Lowell M. Hardy, DO, Personal and Professional Papers 31

1-. What is .Angina Pectoris? 2~

Can heart disease be explained simply on a mechanical basis?

3 ? Have you considered posture as a neglected etiological factor i n heart disease? 4 c Do o steop athic lesi ons serve as primary.or seconda ry etiological f 8 c toro in he a rt dise a se? or both? 5 o 'JVhn t is t he most plausible explanation of sclerotic changes? C-. iVh -:;r d oes d i ab et e s cause he a rt disease?

Upon what grounds can a diagnosis of heart dise a se be made?

7 .,

8-. Upon nha t 9~

grounds do you consider that a he a rt is not diseased?

Is there any significance in the various relations between systolic, diastolic and pulse pressures?

~ 0 ~ Does the quality of the blood (~nemia-polycythemia)

influence oneis opinion as to the diagnosis, treatment and prognosis of hcnrt disease?

ll - A.re the so called functional heart tests reliable?

1 2 . Is it possible to make an accurate diagnosis in the heart field without the bene.fit of complete and e::~acting history, physical examination and laboratory aids? ~3 .

Is electrocardiography of value in diagnosing. valve lesions?

:L4~ Ha s

electrocardiography ever any value without other diagnostic procedures?

~Sp

-~ . r-

Is it always possible for a specialist in cardiovascular disease to decide where .functional heart disease s t ops and organic begins?

路.路 Is soreness in the tissues o.f the precordium a symptom of heart disease?

17. Do es coronary pain always manifest itsel.f in the chest? 1 8 ~ ~bat is the usual location and nature of true coronary pain?

19,. What is "hea rt failure 11 7 20o What do murmurs mean?

2le Are you of t h e opini on that treatment of c a rdi a cs is useless? 22. Is i t n ec e s s ary to know the exact etiology and pathological lesion pre s e ~ t inn ; 1 r c n .case to efficiently treat a cardiac emergency? 23o 'v'ihat

n re the two principal \vayc of considering heart failure as f a r as t her apy is c oncerned?

24, Does drug therapy have a part in the osteopathic management of cordiacs? 25 o Is it alvmys desirable to roduce blood pressure, in hypertensives? 26=

:n how many h~nJ rtonsives do you succeed in lower ing blood pressure significantly?

<Y7, "IIhtl t pr rt does

11 wishful

thinking" play in the reading of blood

presrure findings?

;:;se Undor wh路 1- cond.l tions are you justified in making a definite prognosis? 29~

vfr1at relation does heart size have to heart health ?

30o Do we know the diseases in which organic heart change is an almost inevitable outcome? 31 .. Upon what bo.sis do you allow resumpti on of o.ctivity after attacks of coronary thrombosis? rheumatic fever? measles? 32. Is other a safe anesthetic for the cardio.c? 33. On what b2.sis should the type of anesthetic be chosen for the c ardiac? 34o In what manner can the cardiolo gist prove the essentiality of his specialty?

January 1, 1962

ON CONSULTATION

The recent interest in consultation is a commendable one and its introduction at this time is both timely and valuable. A consideration cf this subject has, however 11 very little value unless i t is related to a 11 thoce conr.erned and thereby having taken a long and searching look at it in it.s ent:'.rety\ pra r. ti~es and philosophies may be changed to the benefit of the patient, to the benc:flt of the Staff and the hospital. In this consideration, it is neces"' s~ry to ta:k about natters which are perhaps unpleasant and bitter pills to swallow. Continual talk about how good things are, without thought of the bad, fails to stimulate a beneficial effect and, as a matter of fact, things would get worse, since we cannot stand still but must go ahead or fall behind. It has been said, by those who are critical of the profession, that the three cardinal sins of doctors are: Ignorance, Greed, and Pride. Now these things could be said about almost any group, ~owever, when it is said about our group it has a serious connotation~ The Public Image of the Physician as a dedicated, sincere, truthf,ll friend and healer of the sick has slipped, not slightly, but seriously. This presentation is not being made to a lay group so we do not have to get on the defensive among ourselves. Unfortunately, the cardinal sins of Ignorance, Greed, and Pride are found among us in proportions great enough to cause us all to be concerned and to indulge in thoughtful introspection. Now you may ask what this has to do with consultations. It has everythin~ to do with them. These cardinal sins of Ignorance, Greed and Pride are working in almost every case where consultation should be held, but is not. Ignorance is the most difficult of them to overcotre â&#x20AC;˘ How can one hope to deal with a problem that a man doesn't know he has? It has been said over and over that when one knows that he doesn't know he is then at the beginning of wisdom. This sin is found in the man who Has been washed out of the main stream of medicine into the eddies of complacency by the passage of time. Has not taken special postgraduate work in the fields in which he practices. Has an inadequate library of books and journals. Has never learned to separate the wheat from the chaff in what he reads. Has restricted his practice to the point of being a technician rather than a physici'ln. Has such limited experience that he has not yet learned to discriminate between fact and fancy. Has learned his medicine from myths passed down bv his grandmother from the dark history of the past. Has learned his medicine from the patients. Has learned his medicine from the

dru~

salesman.

Is a man who perhaps should never have been a doctor.

- 2 Wh~t

is the answer to the problem of Ignorance? Can a man, if he reco~nizes this sin in himself, cha nge enough so that he will not be a mero.ce to the patient and the very e:yist ence of bi s profs ssion and his hospital? Is the answer that all of his cases f a l JJ ng in ce:rtain ca tegories shcmld be restricted?

Gra<ecl l.s -m eDd i ~m s r6p-rs":len3 ~_ble to all of us, but present to a degree in all of ur o I t 0 '? \: :>~~ s ~ rJc: ~1rre ·c to the p;:! tier;t J t '>J.e p l ' ')fes;.;:i. :'ln, :,.nd t.he hospital when it be-: Jltes o~ a }Yf">Lo:·i.i on unccnitl'oi l&"ole by -:.he intelJ.e •:;t and by a we~l .... cJeveloped s c n JEJ of r-:g-~t r1. r,d -wr'mg. This sin is f ound in the na n who ·Att empts procedures for which he is not qualified for the sake of the fee and not for the good of the patient. Attempts procedures for which there is not a legitimate medical reason. At t empts illega l At-+. emr ts eve nt~ai

procedures~

prCJcedures to please a family or other group, with the thought of the profit, even though not indicated or legal.

Attemps procedures for the purpose of fraudulent collection from insurance companies or other agencies. Withholds the services of other physicians so that the patient may pay his own fee. Defrauds or helps to defraud the

hospit~l.

Makes a hero of himself with a patient or patient's family bv criticising the bills of a cooperating colle~gue. Makes charges out of proportion to the value of his services. lN'ants all the patients of a 11 the doctors for himself. What is the answer to the problem of Greed? Is it that a man who cannot control himself must be controlled by hospital safeguards and by the disapproval of his colleagues? And now for the consideration of Pride as a sin. This sin is found in the man who -

How does Pride manifest itself?

Runs down his colleagu~'s ability to enhance his own prestige. Fails to get advice because it will injure his practice. Is unable to admit mistakes. Is always blaming someone else for his misfortunes. Is unable to forget fancied slights or injuries. Is difficult to teach because he doesn't want it known that he needs to ~e taught. Never builds up the reputation of a colleague until the day when he wants to get out of a jam and then \-vishes he had. There is more help for this sin than the others, since all that is necess~rv is to prove to the individual that "enlightened selfishness" pays tremendous dividends in stature and prestige.

- 3 ... These, then, are many of the reasons why consultations are not held more frequently~ The experience of a PT~~~r.J:..y_~~-t-up Clinical Group, where all members are sharing f1·~m t:1c s<"mc pool i·.he ~-;re-fits of the association on the ba~is of skills, seniori-· t~· ,u.O r;o:cr;·,:c.L'cu.l-J 011 tCJ 1,he wh::JJ.e 9 c'lernonstrates that the three sins are greatly sub .. ~i-~_1''1",3d. ::rrr:v .r;u·~e i.s not t.clcratE:d by a ;Y,roup, r-reed cannot be condoned a.nd Pride ir- c 1-_·: ni·erJ f:rcm -t;··:"le "Ln·.'i.v:!rj:l'"'..l. to +.he g:r.c1p wllen all can s ee that the welfare of t.he 1!,: .:·w. ::_~ .-;._pel d~r.J-. q:.;rJt: 0i .; v•e Lf1.:r.e ard .:tc·!~~_vities of e"'..ch member? While it is true tla"':. t;i~' ·w :·.t·~- TS of tJ.c dn 1)lf.''-L-~'<.\"G f,TOl:p ( the ri::t:n1::'tal staff) is D.S J~ruch dependent u1.c:1 r/1- i;·.ahirlt.a"c~ i"L lS m.;re dHfi·~·.lL~ tc visualize and an intan§'ible which seems tu ·:ke:J t:-:-cat.r.,e'"lt.- b·1t not to·Jc.y- tomo~rows As to \-Then C:Jl1S'llt3.tion should be held, there are certain rules which cover almost all cL·<..:u .ns"C mces a.nd shnuld be used as a yardstick in determinin~ whether consultation ~hould be o-r should have been carried out in a particular caseo ·-Then t~1e physici'3.n believes he has found the existence of a malady he is not eo;, i.nf·2c:i oy sxper:;.ence or technic'3.l training to diapnose.

l

1

2

Wht:n the physician believes he has found the exist~nce ef a rralady he is not equi~ped~ by experience or technica.l training, to treat.

3 When the treatment, in contrast to his previous experience, does not produce beneficial results.

4

1.ofuen hie.; prescription cres.tes unexplain~ble side reactions.

5

W:1e:1 r.riti.::.nl developments force the need for sur~ery or other soecial technics cf tTeatmente

6 Hhen the patient must be examined or treo3ted with complex instruments o"f apparatus which o3re beyond the scope of his

7

trainin~

or resources.

When the law or hospital rules specifically call for consultation in certain cases.

8 When the physician senses that a particular case has an unusual potential for professional lio3bility.

9 When the physician believes that consultation will increase the confidence and decrease the fears of a patient or his family. Search your own consciences and see if you are I'm puiltya

~uiltv

of any, or all, of these sins.

How about you? LOWELL M HARDY, D. O. Director of Graduate Educ~tion.

DIABETIC ACIDOSIS

Diabetic acidosis should be suspected in every case of unexplained unconsciousness. It is aneWrgency situation. Howeverâ&#x20AC;˘ its occurrence is relatively infrequent. Conditions which may precipitate diabetic acidosis are: (1) Omission of insulin or error in measurement or administration. (2) Excessive food intake.

(3) Infections (carbuncles, pneumonia, bronchitisâ&#x20AC;˘ kidney infection, etc.). (4) Surgical emergencies (appendicitis, ruptured viscous, intestinal obstruction, etc.) (5) Medical emergencies (myocardial infarctions,CVA, CHF). (6) Severe psychic disturbances. (7) G I disorders with vomiting and/or diarrhea. (8) Other conditions which increase insulin requirements, such as insulin resistance, hyperthyroidism, and toxemia of pregnancy. Some authorities suggest that if the unconscious patient is a known diabetic the practice is to assume hypoglycemic coma until blood glucose determinations can be made. Thus, recommending giving Glucagon 0.5 to 1 mg suhutaneously or 50 cc of 50% glucose I. v. or 10% glucose I. v.. If the patient responds in 20 minutes, then a diagnosis of hypoglycemia can be made. I think that one should keep in mind that, if one is actually dealing with a hypoglycemic coma, Glucagon may be ineffective due to the exhaustion of the glucose stores. Consequently, one may make the diagnosis of diabetic acidosis when one is actually dealing with a hypoglycemic coma. Secondly, delay in instituting therapy in either diabetic acidosis or hypoglycemic coma may prove fatal since the condtion may become irreversible. It, therefore, becomes paramount that the physician be able to differentiate between diabetic acidosis and hypoglycemic coma. Hypoglycemia liberates epinephrine, resulting in plapitations, tachycardia, diaphoresis, pallor, hunger tremor and headache. If allowed to continue, this may progress to malfunction of the CNS due to the lack of glucose to the brain. This results in confusion, anxiety, delirium, somnolence, coma and convulsions. The onset of hypoglycemia is rapid (minutes-hours). The onset of diabetic acidosis varies from hours to days. Symptoms include excessive thirst, anorexia, nausea, vomiting, abdominal pain, constipation, blurred vision. There is a slow transition from apathy to somnolence to stuppr to coma. Physical findings include deep and rapid breathing (kussmaul-air hunger), dehydration, tachycardia and abdominal distention. The breath has a distinctive acetone odor.

2 Once the history and physical findings have been evaluated and you suspect ketoacidosis, the following should be instituted immediately: 1.

Pass Foley and check urine sugar and acetone.

2.

Obtain 5 cc of blood, do Dextrotest and Acetest. (Glycosuria, ketaenuria, ketonemia and hyperglycemia confirm the presence of diabetic acidosis.)

Mechanism of ketoacidosis 1. Glucose entry into the cells is drastically reduced. 2.

Liver glycogen is broken down to glucose.

3.

Intracellular glucose deficits call forth release of free fatty acids from triglycerides in fat tissue.

These are used a s fuel and give rise

to ketone bodies. 4.

The lack of glucose i n the cells provokes the elaboration of a number of hormones , namely growth ho rmone, epinephrine, glucagon, ACTH and cortisol, which resul ts in further mobilization of fatty acids and gluconeogenesis .

Growth hormone and cortisol have the undesirable side effect of

increasing the body's res istance to adminis t e ed i nsulin. 5.

The comb ination of hyperosmol arity (resulting from hyperglycemia) and acidosis (due to production of excess ketone bodies) leads to progr es sive dehydration and depression of sensori um.

6.

When the blood pH f alls below 7.0

the nervous system becomes so depressed

that the person first becomes disoriented and later comatose. 7.

The increase H ion concentration causes increased rate and depth of respiration (Kussmaul breathing), a diagnostic sign of metabolic acidosis is increased pulmonary ventilation.

In contrast respiratory acidosis re-

spiration is depressed. 8.

Electrolytes imbalance is very prevalent.

Large amounts of Na are lost

- 3 as Na bicarbonate is secreted with the ketoacids.

In addition during the dehy-

dration process large quantities of K are removed from the tissue cells, along with the removal of H20 from these cells.

Consequently, on administering fluids and in-

sulin to the comatose patient, as these fluids and glucose are absorbed into the cells, large quantities of K are also absorbed into the cells to re-establish electrolyte balance.

This may greatly depress the K level in the extracellular fluids.

Once the diagnosis is established, adequate amounts of insulin and fluids should be given promptly. Additional laboratory tests should include serial blood sugars, serial plasma ketones, C02 combining power (severity of ketoacidosis is indicated

by plasma ketones

and C02), Het (measures dehydration), BUN (is a clue to underlying renal disease), serum electrolytes, urinalyses, serum amylase (detects acute pancreatitis), LDH, CPK, SGOT (detects myocardial infarction), EKG (detects myocardial infarction and hypo= kalemia, and cultures as necessary. Treatment: Opinions vary somewhat osis.

dosage and other aspects of the treatment of acid-

Insulin thereapy as previously mentioned should be started as soon as the

diagnosis is made. present. ly.

regard~ng

All the insulin is given subcutaneously, unless hypotension is

Then 1/2-1/3 of the dose should be given I V and the remainder subcutaneous-

Regular insulin is is used exclusively. Adults in coma - 80-100 units. Adults in early ketoacidosis and children over 10, 25-50 units. When blood sugars exceed 600 mg/100 ml, the insulin does is doubled. In rare cases of blood sugar, gre ater than 1000 mg/ 100 ml, 4 times the initial values are used. ~ The blood sugars should be monitored very closely avoiding putting the patient into hypoglycemic shock. Subsequent insulin must be titrated according to the clinical and laboratory findings. Five units of Regular insulin could be given for each plus of urine sugar. and electrolytes. Isotonic saline, except when co 2 meq/1 should be administered one liter in 1-1-1/2 hrs. If the patient is in heart failure give 0.45%, (1/2 normal) and

Flu~ds

4

at aaower rate. Children should be given Ringer lactate 20 ml/kg. If C02 combining power is below 8, 1/6 molar Na lactate should be administered at lOcc/ min. This should be continued until C02 combining power is greater than 13 meq . Follow with Hypotonic saline (0.45%) 10 cc/min, continue until Ret is below 50% and specific gravity of whole blood is below 1.055. Do not exceed 5000 ml of fluid in 24 hrs or pulmonary edema may ensue. If after administration of 3000 ml t he urinary out put exceeds 40 ml/hr , severe dehydration has been corrected. All electrolyte deficiencies must be r eplaced. Potassium may be given to avoid K deficiency. If shock is present . institute plasma expanders and vasopressors a s necessary. If abdominal distention, abdominal pain or vomiting is present, the stomach should be lavaged and 8 oz of warm normal saline instilled. Saline enemas may be employd to remove fecalimpaction once the patient's condition becomes stable. Antibiotics should be given if necessary. Surgical consultation should be obtained if necessary. Diet is instituted as soon as can be tolerated. Start with liquids and gradually progress to solid foods. Include foods high in K (tomatoes, f~esh orange juice, canned grapefruit). ' Low potassium may be reflected in an EKG. The following would be present: 1) Lowered or inverted T-waves, 2) Depressed ST segments, 3) Lengthened QT, 4) Appearance of U wave, 5) Prolonged PR interval. Symptoms of low potassium are muscle flacidity, weakness, rapid and shallow respirations, areflexia and quadriplegia.

ACIDOSIS 1)

Beeson & Me Dermott:

2)

Duncan, G:

3) 4)

Ellenb~rg,

Diseases of Metabolism, W B Saunders, Phila 1964 M. and Rifkin, H: Clinical Diatbetes Mellitus:

Harrison, R. T:

5) Huriwitz, D: 48:361-70

Textbook of Med - W B Saunders, 1967

Me Graw Hill, NY 1962

Principles of Internal Medicine - Me Graw Hill, N Y 1962

~poglycemia

and Hyperglycemic coma:

Surg - Clin of N Amer.

April 1968

6)

Lilly, Eli: Diabetes Mellitus:

7)

Upjohn:

8)

Upjohn Co: Diabetes Mellitus:

9)

Sodeman, Wm:

Eli Lilly & Co, 1967

A Monographs on Diabetes Mellitus:

Upjohn Co., Kalamazoo, Mich 1965

A Collection of Monographs:

Upjohn, 1968

Pathological Physiology: W B Saunders, Phila 1968

DIABETIC AC

SIS

Diabetic acidosis should be uspected in every case of unexplained unc nseio n ss. It is · erg cy situ tion. H ver , it occurrence is relatively infr quent . Conditions which (1}

y precipitate diabetic acidosis are:

sion of 1 sulin or rror in casur ent or administration. sive fnod

ntek~.

(3) Infections (carbuncles , pneumonia, bronchitis , kidney infection,

tc . ) .

(4) Surgical

rgeu ies (appendicitis , ruptured vi cous, inte tina! obstruction, etc. )

(5) H dical emergencies (myocardial infarct!ons , CVA, CRF). (6) Severe ps7chic disturbances . (7) G I disorders with vomiting and/or dian:hea. (8) Other conditions which increase insulin requirements , ntch a

resistance,

h)~erthyroidism ,

and toxemia

insulin

f pregnancy.

So uthorities suggest that if the unconscious patient is a known di b tic the ractiee ~s to assume hypoglycemic cou~ until blood glucose determiuation ca be made ~ Thus. recomm ndinc giving Glucason 0. 5 to 1 uhutan ously or 50 ec of 50% glucose I . v. or 10% glucose I . v.. If the patient responds in 20 nutes , the a d gaos:f.s of hypoglycemia can be cade.. I think that on should keep in mind that • if one is ~ctually dealing with a hypoglycemtc co , Glu gon y he ineffective due to the exhaustion of the glucose tores. Cons quently , o a y make th diagnosis of diabetic acidosis h one i actually d lin with a hyp sly ic e • Secondly, delay i instituting therapy in either diabetic cidosis or hypogl;cemis coma y prove fatal since the condtion may b co irr varsible.

It , ther for • beco paramo t that tbe phy ician be able to differ en diabetic acido is and hypoglycemic c •

ti

t

ypoglyccmia liberates epinepltrine. re ulting in plapitation • t chyeardi • phore is, pallor, bun~er tr mor and head che. If allowed to co tinu • thi pro ress to malfunction of tb c~s due to the lack of glucos to the br in . re ult in conf ion , awd ty • d irim• somDOlenc • coma and convulsion • t of hypoglycemia is rapid (minutes-lours) . hour to daya. Symptoms incl • abdominal pain• constip tion , ition f apathy to lenee to tupor to e r pid breathi g ul-nir. hu P. r), 1 diat iOD. Th th baa a diatincti £~

b

y

This The

Once

t~·

bist ry

~

d physical finding

1do i • th 1.

p

2.

Obtai

2 been eval

ha

you

t d

aho ld

s

ar and·ac tone. Aeetut. (Gly oauria, k

5 cc of blood, do

nuria ,

...

co fi

ton da

osi . )

is dr tieally to

d

3.

I tr

ellular

yceride

tri

fr

to keto

4.

lucoa

bod1

1

due

•

OS •

defi ita call

in f t

is u •

f tty

cids ri

'1'h

•

The lac of gl cos rmon

, in furth r

which r

1 •

G

tion of fatty

~z

cid

th

h

irabl

th

ff ct o

1nsul1 •

or1

ion of

d

7. 0

•

the ori

tilatio •

depru

rvous syatem t d and 1 t r co

to

s increaa d r te

d

a diagn

nary v

ai

progr

t

bocli · ) 1

to prod ction o

) and

hyp r lye

f

t1on of h

1• inc

id

tic

!n c

tr

pth

f

r

abo lie

1 5t

•

r

pir tory

1d aia

d.

•

1

t •

lo

t

- 3-

bicarbon t

is secreted

t

th

toacida. are

drati val of H20 from th

the r

aulin to th c

to

e c

Once th

tbe tissue cells 1

fluids and

th

11 to r

y greatly depr a th K 1 vel 1n the diagnosis i

eat lishe

1

ong wit

d

te

at 11 h 1 c-

tr e

ta of insulin

lul r fluids .

d fl

d should be

pro ptly.

iv

Addlti nal 1 bor tory testa should iuclud aerial blood tones 1 C02 co ining powe and 002) 1

••

(s

el ctrolyte

1

urinalya

k

1

rity o ketoacidosis is indicat d by plasm keton s

auree dehydrati

t (

u ar

) , BUN (is a clue to e (det ct

•

d rly

d

r

cut

tit

emia,

d culture

)1 1

CP ,

d h

ary.

tl

Opini ns

osi •

d oth

ry

tioned sh uld b

In u1

diagnosis 1 pr

s nee

ea

) 1 LD

SGO'l' (d t ct myoc rdial inf rctio ) , EKG (det ct my card 1 infarction

Treat

in-

ucose are absorbed into the

are a1 o ab orbed into th

of trolyt b

ved fro

Con equently1 on dminiatertng fluids

ls.

patient,

In addition during th deby•

t.

d •

All th insulin is gi en ubcut

Then l/2-l/3 of he dos

hould be gi

start d aa soon

ously• un1 IV

h

th

ot

ia.der s

d t

ini-

ch pl

of

ine u r .

d lit r in 0 . 45%: (1/2 nor 1) and

adJIIJ.WLSt

-

4

-

at a4ower rate. Children should be given Ringer lactate 20 ml/kg. If C02 co binina power is below 8, 1/6 molar N lactate should be administered at lOcc/ min. This should be continued until C02 combining power is greater than 13 • Pollow with Hypotonic saline (0. 45%) 10 cc/min, continue until Hct is below 50% and specific gr vity of whole blood is below 1. 055 . Do not xceed 5000 ml of fluid in 24 hrs or pulmonary ed y ensue. If after adminiatratio of 3000 ml the uri ary output exceeds 40 ml/hr , aev re dehydration has been corrected. All electrolyte deficiencie st be r placed. Potassium may be giv to avoid Y deficiency.

If shock is present, institute plasma expanders and vasopressor& as uece sary. If abdominal distention, bdominal pain or vomiting is present, the sto should b lavaged and 8 oz of warm normal lin instilled.

cb

S line enemas y be e ployd to remove fee li b comes st ble.

condition

actio

once the patient'

Antibiotics should be given if necessary. Surgical consultation should be obtained if necessary. Diet i instituted as soon as can be toler ted. Start with liquids and gradually progre a to solid food • Include fooda high in K (t to a , fee h or g juice, canned grapefruit) . Low potassium may be reflected in an EKG. The following would be pres nt: 1) Lowered or invert d T-w ves , 2) Depres d ST e nts , 3) Length n d QT, 4) Appearance of U wave, 5) Prolong~d PR interval. Symptoms of low potassium are muscle flacidity , wea ess, rapid and shallow respirations , areflexia and quadripl i •

"'\

'

If\,.- 1.-'J

~~~

21 July

1970

I have been asked to speak about Myocardial Infarction and Arteriosclerotic Heart Disease.

No specific requirement as to the content of my talk has been made, so I

have proceeded to go at the subject in a way which I think will be most helpful and

/ ~he .ll

stimulating. }e ...'f'\<-~o...

recent graduates do not need a review of what they have undoubtedly

~ ~ in their college training, and the older group would be bored. w\-¥"t_l. • \eJ

· tV

'(Cl.,. I

b'1;~~·

Some comment should be made concerning the Government's program in which vast sums \,Q.v~ b~~~ ~ <' ~ of money ~ spent for peart, ~ncer and stroke. Th~ original limiting aspect ef the

p~crgram

has later been amended to include related

diseases ~Medical

schools, re-

search people, hospitals, and others have built in radar and homing devices which react strongly to the smell of money, with the result that extremely amb~tious programs -to -\~"t ik'l Ht~>-r",CII4<..'-v ~ ~.... ~~~

-ct\"\""..,...1\

were instituted, particularly in heart disease, with the result that the <;oronary

~are ~nit

J\

was born.

For a time doctors talked about little else, and the

~ublic,

which includes the trustees of hospitals, were swept into the almost hysterical neecessity for these units everywhere, regardless of the ability of the particular hospi~ ~~~l'>~'""\ ~tr.St."~'~c.. It seemed for a while that these programs would sweep up most of the nu•w~ of the

tal to provide the necessary trained personnel.

t~.ti~~ T(, ~Tt.vc. ••."\\1>"- ~ ~... ~~>y-~ je ... ~\"~ -tl) illo.~~~,.\~"\-.. ~~~

country, leaving very few to .care f or tAQ vi etimf! of all o:t l•er.2:~H s aases.

C'l\1

It seems to

me that the hysteria surrounding this particular effort is subsiding somewhat, with se-~ cond thoughts and critical evaluation of the relative importance of these units t 'I would prefer to give the coronary care unit a different appellation which would focus attention upon the fact that most of the patients who enter this sort of a facility represent

~/

failures on either their own part, or on the part of their physicians, to do even the • limited things we can now offer in a prevent4tive sense. P~rhaps the desi~tion, "CoroVl" o.. l.?10i\~v- .._,_ ........ -ljor ~e.,$e. ·,1li'to.\'-'\ l'~. \., ~..;; ,..~' nary Disaster Unit" might fit the act:t1al ei.~eYmatenaew. ~·w c~ ._ 1\ ' 1111-ce ~~ kecH•f,-t ~ '..\- +~\ s J; ""s-t~r c ,_v-c ~ 1 Physicians themselves should become crusaders for 'lPel"b

~\T

~hysical

fi tness and teach their pat-

ients to regard,_,physica~~aes as a desirable and a necessary goal, and set an example A

,.

2

Obesity, Jlmoking, ~ir c_e.u ... Public education,by thousands of physi-

in their own behavior to give leadership in this regard.

A.J -H~~~· "'l\

pollution, \Jnderexercise should be abolished. ~

l•"'~ -h i"~Q..

cians, as they go about seeing .~ patients, along these lines , could have a tremendous effect on morbidity and mortality.

-

-

Physical fitness could be made to be the "In-

Thing".

~~~-~ \.-j *~ "¥7t'\~~~ c;..\oll~

One of the important factors

in A~

intelligent care of the potential so-called coro-

nary victim is a misconception regarding the pathophysiology of the myocardial infarct. It has become the generally accepted practice to attribute myocardial infarction to .fv~

impairment of vascular blood supply, ranging

~

coronary spasm• to sclerotic stenosis ) )

and thrombotic occlusion. The clinical features of this disorder, with individual \J' """d 'l)\o".~ ~~c,;\e.-\\"'1 differences, Aappear to form a recognizableApicture. Such diagnostic expressions as "Myocardial infarct", "Coronary Thrombosis", "Coronary Occlusion", "Coronary Disease", "Coronary Insufficiency", "Atherosclerotic Heart Disease", and "Ischemic Heart Disease" are frequently used synonymously with no regard for the specific nature and morpholosic characteristics of a given myocardial lesion, its chronological evalua~v-6 -

tion

~ the

total etiopathological background in which the lesion evolves.

Myocardial

o~l~

infarct would seem to be a term which should be applied Ato ischemic necrosis of the cell~

heart musclel , secondary to mechanical obstruction of coronary arteries, and myocardial II' t-1o'-\ l

infarct and ischemic necrosis J'-seem to be overlapping terms, however, there is a dis\~ --n.-~ rv.c."'\. .. .-."\1\i" col'\.'-t3'"t fl~Yes ri'~ io tr ... \ .... t.~ 1 tinct Adifferent etiologic significance. o-t -th<~.. ~ cc;. ..... 'r ~ \... 1-"-" w h.c\~ f'\ C.l'\ ·,"' t\..t c._c.,u.

'*""'

(>.....

Ischemic necroses may develop through a variety of mechanicms other than coronary obstruction, thus, all infarcts are ischemic necroses, but an ischemic necrosis is not necessar~ily an infarct.

In experimental medicine myocardial infarct arises

from failure of the collateral circulation to compensate with sufficient rapidity after reduction in normal coronary inflow because of coronary constriction or occlusion.

Actually, a sudden coronary occlusion is only an extreme among the many possi411'"

h.e-1-~'oo\~t...

ble mechanisms that may upset the normal oxygen balance and result in structural damage. 1\

3

It should be pointed out that a comparative analysis of experimentally induced neerotizing myocardial lesions make it clear that distinction between heart ~uscle injuries of vascular or non-vascular origin is extremely difficult.

Small foci and

more confluent larger areas of ischemic necrosis, morphologically indistinguishable from

a true infarct, can be induced by provoking micro-curculatory disturbances, aug-

menting myocardial oxygen consumption, irritating certain areas of the central nervous system, and by other

techniques,~at

there is many times a discrepancy between the

clinical diagnosis and autopsy findings has been disturb ing to researchers in this field, however, this has had very little influence on the traditionally conservative and predominately mechanistic thinking of the clinician. where from

fail~~~to

~16

Various reports indicate any-

to 95 percent of cases diagnosed clinically as myocardial infarction

disclose the presence of a recent occlusion or establish a clear-cut topical

relationship of the anatomical vascular lesion to heart muscle damage.

Obviously the

term "myocardial infarct" does not fit these circumstances, and, likewise, to term them all ischemic necrosis does not really satisfactorily describe the situation. The fact that~udden occlusion of a major coronary artery may, and does, elicit myocardia! infarction is unchallenged, however, in the majority of human beings and ani\ I mals with coronary disease) thrombosis, when present, is regularly associated with such an advanced degree of atherosclerotic stenosis that the observer may wonder what differ-

-

ence

---

the minimal added insult of total occlusion might actually have made.

A slowly progressive thrombo atherosclerotic incrustation,which can be closely reproducted by gradual narrowing of a coronary artery in laboratory animals, does not usually induce structural

and/or metabolic changes characteristic of myocardial ischemia be-

cause its effect is neutralized by apparent increase in the. anastamotic

compensation.

Moreover, the myocardial cell itself possesses the ability to adapt its metabolic pathway to progressively changing circulatory conditions.

4 Investigators are beginning to interpret the genesis of all forms of degenerative heart muscle diseases as metabolic derangements in myocardial cells, influenced by sensitizing and

s

dese~tizing

factors.

The myoeardial cell constitutes the primary

site of injury in most common cardiac diseases and, on the basis of recently experimental observations it is reasonable to suggest that the ability of one individual successfully to resist potentially cardiotoxic episodes, especially of vascular constriction or occlusion, and the tendency of another to develop fatal degenerative changes in the heart muscle depend upon the nutritional maintenance of the myocardium. Consequently a classic

myocardial infarct, just as other forms of disseminated and

unifocal ischemic necroses which

occur often but not necessarily in conjunction with

coronary atherosclerosis , should be considered the result of an integrated, though fluctuating, pathogenic triad: 1) vascular factors, 2) Direct actions influencing the metabolic requirements and

biochemical efficiency of myocardial cells and, 3) Factors

that determine the vulnerability) as against the resistance of the heart muscle , at the time of potentially cardiotoxic episodes.

This dynamic concept shifts the emphasis

from rigidly vascular~oriented thinking to still largely underestimated or ~t~ ~ disregarded contributory factors, that is) neurogenic and hormonal ,metaboli~ and functiona~ that should not be excluded from the total pathogenic picture.

It has been

demonstrated that, apart from direct interference with coronary circulation myocardial lesions can be induced in laboratory animals by a wide variety of agents and conditions that exert a direct action on cardiac metabolism.

These include neurogenic and hormon-

al stimuli, emotional and physical stresses, chemicals and dietary imbalances.

It is

not easy to determine the exact interaction, however, we should devote a great deal of effort to study the situation, keeping these factors in mind. Two broad groups of factors seem to exist, that is, 1) Factors that directly influence the oxygen economy of the myocardial cell, and 2) Factors that affect the normal electrolyte balance of the heart muscle.

Wide fluctuations in myocardial oxygen consump-

5

tion are now believed to represent the logically inseparabl~ corollary of coronary oxygen supply in determining the fate of the individual cardiac muscle cell in states of relative vascular hypoxia.

For example,

androgenic catecholamines, {?orepineph-

rine and epinephrine) act directly upon myocardial oxygen consumption.

They cause

uneconomically augmented consumption of oxygen that surpasses the energy requirements of cardiac work performance.

If coronary compensatory dilatability is impaired

by vascular rtgidity and narrowing, even moderate or slight augmentation consuming sympathetic and adrenal medullary activities• tiona! annoyances and environmental stresses, may result in manifestations of severe local anoxia, including micro and macro~focal cell destruction. Among the many factors which play a role, electrolyte disturbances, particularly related to potassium and magnesium, have great importance and should have great study. It would appear

that, whether or not coronary atheromatosis is a reversible pheno-

menon or not, myocardial metabolic disturbances appear amenable to rational prevenQV\r ~v-,· ~cn·~ C.o~<oC.t:.l""" ~~\no\~~-\ \"V~o vnv4'\l\~llr'\. . 'Jh,' ~ 1 -.:. "r\'0-+ ~ ~~~· ~e c_c. u/~ll"'"- P 04-t .-'-1"-tY +o -ric w ·, -T ~\ 'v\. fn~Y' "\'fr$d't'~; ..a-.

THIS PAPER. WAS PRESENTED TO THE SURGICAL DEPAR OF THE OSTEOPATHIC HOSPITAL OF MAINE, on OCTOBER 7 THE ATTENDANCE INCLUDED SURGEONS, G Ps • AND NONIALISTS. THOSE PRESENT BEING IN SYMPATHY WITH PRESSED, REQUESTED THAT THE PAPER BE COPIED AND TO THE STAFF AS A WHOLE •

ING

*********** I was asked to praaent aomething regarding the rol

iat in the Osteopathic Hoapital . be easily developed.

My

firet thouahtwas, t hat thia aubj ect could

However, the more I considered ) the .ora I becaae convinced

that this is a moat difficult assignment. Osteopathic Spacialiat ia. future.

of the Spacial-

I

am not aura w t the role of the

Nor ia it clear to me what that role will be in the

In any avant, I cannot visualize the role of the Specialiat in the fu-

tura being vary different than that of the G. P., or Family Practit i oner aa now terms himself.

The aubject ia quite impoasible unleaa it i

conside red wit

in the context of thina• aa they are and thina• aa they will b •

The survival of a physician, aa s uch, and not in the role of adailliatrator, -.dical director, educational director, Medicare

ina,--.~~~··,

induatrial

phyaician, iuauruce phyeician, or aovermaental 811lployae, wil wall he adjuata to currant, aweapina changes in public attitude

a

ct

na,

t

axpaaaioD of . .dical kaowledaa, iacr... ad aophiaticatiou of data-aatherina and co..unicatiou, tacbaoloaical advancaa, pattarna in the delivery of medical care , the re-dafiRition of phyeiciana' r ..ponaibiliti.. , govern.antal control and, laatly, the physician' • concept of h:.IJuelf.

That soma will survive ud cont i nue

ill contact with patiaata iR a aatiafactory way to both, there ia no doubt, aa

a.laptatioD 18 a fact of life. aatiraly.

Soaa will lUke a poor adj uataent, and ao.a will f ail

You will nota that I did not differentiate between the D.

K. D. • or batwaa the faail.y practitioner and the apaci&list. apply to all, differina only iR degree. lective D.

o.

will also happ n to th

o.

The aa.e forcaa will

That ia to aay, what happana to the col-

collectiv M. D., how v r, th

djust

nt

2 will be more difficult for the D.

o.

than for t he M. D.

Chanaâ&#x20AC;˘â&#x20AC;˘ in practice patterns, which once aisht ha

taken a phyai-

cian's lifatiae, now occur overniaht, ao that no one really knows where be stood yesterday, not to mention tomorrow.

The sudden need to change everythins for the

cr

better, immediately, has occurred in all aapacts of life, or for that matter ~ death.

In the case of medicine, the take-over of administration by and for the

Public is nearly complete.

~

.~

This is revolution~ and not an evolutionary process, ~

occurrina so rapidly that the mistakes of yesterday are not remedied before they are compounded by the mistakes of today and tomorrow.

Unfortunately, there ia

a areat deal of truth in the reasons for this revolution, however, there are ~ ~,s c

~y half-truths and downright lias entering into decision making. That the intent was beneficial and that the arguments for improvement of medical care are valid ia not doubted. we can all agree.

Better medical care at leas cost is an objective with which

In 1968, the President stated that we must find ways to en-

courage efficiency and penalize waste in hospitals.

This is a moat com.endable

atateaent, however, coming from Government, it is ironic.

In the Poverty Program

alone the Government spent so much aoney in talkina about, and investigating poverty, that, if the money were distributed to the poor, the problem would be solved. That history will record poorer medical care at greater coat, is a great posaibility.

The coat will simply be ahifted to leas identifiable factors.

There is always

the quaation whether the new holders-of-the-pur aestrings will be more, or leas, fruaal than the former.

One thins quite certain is that the new manipulators of

the Public Haalth funds will hide the fiaurea so well that it will be impossible to find out. The old sona that aoae of us remember, said, "It ain't what you do, but the way you do it", is ~pplicable to this entire situation, as burning down a city 80

that a new one will riae clean from the ashes is rather drastic treatment

3

and throwing the baby out with the bath water might help the population explosion, but will be regretted by the parents. Greater statesmanship by the A. M. A. and the posaeaaion of a better crystal ball mi&ht have eliminated much of the currant turmoil had the A.M.A. shown wise leadership in developing a workable plan inetead of having the present mess shoved down its throat. As usual, the A.

o.

A. displayed its lack of states-

manship and imitated the A.M.A., as we have been wont to do, much to the detriment of ourselves on many occasions. Like the Arab's camel, which, once it gets its nose under the tent, insinuates the entire camel, we have let the social workers, the economists, the computer experts, the professional administrators, the inspectors, the matematicians, ~ the feather-brained do-gooders and the politicians move into the tent until there

is very little room for the Arab.

That we need the help of others in all discipline s

is undoubted, but their help, and not their dominance. Is it any wonder that doctors are fleeing into salaried jobs as administrators, inspectors, or permanent residents in hospitals to escape from the uncertain future of solo practice into the safe anonymity of the s,stem?

These aafe jobs

'J'.. -.,.;

will multiply as the bureaucracy of health ~. aa it will grow, but these positions will be mostly for M. Ds.

Relatively few will be available to D. Os.

The

separation of Health from Health, Education and Welfare, with Health having cabinet rank in itself, is inevitable in my opinion.

Jobs in the new independent Bureau

will create more jobs until it will resemble the Department of Aariculture, in which, it is said, there are more employees than farmers. Arrogance ia a trait that certain physicians have displayed, however, physician arrogance will not hold a candle to the arrogance of a new Health ~erarchy, armed with righteousness, as it plans and regulates the Public good.

The

arrogance of some public officials in this field i s already apparent, like rook policeaent in their first uniforms, feeling the thrust and surge of power.

Any j TI

4

Ally problems in the delivery of medical care will be, and have been, bl.aaed on the greateat whipping boy in history, the doctor.

Nobody in this entire con-

apiracy has done anythina contructive to t.prove the imaae of the phyaician, which has been

deli~erately

deatroyed.

Thia baa been called the triuaph of those

who administer over those who ja. The survival of the hospital ia at risk. is here today.

The hospital of the future

It is the hoapital which haa elected to call itaelf The Medical

Center and has aet out deliberately and by planned action to center all community

heal~services

in its complex.

These graaping complexes are seeking out foun-

dations and the control of their funds, aovernmental grants, the exclusive rights to treat certain diseases, centralization of sophisticated equipment, and specialists in all fields, especially in the narrow fields.

Thus, they are drying

up funds and services, making them unavailable for the development of the hospital which is independent of the complex.

Public relations firms are employed to work

at this process on a full-time basis.

Bitter battlea have been fought, not only

between small hospitals

~or

control of the power structure, but also between large

medical complexes, hoping, each of them, to become the top medical center of a particular area. The medical center of a particular community is to be the place to which all are expected to look, and from which all things medical will flow. The staffs of these inatitutiona have become entirely, or almost entirely, apecialiats.

The G P has been more and more forced to the smaller hospitals

and, aa these hoapitala disappear, he will be out of hospital practice entirely.

Small allopathic hoapitala, aa well aa saall oateopathic hospitals, for elimination.

are slated

Changing the name of general practitioner to family practitioner

will not chanaâ&#x20AC;˘ the eventual outcome one bit.

In this situation staff membership

of D. Oa, as for example on the Portland City Hospital staff, which does not offer a full range of services, will certainly be an excuse for M. Ds to apply to the Oateopatbic Hospital.

However, it should be remembered that City Hospital member-

ship and Medical Center membership is two different things. ------------~~----~

5

Using the CAlifornia aituation aa a model ia fallacious, aa there

G. Ps were allowed to join allopathic hospital staffs, whereas the osteopathic specialists ware given no reco;nition. game, and thinas ara not the same.

This is another day and another ball

The only interut the varioua Medical Centers

will have in G. Ps and osteopathic or allopathic G. Ps, will be in their ability to round up and refer patients for the apecialized services of the Medical Canter. The help of the G. P., D.

o.,

or M. D., or the osteopathic specialist in managing

patients in these Centers will not be wanted or needed. The G. Ps, to their everlasting credit, are trying, through their organizations, to raise their standards and to bring updated medical education to their members.

This ia all to the aood, however, one or two things will happen.

The M. D. general practitioner will get enough credits, or develop enough skill, to become a recognized specialist himself in some particular field.

Ha certainly

will not be able to become a specialist in all medical fields, or he will, temporarily, become well informed in all of the fields of medicine.

If the latter, he

will need to go through the frantic process of reviewing medicine entirely at least once in five years, when it is said that everything that one learned before has become obsolete.

Either one uses a field of knowledge or he loses it.

In

the meantime, when will he find time to practice and where? The small hospitals are bringing about thair own downfall in many ways. One of the most effective ways of losing the ball game is to indulge in the committee game. the large.

Medicare requires the same committees of the small hospital as of These committees require only a relatively small number of staff mem-

bers in the large hospitals, however, in the small hospital the entire staff may be engaaed in committee work, to the serious detriment of patient care.

If the

saall hospital does not exhibit restraint, then its committees may be so large that each member of the staff has multiple responsibilities aa a physician.

and is noneffective

6

Committees have proliferated and enlarged and with thia achieving conaenaua and approval haa becoae a nightaare.

So .any people inaiat on beina

informed that prompt decisiona are alaoat t.poaaible.

Leaa urgent problema are

likely to becoae so watered-down by comproaiae and then overatuffed with worda as to inaure that they will be filed unread.

Individual reaponaibility ia too

dangerous, hence the aystea of dividing reaponaibility into aaall, unattributable bits.

One of the best reaaons for committee&~A'to avoid doing anything construe-

tive. It has been said that D.

o.

apecialiata repreaent thirty percent and

G. Ps seventy percent of the total nuaber, whereaa M. Da are aeventy percent apecialiat and thirty percent G. P.

These figurea are old and it is more likely

that eighty-five percent of M. De will be apecialists aoon.

In the pattern of

things as they are, it would seem apparent that, with the specialiats manning the ~M. D. Medical Centers, the place for both M. D. and D. O. aeneral practitionexswill be somewhere in the boondocka, scurrying around and finding patients ·~

to refer to the Medical Canter. more or leas

Some areaa will have groupe of doctor• giving

sophisticated outpatient care, while the only place for the solo prac-

titioner will be where no one really wants to practice. One would think that, with all of the expansive conaultanta we have had and the expert by-lawa write%\, we would have p~agreaaed.

None of the conaultantJ

baa told us the thing& we need to know to get down to planning our future.

Rather

~e

. ~ are being blown to-and-fro, reacting inaffectually to constantly occurring

criaea.

Instead we have concentrated on trivia rather than on a great design for

the future.

It aeeaa incredible that wa atill get our elbows out of joint patting

ouraelvea on the back about what a marvelous job we are doing, while the world of -.dicine come& tumbling down around ua. With very few exceptions, D. Oa are not team workers.

It is imperative•

t

7

right now, that osteopathic physicians become so and work aa a team in displaying our acceptance of responsibility and in aaking contributiona to better medical care. There is much more which could be said, however, simply writing this has scared the Hall out of me.

Some people will probably do some thinking, and W,lc.A.V~

some people will be so infuriated at my 路 ~making that further elaboration will get me tarred and feathered. In view of what I have said, I think it ia possible to see why the role of the specialist is cloud

with uncertainty.

I LOWELL M. HARDY, D. O.

, 0.

H'HEN I SIT DOWN WITR A CHART 1 DO I ASK 'r-1YSELF - A

1.

What is the worst thing that could happen to this patient?

It l'lo-t c.-,\,.:,.,\ 2. Could this patient " yc,"\ •··''-{

~

become· critical suddenly?

3.

If the ~could become critical, or is critical, does the patient's family know of the situation?

4.

Would the patient benefit by immediate referral to a physician or institution where greater skills or facilities are available?

5.

Have I started therapy in a non-emergept case before diagnosis has been established~

f

6.

Have I ordered procedures or treatment in advance which may be unnecessary or unwise as the case unfolds?

7.

Should I start long-range treatment on a patient who will be hospitalized only a few days?

8.

Is this case serious enough to warrant the use of new, or potentialiy dangerous methods or treatments?

9.

Are the procedure,s skills available to diagnosis and instit~proper treatment?

cwA

/o Cl}(

o.+

m~

sufficient to make a definitive

10.

Hust I write an order every time I

11.

Have I succumbed to routinism?

12.

Am I prescribing diagnostic tests, procedures, or treatments which will ex1 haust the patient unduly?_,

13.

In a case which is progressing well, should I be · very careful in making changes?

14 .

-~

,.. the

chart?

/

Am I making my diagnosis and prescribing treatment to a patient on the basis . of clinical judgment or am I treating a symp~om? A lab report? Or an x-ray report~

-

'( (7P

I

\,Ill

15.

Do I constantly remind myself of thetplacebo effect of almost any drug or method, or do I assume that random(?) oruncontrolled effects prove efficacy?

16.

Do I remind myself constantly of the aid maxim, ' "If I, can do my patient no good, I must be careful lest I do him harm"?

17.

When I am about to write an order, have I reviewed the patient's status sufficiently to know whether this new order will be compatible with the orders written before? Am I personally familiar not only with the~~ ~ ~... ~story of efficacy and freedom from side effects of a drug, or 4oe-- I also ~ its potential dangers~ ~~.J "~l'fl

_,

- 2 19.

Am I treating the patient objectively, or am I emotionally involved and

treating him subjectively? 20.

Did this patient actually get the treatment ordered and given in a manner and dosage which was prescribed?

21.'

Have I reviewed this chart, including every aspect - the nurse's notes, progress notes, etc.,- sufficient]$. to pick up~ hints about the patien t 's conditionl~ ~ - - - - - - u.. n.N. . -Yf''' tt.

22.

Am I justified in prescribing a new treatment for. a di&eas'e for which there ~already satisfa~tory,u~lder, and tried therapy?

ts

CO J\~ . \- I~""

.

,.

.

v

~~~ ~

23 •. Would older, more experienced and "often ~ physicians have as much courage as I in experimenting with new drugs'b'\. m.rfi,!:;;

24. 25.

t\

Am I doing everything reasonable and practical. to treat the whole man, or am I treating only a part of him? ,.1~ 1 o :;\'' ( oj,l I ,1'' ,tt>lfl.••r""' I' ,,.: •' Am I attempting to treat pathology or am I trying to ~~~ improvei ~hysiology, so that the patient can accomplish his own cure?

26.

Does every patient in my care, even though apparently routine, get thoughtful, careful attention, or am I unduly fascinated by rare and exotic diseases?

27 .

As I sit here with the graphic record in my hand, do I reflect on my own inadequacy and resolve to do a better job to warrant the trust which patients repose in me?

October 12, 1971 Humpty-Dumpty sat upon a wall, Humpty-D~pty had a great fall All the Kings 1 Horses and all the Kings â&#x20AC;˘ Men CoYldn't put Humpty-Dumpty together again Poor Humpty is the hospital sitting precariously on the edge of the wall.

It isn't so much in danger of accidently falling

s it is

in being pushed. Daniel Webster said, "As men may be protected against murder, but cannot be guarded against suicide, so government may be shielded from the assaults of

foes, but nothing ean save it when it chooses

exte~al

to lay violent hands upon itself."

Simply substitute for the word

"government" the words "Osteopathic Hospital." We are meeting here tonight as concerned Specialists of the Osteopathic Hospital of make our hospital

.,work â&#x20AC;˘

~

~~ine

to try to plan constructive efforts to

better place for the sick, and a better place to

There are those in our hospital whose personal ambitions are so

powerful that everything, the patient, the hospital and the profession are of secondary importance to them. and antipathies prevail.

Political consideration, self interest,

The complacency, laziness, and disinterest of

the etaff, aa a whole, has made it possible for a determined minority to seriously attempt to take over and run the staff.

The General Practice

group bas come up with the "Revised Rules and Regulation of the Department of General Practice" which establishes a sep rate staff within the staff. The Specialists are excluded from this new staff.

If the Specialists

are to have any influence in the Osteopathic Hospital then it will be necessary to organize, in some way, to keep a balance in the operation and progress of the hospital.

The type of organization should not follow

that of the GPs as it would be ridiculous to establish a Department of Specialists.

- 2lr

There is a striking parallel between the attitude of the blacks and that of the GP.

The black blames -whitey" for his problems and the

GP blames the Specialist.

Both have organized to get their "rights",

and they intend to get whatever Uytghtsâ&#x20AC;˘ they think they are denied, in any l-tay they can.

s

Both groups have moderate. . in their ranks, and both

have their extremists.

The GPs rank and file are mostly conservative

in their views, however, they have a militant group who can be compared to the "Black Panthers" of the black movement.

It is relatively easy to

comprehend these attitudes on the part of the MD-GP as he really has been squeezed out of allopathic Hospitals.

It is very hard to understand the

DOâ&#x20AC;˘GP who has not been squeezed out of Osteoppthic lloopitals and is in

no danger of this occurring.

'Reading GP literature reveals ample evidence

of the "hate the Specialist" attitude whether justified by fact or not. Any

Specialist, in any field I who thinks he is loved by his referring GPs

is living in an unreal world. patient to a Specialist,

The GP does not really want to refer any

~esents

it when he is forced to do so, and envies

every doll r a Specialist collects. tf

We are a heterogeneous group, some of us have been here a long time, some have made a lot of money, some are just starting and some are near retirement. It would seem impossible to make an effective organization out of such differing circumstances, howev$r 1 it must be is to survive, and prosper.

accomr-lishe~

if tho hospital

If we can make this organization work we can

take a major role in working out the problems we now have and will have in the future.

It has been anid that he who is not a part of the aolutiou of a

problem is part of it.

Regular

etings of all the Specialists should be

held regularly with a meaningful! agenda.

No one, we are sure, expects

that we will always agree nor that we will all be vit lly interested in the same problem.

Patience and helpfulneas to each other is es entisl as we will

. ---------- - ~----- - - · -- · --------- - --- - ---------------

- 3 -

expect this of others in our own problems. The Specialist of the Osteopathic Hospital of Maine has carried on as · an individual• each doing his own thing as if in a vaccuum without of services or even meaningful dialogue with other Specialists.

coordination

We are

at fault in not recognizing the weakness of this course and taking steps to develope the potential which could be the salvation of the Osteopathic Hospital of Maine and the keystone of the best medical care. The Board of Trustees has not had the opportunity to benefit from the thoughts and opinions of the group here at this meeting.

Because we

are usually busy trying to keep our heads above water we have failed to take an active part in decision-making leaving this to those who have personal axes to grind.

It would seem that a great deal of effort has gone into

the enlargement of the hospital with the mistaken assumption that bigger means better.

These words are not synonyms.

more often means worse. than better. planning to make the hospital better.

As a matter of fact• bigger

Too little time has been spent in This concept should be brought to the

attention of the Board.

"

Closing this with a Confucianist prayer I would like to say, "Dear Lord,

make this a better world and please begin with me."

f'oo"l.

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PEACE AT ANI PRICE The Osteopathic Hospital was born of a rebellion and has progressed, not in spite of,but because of rebellions. The first Osteopathic Hospital recognized in our official history was born of a rebellion fostered by the xxaaxma»xx•x bad treatment of the patients of Osteopathic Physicians and the bad treatment of Osteopathic Physicians by the allo paths. There was no peace during the years of Pleasant Avenue and early Bright nAve., The State Street H spital was the result of a rebellion of the Staff at Brighton Avenue and there was war and progress. The Board of Trustees was the outcome of a long and bitter fight. The first new building at Brighton Avenue c••sssa•t was built an spite of the spilling f considerable blood. It is only in the last few years that a state of unreality has gripped the hospital. Now all is to be peaceful, no-one is to disaggree, those who dissent from the"official"opinion must be punished and the lambs will lie down with the wolves.

PUBLISHING COMPANY, INC. Executive Offices West Nyack, N.Y. 10994

914 â&#x20AC;˘ EL 8-8800

November 21, 1977

Lowell M. Hardy, D.o.

166 Pleasant Avenue Portland, Maine

04103

Dear Dr. Hardy: Some time ago you expressed some interest in writing a book on health for lay men and women. vle remain very interested in such a book, since we feel that the public is more and more in need of ways to deal with ailments and minor illnesses. Our health books, as you'll recall, are not intended to substitute for regular visits to one's physician, but attempt to explain what people can do for themselves to achieve good health.

..

A new health book should describe various common ailments which men and women can relieve, and perhaps handle entirely, without a physician. It should describe actions ordinary lay people can take in order to obtain definite and tangible health benefits. People who are not feeling well should be told how they can make themselves feel better. As I mentioned, we feel such books should contain many case histories, in support of the methods described. They should tell each reader how other people like himself achieved long-lasting relief, by following the methods you advocate. These persons would be identified only by their first names, which should be fictional to completely guard their privacy. As I told you earlier, the expected readership of our books is almost entirely middle-aged. Therefore, we would not want much emphasis on the health problems of very old people, or of children and teenap,ers. As I mentioned, we do not want authors to deal w¡ith contentious subjects such as cancer and diabetes and their treatment. lve do not include such subjects in our books, because they are not areas for self-help, expect under the direct, continual care of a physician. I am sure you recognize that this leaves many important areas of selfcare in which men and women can use authoritativ advice. Undoubtedly your own experiences suggest many ways of pbrsonal health imnrovemcnt.

Lowell M. Hardy, D.O. Page 2 November 21, 1977

I hope you do not feel that preparing our manuscript would be too demanding upon your time. Our books are all short books, not more than 65,000 words--or about 14 or 15 chapters. We have to be flexible about author deadlines, since so many of our authors have other important responsibilities. You would be allowed to set your own completion date. As I mentioned earlier, you would, after publication, receive regular royalties, amounting to five percent of actual income from mail-order and book-club sales, and ten percent on bookstore sales. We can offer maximum exposure for the sale of your book. Our widespread marketing operations include very extensive direct-mail programs, personal calls by salesmen to wholesale and retail book outlets throughout this country and throughout the free world, as well as distribution in our own health book clubs. \ve feel there is a large readership waiting for a ne1., "selfhelp" book on health, and I await word from you about the form such a book might take. In any case, I would very much like to hear Cordially,

~~~ Hal L~~ /..'..l/11\_ Associate Editor

HL:hl

from you again.

UPA 'l'H IC HOSP T1'A L 0!"

~-~I~

11/22/61.t Our ol-jectiv(' rc-'!· t.h~ patie-nt

'RIUSt

1:-~ t.he b~'<st. eare obt.ain.qble anywhf'lre, and

thiR C$.re under th., sup"':rvisicn of an 0st•opathic »bva1.cian.

Our objective for t~e hoepi.tal must be, t-hat hera, tr.e pa.tlent m.::-y enter with confidence that ha will receive the fi..nest in dial."nO$t.1c and therapeutic ef-

fort, tb&t he will be serve~ by an alert, vell-trai~ed, ir-tAlle~tugllv ho~est and dedie&hd {.!roup

or

physici~ns and pan-nadical pert!onr-€1.

That in this in-

EtHut.'ten ~e wi.l1 b£1 trnted as an individual, \>lit'· jS.,. Ilit.,Y, r"'t:;>€:t ':'cr '11~ h~lie:f's, thtiUf?'htfulnass, and tt:~nder lovinp care.

··'1.1r o't:-jec~.bre ror th~ lll:V m'.'mbera of our or~ani7.ati.on, illc-htd1 nr our au,..-1_ 1-

11a2'1Pa

'lrl-"

P.~r-1

of Trustees, must

b~ an intarest~d understancJinll of th,.

T'l"P.-

cise condittons 1m::ter wMeh excellent care is to ;,.- prov~de1.

lur cLjet"ti7e fcor t)-;e corrmunity must. b:-:

~-~ E' demc•·c.etr'lt1nl"'

t.l•'lt. the C'sto('lrmt.hi.c

·~or:~lit41 ta ju~t.if1.ed bv the excel1E'ncl! o~ its wor~ in 'I!!Prit.tnrr pu"::J f" ~ 0ur objeotive "or the f'st.enpat.hic !"!hysicilln nmst be. th.qt ho is

pro!'c ":' sl ort .s nd i. n tt->P.

CO!!il'T1t .,1

ty,

th:!l t.

F'"'C':r"t. •

ro~pr->('ter;l tn

he 1" in~.e Uectua 11·. ~('l~o.tt ,

t

t.he

~l'l t ~~ tq

cont.iJll1:J.lJ.y strtvlnp- to 1.1n:lrove hl~ seo:rviell'., to tl-,. ~lek, t.l~t, he tn h.!.ipoy and

oontent 1.n hia prof'tns1C'nal efforts, and t. h·~t hP has rtrvn~c~aJ socurtt;v

c~ssary to practice his profes ion ~Uhout. undue a nx1e t r. sic:ian shonld do ~11 tb!s

S<l

'"}'lF

'WC-

f'~t.~"np'it,'hic

r.,.,_

part nf a tt-aJ!l tn·prcach to r.ea1n c~~.

::-·ur obj~ctive ror th" prof~sstcr !1~ a whol~ mu~t. hi" -t.n d~l'I'C'n!'!": mt.j "" thstt thort!' is a plus in oflt.e-opsthtc "'e3'31.on

!r-'dnt.3't"l

t-e served

~ro, ~ki1'l~· t-:.. iroPra t ''·~" tl,~t

'l Sf':'t).<\t'tJtA

\cJs"lt.ity in .1rc1e r '.. h..'.t

t '1,~

t

O' lt

' n cstnopathte pro-

1

~1.~ '~-l ?Rlth 1r.t1y b

Bt

'fhe Prof'eseiona.l nevelopment and Careers ~"'Orl'll'flitt.e~, w1 tch ;._rill operate ~.,ithtn the

PUide

lil"'l'IS

Sl"

set dovm bA1ow.

Tt tr1

ll

..

l"'f'~~\11-'r;'b)~ pl"'·i'.l~Uou U~9t.

tl;f'

qc-

ttvi.ti<"'lS nf th1.s conn:i.ttec will rF.sul t tn th~ ('ll~ t.f' neoessary.

1.

The Professioml Dl"velo;:.nr.ent and ("areers Gol'!'mittee o~ t.he C:taff should

~"'rvices.

ft st•all ~m·trul.s:tt., pc,Uc:· witl-.in th~ r·!•rt 11'>-l r,::-,~.idE>-:":.ae:: s~t repo:rth? dol-.-n h~~'ellft~r, ~ 1+.s l'!?C'Or-rrc!·v'lattons to th€ Flanr:inq B<'19rd

qnd t.hence to the ~~rr '~"xecut.ive Co!'lwitt.E>F end P.oard of '.l':n.i.;;t.,es for

ly.

the b!'Mfit of th~ ~'iltir:n"!'~ ol.' thi~ h~n~.tq J.

t1cular

starr

meviber, ~roup of stlP~f memoors, or non-start mel!lbeN:I ~e fre-

quently

6.

A:'J

neees!t'lry to b:plement the d~velopmcnt o" ser-..rio::-es.

The Prot'essional Develo!)mant. and C"lraers Co"'rnittee will rec,.ive applleations f!'orn sta!'f Jlerrh.Jr.J ror

•1f"W

servi.cc: s anJ !JdvtlePes.

who arl." present.ly holders of priviJeres to daten!li.nA hCiw their serviees may be il'lproved.

8.

'l'he Professional Development an1 C'-~reera Commtttr e shall project both short an~ lo~ rarwe c.bj€'C?1.i.vetl in th:? pro+'~:'5[doml area.

9.

Tt"3 ~roresgioMl llf'i•E~lo~,..,ent and r:art>er.s C.C'I~r.•ittA~ w;.11 <.t. t.a ~t in

.,.u

woye po3siblfl t.o mke BV·' 31.lable etpProp1•bte t.rain'J..q• f"m' ~,hose 1n c:~•)­

proved pr~p·rom~ witr eJP?h-'l3is o:-. e>l'!tt<op~u~t~ .:.p·1nrtu.nit.t(>!'; V 10.

'!'he F'rc!'essional r~F?lopment anti C'areers ~OJ'lri'Htee wUl SE't re&13on::.tl'-le

t.f.m? Umtt-s on lle

deYelo;>:r..;~t of sr<-ci.f:tc pror·rams.

The Prof~ ·:: ,., ·~c'"llll ~~~vto-10pr:ent:. an~ f".:a 1~~rs ·· orri"'tttAe h:Jl oeek fin~ndal as~'t ::: tsn~""~ mPS.~s or

1?.

:.cr.-

+ho~e on ~rp· oved proo;-:rRms ur<' rr.r; te c..: i.te it, bv ••hat.f'vf'r

th:r·'"'l.iCT/:

l.J?:;:

"ev•? l' :ir~nci"'o r·u:-

t ·r-

nE r.. e "' s~ry.

'1''-~ Prof'l!t=~Picna'l "'€vPh•rmer.t. ~nt~ C.. rcarB C' mr.r.itt~.ze

whtoh W'!D h!H•P

n ...

t

l;:-. 11 p:-CipO<H) co}'\.ci~"o

cr,h'r+i··~ ('tf c0rr~~:r.tim.· p-:-<'"EJenf :i.:-'1equ1.tic,;B e>"dsttnp

in t.h~ d~tpart.trl"nts a. nd service J).

a,r.-a~hl)le.

3

reas.

'!'hE'! Pr<'rectgi. oi"-:~1 Do'"'"~cpr· ·~ nt :tnd r:~rcArs ''cf'l~i. ... ~. Ele ~:11 prono~e or:-rt.r.dn erpecial areao o:· tt:Pr\11.ce frClm til"E'! t.c. ti'T:a, of ;l' t"h t.i r <:+,a''" shCI''1 · hP notif1. ~ 11.nd 1. ;·.1liert t.ions ""or t!Fse qrF-as ~O l• rht.

lL..

Th~ Pro"eaa~or~1 ;0">Vt..1opl"'f'.,t.

t1 j

r- .,'! Gcrs ,.. ow:ritt~H' ;1 1 ll 1nvrr-t.1 atr. t•l~

potertti.'l} or nr•r>-St.S.ff m~m~rS )!"d t.h •. ~t.liff IT'~!d:H,~

(I I'

0

't

~!at.,H 'l,nqp'\.-

ta.le tn t.hc possible; dF.val~mEnt ir. a c<:wrre"'"!"!!;lY"" -;.lar. r ,::~:r ::J ,"'r,no <:~nr1c­

. . . , . .... ~ · :-tj't r ·:l1

ial s~>!'Vice~ 1.n the e•rf:l!"+~Jl'll <:>VCitllt.inr <'~ ~~ .~ .,+., ,

1'bs reeorrll'G!'l'Uivioros o~" tl-)e 0 rofl';! ~ 31.onal n,~·.re]opn ···~t nn ·

made with the rollow\np puidina

prin~iol

sa

~'" r. rr1:.e r.

a ,-r<!rB "cl"llr.i t~A will l· e

3.

A·, dttio::-..al personnel wi.ll n('t be prant-e-1 nrlyiJ. ... ~es h

~ccouht

I

or incapac1tv.

~ti~ment

a s::-rvice or de'Jar•t-

There are a nwnber of specific areas in which a discussion of consultation would be helful. The Consultation to aa.ve the D.ootor - Thb consultation was discussei. very well by Dr Dale Pear son when he addressed the staff' some years agoe This is the case which has gone to the poiht where the confidence of the patient is so shaken that only with outside help will the physician be able to XP'Iril! keep his patient. All of' the consult& nts can cite case after case where they have been able to sell the patient back to the referring man. Much unappreciated effort goes into this type of enterprise. Same patients are lost to the referr!Qg man even tho consultation is held. This is usually blamed on the consultant. The Interne or Resident as Consultant• Since the Internes are eager and sae:xi•*'cbnrts times the Resident is willing a wide spread practice has grov.m up of' letting the most inexperienced members of the staff' (the internesO• actually manage a case that the staff' man could ncbt manage without help. This avoids consultation with one of' the men who would make a charge for the servioe::a The referring man does however get paid for this ghost management.

ma~

Consul&C:tion to Impress an Importamt Patient- Thb m8\)7 fail since the referring man has not prepared for this eventuality by building up the reputation and prestige of' his specialists. Continuing ~onsultation- In this t.Jpe of' consultation the referring man gets one of the consultaabta to guide him thru diagnosis and treatment of a case while remaining in the patients mind the doctor who has served him and is naturally to be paid. Bills from consultants in this type af case are very unpopular with the patient • cause poor public relations and financially poor consultants. In the event a malpractice action were to be forthcoming howver the consultant will be allowed to participate in being sued • Consultation to Agree with a Desire to Do Illegal Acts• In this type of' eonsultation the consultatm is expected to give his opinion condoning the desired act. Refusal to do so brings aboutreprisals and employment of' a consultant who will be more pliable. Consultation as a Political Instrument• Thie consultation is one which is given as a reward for fa ithf'ul party line adherence and withheld from others as a punish• ment for unorthodoxy. This type switches back and forth depending upon whose ox is being gore4. lum•U*•ax taw-:par.tyxft·t+kfrid•w••n• This type of withhold!Qg is practiced particularly on those who are doing things for the hospital since this cannot always be understood or universally popular. 1his type sw:ings widely fran time to time. however as the party hero ot today is the party bum of' tomorrow. Generally these consultations go to the smart guy who says nothing and does less for the group as in this way he is never in controversies. Consultations for Fear of' Professional Liability Action• This is :bee usually in a. thoroughly m.. bolixed up case. In this type the oonsultatnt is expected to :a::tK% straightn everthing out • lie on the chart • sell out his intellectual honesty and be a co-defendant (with his larger amiunt of' malpractice Insura.noe) with the referring man. Consultation with an Outsider• Distance leDih enchantment so that the staff speaker of last night becomes the oracle of' today. Almost invaria.bl!J followi.t3g a staff' program the speaker gets a many consJilta.tions even tho his ability may be no sreater and possibly a great deal less than poor old Joe who is too close to home to know anything. In this wa:y too the referring man feels that it does his local prestige less harm if he consults with distant consultatnts.

..Consultations to Protect One from The :Medical Audit Canmittee• In this type the quality of the consultation or its hel p to rnthe patient is not considered. The rules say that consul&ation shall be held so its held. Its presence on the chart stops further consideration of the medical merits of the case. Consultation. to Provide Help and Coverage to a Man Preparing to Specialize in the Same Field as the Consultant- This type pays the consultant very poorly now and in the the future. This is worse than RUSSIAN Roulette since the helper ends up being callod a bum by the one taught. The only safe wq to ha.rxile these consultations is to get a long term contract with the hospital. with retirement benefits. Con.sultation to Make a Menke~ Out of Someone• lhis consultation is a very difficult one to deal with in that it may seam to bring out a legitimate opinion when it is actually for the pmpma purpose of diagreeing. Kow that there are two entirely opposite opinions where"the patient have to go to hide from the result. do~

Consultation to Get Rid of the Unwanted Fatient• In this variety the patient is uncooperative, unp)leasant or doesn't pay so the referring man can get along without the income very. This type is also used to throw the care on to someone else when the referring man wants to get away for the holid8\YS.

Every dollar earned by a consultant who doesnT have the key to the vault and an unlimited expense account is earned the hard way, by sleepless nights.uloera• early coronary arttacks, sweat of the brow. worry. gr8\Y hairs, a.rxi sacrifice of his rights as a dignified human being. aeyone If DB thinkJS that the consultant has anything to be joyful and thankfull about

he's.>a nut.~ Th.~ consultant buys all the grief am unless he is very fast with his footWork ends up with the love of his wife(sometimes) and his dog (always). Recommendations- That internes and Residents cease manging cases except those assigned by the Chiefs of the Services under supervdsion. That very Junior and inexperienced men on the staff call tor frequent consultation and that their work be carfully supervised. 'l'hatthe surgeons make up their own minds about a partioular case and express themselves onthe chart before surgery. That the welfare of the patient receive the first consideration rather that the whetting of the political or economic ax of the referring man. That the referring men give thought to the care and feeding of the man who will be expected to get him out of a hole he has dug for himself • That the referring mAn realize that the prestige of the men with whom he works is reflected in his own prestige.

-

.

----------- - - -- - - -- -

-- ~ .

THE PHYSICIAN AS A TEACHER

The physiciAn's sphere of influence as a source of health informa• tion is extended fur beyond the confines of the medical school classroo~ Although the word doctor means teacher, for centuries the tral. it:io nal role of the physician was predominan~y tliat of healer. SUch teaohing as he did conduct was limited largely to hjs apprentices and, to a minor extent, to his patients. The fundamentals of medical practice were handed dew~ authoritatively and individually~ Only occasionally did learned physicians ga-t;h3r together and pool their medical knowledge so that it might be kept alive to serve the common man. 1,2 However) as society gradually became more complex, the concept of the physician as a source of knowledge as well as a healer slowly evolved• Tod~y, in fact, the publica eager for knowledge on health and the pre• vention of disease, turns to the physician for guidance. At no time has an examination of the physician's responsibility as health educator been more timelyo Actually; this phase of activity is an integral part of medical practice, for good communication is the core of the doctorpatient relationship and vitally important to successful treatment. 2,3 SCOPE OF

TEACHih~

Although the scope of the physician's teaching activity has expanded, the concept of his duties with respect fo such endeavors has been delineated in the past~ Sir Viilliam Osler 1 for example 1 assigned to his profession the task of disseminating the highest level of available know• ledge, pointing out that nothing short of this goal could be deemed worthy of anyone truly desirous of being regarded as a teacher • 4 Worthington Hooker~ in describing the obligation of the physicianteacher, maintained that as a citizen he must be concerned with public welfare and be ready at all times to impart his knowledge on all manner of problems, ranging from questions on public hygiene to social matters, as well as on legal problems, related to the practice of medicine. As a member of the community, it is within his province to enlighten the public on such vital questions as the prevention of epidemics and the need for quarantines, and to advise court officials and coroners of every aspect of medical jurisprudence.5 Through appropriate counseling that sometimes is anticipatory, the experienced practitioner gives advice about treatment in a manner that contributes to his patient's health and education. Indeed, in this respect, the medical profession has indirectly changed many of the attitudes and habits of the publico Knowledge newly acquired by a patient is often passed on to other members of his family or ~ocial circle, thus indirectly expanding the physioiants sphere of influence. 3

The relationship between patient and physician depends on understanding and acceptance of health education as an important adjunct to tr0 at~ ment of most illnesses,.. Without the cooperation of knowledgeable pa~;H~ nts, physicians cannot make progress in the prevention and ma.nagement o1' diReare â&#x20AC;˘ The physician's accomplishments in this area have enhanced his importance and placed him in a favorable position to educate the public on many phases of health. 3,6 TOOLS FCR TEACHING To fulfill his enlarged program of teaching and to present it effectively to large audiences, it has been necessary for the modern physician to master modern techniques of communication. At the same time, he must familiariae himself with the problems of everyday living that may threaten health or safety. In Phoenix, for example, local physicians launched an automobile safety belt campaign, with far-reaching effects. Thousands of cars added this precautionary equipment, and it became a standard measure for official highway patrol vehicles. This same medical group also cooperated in a campaign against accidental poisoning and in publishing a booklet on home safety~ l1ore than two million copies of the booklet were distributed here and abroad. 7,8 At the University of Kansas Medical Center~ a series of health education programs were presented over an educational television network, three of which were recorded for national distribution. 8 In a somewhat different approach, the University of Nebraska,has inaugurated a course in child health, given at the undergraduate college level. The department of physiology formulated the course to meet tho growing need for instruction of the lay public in matters of child health. T~o course covers such vital aspects of child care as the relative roles of the physician, parents, teacher, and others involved with the child's welfare. At the same time, the lectures consider in detail hereditary and environmental ns well as emotional factors that influence the child's well-beingD Diverse topics are taught by specialists in several fields, including surgery, gynecology, and pathology. Since no textbooks were designed to deal with such a course, the University prepared n special syllabus and glossary to cover the subjects in these lectures. 9 In a:ldition to pablic campaig ns~ formal courscs 11 and tolovioion programs, n numbor of other media are used by the physician for co~auni­ cnting with the public. The health forum, with its panol of experts to answor questions from the audience, has become an important touching dovice in health education. Exhibits and displays in health museums are some of the additional innovations that have been ueod with considerable success. Health museums havo been established in cleveland, Dallas, Chicago, and Boston, among other cities, and at the Smithsonian Institution in Washington, D. Co Some of these organizations also have assembled exhibits which can be shipped to various convenient places for

public viewing. The Clev8land AcadeiTJY of Medi<:inE'I 1 for exampJe ,. in cooperation w:i.th the local health museum., is using vi:rtuall~r e.~ l f?r.ms rf mass communication, including lectures and IJovies,, to prov~.de information on public health questions 0 10 Not only individual physicians but medical societies as well have been drawn into school health programso At least one medical society has encouraged its local members to assume responsibility for teaching teachers how to observe children as a. means of l'ilUking the aohool ~ s health progl'a.m more effective. Similarly, tho increasing popularity of symposia on sports medicine and of clinics for the instruction of coaches is multiplying the physician's dutios as a teacher in those a.reaso 11

THE PROFESSIONAL AUDIElfCE

Another reflection of the growing interest in health information and health services is the increased number of trained paramedical personnolo These persons~ too., rely in large measure on the physician for leadership in coordinating their efforts with that of the medical profession. Many specialists in allied fields now are required to have a firm grounding in medical sciencese Technologists, statisticians., nurses, sociologists,, and physical therapists, to mention a few 8 are among those rendering health services~ It is incumbent on the modern physician to assume the rosponâ&#x20AC;˘ sibilit2 for reliable leadership in the training of members of such health t~a.,~

The physician must participate actively in teaching certain of the newer medical specialties in which advances are being made rapidly. Public health teaching, for example, has been revised by minimizing the didactic approach and emphasizing clinical preventive medicine and social medicine. The immediate goal in this field calls for the training of a large number of doctors who will play a more active role in assessing and altering tho ecologic factors in health and disease. To help achieve this o9jective, nine medical sohai~ have already accepted stu~ents for teaching res~dencies in their departments of preventive modicino.~3 In teaching medical students at~ colleagues, as in informing tho public on health mattersJ the physician has used to advantage the latest methods for instructing both small and largo groups~ Closed-circuit television fills a. special need, particularly in medica.l schools where certain procedures may be too costly or time-consuming to repeat. ~ means of closed-circuit television., those techniques can conveniently be shown time and again to la.:rgo audiences with little effort for the lecturer. such an innovation n0t only onsuros more effective use of the busy phy s l.c ian" s teaching t imo" but also introduces now e loment s into the medical curriculum 8 thereby enriching it far beyond the scope envisaged by those who first practiced tho healing arts. 8â&#x20AC;˘14

sweeping changes in hospital and nursing practices in tho past 20 years have raised many now questions that require clariflcation by the physician 0 To fulfill its present function to maximum, the university medical center must assume responsibility for tho continuing educattcn of nursoso In a sense, these institutions must become centers for training of all those who servo the health needs of the nationo 15

REFERENCES s 1. 2e 3o 40 5• 6o 7• 8o 9. lOo llo 12 o 13o 14~

15.,

Halo-V~ite.

w.,

in Contribution to Medical and Biologic Research, New York, Paul Be Hoeber 1 Inc.,, volo I, 1919. Wheatley 1 Go M.a: PEDIA'IRICS 2.7 s489 11 1961. Clements, Fo Vlo: WORlD M.J • 8 ,199,_ l96lo Osler, W.: Teacher and student, Baltimore, John Murphy & Coo, 1892. Hooker, Wo r Physician and Patient 11 New York, Baker & Scribner • 1849. Fry, J.s WORlD M.J. 8:200, l96lo Dessen, Eo Lo: PENNSYLVANIA M.J • 64 :.267, 1961 Ruhe, De S. & Gentry, Ko Co: Je KA!JSAS M. SOC. 62:94, l96lo Sta.fford, G. E.: NEBRASKA M.J • 46:387, 1961. Bauer, w. w.: WORlD M.J • 8:.203, 1961. Dukolow, D. Ao: J. SOUTH ClillOLiiJA M. Ao 57:375, 1961. I.e ake 1 C• Co : J .A .M .A • 17 8 :151., 1961. Taylor, Co E.' J .M. EDUC. 36:.943, 1961 0 McGuire, Fo Lo, et al.: J.M. EDUC. 36:..715, 1961 0 Nlhm, He & Miller, Do Io: J .M. EDUC. 36 t849, 1961.

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SPHERE CF Elli'LUENCE OF THE PHYSICIAN' AS TEACHER

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Changing concepts of the funct:i.on of tho physician, including emphe. ::~.s C:J. t.hb :L"nrort-anr.G of preventive medicine, have added to hi~ t.aflcln% ra~ponsibil:i.ties. More and more, the discharge of his medical duties involves the physician in disseminating medical information to many professional and community groups.

:MEDIA OF CCB:Il:I!JITJNICATIOU UCED BY THE PHYSICIAN

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Development of now avenues of communication and expansion of established ones give the physician a larcor audience than he has ever had before e Media through which the physician can disseminate information range fr~m direct discussion in selected groups to the use of nationwide broadcasting and television facilities.

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