Thank you for your article ("Atypical heart attack symptoms often misdiagnosed: study," Aug. 11, MP Stat) on atypical symptoms that can obscure the diagnosis of acute coronary syndrome, or ACS. This is well-known in the emergency medicine community, the front line for treating ACS. There have been a number of recent articles in our literature addressing this. As an example, patients over the age of 65 frequently are more likely to complain of shortness of breath than they are of chest pain when they are experiencing ACS. Women and diabetics are other examples of patients who are more likely to experience nonclassical findings for ACS.
The problem faced is that many nonclassical findings of ACS also can represent other diseases. Shortness of breath, dizziness, nausea, abdominal pain and lightheadedness can be the presenting symptoms for a number of other life-threatening emergent conditions. To believe that these should always trigger the aggressive work-up of ACS ignores the realities of providing care in the emergency department.
This brings up the related issue of limited resources in emergency medicine and medicine in general. While the U.S. is often cited as being the most technologically advanced in the field of medicine, the reality is that there are not enough resources dedicated to emergency medicine by the Medicare and Medicaid programs and private insurers to preserve the safety net of emergency care. This net is fraying, and all of us in the trenches balance off what we can do physically and what we would like to do ideally.
My point is that this information is well-known to the emergency medicine community, and the majority of us are working with this in mind already.
John Hipskind, M.D. Assistant director of the emergency department, Kaweah Delta Hospital, Visalia, Calif. President, Tulare County (Calif.) Medical Society
Docs disruptive ... or quality-conscious?Regarding "Disruptive physicians need a timeout: survey" (Aug. 27, MP Stat) there is no doubt that aggressive, disrespectful behavior by medical staff toward one another has a deleterious effect on patient care, has no place in medicine and must be eliminated. Such behavior has existed since hospitals evolved from charity wards for the poor and homeless and is often tolerated simply because the practitioners of such behavior are often also big moneymakers for institutions. It is refreshing to find healthcare executives taking a stand on this problem -- if that is what they are doing. A superficial inspection of the facts, however, suggests that there is another agenda.
There are simply not that many "bullies" in most low-security prisons, let alone on most medical staffs and, in any case, this type of inappropriate behavior is remarkably simple to address if there is any interest in doing so -- starting with the offended party, with the full support of supervisors and administration, telling the bully to "Stop it!"
The sudden interest and widespread "discovery" of relatively large numbers of disruptive physicians and systematic development of means and methods to deal with them rather relates to the fact that healthcare executives today frequently use the term "disruptive physician" to describe members of the staff who insist on the correction of chronic, well-recognized problems with the quality of care within institutions or will not go along with "suggested" codes or lengths of stay or other hospital guidelines, as well as the types of real "problem physicians" that the article describes. Once labeled "disruptive," these patient advocates, along with their patient-care issues, are terminated. Thus labeled, these physicians qualify to be reported to the National Practitioner Databank. Getting a databank report reversed is extraordinarily difficult even after one's name is cleared in court.
Steve Twedt has done the seminal work in this area ("The cost of courage," a series the Pittsburgh Post-Gazette ran from Oct. 26-29, 2003), which seems to be one that people don't want to talk much about, let alone do anything about. While seminars regarding how to handle "disruptive physicians" are sprouting up everywhere -- online, teleconferences, etc. -- ethical physicians who are trying to address the patient-safety crisis, malpractice crisis, healthcare cost crisis, compliance fraud crisis and the multitude of other crises that are facing our healthcare system today are on their own in trying to address the epidemic practice of medicine by conspiracy. Organized medicine, the media and their colleagues, whose primary concern is to avoid sharing the same fate that these martyrs face, will have little to do with them.
I applaud healthcare executives who are trying to rid our hospitals of aggressive, disrespectful behavior. I challenge them to start a simultaneous movement to support and respect healthcare workers who try to meet their professional obligations by working to make our hospitals safer places that provide adequate, cost-effective care.
W. Harry Horner, M.D. Waynesboro, Va.
Malpractice insurance for academic docsOne of our physician organization members has informed us that Modern Physician?s July 2004 issue listed physician-owned medical malpractice insurance companies and neglected to list the Academic Health Professionals Insurance Association. Academic is a best-rated insurer licensed originally in New York in 1990 and now serving more than 1,500 faculty physician-owners in several states. It is a professional liability medical malpractice insurance association developed specifically by and for academic physicians and dentists. It offers faculty the maximum possible control of their professional liability risks by providing excellent professional liability insurance and defense against claims while reducing premiums to levels that reflect their excellent loss history. Academic's all-faculty Board of Governors invites faculty practice organizations to visit its Web site at academicins.com or call 800-416-1143 and inquire about joining the association.
Thank you for placing our very successful faculty physician-owned association on your list.
Jay Roberts Marketing director Academic Health Professionals Insurance Association New York
A taxing approachRegarding "Americans dissatisfied with U.S. healthcare: poll" (Aug. 30, MP Stat), did the poll also ask the American healthcare consumers if they are willing to pay the additional 6% to 9% national sales tax, or value-added tax, that is charged in Canada to cover this system in addition to the taxes they are already paying? And to have the services rationed and limited as to where they can go? They better talk to some Canadians who have to use the system. It is great unless you are elderly or want elective surgery or would like to have your hospital stay in a city near family members, etc.
Chuck Geiss Assistant vice president of compliance Salem (Ohio) Community Hospital