(responding to "reasonable, thoughtful, bona fide letters") though JAMA does not mandate responses. In order to defray the issue of responsibility, let me answer Fischer's letter. Above all, let me note that family practice has matured as a prestigious field replete with rigorous train¬ ing, certification, and recertification requirements and an academic base. Family practitioners are vital contributors to even
care in America. There are three main reasons why Washington University School of Medicine has not yet chosen to develop a depart¬ ment of family practice. First, students can enjoy effective learning experiences in family practice without an organized department; indeed, we are considering the provision of such experiences. Other important educational programs are not organized as departments and yet attract students for post¬ graduate training. Second, our students are exposed to pri¬ mary care in internal medicine, pediatrics, and other special¬ ties; exposure in the ambulant patient setting is increasing. Third, the 126 medical schools in the United States are di¬ verse in their allocation of limited resources. The strong research mission of our school requires substantial support of any new department. In light of current fiscal reality, out¬ standing departments would be curtailed in order to fund a new one. This is not to say that family practice is anathema to medical schools with strong research commitments, but many such schools with family practice departments, though by no means all, receive support from state appropria¬ tions. By contrast, almost all medical schools without de¬ partments of family practice are components of private universities. Wonderful students elect to study at Washington Univer¬ sity School of Medicine. They earn residencies at outstanding teaching hospitals and pursue productive careers in patient care, teaching, and research. Few would argue with the need to expand primary care, and hence primary care education, in the United States. The expression of primary care, as, for example, in general internal medicine or family practice, is a matter of debate and discussion. There is certainly room for diversity of thought and action. It is the intent of the Wash¬ ington University School of Medicine to remain at the fore¬ front in the educational process.
primary
William A.
Peck, MD
Washington University School of Medicine St
Louis, Mo
JAMA encourages authors of original articles to reply to letters. We assume that when there is no reply and there is a note that the author has been shown the letter, readers will draw their own conclusions.—ED.
Outpatient Anterior Cruciate Ligament Reconstruction and Patient-Controlled Analgesia To the Editor.\p=m-\Therise in medical costs and the need for cost containment are realities. My concern is that those of us who are "proceduralists"\p=m-\wewho look at what we are doing\p=m-\ must try to devise methods that are more efficient and more economical without jeopardizing the patient's safety and without attaining less desirable results just to reduce costs. When I began promoting the idea of 1-day anterior cruciate ligament (ACL) reconstruction surgery for our patients in an outpatient clinic and patient-controlled analgesia (PCA), I confronted all sorts of objections from my colleagues, nursing staff, and patients. After approximately 160 consecutive cases under the outpatient ACL-PCA protocol at our clinic, I can document and demonstrate excellent results with a net savings of approximately $5000 per patient or $800 000 to whomever pays the bill. The net savings takes into account the cost of PCA and home health care. These dollar figures represent
practice of only one surgeon. If many knee surgeons adopted this ACL-PCA practice, the economic impact would be exponential. We know the safety and comfort of the patients has not been compromised. The ultimate successful results are evi¬ denced by the patient's walking without a limp by the end of the fourth week. The number of patients who have required treatment for limitation of motion has been less than or equal to the percentage reported in the literature (of patients with an accelerated rehabilitation program).1 Within the follow-up period (6 to 14 months), we have detected no detrimental sequelae. In developing an outpatient ACL program, two features are indispensable—teamwork and patient counseling. The team is composed of the patient, surgeon, ambulatory sur¬ gery center personnel, office staff, and home health care the
agency. The teamwork must stem from absolute devotion to the concept. The surgeon, as team leader, must assume that any failure by another team member is ultimately an evidence of failure in his or her leadership. The patient is first in the "team." Counseling of patient and family and the dedication of the patient and family to the concept are foremost and essential. Other members of the team subsequently reinforce the patient's decision and support the patient and the family
members. I do not recommend the system for those surgeons who do ACL reconstruction infrequently (average, less than six per month). Furthermore, the volume of ACL injuries requiring surgery must be large enough to warrant the development of an outpatient clinic with the team to sup¬ port the system. I offer my experience as an example of what may be ac¬ complished economically by looking critically at our methods and by trying to find more efficient ways to treat patients. Others are gathering data on cost factors related to outpa¬ tient ACL reconstruction.2 My emphasis is not only on costeffectiveness, but also on patient care and the willingness to learn from members of the health care team.
Highgenboten, Dallas, Tex
Carl L.
MD
1. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate reconstruction. Am J Sports Med. 1990;18:292-299. MM, Deluca JV, Staffen AS, Knable KR, Fanelli G. Outpatient anterior cruciate ligament surgery: a review of safety, practicality and economy. In: Book of Abstracts, ACL Study Group; January 18-24, 1992; Vail, Colo. Abstract 4445.
ligament
2. Malek
Pulmonary Toxicity of Amiodarone To the Editor.\p=m-\TheEditorial by Estes1 on the role of amiodarone for the management of atrial fibrillation describes several amiodarone dose-related adverse effects. However, we were surprised that there was no mention of pulmonary toxic effects, which are the most serious side effects, and
which have an incidence estimated from 0.5% to 10% and a mortality of 1% to 33%.2 Although an immunologic mechanism may contribute (as shown by improvement with corticosteroids and elevation of CD8 lymphocytes in bronchoalveolar lavage), some findings argue for a toxic dose-dependent mechanism.3 Unfortunately, routine pulmonary function tests have not been useful to predict pulmonary side effects of amiodarone.4 These effects have most frequently included diffuse interstitial pneumonitis, but cases presenting with segmental pulmonary consolidation, fatal respiratory distress syndrome, pulmonary fibrosis, and pleural effussion have also been described. These kinds of clinical presentation might lead to a wrong diagnosis of acute heart failure refractory to treatment. Therefore, a high level of suspicion is required in deal-
Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/17/2015
ing with the differential diagnosis of a patient treated with amiodarone who develops unexplained dyspnea, nonproduc¬ tive cough, and fever. Esteban Mart\l=i'\nez,MD Pere Domingo, MD Universitat Aut\l=o'\nomade Barcelona
Spain 1. Estes NAM III.
Evolving strategies for the management of atrial fibrillation: the role of amiodarone. JAMA. 1992;267:3332-3333. 2. Nicolet-Chatelain G, Prevost MC, Escamilla R, Migueres J. Amiodarone-induced pulmonary toxicity: immunoallergologic tests and bronchoalveolar lavage phospholipid content. Chest. 1991;99:363-369. 3. Roca J, Heras M, Rodriguez-Roisin R, Magri\l=n~\aJ, Xaubet A, Sanz G. Pulmonary complications after long-term amiodarone treatment. Thorax. 1992;47:372-376. 4. Magro SA, Clinton PE, Wheeler SH, Krafchek I, Lin H, Wyndham C. Amiodarone pulmonary toxicity: prospective evaluation of serial pulmonary function tests. J Am Coll Cardiol. 1988;12:781-788. This letter was shown to the
author, who declined to reply.—ED.
Providers? To the Editor.\p=m-\Iappreciate the objective approach of Lurie et al1 to a difficult problem. The authors were appropriately cautious in interpreting results of their study. My principal criticism is of the almost inexplicable tendency of physicians to avoid the use of the word patient when they are writing or speaking of people with an illness. I suppose it is another example of the apparent preference for some physicians to refer to themselves as "providers." I think all of this proceeds from an inappropriate and ill-conceived notion of the relationship between physicians and patients. We have a responsibility to our patients, to our profession, and to ourselves to see these relationships appropriately. Therefore, I urge writers and editors to adhere to original meanings. "Clients" are generally people seeking assistance from attorneys and social welfare agencies. Robert A. Gutman, MD Durham, NC 1. Lurie N, Moscovice IS, Finch M, Christianson JB, Popkin MK. Does capitation affect the health of the chronically mentally ill? results from a randomized study. JAMA. 1992;267:3300-3304.
In Reply.\p=m-\Peoplewith illnesses do not become patients until they seek help from the health care system. Not all of the individuals we studied did so. Furthermore, not all "providers" are physicians. Many are psychologists or social workers, and these caregivers refer to their "patients" as "clients." Nicole Lurie, MD, MSPH Ira Moscovice, PhD Michael Finch, PhD Jon Christianson, PhD Michael Popkin, MD University of Minnesota
Minneapolis
Estimates of Physician Joint Ventures To the Editor.\p=m-\Thearticle by Mitchell and Scott1 presents a picture of the relationship between physicians and the businesses to which they refer patients as both extensive and alarming. However, as principal investigators in the Office of Inspector General (OIG) study on physician ownership,2 we feel it is necessary to correct a misunderstanding on the part of the authors. We found it very difficult to identify diagnostic imaging facilities, as they are not a separately classified entity in the Health Care Financing Administration (HCFA) data. Therefore, we defined independent physiological laboratories using the HCFA Common Procedure Coding System (HCPCS), which included codes that identified diagnostic imaging facilities as well as radiation therapy facilities and independent cardiology laboratories, among others. The pro-
portion of facilities owned by referring physicians (27%, which Mitchell and Scott refer to as diagnostic imaging facilities in our report) is, in fact, for these broadly defined independent physiological laboratories. We feel this distinction is important, both because of the problems in identification of such facilities using administra¬ tive data and in the contention that physicians tend to own high-cost, high-revenue facilities. Our definition of indepen¬ dent physiological laboratories would include a much broader range of services and hence a noncomparable ownership rate to that reported by Mitchell and Scott for diagnostic imaging facilities.
Finally, the authors contend that their results suggest that previous reports, including our study, understate the pro¬ portion of health care businesses owned by physicians. Ex¬ trapolating from the data of Mitchell and Scott to the rest of the nation should be approached with caution. Florida may well be unusual in its high percentage of joint ventures and physician ownership. We would argue that our data demon¬ strate a wide range of ownership patterns among the various states and types of health care businesses. Our data sug¬ gested to us in 1988 that Florida was an outlier in relation to the other seven states in our study. On a national level, the true proportion of physician ownership is probably somewhat
less than Mitchell and Scott's
figures.
William Mark Krushat, MPH, ScD Penny R. Thompson, MPA Baltimore, Md The views expressed herein represent those of the authors and should not be interpreted as those of the Office of the Inspector General, the US Depart¬ ment of Health and Human Services, or any other component of the federal
government.
1. Mitchell JM, Scott E. New evidence of the prevalence and scope of physician joint
ventures. JAMA. 1992;268;80-84. 2. Financial Arrangements Between
Physicians and Health Care Businesses. Washington, DC: Office of Inspector General, US Dept of Health and Human Ser1989. May vices;
In Reply.\p=m-\Wethank the authors of the OIG study on physician joint ventures1 for their interest, their pioneering research, and for clarifying the criteria used to identify independent physiological laboratories. In our article on the prevalence and scope of physician joint ventures in Florida,2 we defined diagnostic imaging services to encompass all radiology Current Procedural Terminology (CPT) codes. We compared the CPT codes used in the OIG study with our criteria to ascertain the differences between the two approaches. This comparison revealed that more than 85% of the 82 HCPCS codes used in the OIG definition were radiology procedures.1 The codes in the OIG definition not captured by our criteria
included procedures such as electronic pacemaker analysis and cardiac events recording, which are typically performed in physicians' offices and not in freestanding facilities. Moreover, the OIG definition, like our criteria, did not include any radiation therapy procedure codes. Thus, since the criteria we employed are almost identical to the definitional param¬ eters of the OIG study, it appears that the ownership rates of diagnostic imaging facilities in Florida are comparable with the OIG estimates for independent physiological laboratories. The OIG researchers also note that Florida may well be unusual in its high percentage of physician joint ventures and therefore, nationally, the proportion of health care businesses owned by referring physicians is probably somewhat less than the estimates we reported for Florida.2 While this point is valid for some types of services, for others, the Florida rates are probably indicative of the national average. One factor contributing to the differences is that the OIG study is based on data from 1987, whereas the Florida estimates
Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/17/2015
care in America. There are three main reasons why Washington University School of Medicine has not yet chosen to develop a depart¬ ment of family practice. First, students can enjoy effective learning experiences in family practice without an organized department; indeed, we are considering the provision of such experiences. Other important educational programs are not organized as departments and yet attract students for post¬ graduate training. Second, our students are exposed to pri¬ mary care in internal medicine, pediatrics, and other special¬ ties; exposure in the ambulant patient setting is increasing. Third, the 126 medical schools in the United States are di¬ verse in their allocation of limited resources. The strong research mission of our school requires substantial support of any new department. In light of current fiscal reality, out¬ standing departments would be curtailed in order to fund a new one. This is not to say that family practice is anathema to medical schools with strong research commitments, but many such schools with family practice departments, though by no means all, receive support from state appropria¬ tions. By contrast, almost all medical schools without de¬ partments of family practice are components of private universities. Wonderful students elect to study at Washington Univer¬ sity School of Medicine. They earn residencies at outstanding teaching hospitals and pursue productive careers in patient care, teaching, and research. Few would argue with the need to expand primary care, and hence primary care education, in the United States. The expression of primary care, as, for example, in general internal medicine or family practice, is a matter of debate and discussion. There is certainly room for diversity of thought and action. It is the intent of the Wash¬ ington University School of Medicine to remain at the fore¬ front in the educational process.
primary
William A.
Peck, MD
Washington University School of Medicine St
Louis, Mo
JAMA encourages authors of original articles to reply to letters. We assume that when there is no reply and there is a note that the author has been shown the letter, readers will draw their own conclusions.—ED.
Outpatient Anterior Cruciate Ligament Reconstruction and Patient-Controlled Analgesia To the Editor.\p=m-\Therise in medical costs and the need for cost containment are realities. My concern is that those of us who are "proceduralists"\p=m-\wewho look at what we are doing\p=m-\ must try to devise methods that are more efficient and more economical without jeopardizing the patient's safety and without attaining less desirable results just to reduce costs. When I began promoting the idea of 1-day anterior cruciate ligament (ACL) reconstruction surgery for our patients in an outpatient clinic and patient-controlled analgesia (PCA), I confronted all sorts of objections from my colleagues, nursing staff, and patients. After approximately 160 consecutive cases under the outpatient ACL-PCA protocol at our clinic, I can document and demonstrate excellent results with a net savings of approximately $5000 per patient or $800 000 to whomever pays the bill. The net savings takes into account the cost of PCA and home health care. These dollar figures represent
practice of only one surgeon. If many knee surgeons adopted this ACL-PCA practice, the economic impact would be exponential. We know the safety and comfort of the patients has not been compromised. The ultimate successful results are evi¬ denced by the patient's walking without a limp by the end of the fourth week. The number of patients who have required treatment for limitation of motion has been less than or equal to the percentage reported in the literature (of patients with an accelerated rehabilitation program).1 Within the follow-up period (6 to 14 months), we have detected no detrimental sequelae. In developing an outpatient ACL program, two features are indispensable—teamwork and patient counseling. The team is composed of the patient, surgeon, ambulatory sur¬ gery center personnel, office staff, and home health care the
agency. The teamwork must stem from absolute devotion to the concept. The surgeon, as team leader, must assume that any failure by another team member is ultimately an evidence of failure in his or her leadership. The patient is first in the "team." Counseling of patient and family and the dedication of the patient and family to the concept are foremost and essential. Other members of the team subsequently reinforce the patient's decision and support the patient and the family
members. I do not recommend the system for those surgeons who do ACL reconstruction infrequently (average, less than six per month). Furthermore, the volume of ACL injuries requiring surgery must be large enough to warrant the development of an outpatient clinic with the team to sup¬ port the system. I offer my experience as an example of what may be ac¬ complished economically by looking critically at our methods and by trying to find more efficient ways to treat patients. Others are gathering data on cost factors related to outpa¬ tient ACL reconstruction.2 My emphasis is not only on costeffectiveness, but also on patient care and the willingness to learn from members of the health care team.
Highgenboten, Dallas, Tex
Carl L.
MD
1. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate reconstruction. Am J Sports Med. 1990;18:292-299. MM, Deluca JV, Staffen AS, Knable KR, Fanelli G. Outpatient anterior cruciate ligament surgery: a review of safety, practicality and economy. In: Book of Abstracts, ACL Study Group; January 18-24, 1992; Vail, Colo. Abstract 4445.
ligament
2. Malek
Pulmonary Toxicity of Amiodarone To the Editor.\p=m-\TheEditorial by Estes1 on the role of amiodarone for the management of atrial fibrillation describes several amiodarone dose-related adverse effects. However, we were surprised that there was no mention of pulmonary toxic effects, which are the most serious side effects, and
which have an incidence estimated from 0.5% to 10% and a mortality of 1% to 33%.2 Although an immunologic mechanism may contribute (as shown by improvement with corticosteroids and elevation of CD8 lymphocytes in bronchoalveolar lavage), some findings argue for a toxic dose-dependent mechanism.3 Unfortunately, routine pulmonary function tests have not been useful to predict pulmonary side effects of amiodarone.4 These effects have most frequently included diffuse interstitial pneumonitis, but cases presenting with segmental pulmonary consolidation, fatal respiratory distress syndrome, pulmonary fibrosis, and pleural effussion have also been described. These kinds of clinical presentation might lead to a wrong diagnosis of acute heart failure refractory to treatment. Therefore, a high level of suspicion is required in deal-
Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/17/2015
ing with the differential diagnosis of a patient treated with amiodarone who develops unexplained dyspnea, nonproduc¬ tive cough, and fever. Esteban Mart\l=i'\nez,MD Pere Domingo, MD Universitat Aut\l=o'\nomade Barcelona
Spain 1. Estes NAM III.
Evolving strategies for the management of atrial fibrillation: the role of amiodarone. JAMA. 1992;267:3332-3333. 2. Nicolet-Chatelain G, Prevost MC, Escamilla R, Migueres J. Amiodarone-induced pulmonary toxicity: immunoallergologic tests and bronchoalveolar lavage phospholipid content. Chest. 1991;99:363-369. 3. Roca J, Heras M, Rodriguez-Roisin R, Magri\l=n~\aJ, Xaubet A, Sanz G. Pulmonary complications after long-term amiodarone treatment. Thorax. 1992;47:372-376. 4. Magro SA, Clinton PE, Wheeler SH, Krafchek I, Lin H, Wyndham C. Amiodarone pulmonary toxicity: prospective evaluation of serial pulmonary function tests. J Am Coll Cardiol. 1988;12:781-788. This letter was shown to the
author, who declined to reply.—ED.
Providers? To the Editor.\p=m-\Iappreciate the objective approach of Lurie et al1 to a difficult problem. The authors were appropriately cautious in interpreting results of their study. My principal criticism is of the almost inexplicable tendency of physicians to avoid the use of the word patient when they are writing or speaking of people with an illness. I suppose it is another example of the apparent preference for some physicians to refer to themselves as "providers." I think all of this proceeds from an inappropriate and ill-conceived notion of the relationship between physicians and patients. We have a responsibility to our patients, to our profession, and to ourselves to see these relationships appropriately. Therefore, I urge writers and editors to adhere to original meanings. "Clients" are generally people seeking assistance from attorneys and social welfare agencies. Robert A. Gutman, MD Durham, NC 1. Lurie N, Moscovice IS, Finch M, Christianson JB, Popkin MK. Does capitation affect the health of the chronically mentally ill? results from a randomized study. JAMA. 1992;267:3300-3304.
In Reply.\p=m-\Peoplewith illnesses do not become patients until they seek help from the health care system. Not all of the individuals we studied did so. Furthermore, not all "providers" are physicians. Many are psychologists or social workers, and these caregivers refer to their "patients" as "clients." Nicole Lurie, MD, MSPH Ira Moscovice, PhD Michael Finch, PhD Jon Christianson, PhD Michael Popkin, MD University of Minnesota
Minneapolis
Estimates of Physician Joint Ventures To the Editor.\p=m-\Thearticle by Mitchell and Scott1 presents a picture of the relationship between physicians and the businesses to which they refer patients as both extensive and alarming. However, as principal investigators in the Office of Inspector General (OIG) study on physician ownership,2 we feel it is necessary to correct a misunderstanding on the part of the authors. We found it very difficult to identify diagnostic imaging facilities, as they are not a separately classified entity in the Health Care Financing Administration (HCFA) data. Therefore, we defined independent physiological laboratories using the HCFA Common Procedure Coding System (HCPCS), which included codes that identified diagnostic imaging facilities as well as radiation therapy facilities and independent cardiology laboratories, among others. The pro-
portion of facilities owned by referring physicians (27%, which Mitchell and Scott refer to as diagnostic imaging facilities in our report) is, in fact, for these broadly defined independent physiological laboratories. We feel this distinction is important, both because of the problems in identification of such facilities using administra¬ tive data and in the contention that physicians tend to own high-cost, high-revenue facilities. Our definition of indepen¬ dent physiological laboratories would include a much broader range of services and hence a noncomparable ownership rate to that reported by Mitchell and Scott for diagnostic imaging facilities.
Finally, the authors contend that their results suggest that previous reports, including our study, understate the pro¬ portion of health care businesses owned by physicians. Ex¬ trapolating from the data of Mitchell and Scott to the rest of the nation should be approached with caution. Florida may well be unusual in its high percentage of joint ventures and physician ownership. We would argue that our data demon¬ strate a wide range of ownership patterns among the various states and types of health care businesses. Our data sug¬ gested to us in 1988 that Florida was an outlier in relation to the other seven states in our study. On a national level, the true proportion of physician ownership is probably somewhat
less than Mitchell and Scott's
figures.
William Mark Krushat, MPH, ScD Penny R. Thompson, MPA Baltimore, Md The views expressed herein represent those of the authors and should not be interpreted as those of the Office of the Inspector General, the US Depart¬ ment of Health and Human Services, or any other component of the federal
government.
1. Mitchell JM, Scott E. New evidence of the prevalence and scope of physician joint
ventures. JAMA. 1992;268;80-84. 2. Financial Arrangements Between
Physicians and Health Care Businesses. Washington, DC: Office of Inspector General, US Dept of Health and Human Ser1989. May vices;
In Reply.\p=m-\Wethank the authors of the OIG study on physician joint ventures1 for their interest, their pioneering research, and for clarifying the criteria used to identify independent physiological laboratories. In our article on the prevalence and scope of physician joint ventures in Florida,2 we defined diagnostic imaging services to encompass all radiology Current Procedural Terminology (CPT) codes. We compared the CPT codes used in the OIG study with our criteria to ascertain the differences between the two approaches. This comparison revealed that more than 85% of the 82 HCPCS codes used in the OIG definition were radiology procedures.1 The codes in the OIG definition not captured by our criteria
included procedures such as electronic pacemaker analysis and cardiac events recording, which are typically performed in physicians' offices and not in freestanding facilities. Moreover, the OIG definition, like our criteria, did not include any radiation therapy procedure codes. Thus, since the criteria we employed are almost identical to the definitional param¬ eters of the OIG study, it appears that the ownership rates of diagnostic imaging facilities in Florida are comparable with the OIG estimates for independent physiological laboratories. The OIG researchers also note that Florida may well be unusual in its high percentage of physician joint ventures and therefore, nationally, the proportion of health care businesses owned by referring physicians is probably somewhat less than the estimates we reported for Florida.2 While this point is valid for some types of services, for others, the Florida rates are probably indicative of the national average. One factor contributing to the differences is that the OIG study is based on data from 1987, whereas the Florida estimates
Downloaded From: http://jama.jamanetwork.com/ by a Carleton University User on 06/17/2015
