Los Angeles
Family Practice Center Los Angeles 1. Kelly S: Physician's knowledge of hospital costs. J Fam Pract 6:171, 1978.
In Reply.\p=m-\I am extremely gratified that there is an increasing number of physicians like Dr Rodney who are not only concerned about the costs of health care, but who are doing something about them. I thoroughly agree that traditional training in our medical educational institutions is biased toward extravagant use of expensive technology, more costly medications and therapies, and overuse of hospitals and medical personnel. Residents in training and those physicians who have recently finished their training may be quicker to use pulmonary function studies than their stethoscopes, intravenous aminoglycosides instead of oral penicillin, or an operating room instead of the office for a minor
procedure. Fear of malpractice suits has something to do with this of course, but in many cases the young physicians just have never been shown how to practice in any other way. They appear to believe that anything that is more expensive, more time-consuming, and more difficult simply has to be better.
Downloaded From: http://jama.jamanetwork.com/ by a University of Manitoba User on 06/15/2015
tee.
Where
a
physician consistently
runs
by neglecting his patients or by superior efficiency. he does it, whether
George B. Markle IV, MD Medical Center
Guadaloupe
Carlsbad, NM
Commentary on a Commentary Improving the Public Health To the Editor.\p=m-\CharlesD. Aring, MD, is a highly intelligent physician who uses his intelligence. His COMMENTARY, however, needs a commentary, because it clearly blames physicians for not preventing enough disease (239:2557, 1978). Ivan Illich, Ren\l=e'\Dubos, Thomas McKeown, and A
on
Michael Wilson are all cited as authorities for what is made to seem a new idea that people should take more responsibility for their own health, and that since they do not, physicians are at fault. It is made to appear that if doctors could do less doctoring and more educating, all would be well. Congress and Senator Kennedy vociferously concur. Free enterprise is obviously a failure. Charitably overlooking the end-to\x=req-\ end clich\l=e'\s,the message is clear that we physicians had better do something about it or else the government, committees, and an assortment of humanitarians will. No physician I have ever known denies that preventive medicine is preferable to curative medicine, but by the same token, they have learned how obdurate people are. Have you tried lately to tell your children that they dare not smoke, eat junk foods, and be sexually promiscuous? Have all the social workers in India headed off the catastrophic population in-
crease? Just how effective is your own voice in convincing business to stop selling mouthwash to prevent colds? And incidentally, how do you prevent colds? What about telling a person suffering from angina that if he could only keep calm and not get upset, he would get along just fine? Just leave your diseases alone, live right, avoid physician dependence, and all will be well. I hate to say it, but all the extreme preventive medicine advocates need to do is teach us how to do all these things and I guarantee medicine will change overnight, as it always has when a way has been found to prevent disease. Prevention of rheumatic fev¬ er is an example. In the meantime, we have enough troubles to deal with, many of which are soluble, without holding out illusive promises that we simply cannot honor. Our hearts are in the right place, as witness the American Medical Association sup¬ port of the Kennedy Health Preven¬ tion Bill (S 3115). Irvine H. Page, MD
Cleveland Clinic Cleveland
Cardiac Exercise Program To the Editor.\p=m-\Thereport "Ventricular Fibrillation in a Medically Supervised Cardiac Exercise Program: Clinical, Angiographic, and Surgical Correlations" by Fletcher and Cantwell (238:2627, 1977) brings out some pertinent information. It would be valuable to know the most important predictor of arrhythmia during exertion: the smoking history. Three of the five patients exercised in excess of their prescribed heart rates. The precise mode of exercise
prescription was not given, although completion of a 1.6-km jog was mentioned for one of the subjects.
This suggests that short bursts of anaerobic activity are being used. If these episodes of arrhythmia have occurred in smokers in oxygen debt, correction of these two factors should take precedence over bypass surgery. The study of Tilkian et al1 shows that "coronary surgery improves exercise capacity without decreasing associated ventricular arrhythmia." Three of the five patients had myocardial revascularization and were presumably able to continue the program. Patient 5 refused surgery and was not allowed to continue the exercise program. It is reasonable to assume that patient 5 would get as much benefit in the program as those patients who underwent surgery and
with the same possibility of the devel¬ opment of arrhythmia. The authors' reluctance "to grad¬ uate" patients makes the whole con¬ cept of cardiac rehabilitation seem fruitless. Structured and monitored programs should be reserved for the early phases of cardiac rehabilitation and thereafter for selected high-risk groups. I think that the morbidity and mortality of the majority of the patients are low enough to give grad¬ uated cardiac patients the feeling of freedom and enjoyment of the fun associated with free exercise in a nonstructured program. Frank P. Cardello, MD Torrance, Calif
1. Tilkian AG, Pheifer JF, Barry WH, et al: The effect of coronary bypass surgery on exercise-induced ventricular arrhythmias. Am Heart J 92:707-714, 1976.
Reply.\p=m-\Only one patient of our (patient 5) continued to smoke cigarettes despite our repeated urging
In
group to
stop. After reversible ventricular
fibrillation, he had
coronary arteri-
ography and had noticeable lesions that were deemed operable. He
refused surgery, however, and we thought that he should not exercise. With regard to types of anaerobic activities, we do use "short bursts" of such in our session. The patient's program is gradually increased from a
walking program to a jogging always setting the target
program,
heart rate at 75% to 85% of the maximum tolerated heart rate on his treadmill testing. With regard to graduation of patients, we do think that some patients can leave a supervised exercised program. Many exercise programs now have an initial therapeutic phase of exercise that is medically supervised and usually entails the first 12 weeks after the cardiac event. After this, certain patients can be graduated to a nonsupervised maintenance program but continue to have exercise testing and follow-up by their physician. Coronary atheroscle¬ rotic occlusive disease is a progressive problem, and we do believe that medi¬ cal supervision in the therapeutic phase is most important. The physi¬ cian should be knowledgeable in the disease and help determine when the patient should have coronary arteriography, when drug changes or initia¬ tion of medication should be made, and when the patient's exercise pre¬ scription should be changed; he should place continuing emphasis on multiple risk-factor modification in addition to exercise. Exercise, of course, in all patients should be individually prescribed, and
Downloaded From: http://jama.jamanetwork.com/ by a University of Manitoba User on 06/15/2015
this determines the time of change from a therapeutic supervised pro¬ gram to a nonsupervised maintenance program of long-term duration. Gerald F. Fletcher, MD John D. Cantwell, MD
Emory University School of Medicine Atlanta
Regimen for Alkalinization of Urine
To the Editor.\p=m-\InQUESTIONS AND (239:2385, 1978) Donald R. Bennett, MD, PhD, described the recommended daily dosage for a healthy 70-kg adult of sodium bicarbonate taken daily as a urine alkalinizer. He mentioned the usual dosage range of 325 mg to 2 g, one to four times daily, with a maximum total daily dosage of 16 g. He very properly specified great caution with these dosages in patients with "edematous sodium-retaining states." In many years of alkalinizing the urine of patients with lymphoma (in ANSWERS
pre-allopurinol days) undergoing lympholytic chemotherapy with attendant hyperuricemia and hyperuricuria, I have successfully followed the dosage plan recommended by Dr Bennett with the exception that acetazolamide, 0.5 to 1.0 g, is prescribed at bedtime. Through inhibition of carbonic anhydrase, this leads to renal secretion of the sodium ion
that has been administered during the day, thus achieving sodium balance and alkalinization of the urine at the same time. Daniel S. J. Choy, MD New York
Gustatory Sweating To the Editor.\p=m-\In"Recurrent Severe Facial Perspiration and Redness" (239:2701, 1978), I believe the answer
to the question was incorrect. This patient has gustatory sweating, also called Frey's syndrome. The patient perspires profusely in the region innervated by the auriculotemporal nerve. Usually, no treatment is needed unless symptoms are severe. If symptoms are severe, it may then help to resect the tympanic plexus in the middle ear, since it is through this pathway that parasympathetic motor fibers from the petrosal ganglion reach the otic ganglion and finally the auriculotemporal branch of the mandibular nerve.
given
Gerald T. Schultz, MD Fort Lauderdale, Fla
