he has not served them well. It would have been better to have remained silent, for an inaccurate account of one small portion of a lengthy consultation is, indeed, a dangerous thing. It can lead to the very reasonable assumption that practice management advice is just so much poppycock and not, therefore, worth paying attention to. Our clients (who are, in most cases, ophthalmologists, al¬ though we have worked with doctors in at least seven other specialties) will tell you that our advice is well worth paying close attention to, but they have paid us for that advice. Free advice is seldom taken. One can only hope that your readers feel this way, for if they were to attempt to develop a highperformance practice based on the snippet of free advice that Dr Ellenberger offered, they will be sadly disillusioned. Dr Ellenberger was right about one thing: we call the method we teach for seeing patients the "EDC One Pass" system. It is a system that works as effectively for the physi¬ cian who treats 30 patients a day as it does for the physician who treats 165 patients a day, and it allows the physician to see every patient in a manner that results in total patient satisfaction. This, of course, leads to more patient word-ofmouth referrals, which is why Dr Ellenberger's host was called upon "to attend to up to 90 patients daily." I trust that none of your readers will judge the results of the Executive Development Center's teaching by testing Dr El¬ lenberger's advice on their own patients. That would be akin to passing judgment on Hamlet's soliloquy after hearing an actor summarize it with the words, "To be or not to be. That's what it's all about." Our clients will tell you that they learned to use the "EDC One Pass" system from us—not by reading a synopsis and not by watching someone else. Like surgery, our system can best be learned by being watched by someone who knows the system well. William A. Sullivan Dover, Mass Mr Sullivan is president of Executive Development Center Inc. 1. Ellenberger C Jr. High-performance ophthalmology. Arch Ophthalmol. 1991;109:1638-1639.

In Reply. \p=m-\"For'tis the sport to have the enginer/Hoist with his own petar" (Hamlet. III;iv;206). Carl Ellenberger, Jr, MD Lebanon, Pa

Birth Incidence of Down

Syndrome

To the Editor.\p=m-\In the June 1991 issue of the Archives,1 Dr Flynn responded to a question about an association between retinopathy of prematurity and Down syndrome based on the notion that individuals with Down syndrome may have altered superoxide dismutase activity and, therefore, be more susceptible to oxygen or free radical injury. Dr Flynn correctly comments about elevated levels of superoxide dismutase in Down syndrome and also notes the absence of reported cases of retinopathy of prematurity among infants with Down syndrome. However, he reports that "Down syndrome occurs once in every 4000 to 5000 live births. ..." Even with the advent of prenatal testing and selective termination of pregnancy for Down syndrome, the incidence in most epidemiologic studies remains between one per 700 to one per 1000 live births, with the occurrence of trisomy 21 among fetuses aborted spontaneously being much

higher.2,3

In view of the absence of reported cases of retinopathy of prematurity in Down syndrome, one wonders if the extra "dose" of Superoxide dismutase protects newborns with Down syndrome. W. Carl Cooley, MD

Hanover, NH

The author of the original "Answer" does not wish to respond. —ED 1. Flynn JT. Retinopathy of prematurity and infants with Down syndrome. Arch Ophthalmol. 1991;109:785. 2. Stoll C, Alembik Y, Dott B, Roth MP. Epidemiology of Down syndrome in 118 265 consecutive births. Am J Med Genet. 1990;7(suppl):79-83. 3. Cooley WC, Graham JM. Down syndrome: an update and review for the pediatrician. Clin Pediatr. 1991;30:233-253.

Currently in Other AMA Journals ARCHIVES OF OTOLARYNGOLOGY Mucoceles of Ethmoid and Sphenoid Sinus With Visual Disturbance Hiroshi Moriyama, MD; Hrohiko Hesaka, MD; Iboshiro Tachibana, MD; Yoshio Honda, MD (Arch Otolaryngol Head Neck Surg. 1992;118:142-146)

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