Readers are advised that in view of The Copyright Revision Act of 1976 all Letters to the Editor submitted for publication must contain on the transmittal letter the following language: "The person(s) undersigned hereby grants the American Medical Association
permission to publish this Letter and in addition, hereby assigns all copyright ownership therein to the AMA.
"
Letters will be published as space permits and at the discretion of the editor. They should be typewritten double-spaced, with five or fewer references, should not exceed 500 words in length, and will be subject to editing. Letters are not acknowledged.
Primary Care To the Editor.\p=m-\Having a personal interest in the evaluation of costs and
primary care,1 I read and reread the article of Wright et al (238:46-50, 1977) with interest and with difficulty in evaluation of the outcomes in
data. Under "Methods," they include "patients who came to the clinic with any complaint of acute illness. To me, this is a vague definition without some examples of problems included and excluded. Since a comparison of costs generated by five different groups of providers is made, I wonder if comparable percentages of various problems were treated by each group of providers. For example, could most of the viral upper respiratory infections have been seen by first-year residents and most of the fractures seen by faculty? I am perplexed by the high percentage of patients with acute problems with bad outcomes (almost 25% for the whole study). It would be my expectation that 90% to 95% of the acute illnesses in primary care return to the same functional status they had prior to acute illness. I am also concerned about some of the comments and the incomplete description of the supervision of differ¬ ent resident levels. Do all levels of residents work without supervision, or are first-year residents decisions close¬ ly monitored by faculty (as in our resi¬ dency)? I wonder what "improvement in performance," perhaps lower labora¬ tory costs, was anticipated to "confirm the value of advanced training" if there is not faculty supervision. I would also question the reliability of any comparison of data from only two physician assistants. In spite of my questions, I emphat¬ ically agree with the authors that we do need to study and document wheth¬ er and how medical training in prima¬ ry care can improve quality of care and reduce cost. To me, this is a major Edited
by John D. Archer, MD, Senior Editor.
challenge to family practice and other primary care programs in the coming
large measure reactive rather than proactive. The faculty member re¬ sponds to the resident when the latter identifies a problem or when charts are being reviewed after treatment is completed. Nonetheless, one would an¬ ticipate that over time this supervision should result in improved resident performance. Unfortunately, we were not able to demonstrate this.
If our report provoked family prac¬ tice educators like Dr Burdette to think more carefully about whom they are training to do what, then we consider it worthwhile. Diana Dryer Wright, MD Robert L. Kane, MD University of Utah Medical Center Salt Lake City
five years.
James A. Burdette, MD
University of Kentucky College of Medicine Lexington 1. Burdette JA, Babineau RA, Mayo F, et al: Primary
medical
care
evaluation: The AAFP-UNC collaborative
1. Kane RL, Gardner HJ, Wright DD, et al: Differences in the outcomes of acute episodes of care provided by various types of family practitioners. J Fam Pract, to be
published.
study. JAMA 230:1668-1673,1974.
In Reply.\p=m-\Dr Burdette raises a number of interesting points. Perhaps the' most important issue has to do with how patients are classified. We depend a great deal on the concept of the diagnosis as a means for comparing groups of patients. In primary care we must be constantly aware that the diagnoses made are based on few, if any, reliable criteria. To expect a clear definition of a problem entity in a heterogeneous case mix such as that found in family practice may be overly optimistic. We deliberately chose to include all patients with evidence of an acute illness to avoid this trap of false accuracy. We1 have used the diagnoses made by the various levels of provider to examine such differences within subgroups. When one controls for diagnosis, there is no substantial difference in outcome according to provider level. Moreover, there is no specific pattern of distribution such that the easier cases go to the more junior providers. This problem of diagnosis is also reflected in Dr Burdette's observation about the surprisingly high proportion of seemingly self-limited problems that had bad outcomes. Once again we must anticipate that many of the problems in primary care may be misclassified. A bad outcome for a condition identi¬ fied as self-limiting must be inter¬ preted to mean that the diagnosis was likely incorrect. The ability to achieve high levels of sensitivity and specificity in a high-volume practice where most of the case material is not terribly serious represents one of the major
challenges to primary care. The residents in the family practice program are indeed supervised by faculty. The supervision, however, is in
Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/04/2015
Continuing
Medical Education
To the Editor.\p=m-\In the article "Stop the Continuing Education Bandwagon" (237:2518, 1977), Daniel M. Baer, MD, stated, "It appears [in continuing education] that a formalized structure is being developed that is constraining rather than stimulating the pursuit of knowledge." He further stated, "A system of recognition, certification, and accreditation is being established that stresses traditionally oriented organized programs and fails to recognize the needs, objectives, initiative, and responsibility of the individual in planning and seeking his own continuing education." There is a group in Denver that recognized the need for continuing education 13 years ago and has been striving to fulfill that need using a formalized structure. What began as a tutorial in-service program set up at the request of medical technologists from several Denver hospitals grew because of popular demand so that in 1976-1977 there were 102 different courses, varying from two-hour evening sessions to four-day workshops, presented for over 1,410 participants from ten states. This group is now known as the Colorado Association for Continuing Medical Laboratory Educa¬ tion (CACMLE). Each person attending a session is requested to complete a course evalua¬ tion and to suggest other subjects of interest. Based on this information, the CACMLE staff designs a curriculum to meet the personal needs and objectives of the participants. Also, course con¬ tent is revised and expanded to attract not only persons directly involved in laboratory medicine but also those
from
a variety of medical subspecialties, including nursing, veterinary medicine, dentistry, hospital manage¬ ment, and education. All find topics of
interest within the structured program of CACMLE. In contrast with Dr Baer's opinion that formal group instruction tends to constrain the pursuit of knowledge, the experience of CACMLE seems to be the opposite. The formal courses recently given, in which allied health professionals from related disciplines came together, were planned to include time for informal dialogue whereby the participants learned from one another the mutual problems in providing more effective health care. The CACMLE program has been effective in developing teaching skills within many persons in the community to the extent that more than 200 volun¬ teers from a diversity of disciplines currently serve as instructors. This formalized program certainly has not stifled initiative. In contrast with Dr Baer's view that programs are generally oriented to the needs of the person affiliated with the urban hospital, CACMLE has rec¬ ognized the needs of those working in rural settings and has developed learn¬ ing activity packages (LAP) that are distributed on a monthly basis for home study. Each package consists of objectives for the LAP, 20 to 40 pages of educational information on a specific topic, a self-examination covering the LAP content, and an answer key. Every three to four months CACMLE instructors are sent to the various rural areas to provide additional instruction and to answer questions on the LAP content. The CACMLE must agree with Dr Baer when he states, "It is yet to be shown that mandatory continuing edu¬ cation prevents incompetence." However, in the experience of CACMLE the organized continuing education program currently being conducted has gone a long way in reducing incompetence and has up¬ graded the quality of laboratory medi¬ cine in the Rocky Mountain region.
plastic cap and was thus several centimeters longer than shown in the X-ray films (Fig 3 and 4). The patient was given 0.5 ml of tetanus toxoid, and therapy with phenoxymethyl penicillin, 250 mg four times a day for ten days, was begun. Follow-up examination then showed the puncture site to have healed.
Comment. —Because the metal ink did not traverse the cap of the pen, the depth of penetration was underestimated. Fortunately, there was no serious consequence in this patient. However, one must be wary of fallacious depths of penetration of foreign bodies that are "obviously source
Figure
1.
radiopaque."
Stephen D. Boren, MD Norman Harris, MD Clinton
Hospital Clinton, Mass
Robert E. Boyd III, MD Massachusetts General
Ultrasonic Sounds and Pancreatic Carcinoma To the Editor. \p=m-\I am
Figure
2.
.
Merilyn Wiler, MT(ASCP) Colorado Association for Continuing
Laboratory Education,
Inc
Denver
'Radiopaque' Foreign Bodies Editor.\p=m-\Foreignbodies are a common emergency room problem. Diagnosis and treatment frequently are relatively simple, especially if the object is radiopaque. We recently had a case that demonstrates a possible diagTo the
nostic hazard.
writing in
response to the article "Pancreatic
.
.
Hospital
Boston
Figure 3.
Figure
4.
Report of a Case.\p=m-\After
an
altercation,
with a classmate, a 13-year-old boy arrived at the Clinton Primary Care Center with a ball-point pen embedded in his palate. His vital signs were stable, and results of physical examination showed only a blue pen projecting approximately 15 cm from his palate. X-ray films were taken (Fig 1 and 2). The area was anesthetized with 1% lidocaine with epinephrine, and the pen was extracted. It was noted that the pen had a
Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/04/2015
Carcinoma: Survival Following Detection by Ultrasonic Scanning" (238:240, 1977). While I agree with the statement that ultrasound is not as sensitive as one would like in detecting pancreatic neoplasm, evidence would suggest that it is probably still the most sensitive diagnostic modality available at this date. This is particularly important since it is relatively inexpensive and noninvasive. Computerized tomographic scanning may well prove more sensitive, but this has not been proved as yet. The implication in the article is that diagnostic ultrasound probably is not worthwhile in attempting to diagnose pancreatic neoplasm since the patient's survival after detection is unaltered. I feel this is an unfair condemnation of diagnostic ultrasound. It appears in this article that all patients were treated only with surgery. There is increasing evidence that aggressive chemotherapeutic regimens increase survival in pancreatic carcinoma. I think it is unfair to condemn the diagnostic modality used to detect pan¬ creatic carcinoma simply because the treatment for that disease is unsatis¬ factory and has changed little in the past 50 years until the recent advent of
sophisticated chemotherapeutic regimens. Should we have given up taking chest roentgenograms to detect bronchogenic carcinoma if we had not developed satisfactory ways to treat this disease and prolong patient sur¬ more
us continue to improve the sensitivity of diagnostic modalities but
vival? Let
permission to publish this Letter and in addition, hereby assigns all copyright ownership therein to the AMA.
"
Letters will be published as space permits and at the discretion of the editor. They should be typewritten double-spaced, with five or fewer references, should not exceed 500 words in length, and will be subject to editing. Letters are not acknowledged.
Primary Care To the Editor.\p=m-\Having a personal interest in the evaluation of costs and
primary care,1 I read and reread the article of Wright et al (238:46-50, 1977) with interest and with difficulty in evaluation of the outcomes in
data. Under "Methods," they include "patients who came to the clinic with any complaint of acute illness. To me, this is a vague definition without some examples of problems included and excluded. Since a comparison of costs generated by five different groups of providers is made, I wonder if comparable percentages of various problems were treated by each group of providers. For example, could most of the viral upper respiratory infections have been seen by first-year residents and most of the fractures seen by faculty? I am perplexed by the high percentage of patients with acute problems with bad outcomes (almost 25% for the whole study). It would be my expectation that 90% to 95% of the acute illnesses in primary care return to the same functional status they had prior to acute illness. I am also concerned about some of the comments and the incomplete description of the supervision of differ¬ ent resident levels. Do all levels of residents work without supervision, or are first-year residents decisions close¬ ly monitored by faculty (as in our resi¬ dency)? I wonder what "improvement in performance," perhaps lower labora¬ tory costs, was anticipated to "confirm the value of advanced training" if there is not faculty supervision. I would also question the reliability of any comparison of data from only two physician assistants. In spite of my questions, I emphat¬ ically agree with the authors that we do need to study and document wheth¬ er and how medical training in prima¬ ry care can improve quality of care and reduce cost. To me, this is a major Edited
by John D. Archer, MD, Senior Editor.
challenge to family practice and other primary care programs in the coming
large measure reactive rather than proactive. The faculty member re¬ sponds to the resident when the latter identifies a problem or when charts are being reviewed after treatment is completed. Nonetheless, one would an¬ ticipate that over time this supervision should result in improved resident performance. Unfortunately, we were not able to demonstrate this.
If our report provoked family prac¬ tice educators like Dr Burdette to think more carefully about whom they are training to do what, then we consider it worthwhile. Diana Dryer Wright, MD Robert L. Kane, MD University of Utah Medical Center Salt Lake City
five years.
James A. Burdette, MD
University of Kentucky College of Medicine Lexington 1. Burdette JA, Babineau RA, Mayo F, et al: Primary
medical
care
evaluation: The AAFP-UNC collaborative
1. Kane RL, Gardner HJ, Wright DD, et al: Differences in the outcomes of acute episodes of care provided by various types of family practitioners. J Fam Pract, to be
published.
study. JAMA 230:1668-1673,1974.
In Reply.\p=m-\Dr Burdette raises a number of interesting points. Perhaps the' most important issue has to do with how patients are classified. We depend a great deal on the concept of the diagnosis as a means for comparing groups of patients. In primary care we must be constantly aware that the diagnoses made are based on few, if any, reliable criteria. To expect a clear definition of a problem entity in a heterogeneous case mix such as that found in family practice may be overly optimistic. We deliberately chose to include all patients with evidence of an acute illness to avoid this trap of false accuracy. We1 have used the diagnoses made by the various levels of provider to examine such differences within subgroups. When one controls for diagnosis, there is no substantial difference in outcome according to provider level. Moreover, there is no specific pattern of distribution such that the easier cases go to the more junior providers. This problem of diagnosis is also reflected in Dr Burdette's observation about the surprisingly high proportion of seemingly self-limited problems that had bad outcomes. Once again we must anticipate that many of the problems in primary care may be misclassified. A bad outcome for a condition identi¬ fied as self-limiting must be inter¬ preted to mean that the diagnosis was likely incorrect. The ability to achieve high levels of sensitivity and specificity in a high-volume practice where most of the case material is not terribly serious represents one of the major
challenges to primary care. The residents in the family practice program are indeed supervised by faculty. The supervision, however, is in
Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/04/2015
Continuing
Medical Education
To the Editor.\p=m-\In the article "Stop the Continuing Education Bandwagon" (237:2518, 1977), Daniel M. Baer, MD, stated, "It appears [in continuing education] that a formalized structure is being developed that is constraining rather than stimulating the pursuit of knowledge." He further stated, "A system of recognition, certification, and accreditation is being established that stresses traditionally oriented organized programs and fails to recognize the needs, objectives, initiative, and responsibility of the individual in planning and seeking his own continuing education." There is a group in Denver that recognized the need for continuing education 13 years ago and has been striving to fulfill that need using a formalized structure. What began as a tutorial in-service program set up at the request of medical technologists from several Denver hospitals grew because of popular demand so that in 1976-1977 there were 102 different courses, varying from two-hour evening sessions to four-day workshops, presented for over 1,410 participants from ten states. This group is now known as the Colorado Association for Continuing Medical Laboratory Educa¬ tion (CACMLE). Each person attending a session is requested to complete a course evalua¬ tion and to suggest other subjects of interest. Based on this information, the CACMLE staff designs a curriculum to meet the personal needs and objectives of the participants. Also, course con¬ tent is revised and expanded to attract not only persons directly involved in laboratory medicine but also those
from
a variety of medical subspecialties, including nursing, veterinary medicine, dentistry, hospital manage¬ ment, and education. All find topics of
interest within the structured program of CACMLE. In contrast with Dr Baer's opinion that formal group instruction tends to constrain the pursuit of knowledge, the experience of CACMLE seems to be the opposite. The formal courses recently given, in which allied health professionals from related disciplines came together, were planned to include time for informal dialogue whereby the participants learned from one another the mutual problems in providing more effective health care. The CACMLE program has been effective in developing teaching skills within many persons in the community to the extent that more than 200 volun¬ teers from a diversity of disciplines currently serve as instructors. This formalized program certainly has not stifled initiative. In contrast with Dr Baer's view that programs are generally oriented to the needs of the person affiliated with the urban hospital, CACMLE has rec¬ ognized the needs of those working in rural settings and has developed learn¬ ing activity packages (LAP) that are distributed on a monthly basis for home study. Each package consists of objectives for the LAP, 20 to 40 pages of educational information on a specific topic, a self-examination covering the LAP content, and an answer key. Every three to four months CACMLE instructors are sent to the various rural areas to provide additional instruction and to answer questions on the LAP content. The CACMLE must agree with Dr Baer when he states, "It is yet to be shown that mandatory continuing edu¬ cation prevents incompetence." However, in the experience of CACMLE the organized continuing education program currently being conducted has gone a long way in reducing incompetence and has up¬ graded the quality of laboratory medi¬ cine in the Rocky Mountain region.
plastic cap and was thus several centimeters longer than shown in the X-ray films (Fig 3 and 4). The patient was given 0.5 ml of tetanus toxoid, and therapy with phenoxymethyl penicillin, 250 mg four times a day for ten days, was begun. Follow-up examination then showed the puncture site to have healed.
Comment. —Because the metal ink did not traverse the cap of the pen, the depth of penetration was underestimated. Fortunately, there was no serious consequence in this patient. However, one must be wary of fallacious depths of penetration of foreign bodies that are "obviously source
Figure
1.
radiopaque."
Stephen D. Boren, MD Norman Harris, MD Clinton
Hospital Clinton, Mass
Robert E. Boyd III, MD Massachusetts General
Ultrasonic Sounds and Pancreatic Carcinoma To the Editor. \p=m-\I am
Figure
2.
.
Merilyn Wiler, MT(ASCP) Colorado Association for Continuing
Laboratory Education,
Inc
Denver
'Radiopaque' Foreign Bodies Editor.\p=m-\Foreignbodies are a common emergency room problem. Diagnosis and treatment frequently are relatively simple, especially if the object is radiopaque. We recently had a case that demonstrates a possible diagTo the
nostic hazard.
writing in
response to the article "Pancreatic
.
.
Hospital
Boston
Figure 3.
Figure
4.
Report of a Case.\p=m-\After
an
altercation,
with a classmate, a 13-year-old boy arrived at the Clinton Primary Care Center with a ball-point pen embedded in his palate. His vital signs were stable, and results of physical examination showed only a blue pen projecting approximately 15 cm from his palate. X-ray films were taken (Fig 1 and 2). The area was anesthetized with 1% lidocaine with epinephrine, and the pen was extracted. It was noted that the pen had a
Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/04/2015
Carcinoma: Survival Following Detection by Ultrasonic Scanning" (238:240, 1977). While I agree with the statement that ultrasound is not as sensitive as one would like in detecting pancreatic neoplasm, evidence would suggest that it is probably still the most sensitive diagnostic modality available at this date. This is particularly important since it is relatively inexpensive and noninvasive. Computerized tomographic scanning may well prove more sensitive, but this has not been proved as yet. The implication in the article is that diagnostic ultrasound probably is not worthwhile in attempting to diagnose pancreatic neoplasm since the patient's survival after detection is unaltered. I feel this is an unfair condemnation of diagnostic ultrasound. It appears in this article that all patients were treated only with surgery. There is increasing evidence that aggressive chemotherapeutic regimens increase survival in pancreatic carcinoma. I think it is unfair to condemn the diagnostic modality used to detect pan¬ creatic carcinoma simply because the treatment for that disease is unsatis¬ factory and has changed little in the past 50 years until the recent advent of
sophisticated chemotherapeutic regimens. Should we have given up taking chest roentgenograms to detect bronchogenic carcinoma if we had not developed satisfactory ways to treat this disease and prolong patient sur¬ more
us continue to improve the sensitivity of diagnostic modalities but
vival? Let
