legal factor is profoundly different, viz, no contingency fee applies except

in the United States. Resolution of this inequity will be necessary to get the malpractice lawyers off physi¬ cians' backs. Of the 200 million people resid¬ ing in these United States, ap¬ proximately one tenth of 1% are physicians, and an equal number are lawyers. Therefore, 99.8% of the popu¬ lation may be affected by psychologi¬ cal and emotional changes in the way doctors approach and care for their patients. Thus, this is the major part of the problem, and it should be the primary concern of the population who may require the services of a

requires as physician. Optimal its bedrock confidence in the physi¬ care

cian and a climate of mutual trust, concern, and friendliness. When these are supplemented by the physician's reasonable skill and knowledge, chances of recovery from an illness or

operation

are

good.

Now enters the informed consent. If detailed and explicit, such a con¬ sent form given to a layman can only stir up his sympathoadrenal system to such an extent that either flight from the office or hospital will occur, or the patient, trapped by his fear, will remain for the "onslaught" in a state of near paralysis. How dreadful a situation! Such a patient is far more

likely to experience operative or post¬ operative disaster than a calm, trust¬ ing one. There are many analogous situ¬

ations in sports where confidence and clearheadedness are vital for success and a safe outcome. Skiing and fox¬

hunting are two examples. Obviously, a fit individual with proper training will do better than his unfit, unedu¬

cated counterpart, but still there re¬ mains the important realm of the psyche, where faith and confidence play a major role. As a surgeon who has been on the receiving end of seven general anes¬ thetics, I admit unabashedly to fear before each encounter. However, faith in my doctor and in the hospital environment proved to be unshak¬ able. The only consent form given me stated that the procedure in each in¬ stance was advisable in the surgeon's judgment and that "all would go well." Thank God no one gave me an "informed consent" form. Physicians who are poorly trained, or less than competent or unscru¬ pulous in their ethical behavior, must be curtailed and possibly separated

from the care of patients. The public is entitled to this safeguard and, when an unfortunate event occurs from less than proper care, should be

recompensed appropriately. The iceberg of malpractice

is upon us, and to avoid the fate of the Titan¬ ic, it must be controlled, not only in

the visible economic

area

but also, of

greater importance, in the psycholog¬ ical and emotional realm.

Jere W. Lord, Jr., MD Cabrini Health Care Center Columbus New York

Hospital Division

Propranolol To the Editor.\p=m-\Asphysicians and cardiologists, we are sensitive to the very important hemodynamic effects that are accomplished with propranolol hydrochloride. Unfortunately, the patient is not always fully aware of the extent to which propranolol may mask various physiologic stresses to

the cardiovascular system. Moreover, as a result of accident or acute illness, he may be unable to communicate the fact that he is under the influence of this drug. I, therefore, strongly urge all patients to carry a card or some other form of identification that identifies him as a recipient of propranolol. I trust that readers of The Journal will see fit to encourage their patients who are taking this drug to follow a similar program. Morton A. Goldmann, MD Skokie, III

A Death in the Family To the Editor.\p=m-\Dr. Melvin Krant's article, "A Death in the Family," in the Jan 13 issue of The Journal (231:195, 1975) does indeed remind us physicians of feelings of inadequacy we experience as we offer professional care to family members during bereavement. This role is challenging and difficult. When we try to help a bereaved individual, we inevitably experience some of that person's distress. How much help we can offer depends on the magnitude of the distress of the bereaved individual and the confidence we have in our ability to cope with our own reactions to this distress. One of the main problems up to now has been the relatively few clinical studies of the natural history of the grieving and mourning process, in spite of the fact that all human beings experience this syndrome at one time or another. The publication

Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 06/13/2015

Bereavement\p=m-\Studiesof Grief by Colin

Murray Parkes, MD, (New York,

International University Press, 1972) is worthwhile reading for individuals who wish to better understand the natural history of this clinical entity. It is true indeed that bereaved indi¬ viduals suffer. They turn to their phy¬ sician for help with restlessness, ex¬ haustion, bodily aches, insomnia, loss of appetite, and weight loss. Of even greater concern is the fact, as Dr. Krant and Dr. Parkes emphasize, that hypertension, strokes, coronary thrombosis, and anginal attacks are aggravated by the stress of bereave¬ ment. This results in a substantial in¬ crease in death rates among the be¬ reaved in the immediate six months following the death of a loved one. Colin Murray Parkes writes in such a free-flowing and vivid manner that the reader can easily visualize a pa¬ tient in the midst of the grieving process. Indeed, many physicians will recognize patterns of reaction and be¬ havior that they themselves have ex¬ perienced in their own episodes of grieving. When we are able to rec¬ ognize and understand normal be¬ reavement processes, we are better prepared to be helpful and derive pro¬ fessional and personal satisfaction in caring for family members in the midst of this experience. Eli Weisel, in his novel The Acci¬ dent (New York, Avon Books, 1970), quotes a physician as saying, "My vic¬ tories can only be temporary. My defeats are final always." The physi¬ cian who so often feels defeated by medicine's failure when a patient dies may find positive satisfaction in con¬ tinuing his relationship with and sup¬ porting the remaining members of the family as they grieve, mourn, and .

.

.

regain equilibrium. Bereaved family members, children as well as adults, appreciate knowing

that their doctors care about them and wish to help them at this difficult moment. The suggestion that a physi¬ cian's role is "to cure sometimes, to relieve often, to comfort always" is as true an admonition now as when stated by Dr. Edward Trudeau more than 50 years ago. Morris A. Wessel, MD New Haven, Conn

To the Editor.\p=m-\Dr.Krant provides us with a comprehensive and sensitive awareness of the many problems induced by a death about to come and one that has already come.

Letter: Propranolol.

legal factor is profoundly different, viz, no contingency fee applies except in the United States. Resolution of this inequity will be necessary to g...
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