Private Office Practice Research Articles

The Social Worker in the Private Practice of Internal Medicine

COMPREHENSIVE medical care is the goal of the internist in private practice today. Such care must often include attention to the emotional and socioeconomic factors that may complicate effective treatment of the patient's physical problems. In an attempt to cope more effectively with these factors, a social worker has been employed in the senior author's private practice. This paper presents our experiences in this relatively undocumented area. 1-3 Social workers have been part of the medical team for many years and their contribution to good patient care in hospital settings and in agencies has been amply demonstrated. The extension of the social worker's services to the field of private office practice seems a logical next step. It is not the purpose of this preliminary report to prove the effectiveness of the social worker per se, but rather to suggest that the private patient treated in the physician's office can derive

PERSONAL INTEGRITY AND THE STATUS QUO.

It is the opinion of competent radiological travelers from this country and from abroad that the people of the North American continent, overall, receive the best radiological care in the world. As a consequence of the sheer weight of numbers one must take for closer observation radiology as it is practiced in the United States and Canada. This is not intended as an arrogant disparagement of our foreign colleagues. Even casual perusal of the radiologic literature in our own English language tells us that many centers elsewhere in the world offer unique and superior methods of providing particular therapeutic and diagnostic radiological services. Let me emphasize again that, overall, what we have to offer is of high quality and generously available. Personal conversation with foreign visitors allows me to state that they themselves often share in this opinion. I, for one, would like to contend that this state of affairs came about through the healthy degree of competition and balance between private practice and hospital radiology. Except for relatively minor trends, radiologists in the United States have not seen any great change in the manner of this practice in the past four decades. Recent events, occurring at a rapid rate, threaten this balanced system. While it may seem only a small squiggle on the total sociological seismograph, there has been a significant change in the manner of practice among our neighbors to the north. Time and observation of the results of this change (which seems great to us) may offer an answer as to whether it is permanent or not. This type of socioeconomic medical change, however, is not likely to be reversed. If this assumption is correct it will be too late to make amends, for the balance of competitiveness between private office and hospital radiology, the difference in private and hospital purveyance, will no longer exist. Private office practice will diminish or, as our good friends tell us, may become nonexistent. A whirlwind of forces seems to want to change this system of balanced radiological practice. Medicare and the insurance industries' desire to label radiology as a hospital service both 100m large. The first has not been established as yet; the other is being palliated by good efforts of dedicated people. As long as the private practitioner can have the help of his own specialty organization and that of all organized medicine he will, we hope, survive to offer his services to the medical public. His colleague in full-time hospital practice is having his trouble in surviving and maintaining his part in what we would like to be believed the best of all systems of radiological practice. While the hazards of legislative professional extinction and insurance company regulation may disturb him, they do not threaten his professional eradication. His perils are closer. They are his “employers” in the hospital administration itself as well as his own human frailty.

Changing times.

The practice of medicine, and its specialty, radiology, is a living, dynamic profession. At no time does it stand still. To make such a statement is to call attention to the obvious, perhaps to the point of being trite, and I do so only because, in the hurly-burly of everyday living, we are prone to forget such basic truths. Much has been said and written, in the past ten years, concerning the future of radiology, and it may well be that I am courageous to the point of being foolhardy in adding my thoughts to what has already been said. However, there is one aspect concerning which I would like to comment. It is my purpose to consider the private office practice of radiology and some of the factors influencing it today. I know that what I have to say will be strongly biased by the state of affairs in that part of the world in which I live, by what is happening to me and to those other radiologists with whom I am more intimately associated. I realize also that there are many who will take issue with my views, and that is good. The rewards of the private office practice of radiology far outweigh its problems. Those of us who have spent our professional lives in this type of practice have the feeling that, except in rare instances, it alone offers the radiologist the opportunity to be a physician in the fullest sense of the word. It is in the private office, where patients come to see him as a physician, that the radiologist can really practice the art of medicine. Few departments of radiology can even attempt to promulgate this sacred patient-physician relationship. It is disquieting, therefore, to have gained the impression that fewer and fewer young men are choosing private office practice of radiology as their way of practicing medicine and thus fulfilling the original purpose of their medical training. Lack of interest in private office practice on the part of our younger men is due perhaps to several things. First of all, it may well be that the men who are attracted to radiology today are those whose basic interest in medicine is hospital or institutional work. From the beginning, they have never wanted to go out into the competitive atmosphere of office practice—to be physicians in the old time-honored sense of the word—and during the three or more years of their training in the specialty little or nothing is ever said which might change their ideas. How can preceptors, who have spent their entire professional lives in hospital departments, knowing little if anything about the fascinations, the problems, the delights, the turmoil, and the tranquility of a private office, inspire enthusiasm for private practice? The emphasis, during the early part of the training period, is too often upon the reading of films; later, when the day of decision approaches, the emphasis may be entirely upon getting a job, finding a hospital, somewhere, that will sign the new radiologist to a contract and put him to work. Except for the few instances where a young man goes into an established practice as a junior partner, a hospital connection may seem the obvious choice. Another factor, which is purely one of economics, exerts a tremendous influence on the young man going into the world of medicine. In a high percentage of cases, by the time he has completed his training he is married and the head of a growing family. With his dependents to think of, he cannot see the logic of going into debt to equip a private office. His paramount thought is to obtain security for his family and to him this most commonly means a contract with a hospital, providing him with a ready-made captive practice and what he considers a good income. In radiology, as in other fields, this search for security has long ago wiped out the pioneering spirit.

Acne: additional data from a national survey.

Acne of all types accounted for almost 1 out of every 5 patient-visits in the private office practices of 50 board-certified dermatologists. In the 4,842 such visits, the female to male ratio was about 2:1. Patients aged 14 through 17 accounted for 40% of the total. The over-all ratio of total visits to initial visits was 7:2. The highest such ratio occurred among male patients aged 16 through 19. Males may wait until their acne is very severe before coming to the dermatologist for treatment. The female ratio was a much more constant one at all ages. The use of x-radiation occurred in 26% of all acne patient-visits and began in significant frequency at ages 14 and 15. It reached its peak at ages 18 and 19. In 30% of all acne patient-visits, the participating dermatologists checked not customarily used in this diagnosis. This number exceeded the number which were treated with x-radiation. From ages 14 through 18 the percentage of patient-visits in which x-ray was not used because patient was too young dropped from 63 to 0. It was found that apprehension about being treated with x-radiation occurred in 2.4% of the acne patient-visits.

Clinical evaluation of phenformin (DBI) in office practice.

One hundred and four diabetic patients of both sexes, ranging in age from 4 to 83 years, were studied for seven months in a private office practice to evaluate the effect of phenformin therapy. Most of these patients had had difficulty in controlling their diabetes before taking phenformin. Fair to excellent control was achieved by 91 (88%) with or without adjunctive exogenous insulin; failures which occurred in 13 cases were attributable to gastrointestinal, behavioral, or environmental difficulties. Special importance was attached to the value of combined phenformininsulin therapy in reducing the incidence and severity of hypoglycemic episodes and in improving the control of previously labile patients.

Clinical evaluation of topical fludrocortisone.

A clinical study of 335 cases of dermatitis treated with hydrocortisone and fludrocortisone (9α-fluorohydrocortisone) applied topically in both lotion and ointment form by the method of paired comparisons was begun Sept. 28, 1954, and is still being continued. Fludrocortisone was supplied for this study in strengths of 0.1% and 0.25% in lotion form in ½ oz. (15 cc.) plastic bottles and in strengths of 0.1%, 0.25%, and 0.5% in ointment form. Corresponding strengths of 1% and 2.5% hydrocortisone in identical vehicles were used for paired comparison with the fludrocortisone preparations. The vehicles were also supplied in similar containers for placebo comparison. Method Patients with selected dermatoses in private office practice were given pairs of the corticoid preparations, the fludrocortisone being 1/10 as strong as the hydrocortisone. They were instructed to apply the lotion or ointment thrice daily to the affected areas. In most cases simultaneous contralateral applications were

Contact x-ray therapy of the common wart.

TREATMENT of common warts is often one of the dermatologist's most perplexing problems. This is especially true if the warts are multiple or if they occur about or beneath the nails. Under these circumstances obtaining a cure may be more difficult than the successful management of, for example, the average basal-cell epithelioma. Warts can be and are treated by a variety of agents. Evaluation of any treatment is difficult for various reasons for many verrucae seem to disappear spontaneously and, on occasion, in response to suggestion. It is also recognized that the virus can exist dormant in the skin for long periods of time,1 and last, new lesions may appear at or near the site of treated lesions which are interpreted as recurrences. During the past two and one-half years, 117 patients, presenting a total of 540 verrucae, were seen in a private office practice and

Duodenal ulcer in children.

The possibility of an inflammatory lesion of the duodenal bulb is not considered frequently enough in the differential diagnosis of gastro-intestinal tract upsets or abdominal pain in children. For one to suspect ulcer in children presenting symptoms referable to the abdomen or gastro-intestinal tract, it is essential to accept the fact that ulcer can and does occur. The purpose of this paper is to cite some significant observations from the literature regarding duodenal ulcer and to present a series of illustrative case histories and roentgenograms of the lesion in children. Thiele (1) reported a series of 248 cases of ulcer in children sixteen years old or younger, half of which were duodenal in location. Hirsch (2), in a very large collected series of peptic ulcer, reported the incidence in children to be between 0.3 and 1.0 per cent, but did not distinguish between duodenal and gastric lesions. Cockovic (3) showed that more than 18 per cent of his cases of ulcer presented clinical symptoms developing between the ages of ten and twenty years. Proctor (4), in an analysis of 1,000 duodenal ulcers in adults, found 26 cases with symptoms dating back to childhood. Bird and his associates (5), in a careful search of the literature, discovered 119 cases of peptic ulcer in infants and children verified by operation, together with 124 cases in which the diagnosis was established by postmortem or x-ray studies. In this group of 243 cases, there were approximately 160 duodenal ulcers. Berglund (6) reported an analysis of 1,323 postmortem examinations in children up to thirteen years of age, in 14 of which duodenal ulcer was demonstrated. Benner (7) in 500 routine autopsies in children reported an incidence of duodenal ulcer of 1.4 per cent. Michaëlsson (8) reported an incidence of duodenal ulcer of 1.5 per cent. The true incidence of duodenal ulcer in children is difficult to evaluate. From scattered autopsy statistics, it would appear to vary from 1 to 1.5 per cent. This would seem to be a very significant percentage, for we know that autopsy statistics based on hospitalized patients do not represent the true incidence of a disease for any age group of the population, but only for that percentage with complications severe enough to require hospital admission. This would suggest that the true incidence of duodenal ulcer in children is much higher and that clinically it should be suspected more frequently and procedures instituted to prove or disprove its presence. This report is based on an x-ray study of the gastro-intestinal tract in 254 children in the routine work of an x-ray department in a general hospital and in private office practice. In this number of examinations, the x-ray diagnosis of duodenal ulcer was made 30 times. The oldest patient in whom ulcer was diagnosed was fourteen years of age, while the youngest was two years of age.

The radiologist--some of his problems.

The high position of radiology among medical specialties is something of which we in the field can be justifiably proud; that position, however, is not entirely an enviable one. The growth and development of the science, so familiar to all of you, have been nothing short of phenomenal, yet with that growth has come an ever-increasing complexity of the many problems confronting those of us who have chosen this as our life's work. The mechanical and technical difficulties of the early days have long since ceased to cause much serious concern. The attempts of lay laboratories to practise medicine through radiology have been fairly well overcome, although still somewhat of a problem in some centers; and protection against the hazards of the rays, once an enigma, is now a procedure of accepted routine. Today's radiologic problems are of a different nature and spring both from within and without the specialty. Intraradiologic problems that plague us have as a common denominator the variance in the economic and social structures within which radiology is practised. These are private office practice, practice limited to hospitals, clinic group practice, combinations of these, and complete occupation in the educational field. We find it vexatious at times to reconcile the divergent individual attitudes produced by these differing professional environments. This is the main circumstance that calls for mental adjustments within the radiologic family circle. Just as every family has its differences that necessitate give and take, so does radiology. We need not, however, apologize to any group for our conduct in reconciling these differences. The family has remained intact, preserved by our intellectual comradeship, our devotion to our professional purpose—better radiology for all—and our recognition of the primary ethic : “Do unto others as you would have others do unto you.” It would be pleasant to be able to render the same sort of report on our problems that arise outside the specialty. That is not possible at this time. Perhaps I should have used the singular and said “problem” rather than “problems.” For, though it appears in many guises, our fundamental problem is the attempt on the part of some hospitals, aided and abetted to an extent by certain hospital groups, to control the practice of radiology by treating it as a hospital rather than a medical service. This is aggravated by the provisions of certain Blue Cross contracts which guarantee in the name of cooperating hospitals to provide radiologic service, rather than offering an indemnification. Parenthetically, this aggravation will remain with us until Blue Shield plans more universally include adequate radiologic service. We may take comfort in one fact. While at first glance our problem seems unique, it is but an extension of the over-all problem facing the entire medical profession—the escape from outside domination. Note that I say “domination” and not interest, co-operation, or even influence.

WEAKNESS AND DILATATION OF THE HEART IN CHRONIC NUTRITIONAL DISEASE.

I wish to invite your attention for a few minutes to some practical questions concerning certain aspects of cardiac pathology and therapeutics. These questions will be discussed with especial reference to my own experience. This experience, or at least that part of it which I have chosen as the basis of this discussion is perhaps sufficiently indicated by the title. It might be well, however, to add that the material among which cases of weakness and dilatation were found comprised about 600 cases of chronic gastritis, with about the same number of other forms of chronic diseases. These cases all occurred in private office and consultation practice. In all cases the heart was subjected to a careful examination with reference to the clinical changes of volume, either transient or permanent in character, which occur with varying states of tonicity of the cardiac muscle. In perhaps no other department of practical