might also want to mention a psychologist's singular and insightful treatment- of a therapy process which "gives a new point of view from which to consider the nature of maladjustment of modern man in his physical and social environments."7 The present writer's research in music therapy8 recalls a significant contribution in that field which gives music "a place in the modern therapeutic armament."9 Perhaps what this argument is saying is that agents in the healing process can be found in a number of professional disciplines. This view is reflected in the article, "Doctoring Isn't Just for Doctors."' 0 Indeed, those who thus argue might well point with pride to the telephone directories which list "Physicians," rather than "Doctors." The traditionalist argument concerning duration of professional preparation is well taken. It is common knowledge that degrees of nearly every description can be obtained from "paper univer-
sities" merely by submitting a check or money order. This is a constant source of embarrassment to all individuals who have worked and studied arduously for a particular degree. In this connection it should be pointed out that in the American academe there are countless scholars of unquestioned probity who are constantly at work to improve academic standards. As for the quick-degree businesses, it is hoped that the various states will take vigorous measures to eliminate the many diploma factories which are rendering a profound and irreparable disservice to the helping professions and to society as a whole.
Summary This paper holds that the individual possessing an earned terminal degree and functioning in the field of medicine rightly deserves a unique appellation that will distinguish him or her from those associated with other disciplines. This is becoming increasingly impor-
tant in a complex society whose helping professionals are to be found not only in medicine, but in psychology, theology, and counseling as well as other related fields. Literature Cited 1. Grant WV, Lind CG: Digest of Education Statistics. Washington, DC: US Department of Health, Education, and Welfare, 1977, pp 123124 2. Deighton, LC (ed): The Encyclopedia of Education, vol IlIl. New York, Macmillan, 1971, pp 29, 118 3. Pair MW (ed): Encylopedia of Associations, ed 12. Detroit, Gale Research Company, 1978, vol 1, pp. 752-753 4. Eells WC: Degrees in Higher Education. Washington, DC, The Center for Applied Research in Education, 1963, p 16 5. Fosdick HE: On Being a Real Person. New York, Harper and Row, 1943, pp 32-33 6. Dewey J: The unity of the human being. In Burnett W (ed): The World's Best. New York, Dial Press, 1950, pp 111-123 7. Rogers CR: Client-Centered Therapy. Boston, Houghton Mifflin, 1951, p viii 8. Williams RB: Music therapy: How it helps the child. J Int Assoc Pupil Personnel Workers March, 1975, pp 74-80 9. Alvin J: Music Therapy. New York, Basic Books, 1966, p 4 10. Yeager RC: Doctoring isn't just for doctors. Reader's Digest December, 1977, pp 237238
The Ghetto Emergency Room Jasper F. Williams, MD Chicago, Illinois
A study of Emergency Room use by members of the Southside Community Health Plan was conducted to assess patterns and economies affected in health care delivery to the population. An analysis of the 141 patient visits is presented. This study of Emergency Room use by members of the Southside Community Health Plan (SCHP) was conducted to ascertain what patterns existed and what economies were affected in health care delivery. Based on Chicago's Southside, the plan serves primarily the Woodlawn and Englewood communities. These communities are identified as being urban ghettos in deteriorating condition and serviced by a markedly deficient number of physicians who are attempting to practice a high standard of medicine in hospitals, some of which need to be replaced, and all of which need additional financial assistance. The plan, whose capitation was paid by the State of Illinois Department of
Requests for reprints should be addressed to Dr. Jasper F. Williams, Williams Clinic Ltd, 408 East Marquette Road, Chicago IL 60637. 1020
Public Aid, paid $7,442.68 for emergency care rendered its members by various hospital Emergency Rooms during 1977. Registered members of the plan averaged approximately 700. Fees were paid for 141 visits to Emergency Rooms which represented approximately 200 visits per thousand per year. Of the 141 patients seen, only four were admitted to the hospital. Williams Clinic, Ltd. serviced this prepaid group of patients on a capitation basis. Williams Clinic staff estimated that it would cost the clinic about $15 per visit to take care of the kinds of problems represented by the Emergency Room encounters. If 1X visits is multiplied by $15, $2,115.00 is the product. If this figure is subtracted from the $7,442.68 paid for the services, there appears to have been an excess charge for the emergency care rendered: $5,327.68. This amounts to an approximate 350 percent mark-up on care ren-
dered by hospitals when compared with the cost of care rendered by the clinic for the same problems. Table 1 indicates the range of hospital charges for Emergency Room care rendered to the patients, the vast majority of whom were treated at St. Bernard or Jackson Park Hospitals. The average figures for the other hospitals listed were based upon such minimal utilization that the fee could not be considered as representative of the usual Emergency Room charges in those hospitals. It appears that the same types of patient were seen at both Jackson Park and St. Bernard Hospitals. In fact in some instances, identical patients were seen at both hospitals. However, it is evident that charges in the two hospitals varied between them by almost 100 percent. A study of Emergency Room records indicated that frequently in St. Bernard Hospital extensive tests and x-ray studies were ordered which increased the patient's bill on such simple conditions as upper respiratory infection. The average cost of a visit to Jackson Park Hospital Emergency Room was $33.87 in con-
JOURNAL OF THE NATIONAL MEDICAL
ASSOCIATION, VOL. 71, NO. 10, 1979
Table 1. Hospital Charges for Emergency Room Care
Hospital
Patient Total
University of Chicago Englewood Provident Tabernacle Henrotin Tyson Co. Memorial South Shore St. Bernard Illinois Central Jackson Park
5 5 4 1 1 1 1 86 1 36
Table 2. Emergency Room Visits by Nature of Condition
Pediatric Adult Chronic Acute Trauma
Number
Percent
60 81 15 126 14
42.6 57.4 10.1 89.9 10.0
trast to $60 for a visit to St. Bernard Hospital Emergency Room. These figures compared to a Clinic visit of $15. Table 2 is an analysis of the type of patients seen in the Emergency Room services. Sixty (42.6 percent) of the patients were pediatric and 81 (57.4 percent) were adults. Only ten percent of the conditions, such as diabetes, hypertension, and asthma, causing the patient to visit the Emergency Room, could be considered chronic. Nearly ninety percent of the visits resulted from acute problems, and trauma accounted for only ten percent of visits. Table 3 represents an analysis of the day and time that the hospital Emergency Room was used. This was an effort to ascertain whether or not the Emergency Room was really used for
emergencies. It is evident that only one of the 141 visits to the Emergency Room occurred on a holiday. Another interesting finding was that 50 Emergency Room visits (35.5 percent) were made at the same time that the Clinic was open with staff available and ready to serve the population. This use of the Emergency Room cannot be explained; however, another study will be made in an effort to determine the reason for its unnecessary use. Thirty-seven of the remaining visits were made after the Clinic was closed and before midnight, and 34 vis-
$0-35
$3549
$50-74
80% 80%
20% 20% 100%
Charges $75-99
$100-124
$125+
Average $42.41 47.00 67.18 32.00 35.00 41.00 51.08 60.00 55.00 33.87
100%
100% 100%
14.8%
33.7%
41.5%
38.5%
100% 28.4% 100% 10%
14.6%
5.6%
2.9%
10%
Table 3. Emergency Room Use by Day and Time
Number
Percent
1
50
0.7 35.5
37
26.1
34
24.2
19
13.5
Holiday Visits at time clinic was open Visits when clinic was closed before midnight Visits when clinic was closed after midnight Visits on Sunday when clinic was closed
Table 4. Emergency Room Problems Problem Encountered Drug Overdose Valium Amphetamines Hypertension Choking Pork skins Fish bone Child Poisoning Birth control pills Bleach Linament Aspirin Asthma Dog Bite
its were made after the Clinic was closed and after midqight. Nineteen visits were made on Sundays. Approximately 65 percent of visits to Emergency Rooms were made at a time when the Clinic was not open. Keeping the Clinic open at all times in order that no one would have to visit local Emergency Rooms would cost approximately $75,000. It is therefore evident
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 10, 1979
Number
Total
1 1
2 3
1 1
2
2 1 1 2
6 4
1
insofar as the clinic is concerned that the availability of Emergency Rooms is essential. It should be possible to eliminate 50 (35.5 percent) of visits made to Emergency Rooms during the time that the Clinic is open. If this could be accomplished, a savings of $2,642 would accrue to the prepaid plan. Table 4 is an analysis of the kinds of 1021
problems presented in the Emergency Rooms. Drug overdose represented two cases: hypertension, three cases: choking, two cases: child poisoning, six cases: asthma, four cases: and dog bite, one case. Most other visits were related to respiratory problems, such as influenza, pneumonia, bronchitis, etc. The careless handling of birth control pills, bleach, linament, other medications and colorful chemicals in the home poses an obvious threat to infants. Most of those affected were less than three years of age. The problem of educating people, who have for years found the Emergency Room the only source of medical care in times of need, and convincing them of the advantage of using a clinic or group practice facility whenever
possible, represents a major undertaking. One cannot easily change habits of people. Educational levels and intellect often bear little or no relation to behavior, especially when that behavior by repetition has become a habit. Evidence of this is the number of intelligent people who smoke, and become addicted to alcohol, to amphetamines, and to sleeping pills despite the vast sums of money spent annually in an effort to educate them to the dangers of these practices. The marked difference between the cost of care rendered in a hospital Emergency Room compared to that rendered for the same condition in a group practice facility opens hospitals to suspicion for generating income through excessive use of laboratory
facilities. When two hospitals in the same community have fees which are basically 80 to 100 percent different from each other, the practices in one or the other may not be what they should be.
Conclusions There is strong evidence that considerable reduction in health care costs can be realized with modification of the current patterns of use of hospital Emergency Rooms in the ghetto. Acknowledgement This article was made possible by Grant #05 P000281 030-MO P31, Department of Health, Education, and Welfare to the Southside Community Health Plan. The author is grateful to Mr. Arthur Brown, Executive Director of the Southside Community Health Plan, for furnishing much of the basic data used in this study.
Mental Illness in Blacks: An Overview, and Treatment Approaches Elizabeth B. Davis, MD New York. New York Provisions for inner city mental health services must recognize the
association between poverty, discrimination, and related social and physical conditions and disproportionately high rates of severe mental disorder-a transcultural phenomenon. Program emphasis should therefore be on the prevention, early recognition, prompt and effective treatment and rehabilitative care of psychosis. The total spectrum of psychiatric services is required for this, and thus an opportunity is afforded for necessary training and research. Poverty has negative impact on general health and cognitive development as well as on self-esteem, self-care, and the ability to utilize medical and health services. This contributes to a vicious, intergenerational poverty cycle. Primary prevention of mental illness, where possible, depends at present on socioeconomic change. Secondary prevention, ie, timely, appropriate treatment, is effective, but requires patient access to and acceptance of all indicated modalities of care. In planning and providing mental health services for any area, it is important to know the general characteristics
Presented at the NMA Region Seminar, "Stress, Economics and the Mental Health of Blacks," May 1978, Cherry Hill, New Jersey. From the Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York. Requests for reprints should be addressed to Dr. Elizabeth B. Davis, 353 E 17th Street, New York, NY 10003.
1022
of the population to be served. Foremost among characteristics of today's American inner city are that its population is largely black and large'ly poor. It has been well documented that being black in America vastly increases one's chances of being poor-irrespective of constitution, motivation, or even factors such as educational, vocational, or social status. The rules of social and economic
competition which have sooner or later applied at least roughly to members of most other ethnic groups in America have, until very recently, been systematically abrogated for blacks throughout their time in this country, in spite of the fact that after emancipation, conformity to the American ideal of equality of opportunity required that the continuing exclusion of blacks from the competitive system be denied, camouflaged, or rationalized. Aside from the complex effect of this arrangement on the motivation, attitudes, and values of inner city residents, there are very specific consequences of the poverty itself. It is to these that professional mental health services in the inner city must be specifically addressed.
Role of Poverty in the Epidemiology of Mental Disorder The work of Ho-llingshead and Redlich' and of Srole, et al2 (The Midtown Study) leave little doubt of the reality of the association between poverty and severe psychiatric illness, particularly schizophrenia, that is so strongly suggested by even casual examination of the correlation between hospital ad-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 10, 1979
sities" merely by submitting a check or money order. This is a constant source of embarrassment to all individuals who have worked and studied arduously for a particular degree. In this connection it should be pointed out that in the American academe there are countless scholars of unquestioned probity who are constantly at work to improve academic standards. As for the quick-degree businesses, it is hoped that the various states will take vigorous measures to eliminate the many diploma factories which are rendering a profound and irreparable disservice to the helping professions and to society as a whole.
Summary This paper holds that the individual possessing an earned terminal degree and functioning in the field of medicine rightly deserves a unique appellation that will distinguish him or her from those associated with other disciplines. This is becoming increasingly impor-
tant in a complex society whose helping professionals are to be found not only in medicine, but in psychology, theology, and counseling as well as other related fields. Literature Cited 1. Grant WV, Lind CG: Digest of Education Statistics. Washington, DC: US Department of Health, Education, and Welfare, 1977, pp 123124 2. Deighton, LC (ed): The Encyclopedia of Education, vol IlIl. New York, Macmillan, 1971, pp 29, 118 3. Pair MW (ed): Encylopedia of Associations, ed 12. Detroit, Gale Research Company, 1978, vol 1, pp. 752-753 4. Eells WC: Degrees in Higher Education. Washington, DC, The Center for Applied Research in Education, 1963, p 16 5. Fosdick HE: On Being a Real Person. New York, Harper and Row, 1943, pp 32-33 6. Dewey J: The unity of the human being. In Burnett W (ed): The World's Best. New York, Dial Press, 1950, pp 111-123 7. Rogers CR: Client-Centered Therapy. Boston, Houghton Mifflin, 1951, p viii 8. Williams RB: Music therapy: How it helps the child. J Int Assoc Pupil Personnel Workers March, 1975, pp 74-80 9. Alvin J: Music Therapy. New York, Basic Books, 1966, p 4 10. Yeager RC: Doctoring isn't just for doctors. Reader's Digest December, 1977, pp 237238
The Ghetto Emergency Room Jasper F. Williams, MD Chicago, Illinois
A study of Emergency Room use by members of the Southside Community Health Plan was conducted to assess patterns and economies affected in health care delivery to the population. An analysis of the 141 patient visits is presented. This study of Emergency Room use by members of the Southside Community Health Plan (SCHP) was conducted to ascertain what patterns existed and what economies were affected in health care delivery. Based on Chicago's Southside, the plan serves primarily the Woodlawn and Englewood communities. These communities are identified as being urban ghettos in deteriorating condition and serviced by a markedly deficient number of physicians who are attempting to practice a high standard of medicine in hospitals, some of which need to be replaced, and all of which need additional financial assistance. The plan, whose capitation was paid by the State of Illinois Department of
Requests for reprints should be addressed to Dr. Jasper F. Williams, Williams Clinic Ltd, 408 East Marquette Road, Chicago IL 60637. 1020
Public Aid, paid $7,442.68 for emergency care rendered its members by various hospital Emergency Rooms during 1977. Registered members of the plan averaged approximately 700. Fees were paid for 141 visits to Emergency Rooms which represented approximately 200 visits per thousand per year. Of the 141 patients seen, only four were admitted to the hospital. Williams Clinic, Ltd. serviced this prepaid group of patients on a capitation basis. Williams Clinic staff estimated that it would cost the clinic about $15 per visit to take care of the kinds of problems represented by the Emergency Room encounters. If 1X visits is multiplied by $15, $2,115.00 is the product. If this figure is subtracted from the $7,442.68 paid for the services, there appears to have been an excess charge for the emergency care rendered: $5,327.68. This amounts to an approximate 350 percent mark-up on care ren-
dered by hospitals when compared with the cost of care rendered by the clinic for the same problems. Table 1 indicates the range of hospital charges for Emergency Room care rendered to the patients, the vast majority of whom were treated at St. Bernard or Jackson Park Hospitals. The average figures for the other hospitals listed were based upon such minimal utilization that the fee could not be considered as representative of the usual Emergency Room charges in those hospitals. It appears that the same types of patient were seen at both Jackson Park and St. Bernard Hospitals. In fact in some instances, identical patients were seen at both hospitals. However, it is evident that charges in the two hospitals varied between them by almost 100 percent. A study of Emergency Room records indicated that frequently in St. Bernard Hospital extensive tests and x-ray studies were ordered which increased the patient's bill on such simple conditions as upper respiratory infection. The average cost of a visit to Jackson Park Hospital Emergency Room was $33.87 in con-
JOURNAL OF THE NATIONAL MEDICAL
ASSOCIATION, VOL. 71, NO. 10, 1979
Table 1. Hospital Charges for Emergency Room Care
Hospital
Patient Total
University of Chicago Englewood Provident Tabernacle Henrotin Tyson Co. Memorial South Shore St. Bernard Illinois Central Jackson Park
5 5 4 1 1 1 1 86 1 36
Table 2. Emergency Room Visits by Nature of Condition
Pediatric Adult Chronic Acute Trauma
Number
Percent
60 81 15 126 14
42.6 57.4 10.1 89.9 10.0
trast to $60 for a visit to St. Bernard Hospital Emergency Room. These figures compared to a Clinic visit of $15. Table 2 is an analysis of the type of patients seen in the Emergency Room services. Sixty (42.6 percent) of the patients were pediatric and 81 (57.4 percent) were adults. Only ten percent of the conditions, such as diabetes, hypertension, and asthma, causing the patient to visit the Emergency Room, could be considered chronic. Nearly ninety percent of the visits resulted from acute problems, and trauma accounted for only ten percent of visits. Table 3 represents an analysis of the day and time that the hospital Emergency Room was used. This was an effort to ascertain whether or not the Emergency Room was really used for
emergencies. It is evident that only one of the 141 visits to the Emergency Room occurred on a holiday. Another interesting finding was that 50 Emergency Room visits (35.5 percent) were made at the same time that the Clinic was open with staff available and ready to serve the population. This use of the Emergency Room cannot be explained; however, another study will be made in an effort to determine the reason for its unnecessary use. Thirty-seven of the remaining visits were made after the Clinic was closed and before midnight, and 34 vis-
$0-35
$3549
$50-74
80% 80%
20% 20% 100%
Charges $75-99
$100-124
$125+
Average $42.41 47.00 67.18 32.00 35.00 41.00 51.08 60.00 55.00 33.87
100%
100% 100%
14.8%
33.7%
41.5%
38.5%
100% 28.4% 100% 10%
14.6%
5.6%
2.9%
10%
Table 3. Emergency Room Use by Day and Time
Number
Percent
1
50
0.7 35.5
37
26.1
34
24.2
19
13.5
Holiday Visits at time clinic was open Visits when clinic was closed before midnight Visits when clinic was closed after midnight Visits on Sunday when clinic was closed
Table 4. Emergency Room Problems Problem Encountered Drug Overdose Valium Amphetamines Hypertension Choking Pork skins Fish bone Child Poisoning Birth control pills Bleach Linament Aspirin Asthma Dog Bite
its were made after the Clinic was closed and after midqight. Nineteen visits were made on Sundays. Approximately 65 percent of visits to Emergency Rooms were made at a time when the Clinic was not open. Keeping the Clinic open at all times in order that no one would have to visit local Emergency Rooms would cost approximately $75,000. It is therefore evident
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 10, 1979
Number
Total
1 1
2 3
1 1
2
2 1 1 2
6 4
1
insofar as the clinic is concerned that the availability of Emergency Rooms is essential. It should be possible to eliminate 50 (35.5 percent) of visits made to Emergency Rooms during the time that the Clinic is open. If this could be accomplished, a savings of $2,642 would accrue to the prepaid plan. Table 4 is an analysis of the kinds of 1021
problems presented in the Emergency Rooms. Drug overdose represented two cases: hypertension, three cases: choking, two cases: child poisoning, six cases: asthma, four cases: and dog bite, one case. Most other visits were related to respiratory problems, such as influenza, pneumonia, bronchitis, etc. The careless handling of birth control pills, bleach, linament, other medications and colorful chemicals in the home poses an obvious threat to infants. Most of those affected were less than three years of age. The problem of educating people, who have for years found the Emergency Room the only source of medical care in times of need, and convincing them of the advantage of using a clinic or group practice facility whenever
possible, represents a major undertaking. One cannot easily change habits of people. Educational levels and intellect often bear little or no relation to behavior, especially when that behavior by repetition has become a habit. Evidence of this is the number of intelligent people who smoke, and become addicted to alcohol, to amphetamines, and to sleeping pills despite the vast sums of money spent annually in an effort to educate them to the dangers of these practices. The marked difference between the cost of care rendered in a hospital Emergency Room compared to that rendered for the same condition in a group practice facility opens hospitals to suspicion for generating income through excessive use of laboratory
facilities. When two hospitals in the same community have fees which are basically 80 to 100 percent different from each other, the practices in one or the other may not be what they should be.
Conclusions There is strong evidence that considerable reduction in health care costs can be realized with modification of the current patterns of use of hospital Emergency Rooms in the ghetto. Acknowledgement This article was made possible by Grant #05 P000281 030-MO P31, Department of Health, Education, and Welfare to the Southside Community Health Plan. The author is grateful to Mr. Arthur Brown, Executive Director of the Southside Community Health Plan, for furnishing much of the basic data used in this study.
Mental Illness in Blacks: An Overview, and Treatment Approaches Elizabeth B. Davis, MD New York. New York Provisions for inner city mental health services must recognize the
association between poverty, discrimination, and related social and physical conditions and disproportionately high rates of severe mental disorder-a transcultural phenomenon. Program emphasis should therefore be on the prevention, early recognition, prompt and effective treatment and rehabilitative care of psychosis. The total spectrum of psychiatric services is required for this, and thus an opportunity is afforded for necessary training and research. Poverty has negative impact on general health and cognitive development as well as on self-esteem, self-care, and the ability to utilize medical and health services. This contributes to a vicious, intergenerational poverty cycle. Primary prevention of mental illness, where possible, depends at present on socioeconomic change. Secondary prevention, ie, timely, appropriate treatment, is effective, but requires patient access to and acceptance of all indicated modalities of care. In planning and providing mental health services for any area, it is important to know the general characteristics
Presented at the NMA Region Seminar, "Stress, Economics and the Mental Health of Blacks," May 1978, Cherry Hill, New Jersey. From the Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York. Requests for reprints should be addressed to Dr. Elizabeth B. Davis, 353 E 17th Street, New York, NY 10003.
1022
of the population to be served. Foremost among characteristics of today's American inner city are that its population is largely black and large'ly poor. It has been well documented that being black in America vastly increases one's chances of being poor-irrespective of constitution, motivation, or even factors such as educational, vocational, or social status. The rules of social and economic
competition which have sooner or later applied at least roughly to members of most other ethnic groups in America have, until very recently, been systematically abrogated for blacks throughout their time in this country, in spite of the fact that after emancipation, conformity to the American ideal of equality of opportunity required that the continuing exclusion of blacks from the competitive system be denied, camouflaged, or rationalized. Aside from the complex effect of this arrangement on the motivation, attitudes, and values of inner city residents, there are very specific consequences of the poverty itself. It is to these that professional mental health services in the inner city must be specifically addressed.
Role of Poverty in the Epidemiology of Mental Disorder The work of Ho-llingshead and Redlich' and of Srole, et al2 (The Midtown Study) leave little doubt of the reality of the association between poverty and severe psychiatric illness, particularly schizophrenia, that is so strongly suggested by even casual examination of the correlation between hospital ad-
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 10, 1979
