HEALTH SCIENCES LIBRARY university of MARYLAND
baliimore^^.
|S>T TO ClRCULATi
htALTH SCIENCES LIBRARY UNIVERSITY Of
BA.IOil\SQfiS
Digitized by the Internet Archive in 2016
https://archive.org/detaiis/iowamedicine8311
bwaMedicine
ary 1993 Joumal of the Iowa Medical Society
^ACtCs
health sciences LIBRAm^
UNIVERSITY OF MARYLAND ^ BALTIMORE
JAN 191993
'nterview with a leading a geriatrician . . .
)w will we care
rst-person commentary. . .
insplant patients jst have realistic pectations, page 13
Bruce K\orrison
PMIT INSURES OWA MEDICAL LEADERS
We have been insured by IPMIT for a number of years. We are extremely pleased by recent actions granting a premium credit and increasing the coverage limits, without an extra charge. We believe the IPMIT Board is achieving its mission — fiscal stability with appropriate enhancements.^^
HAROLD E. EKLUND, M.D.
Des Moines, Iowa President
Iowa Academy of Family Physicians
Across Iowa, physicians have accepted IPMIT medical liability insurance in excellent fashion. There are right at 1200 IPMIT policyholders. Growth continues. Over 40% of the eligible IMS member- ship now holds IPMIT coverage.
Clearly, this is an Iowa program for Iowa physicians. One that’s dedicated to the long term. To financial stability. To competitive premiums. To policy enhancements. To risk management. To special, close-by claims handling.
The IPMIT roster includes insureds from most every medical and surgical specialty. And many IPMIT physicians serve in Iowa leadership capacities.
Personal service is the name of our game. We’re here to assist IPMIT policyholders and prospective policyholders at every opportunity. For coverage and rate information, please call IMS SERVICES at 515/223-2816 or 800/728-5398.
IPMIT
IOWA PHYSICIANS MUTUAL INSURANCE TRUST
Your IPMIT Program Is Supported By IMS SERVICES 1001 Grand Avenue, West Des Moines, Iowa 50265
lowaMedicine
•/ume 83 Number 1 Journal of the Iowa Medical Society January 1 993
ditorials
\ 5 President's Privilege
Physicians are still seated at the health care reform table of discussion.
7 The Editor Comments
Some children require long- term care — often for their entire lives.
16 IOWA MEDICINE Interview
Increased governmental regulations have had a significant impact on Iowa's nursing homes.
Departments
21 College of Medicine Highlights 122 About IMS Members 29 The Art of Medicine 31 Practice Management
33 Biomedical Ethics
34 Classified Advertising 36 Physicians' Directory
About the Cover
this month's seasonal cover photo was taken oy Bruce Morrison of Sheldon at the Big Sioux vVildlife Management Unit in Lyon County. Mr. Morrison does commercial photography and artwork for various regional magazines in Iowa, including the Iowa Heritage Foundation. He operates Morrison Studio in Sheldon.
Editorial Board
IMS President
William Eversmann, Jr., M.D.
Scientific Editor
Marion E. Alberts, M.D.
Executive Editor
Idon E. Huston
Managing Editor
Tina Preftakes
Assistant Managing Editor
hristine McMahon-Clark
Muction/ Advertising Manager
lat I. Nieland
Feature Articles
9 Caring for the elderly: a crisis on the horizon
A leading Iowa geriatrician discusses the future of long- term care and how to assess the health status of elderly patients.
1 3 Advice to transplant patients? Ask questions
Physicians must be sure their transplant patients don't have unrealistic expectations.
Brad Lofton
Scientific Article
25 Suburethral sling — an old procedure revisited
Used to treat urinary incontinence for many decades, this procedure is enjoying renewed popularity.
Larry Lindell, M.D.
IOWA MEDICINE, journal of the Iowa Medical Society (ISSN 0746-8709), is published monthly. Subscription price: $20 per year. Second class postage paid at Des Moines, Iowa and at additional mailing offices. POSTMASTER: Send address changes to IOWA MEDICINE, Journal of the Iowa Medical Society, 1 001 Grand Avenue, West Des Moines, Iowa 50265. NATIONAL ADVERTISING: State Medical journal Advertising Bureau, Inc., 711 South Blvd., Oak Park, Illinois 60302. Phone 708/383-8800. IOWA ADVERTISING: jane Nieland, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Phone 515/223-1401. EDITORIAL CONTENT: The Society is unable to assume responsibility for the accuracy of that which is submitted. Medical items published in the New Products and Programs column are not necessarily endorsed by the editors or the Society. Manuscripts and editorial inquiries should be directed to Editor, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Copyright 1993 Iowa Medical Society.
Lexus LS400 Highest Retained Value Of Any Car In The Luxury Class.
Retain More Of Your Shirt.
One of the most important considerations in buying a luxury car is not how much you spend, but how much of your investment you’ll keep.
Which is why it’s significant to note that, according to recent industry figures,* the Lexus LS 400 has retained more of its original value than any other car in the luxury class.
Possibly because the automotive press has consistently rated it higher than other luxury cars costing thousands more.
Possibly because in J.D. Power and Associates’ latest Initial Quality Study, it ranked in the Top Ten Models, receiving the best score in the history of the survey.
Possibly because prospective buyers can see into the future. Come into your Lexus dealer today.
■J.D. Power 1990, 91, 92 Initial Quality Study. Based on 33,573 customer responses indicating owner reported problems during the first 90 days of ownership.
I
GRAND AT 17th DES MOINES
288-9999 • 1-800-800-9896
Pursuing Perfection... With A Tradition Of Excellence.
lowaMedicine
lume 83 Number 2 Journal of the Iowa Medical Society
February 1993
ditorials
l^5 President's Privilege
; Under any name, the IMS Education Fund does the same good work.
\7 The Editor Comments
The most difficult thing for a pediatrician is telling parents of an unfavorable diagnosis. 53 IOWA MEDICINE Interview There are many advances in cancer treatment, say U. of I. experts.
57 Tribute to a friend
An essay about a special small town doctor.
departments
57 Letter to the Editor 59 About IMS Members 59 College of Medicine Highlights 62A U. of I. Cancer Registry
73 I EMC Case Notes
74 Physician Learner
78 Classified Advertising 80 Physicians' Directory
About the Cover
loe Battles, Indianola, took this picture in Colorado's Rocky Mountain National Park. Mr. Battles works for U.S. West and does commercial photography work in his Indianola studio, Battles Photography.
Editorial Board
IMS President
William Eversmann, Jr., M.D.
Scientific Editor
Marion E. Alberts, M.D.
Executive Editor
Eldon E. Huston
Managing Editor
Tina Preftakes
Ass/sfanf Managing Editor
Christine McMahon-Clark
Production/Advertising Manager
lane I. Nieland
Feature Article
49 Patients benefit if cancer specialists^ family physicians communicate
Patients with cancer need the special skills of the oncologist and the family physician.
Scientific Articles
63 Primary cancer of the head and neck
This study reviews 1 78 cases of squamous cell carcinoma for second malignancies.
William Reynolds, D.D.S., M.D., Richard Firkins, M.D., Susan Aguiar, M.D.
67 A patient with 56 primary malignancies
This Iowa man was within 50 miles of atomic bomb testing and has a family history of cancer.
Ahmed Ghouri, M.D., Carl Peterson, M.D., Richard Firkins, M.D., Lester Dragstedt, II, M.D.
IOWA MEDICINE, Journal of the Iowa Medical Society (ISSN 0746-8709), is published monthly. Subscription price; $20 per year. Second class postage paid at Des Moines, Iowa and at additional mailing offices. POSTMASTER: Send address changes to IOWA MEDICINE, journal of the Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265. NATIONAL ADVERTISING: State Medical Journal Advertising Bureau, Inc., 711 South Blvd., Oak Park, Illinois 60302. Phone 708/383-8800. IOWA ADVERTISING: Jane Nieland, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Phone 515/223-1401. EDITORIAL CONTENT: The Society is unable to assume responsibility for the accuracy of that which is submitted. Medical items published in the New Products and Programs column are not necessarily endorsed by the editors or the Society. Manuscripts and editorial inquiries should be directed to Editor, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Copyright 1993 Iowa Medical Society.
MEDICAL OFFICE SOFTWARE
The Key To Inf omiation Is Access...
Practice Partner™ Patient Records Qives You Access
Designed by a physician, Patient Records software provides quick access to, and instant updating of your patient charts.
Quickly retrieve progress notes.
Pinpoint patient medications, allergies, lab data, vital signs, health maintenance and much more. Improve quality of care.
Enter data quickly and efficiently.
No computer expertise required. Runs on IBM PC-AT,
PS/2 and compatibles. Ready for multi-user networking.
Other PRACTICE PARTNER Software:
Appointment Scheduler, Medical Billing, Medical Writer.
09 • (800) 995-9245
lowaMedicine
jme 83 Number 3
Journal of the Iowa Medical Society
March 1993
I litorials
President's Privilege
Managed competition or cost-shifting?
The Editor Comments Cardiovascular disease is as old as the ancient Egyptians. IOWA MEDICINE Interview Undiagnosed heart disease and Iowa's high school
Feature Article
93 Want to just be a doctor? Try locum tenens
This retired physician and past IMS president has found true professional fulfillment.
Donald Rodawig, M.D.
Scientific Articles
athletes.
^departments
4A 1993 Scientific Session Program 3 Practice and Personal Management
14 The Art of Medicine
6 Classified Advertising
»0 Physicians' Directory
~\bout the Cover
101 Cardiovascular disease: treatment and referral
Good news and bad news for those concerned about the number one cause of mortality in the U.S.
David Gordon, M.D.
107 Intussusception presenting as encephalopathy
One of the most common causes of bowel obstruction in small children.
Gregory Hoisington, D.O., William Bartlett, D.O., Thomas Kelly, M.D.
)wa photographer Kay Danielson took this wely pastoral photo which she calls "Three in ie Morning" while traveling down a back road n Michigan. Ms. Danielson was on her way to * I quilt auction when she spied the horses.
Editorial Board
IMS President
William Eversmann, Jr., M.D.
Scientific Editor
Marion E. Alberts, M.D.
Executive Editor
Eldon E. Huston
Managing Editor
Tina Preftakes
Assistant Managing Editor
Christine McMahon-Clark
Production/Advertising Manager
Jane I. Nieland
IOWA MEDICINE, lournal of the Iowa Medical Society (ISSN 0746-8709), is published monthly Subscription price: $20 per year. Second class postage paid at Des Moines, Iowa and at additional mailing offices. POSTMASTER: Send address changes to IOWA MEDICINE, lournal ot the Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265. NATIONAL ADVERTISING: State Medical lournal Advertising Bureau, Inc., 711 South Blvd., Oak Park, Illinois 60302. Phone 708/383-8800 IOWA ADVERTISING: lane Nieland, IOWA MEDICINE, I00\ Grand Avenue, West Des Moines, Iowa 50265. Phone 515/223-1401 . EDITORIAL CONTENT: The Society is unable to assume responsibility for the accuracy of that which is submitted. Medical items published in the New Products and Programs column are not necessarily endorsed by the editors or the ScxieM Manu,X“a"cl edl.orial inquiries should be directed ,0 Editor, IOWA MiDIONE. loot Grand Avenue West Des Moines, Iowa 50265. Copyright 1993 Iowa Medical Society.
Establish a Complete Pension Package With Complete Confidence
CPS’s Qualified Pension Program
As a professional, you are probably aware of how attractive a qualified pension plan can be to your organization. But you may have heard they are very complicated, full of red tape and too rigid.
That’s why you’ll appreciate the complete and flexible package from Century Pension Services, specialists in Tax-Qualified Employee Benefit Plans for small to mid-size companies. With our turn-key approach to pensions, you will never regret establishing one.
For more information on the complete pension package, call today. |
CENTURY COMPANIES OF AMERICA®
CENTURY PENSION SERVICES
SBO
PARTNERS WITH AMERICA’S SMALL BUSINESS OWNERS
Robert J. Grieser, LUTCF
Representative
3737 Westown Parkway, Suite E West Des Moines. lA 50265 (515) 224-0073
James E. Pede, Jr., CFP
Representative
3737 Westown Parkway, Suite E West Des Moines. lA 50265 (515) 224-0073
Stephen D. Roe Michael E. Diers, CFP,
Pension Consultant LUTCF
3737 Westown Parkway, Suite E Representative
West Des Moines. I A 50265 930 South Gilbert Street
(515) 224-0073 Iowa City, lA 52240
(319) 351-5388
Century Pension Services is a division of Century Life of America, Waverly, Iowa,
• •
lowaMedicine
olume 83 Number 4 Journal of the Iowa Medical Society April 1993
editorials
29 President's Privilege
Thoughts on patriotism and bigotry.
31 The Editor Comments
He's glad lowans aren't trend-setters.
Departments
49 College of Medicine Highlights 57 IFMC Case Notes
59 Physician Learner
60 Biomedical Ethics
62 Classified Advertising
64 Physicians' Directory
About the Cover
Since this month's magazine focuses on the College of Medicine, it is fitting that the cover s graced with a photo taken by Jaymi Meyers, M3 at the U. of I. Jaymi's photo "Looking Back" won second place in a photography contest sponsored by Vital Signs, the medical student newspaper.
Editorial Board
IMS President
William Eversmann, Jr., M.D. Scientific Editor Marion E. Alberts, M.D.
Executive Editor
Eldon E. Huston
Managing Editor
Tina Preftakes
Assistant Managing Editor
Christine McMahon-Clark
Production/Advertising Manager
lane I. Nieland
Feature Articles
132 Primary care: concern and debate
All sectors must work together on this problem, says the interim dean of the Ul College of Medicine.
135 Attitudes toward primary care are changing
Student interest is growing, but demand continues to outstrip supply.
137 Ul Hospitals touches every part of Iowa
Outreach supports physicians and patients across the state.
141 Understanding the problems of the elderly
As the number of elderly lowans increases, so do their unique health problems.
143 Training for Iowa physicians
The latest in AIDS education for health care professionals.
147 Ul researches environmental health risks
lowans need reliable information.
Scientific Article
153 Cocaine abuse in a high risk obstetrical population
Clinical judgment must guide the need for testing.
Steven Keller, M.D., Jennifer Niebyl, M.D.
IOWA MEDICINE, journal of the Iowa Medical Society (ISSN 0746-8709), is published monthly. Subscription price: $20 per year. Second class postage paid at Des Moines, Iowa and at additional mailing offices. POSTMASTER: Send address changes to IOWA MEDICINE, journal of the Iowa Medical Society, 1 001 Grand Avenue, West Des Moines, Iowa 50265. NATIONAL ADVERTISING: State Medical journal Advertising Bureau, Inc., 711 South Blvd., Oak Park, Illinois 60302. Phone 708/383-8800. IOWA ADVERTISING: jane Nieland, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Phone 51 5/223-1401 . EDITORIAL CONTENT: The Society is unable to assume responsibility for the accuracy of that which is submitted. Medical items published in the New Products and Programs column are not necessarily endorsed l^y the editors or the Society. Manuscripts and editorial inquiries should be directed to Editor, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Copyright 1993 Iowa Medical Society.
You Don’t Have To Be A Rocket Scientist To Appreciate These Numbers.
The New Lexus GS 300.
The New GS 300 not only rides smoother,’'’ corners better’’’ and is a lot more spacious than the Mercedes-Benz 300E, but it can cost thousands of
dollars less. Now these are numbers you can relate to. fi,g Mentlm Piimtit ofPeifedm
GRAND AT 17th DES MOINES
288-9999 • 1-800-9896
Pursuing Perfection... With A Tradition Of Excellence
©iOOHLexus, A Dwisum Of Toyota Motor Sa/e.t, U.S.A., hw. Le.ius reminds you to wear seat belts and obey all speed laws.
*AM( I eertified tests of ride eomfort oeer bumps and eornerinp: performance (*93 models).
lowaMedicine
I olume 83 Number 5 Journal of the Iowa Medical Society May 1993
I ditorials
'33 President's Privilege
Will a new health care plan mean more dishonesty?
75 The Editor Comments
Unbiased scientific knowledge vs. phantom data.
Oepartments
i2 About IMS Members )5 Practice and Personal Management 96 The Art of Medicine 98 Classified Advertising
00 Physicians' Directory
Feature Articles
1 76 Clinton staff is listening, but health care reform plan remains a mystery, says AMA trustee
Dr. Nancy Dickey speaks to nearly 200 Iowa physicians at a special IMS program entitled Iowa health care delivery . . . what form will it take?
1 79 Poll reflects sick society
In a must-read editorial, a syndicated columnist shares his views on physician salaries.
Mike Royko
184 Policy regarding HIV-infected health care workers
IMS Committee on AIDS recommends IDPH policy in response to a 1 992 House of Delegates resolution.
Scientific Article
About the Cover
.eve O'Brien, Boone, shot this photo entitled Vindow Reflections in LaCrosse, Wisconsin. Ir. O'Brien is an industrial photographer and raphic specialist for Little Giant Crane and hovel, Inc., Des Moines. He also nnaintains a arkroom in his Boone home.
187 Massasauga rattlesnake bites in Iowa
Although bites from swamp rattlesnakes are generally , mild, a recent case in eastern Iowa was life threatening.
James Christiansen, Ph.D., John Fieselmann, M.D.
Editorial Board
MS President
Villiam Eversmann, Jr., M.D.
Scientific Editor
vlarion E. Alberts, M.D.
Executive Editor
ildon E. Huston
Vanaging Editor
Tina Preftakes
Assistant Managing Editor
Christine McMahon-Clark
Production/Advertising Manager
lane I. Nieland
IOWA MEDICINE, Journal of the Iowa Medical Society (ISSN 0746-8709), is published monthly by the Iowa Medical Society. Subscription price: $20 per year. Second class postage paid at Des Moines, Iowa and at additional mailing offices. POSTMASTER: Send address changes to IOWA MEDICINE, Journal of the Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265. NATIONAL ADVERTISING: State Medical Journal Advertising Bureau, Inc., 711 South Blvd., Oak Park, Illinois 60302. Phone 708/383-8800. IOWA ADVERTISING: lane Nieland, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Phone 515/223-1401. EDITO- RIAL CONTENT: The Society is unable to assume responsibility for the accuracy of that which is submitted. Medical items published in the New Products and Programs column are not necessarily endorsed by the editors or the Society. Manuscripts and editorial inquiries should be directed to Editor, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Copyright 1993 Iowa Medical Society.
Establish a Complete Pension Pacfc^e With Complete Confidence:
CPS’s Qualified Pension Program
As a professional, you are probably aware of how attractive a qualified pension plan can be to your organization. But you may have heard they are very complicated, full of red tape and too rigid.
That’s why you’ll appreciate the complete and flexible package from Century Pension Services, specialists in Tax-Qualified Employee Benefit Plans for small to mid-size companies. With our turn-key approach to pensions, you will never regret establishing one.
For more information on the complete pension package, call today.
CENTURY S* COMPANIES ^1 OF AMERICA®
CENTURY PENSION SERVICES
SBO
PARTNERS WITH AMERICA’S SMALL BUSINESS OWNERS
Robert J. Grieser, LGTCF James E. Pede, Jr., CEP
Representative Representative
3737 Westown Parkway. Suite E 3737 Westown Parkway, Suite E West Des Moines, lA 50265 West Des Moines, lA 50265 (515) 224-0073 (515) 224-0073
Stephen D. Roe Michael E. Diers, CEP,
Pension Consultant LUTCF
3737 Westown Parkway, Suite E Representative
West Des Moines, I A 50265 930 South Gilbert Street
(515) -224-0073 Iowa City, lA 52240
(319) 351-5388
Century Pension Services is a division of Century Life of America, Waverly, Iowa.
lowaMedicine
blume 83 Number 6 Journal of the Iowa Medical Society
June 1993
f.ditorials
:09 President's Privilege
The new IMS president warns about the danger of disunity in the face of health care reform.
!11 The Editor Comments
Acting like an animal isn't necessarily a bad thing.
!16 IOWA MEDICINE Interview
Iowa's insurance commissioner discusses the Governor's Health Care Reform Council.
Departments
119 Letters to the Editor
129 IFMC Case Notes
>32 Physician Learner
234 Classified Advertising
236 Physicians' Directory
Feature Article
213 Stowaway
A true life drama involving an Iowa physician and a young Greek expatriate.
Scientific Articles
221 Sun induced dermatoses
Summer is upon us, the time when many of your patients worship the sun a little too enthusiastically.
Shawn Sabin, M.D.
224 Weight loss and foot drop
A side effect of prolonged or crash dieting is discussed.
Erich Streib, M.D.
About the Cover
This photo of Costello Mill in Maquoketa, Iowa was taken by Joe Battles of Indianola. Mr. Battles works for U.S. West and does commercial photography in his Indianola studio. His favorite subject is landscapes.
Editorial Board
IMS President
John R. Anderson, M.D.
Scientific Editor
Marion E. Alberts, M.D.
Executive Editor
Eldon E. Huston
Managing Editor
Tina Preftakes
Assistant Managing Editor
Christine McMahon-Clark
Production/Advertising Manager
Jane I. Nieland
IOWA MEDICINE, journal of the Iowa Medical Society (ISSN 0746-8709), is published monthly by the Iowa Medical Society. Subscription price: $20 per year. Second class postage paid at Des Moines, Iowa and at additional mailing offices. POSTMASTER: Send address changes to IOWA MEDICINE, journal of the Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265. NATIONAL ADVERTISING: State Medical journal Advertising Bureau, Inc., 711 South Blvd., Oak Park, Illinois 60302. Phone 708/383-8800. IOWA ADVERTISING: jane Nieland, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Phone 515/223-1401. EDITO- RIAL CONTENT: The Society is unable to assume responsibility for the accuracy of that which is submitted. Medical items published in the New Products and Programs column are not necessarily endorsed by the editors or the Society. Manuscripts and editorial inquiries should be directed to Editor, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Copyright 1993 Iowa Medical Society.
THE IOWA MEDICAL SOCIETY ANNOUNCES
A NEW & IMPROVED GUARANTEED RENEWABLE DISABILITY INSURANCE PROGRAM
AVAILABLE FROM BERNIE LOWE & ASSOCIATES, INC IN LIAISON WITH IMS SERVICES
ENROLLMENT AVAILABLE NOW !!!
INCLUDES THESE FEATURES:
Rates have been reduced for the 60-day and 90-day waiting periods.
NEW $10,000 maximum monthly benefit available ($120,000 annually).
"Your Specialty" definition for full term of benefit period.
GUARANTEED RENEWABLE - Plan cannot be cancelled by insurer.
Plan has been continuously underwritten by the same carrier since 1955 - Commercial Life.
Benefits ARE NOW available for members between ages 55 - 59 ($3,000 monthly).
Residual /Proportionate Benefits are available optionally. - Rates have been reduced!
Presumptive Total Disability and Survivor Benefit have been added at NO ADDITIONAL COST.
Benefit waiting periods are available from 30 days, 90 days, 180 or 365 days - no "surcharge" for a lower benefit waiting period of 30 days.
Benefits may be purchased WITHOUT REGARD to any Group Long Term Disability which you may carry.
TO APPLY:
Please complete enclosed application form - SEND NO MONEY - WE WILL BILL YOU | AT THE TIME THE POLICY IS ISSUED.
If you would like further information before making application, please return the enclosed reply card j or contact Ruth Clare or Bemie Lowe at 1-515-222-0811 or toll free 1-800-942-4718. '
Administered by:
BERNIE LOWE & ASSOCIATES, INC.
Insurance Administrators to Professional Associations & Universities and Colleges 515-222-0811 1-800-942-4718 FAX 515-222-0915
2700 Westown Parkway, Suite 410 West Des Moines, lA 50266-1411
lowaMedicine
blume 83 Number 7 Journal of the Iowa Medical Society
July 1993
lEditorials
!45 President's Privilege
: Why should you belong to
the AMA? A partial listing.
147 The Editor Comments
Tobacco marketing strategy targets children.
554 IOWA MEDICINE Interview
The new IMS Alliance president discusses that organization's new name and new goals.
Departments
260 Letter to the Editor
;265 Practice and Personal Management
'266 The Art of Medicine
268 Biomedical Ethics
270 Classified Advertising
272 Physicians' Directory
About the Cover
The seven physicians on the cover are members of the 1993-94 Board of Trustees. Interesting information about these officers appears on pages 252 and 253.
Feature Articles
246A Official proceedings, IMS 1993 House of Delegates
248 Physicians must remain committed to beneficial reform
Health system reform is on the minds of the incoming and outgoing IMS presidents.
William Eversmann, Jr., M.D., John Anderson, M.D.
252 A personal look at IMS officers
Board members answer thought-provoking non-medical questions.
258 Annual Meeting snapshots
You might spot a familiar face.
Scientific Article
261 Clozapine shows promise In schizophrenia treatment
The first significant advance in treatment of schizophrenia.
Robert Smith, M.D.; Mary Sukowatey, R.N.; Kathy Solko, A.C.S.W.; Joan Christensen, A.C.S.W.; Juliann Saak, R.N.; Anne Burnham, M.S.W.
Editorial Board
IMS President
John R. Anderson, M.D.
Scientific Editor
Marion E. Alberts, M.D.
Executive Editor
Eldon E. Huston
Managing Editor
Tina Preftakes
Assistant Managing Editor
Christine McMahon-Clark
Production/Advertising Manager
jane I. Nieland
IOWA MEDICINE, lournal of the Iowa Medical Society (ISSN 0746-8709), is published monthly by the Iowa Medical Society. Subscription price: $20 per year. Second class postage paid at Des Moines, Iowa and at additional mailing offices. POSTMASTER: Send address changes to IOWA MEDICINE, lournal of the Iowa Medical Society, lOOI Grand Avenue, West Des Moines, Iowa 50265. NATIONAL ADVERTISING: State Medical lournal Advertising Bureau, Inc., 711 South Blvd., Oak Park, Illinois 60302. Phone 708/383-8800. IOWA ADVERTISING: lane Nieland, IOWA MEDICINE, lOOl Grand Avenue, West Des Moines, Iowa 50265. Phone 515/223-I401 . EDITO- RIAL CONTENT: The Society is unable to assume responsibility for the accuracy of that which is submitted. Medical items published in the New Products and Programs column are not necessarily endorsed by the editors or the Society. Manuscripts and editorial inquiries should be directed to Editor, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Copyright 199.1 Iowa Medical Society.
St. Luke’s Regional Heart Center
P R E S E N T S
C A R D 1 0 1 0 n
AT THE
B I X
A Symposium for Physicians
Friday, July 23, 1993 • Blackhav/k Hotel • Davenport, Iowa
Intended Audience:
Cardiologists, internists, and family practitioners who deal with cardiovascular disorders.
Symposium Description:
Cardiology '93 at the Bix is the third annual cardiovascular symposium of St. Luke’s Regional Heart Center. An outstanding national faculty has been assembled to present a concise update on the ever-changing field of cardiovascular medicine. Participants will acquire clinical insight into diagnostic and treatment modalities.
Morning Schedule
8;00- 8:20 Registration-Continental Breakfast
8:20- 8:35 Welcome - Symposium Overview - Dr. Giudici
8:35- 9:15 “Lipid Disorders” Dr. Connor
9:15- 9:55 “ Advances in the Treatment of Atrial Fibrillation/Flutter” Dr. Waldo
9:55-10:20 Break
Accreditation:
CME: St. Luke’s Hospital is accredited by the Iowa Medical Society to sponsor continuing medical education for physicians. St. Luke’s Hospital designates this CME offering meets the criteria for 6.5 hours in Category I of the AMA Physician’s Recognition Award.
10:20-1 1 :00 “Renal Implications and the Treatment of Essential Hypertension” Dr. Gratch
11:00-11:40 Panel
1 1:40-12:55 Lunch with the Speakers
AAEP: This program has been reviewed and is acceptable for 6.5 prescribed hours by the American Academy of Eamily Physicians.
Registration Information:
Registration Pee: $95 includes attendance at the symposium, two free tickets for the Priends of Bix’ Cocktail Party, 2 complimentary tickets for the Riverboat Gambling Cruise and 2 entries in the Bix 7 Road Race.
Registration Deadline: July 1, 1993. Confirmation and details about entertainment options will be sent upon registration. Please direct any concerns to Rebecca Gannon(319) 326-8115. Refund policy: A refund less a $25.00 processing fee if your request is postmarked by July 15, 1993.
Afternoon Schedule
12:55- 1:35 “Management of Ventricular Arrhythmias” Dr. Wilber
1:35- 2:15 “New Techniques in Interventional Cardiology” Dr. Pischman
2:15- 2:35 Break
2:35- 3:15 “Non-Invasive Cardiology Update” Dr. Miller
3:15- 3:55 Panel
St Luke's Hospital
St. Luke’s Regional Heart Center • 1 227 East Rusholme Street • Davenport, Iowa 52803
lowaMedicine
Volume 83 Number 8 Journal of the Iowa Medical Society
August 1993
Editorials
!81 President's Privilege
We're only in the first quarter of the health system reform ball game.
J83 The Editor Comments
Physicians must be (re)educated about tuberculosis, a disease which is on the increase.
289 IOWA MEDICINE Interview
Why do patients seek alternative treatments?
Departments
294 College of Medicine Highlights
'303 IFMC Case Notes
305 The Art of Medicine
'306 Physician Learner
'308 Classified Advertising
312 Physicians' Directory
Feature Article
284 Health hucksters continue preying on lowans
Health care con artists are selling ineffective and dangerous products to your patients.
Christine Clark
292 Unusual Case
An exhilarating and rewarding case involving a 90-year- old man.
Frederic Ashler, M.D.
Scientific Article
299 Developments in radiology: techniques new, refined and revisited
New diagnostic techniques for common clinical problems.
Niall Warnock, MB, ChB
About the Cover
"Storm Gathering at Four Peaks" was taken by David Ramsey, president of the Iowa Methodist Medical Center in Des Moines.
Editorial Board
IMS President
John R. Anderson, M.D.
Scientific Editor
Marion E. Alberts, M.D.
Executive Editor
Eldon E. Huston
Managing Editor
Tina Preftakes
Assistant Managing Editor
Christine McMahon-Clark
Production/Advertising Manager
lane I. Nieland
IOWA MEDICINE, Journal of the Iowa Medical Society (ISSN 0746-8709), is published monthly by the Iowa Medical Society. Subscription price: $20 per year. Second class postage paid at Des Moines, Iowa and at additional mailing offices. POSTMASTER: Send address changes to IOWA MEDICINE, journal of the Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265. NATIONAL ADVERTISING: State Medical journal Advertising Bureau, Inc., 11437 West 106th St., Overland Park, KS 66214, phone 91 3/888-8781 . IOWA ADVERTISING: jane Nieland, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Phone 515/223-1401. EDITORIAL CONTENT: The Society is unable to assume responsibility for the accuracy of that which is submitted. Medical items published in the New Products and Programs column are not necessarily endorsed by the editors or the Society. Manuscripts and editorial inquiries should be directed to Editor, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Copy- right 1993 Iowa Medical Society.
10TH ANNUAL
October 14-15, 1993
TOPICS WORKSHOPS
■ New insights into hypertension and diabetes
■ Mandated care guidelines: dementia and
incontinence
■ Pneumonia in Iowa
■ Curent approaches to the management of
migraine headache
■ Hereditaty angiodema
■ Management of BPH: the role of the primary
physician
■ What is a free radical?
■ Office approach to common anorectal diseases
■ Atrial fibrillation: current therapy
■ Spouse abuse: the M
■ Organ transplant: where we are, where we are
going
■ Therapeutics Update: Antibiotics *
■ The Female Genital (Pelvic) Exam
■ The Male Genital/Rectal Exam
:■ Common Thyroid Problems: Interactive Case I Presentations |
■ The Future of Medical Information Transferra:
SPECIAL EVENTS
Big 10 Football, Saturday, October 16: Iowa vs. ^ H- '
Illinois. Limited number of tickets available to |
course participants.'
REGISTRATION
For more information or to register, call 1
319/335-8596. VISA and Mastercard accepted. '
SPONSORED BY
The Department of Internal Medicine The University of Iowa College of Medicine Iowa City, Iowa
lowaMedicine
blume 83 Number 9 Journal of the Iowa Medical Society
September 1993
fditorials
21 President's Privilege
' A few thoughts on the
growth of IMS Services and the retirement of a key IMS staff member.
123 The Editor Comments
. lowans have what it takes to overcome adversity.
133 IOWA MEDICINE Interview
The future looks good for women physicians in Iowa.
Departments
}37 About IMS Members 345 Practice and Personal Management >346 Classified Advertising
352 Physicians' Directory
About the Cover
This month's timely photograph "Run River Run" was taken by Boone resident Steve O'Brien.
Feature Articles
324 After the flood: the dripping faucet syndrome
Psychological effects of the Great Flood of '93 may not become apparent for months after the crisis has passed.
Loren Olson, M.D.
331 Fond good-bye to key IMS staff member
After 29 years of service, executive staff member retires.
Scientific Article
339 Management of community-acquired pneumonia
Accurate diagnosis and effective treatment of this common infectious illness are discussed.
Matt Johnson, M.D.
Editorial Board
IMS President
John R. Anderson, M.D.
Scientific Editor Marion E. Alberts, M.D.
Executive Editor
Eldon E. Huston
Managing Editor
Tina Preftakes
Assistant Managing Editor
Christine McMahon-Clark
Production/Advertising Manager
lane I. Nieland
IOWA MEDICINE, Journal of the Iowa Medical Society (ISSN 0746-8709), is published monthly by the Iowa Medical Society. Subscription price: $20 per year. Second class postage paid at Des Moines, Iowa and at additional mailing offices. POSTMASTER: Send address changes to IOWA MEDICINE, journal of the Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265. NATIONAL ADVERTISING: State Medical Journal Advertising Bureau, Inc., 11437 West 106th St., Overland Park, KS 66214, phone 913/888-8781. IOWA ADVERTISING: Jane Nieland, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Phone 515/223-1401. EDITORIAL CONTENT: The Society is unable to assume responsibility for the accuracy of that which is submitted. Medical items published in the New Products and Programs column are not necessarily endorsed by the editors or the Society. Manuscripts and editorial inquiries should be directed to Editor, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Copy- right 1993 Iowa Medical Society.
Before You Buy A Diamond
Consider Quality
♦
Consider Integrity
♦
Consider The
Jeweler’s History
♦
Consider Real Value
For more than a century, Josephs has maintained a flawless reputation for superior quality, outstanding selection and honest value in diamonds. Before you buy a diamond, you owe it to yourself to visit us.
Without
QUESTION!
MEMBER
DIAMOND DEALERS CLUB, II NEW YORK CITY
iAJoc|Ji lo
Family Owned Since 1871
SIXTH AT LOCUST MERLE HAY MALL
VALLEY WEST MALL
lowaMedicine
Volume 83 Number 10 Journal of the Iowa Medical Society
October 1993
Editorials
361 President's Privilege
The world of medical practice is about to be turned upside down.
363 The Editor Comments
Faith is an inherent part of the practice of medicine.
370 IOWA MEDICINE Interview The Iowa High School Athletic Association has developed new ways to promote healthy lifestyle habits in athletes.
Feature Articles
364 Shared decision-making tested in Iowa
A new interactive video program allows patients to participate in treatment decisions.
Cindy Hockart, R.N.
367 New, improved 'Care for Kids'
The Early Periodic Screening, Diagnosis and Treatment program has been made more user-friendly for Iowa physicians.
Alfred Healy, M.D., Charles Danielson, M.D.
Departments
372 Letter to the Editor
379 I EMC Case Notes
381 Physician Learner
382 Biomedical Ethics
384 Classified Advertising
388 Physicians' Directory
Scientific Article
375 Iowa wrestlers continue detrimental weight loss practices
Are dehydration and semi-starvation an ingrained part of high school wrestlingf
Megan Woodworth, M.Ed., Michael Sitler, Ed.D.
About the Cover
Dr. James Collins, a Waterloo pathologist, took this photo of Interlaken, Switzerland during a cruise down the Rhine last year.
Editorial Board
IMS President
John R. Anderson, M.D.
Scientific Editor Marion E. Alberts, M.D.
Executive Editor
Eldon E. Huston
Managing Editor
Tina Preftakes
Assistant Managing Editor
Christine McMahon-Clark
Production/Advertising Manager
Jane I. Nieland
iOWA MEDICINE, Journal of the Iowa Medical Society (ISSN 0746-8709), is published monthly by the Iowa Medical Society. Subscription price; $20 per year. Second class postage paid at Des Moines, Iowa and at additional mailing offices. POSTMASTER: Send address changes to IOWA MEDICINE, Journal of the Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265. NATIONAL ADVERTISING: State Medical journal Advertising Bureau, Inc., 1 1437 West 106th St., Overland Park, KS 66214, phone 913/888-8781. IOWA ADVERTISING: lane Nieland, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Phone 515/223-1401. EDITORIAL CONTENT: The Society is unable to assume responsibility for the accuracy of that which is submitted. Medical items published in the New Products and Programs column are not necessarily endorsed by the editors or the Society. Manuscripts and editorial inquiries should be directed to Editor, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Copy- right 1993 Iowa Medical Society.
MMIC & IPMIT
FOR IOWA PHYSICIANS
Yes, MMIC and IPMIT have COME TOGETHpR!!!
COME TOGETHER ... to give Iowa physicians even stronger professional liability insurance protection.
Midwest Medical Insurance Company (MMIC) is operating in Iowa as the only liability insurance com- pany owned by its physician policyholders and endorsed by the Iowa Medical Society.
The 1993 merger of MMIC andf IPMIT means that over 5,000 physician policyholders are protected by a company with $200 million in assets — with an A (Excellent) rating from A.M. Best.
With sponsorship of MMIC, the Iowa Medical Society has supplied its member physicians a stable liabili- ty insurance option for 17 years. What’s more, the new Iowa MMIC coverage contains policy features equal and superior to ones from IPMIT.
And, importantly, MMIC offers competitive rates.
MMIC and IMS SERVICES are eager to supply Iowa physicians with specific coverage information. Please contact their offices at IMS headquarters, 1001 Grand Avenue, West Des Moines, Iowa 50265; Telephone (515) 223-2816 or 800/728-5398.
MIDWEST MEDICAL INSURANCE COMPANY 1001 Grand Avenue • West Des Moines, Iowa 50265
lowaMedicine
Volume 83 Number 7 7 Journal of the Iowa Medical Society November 1 993
Editorials
597 President's Privilege
This former member of the BME has a special insight into BME operations.
399 The Editor Comments
Violence among children is a growing and frightening trend.
405 IOWA MEDICINE Interview
The new director of the BME discusses the Board's goals and philosophy.
Departments
1 408 Letters to the Editor
417 The Art of Medicine
418 Practice and Personal Management
420 Classified Advertising
424 Physicians' Directory
About the Cover
Dr. Everett Nitzke, a Des Moines pediatrician, took this photograph in Big Bend National Park in southwest Texas.
Feature Articles
400 Andy and David ... A personal look at two special needs' children
Parents of children with cerebral palsy and Fragile X syndrome discuss their childrens' special needs.
Christine Clark
409 First freestanding hospice inpatient unit established in Iowa
Enhancing the continuity and quality of care for hospice patients.
Ann MacGregor
Scientific Article
41 3 lowans with intestinal bypass — a status report
Are you following up on patients who underwent intestinal bypass for morbid obesity?
Joseph Cullen, M.D.; Edward Mason, M.D., Ph.D.; Themis Economou, M.D.; David Scott; Cornelius Doherty, M.D.; James Maher, M.D.
Editorial Board
IMS President
John R. Anderson, M.D.
Scientific Editor Marion E. Alberts, M.D.
Executive Editor Eldon E. Huston
Managing Editor
Christine McMahon-Clark
Production/Advertising Manager
Jane I. Nieland
IOWA MEDICINE, Journal of the Iowa Medical Society (ISSN 0746-8709), is published monthly by the Iowa Medical Society. Subscription price: $20 per year. Second class postage paid at Des Moines, Iowa and at additional mailing offices. POSTMASTER: Send address changes to IOWA MEDICINE, journal of the Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265. NATIONAL ADVERTISING: State Medical Journal Advertising Bureau, Inc., 1 1 437 West 106th St., Overland Park, KS 66214, phone 913/888-8781. IOWA ADVERTISING: Jane Nieland, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Phone 515/223-1401. EDITORIAL CONTENT: The Society is unable to assume responsibility for the accuracy of that which is submitted. Medical items published in the New Products and Programs column are not necessarily endorsed by the editors or the Society. Manuscripts and editorial inquiries should be directed to Editor, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Copy- right 1993 Iowa Medical Society.
MMIC & IPMIT
FOR IOWA PHYSICIANS
Yes, MMIC and IPMIT have COME TOGETHER!!!
COME TOGETHER ... to give Iowa physi- cians even stronger professional liability insurance protection.
Midwest Medical Insurance Company (MMIC) is operating in Iowa as the only liability insurance company owned by its physician policyholders and endorsed by the Iowa Medical Society.
The 1993 merger of MMIC and IPMIT means that over 5,000 physician policyholders are protected by a company with $200 million in assets — with an A (Excellent) rating from A.M. Best.
With sponsorship of MMIC, the Iowa Medical Society has supplied its member physicians a stable liability insurance option for 17 years. What’s more, the new Iowa MMIC coverage contains policy features equal and superior to ones from IPMIT.
And, importantly, MMIC offers competitive rates.
MMIC and IMS SERVICES are eager to supply Iowa physicians with specific coverage information. Please contact their offices at IMS headquarters, 1001 Grand Avenue, West Des Moines, Iowa 50265; Phones (515) 223-2816 • 800/728-5398.
MIDWEST MEDICAL INSURANCE COMPANY 1001 Grand Avenue • West Des Moines, Iowa 50265
lowaMedicine
Volume 83 Number 12 Journal of the Iowa Medical Society December 1993
Editorials
133 President's Privilege
Stay informed, stay involved and stay united.
135 The Editor Comments
Years of schooling do not necessarily mean a person is educated.
Departments
451 Physician Learner 453 Index to Volume LXXXIII 456 Classified Advertising
460 Physicians' Directory
Feature Article
437 Legislature will address health system reform in 1994
A discussion of IMS priorities in the upcoming state legislative session.
Kevin Cunningham, M.D.
Scientific Article
447 Food allergies: how common are they?
Food allergies exist, but may not be as common as many people believe.
james Wille, M.D.
About the Cover
In keeping with this month's legislative theme, the cover photo is of Independence Hall in Philadelphia. Photo by Christine Clark, managing editor.
Editorial Board
IMS President
John R. Anderson, M.D.
Scientific Editor
Marion E. Alberts, M.D.
Executive Editor
Eldon E. Huston
Managing Editor
Christine McMahon-Clark
Production/Advertising Manager
lane I. Nieland
IOWA MEDICINE, lournal of the Iowa Medical Society (ISSN 0746-8709), is published monthly by the Iowa Medical Society. Subscription price: $20 per year. Second class postage paid at Des Moines, Iowa and at additional mailing offices. POSTMASTER: Send address changes to IOWA MEDICINE, Journal of the Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265. NATIONAL ADVERTISING: State Medical lournal Advertising Bureau, Inc., 11437 West 106th St., Overland Park, KS 66214, phone 9 1 3/888-8781 . IOWA ADVERTISING: jane Nieland, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Phone 515/223-1401. EDITORIAL CONTENT: The Society is unable to assume responsibility for the accuracy of that which is submitted. Medical items published in the New Products and Programs column are not necessarily endorsed by the editors or the Society. Manuscripts and editorial inquiries should be directed to Editor, IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265. Copy- right 1993 Iowa Medical Society.
THE HEART INSTITUTE
James R. Morgan, M.Q and
Joel B. Heilman, M.Q Have Joined The Heart Institute
T
James R. Morgan, M.D., and Joel B. Heilman, M.D., are pleased to announce their association with The Heart Institute® Working with other medical professionals, they provide a full range of cardiovascular services — from diagnostics, invasive and noninvasive treatments to a comprehensive cardiac rehabilitation program. And, The Heart Institute offers innovative health education and preventive care to help reduce the incidence of heart disease.
In addition to Drs. Morgan and Heilman, the cardiology team includes —
Richard E. Collins, M.D., Michael M. Dehning, M.D., Steven j. Diamantis, M.D.,
S. George Sojka, M.D., Mark D. Chouinard, M.D., David A. Sterns, M.D., and Sherrill K. Murphv. M.D.
If you would like to s The Heart Institute re 402/572-3300 or Toll
TT
T H E
HEART
INSTITUTE
Immanuel Medical Center
6901 North 72nd Street Omaha, Nebraska 681 22-1 799
Toll Free 1-800/535-0397 or 402/572-3300
President's Privilege
William Eversmann, Jr., M.D.
Roundtable discussion
The arena of health care reform has convened a heterogeneous group of in- surance executives, businessmen, hospital administrators, physicians, public policy administrators and other interest groups.
Through the Iowa Leadership Consor- tium (ILC) these diverse groups agreed that health care reform should be based on the premise that the uninsured and underinsured should have access to care, that the quality of health care should be preserved and that the rising cost of delivering health care should be controlled. The principles of maintenance of quality, increase in access and control of cost were established and the discussion of meth- ods to achieve these goals began.
For the past two years, the discussions have continued. Presently it appears to this participant-observer that quality is desirable and preservable particularly when associated with cost reduction. If a dramatic increase in
quality could be achieved with increased cost, a detailed statistical justification, re- search projects, data collections and practice parameters would be required to assure that the increased quality was desirable.
In a more recent unofficial discussion among ILC members, the question was raised "why does business have to pay for the unin- sured?" Fortunately the medical profession has continued, as we should, to treat the unin- sured, usually without compensation and without the benefit of cost shifting. However, it appears that not everyone at the table of discussion is so dedicated.
The principles of health care reform for the medical profession have not changed from access, quality and cost to cost, cost, cost.
The brighter side of health care reform is that Iowa physicians continue to participate at the table of discussion and have as yet not been the main course.
January 1993
5
1
9
9
3
5TH ANNUAL CEDAR RAPIDS
SYMPOSIUM
FOR THE PRACTICING PRIMARY CARE PHYSICIAN
February 26, 1993 COLLINS PLAZA HOTEL
Keynote Speakers CEDAR RAPIDS, IOWA Keynote Speakers
Greg C. Flaker, M.D. Michael D. Winniford, M.D.
Ronald M. Lauer Robert L. Replogle
Course Objectives and Intended Audience
This course is designed to provide family practitioners, internists, other primary care physicians and nurses with practical approaches to common cardiovascular disorders. The course will emphasize diagnostic svaluation, treatment modalities and day-to-day management of these disorders from the perspective Df the primary care physician.
Accreditation
Credit hours have been applied for through the ollowing organizations:
American Academy of Family Physicians American Osteopathic Association CME’s by Cedar Rapids Medical Education Program CEU’s by Mercy Medical Center
Registration Fees:
=*hysicians $50.00
\lurses and Residents $25.00
includes course materials, breakfast, lunch and
efreshments)
Registration Deadline is February 18, 1993.
Registration is limited. For registration information, )lease contact June Zenisek, R.N., Symposium :oordinator, 319-362-5118 or 1-800-728-5118.
Agenda
8:30 Registration
9:00 Opening Remarks— Dr. Ersin Atay 9:15 Atrial Fibrillation: New Ideas on an Old Arrhythmii Dr. Greg Flaker
10:00 Interventional Cardiology in the 90’s—
Dr. Michael Winniford 10:45 Break
1 1 :00 Healthcare in the 90’s: Cost versus Technology- Dr. Robert L. Replogle 1 1 :45 Ouestion Session 12:15 Lunch
1:15 The Significance of Cholesterol in Childhood- Dr. Ronald M. Lauer 2:00 Break
Concurrent Workshops
2:15 —Mitral Valve Prolapse— Dr. Todd Langager
—Peripheral Vascular Disease— Dr. Kevin Kope —Rehabilitation of the Cardiac Patient- Dr. David Rater
3:00 Break
3:15 — Echocardiograms in Congenital Heart Diseasf
Dr. Stephen Roth
— Innocent Heart Murmurs — Dr. Ronald Lauer —Medical Case Studies— Dr. Richard Fleming
4:00 Evaluations
The Editor Comments
Marion E. Alberts, M.D.
Children aren't second-class citizens
Most accounts we read about long- term care of ill and disabled persons fo- cus on the adults. But, what of the many chil- dren who require long-term care, oftimes for their entire life span? Children are not sec- ond-class citizens. Most communities do not have long-term care facilities for children. Certainly, the existing long-term care facili- ties designed for adults are hardly the envi- ronment for the care of children.
True, many children with long-term disa- bilities can be cared for in their home, but there is a limit to the services and equipment adaptable to home use. The developing chil- dren require an approach to their disabilities which is different than that for an adult. The entire setting must be appropriate for the mind-set of the child. Education beyond the adaptations necessary for the disability are re- quired, for the child must continue to receive basic education within individual capabilities.
Psychological impacts upon the disabled child are different than that of the adult. The adult may be greatly concerned with self- help, as well as concerns for family members and the implications of employment. The child may not have these concerns, but cer- tainly has concerns about self-worth, future abilities, further education and peer relation- ships. Specialized equipment must be adapt- able to the child's size. The provisions of care must be in the hands of persons trained to
deal with children rather than being adult ori- ented. In addition, the family of the disabled child must develop an understanding of the total picture and be taught to deal with it.
Long-term care for an adult may be mea- sured in months to a few years in many in- stances. For children the time span may be ex- tended . . . from infancy to adulthood. The needs for specialized facilities and the eco- nomics are of no small concern. Herein arises the spector of the source of funds for such care . . . private insurance as well as govern- mental assistance.
Often, governmental assistance is based on care within a hospital setting; the assis- tance ceasing when the child is cared for in the home. Several landmark cases have been reported where presidential intervention has circumvented bureaucratic guidelines and seemingly non-compromising edicts. More concern must be given by the lawmakers to such problems.
To reiterate: children are not second-class citizens. They frequently require long-term care. Provisions through private as well as governmental agencies must provide for these unfortunate children. Let us not be blinded by the well-meaning groups who have the interests of adults foremost in their plans. Give the children an equal opportunity to have a life that has quality, love, compas- sion and concern from all quarters.
January 1993
7
We’ve been defending doctors since these were the state of the art.
i
These instruments were the best available at the turn of the century. So was our professional liability coverage for doctors. In fact, we pioneered the concept of professional protection in 1899 and have been providing this important service exclusively to doctors ever since.
You can be sure we’ll always offer the most complete professional liability coverage you can carry. Plus the personal attention and claims prevention assistance you deserve. For more information about Medical Protective coverage, contact your Medical Protective Company general agent.
Gerry Smeader
Suite 512, Merle Hay Tower, 3800 Merle Hay Road, P.O. Box 94127, Des Moines, lA 50394, (515) 276-6202
Caring for the elderly: a crisis on the horizon
As baby boomers age, the proportion of elderly people will increase. Growing numbers of senior citizens coupled with shrinking budgets may force society to find mernatives to nursing homes, predicts a Des Moines geriatrician.
Yesterday, a woman who was my neighbor brought an 86-year-old man to my office. She said she was his 'good friend' of many years. Maybe she was his girlfriend once, long ago. He was very confused and she had been trying to help him . . . fixing his meals, even calling him when it was time to take his medication. Elderly people deteriorate so gradually that not even their fami- lies realize how much the neighbor is doing. No one realizes until the neighbor — like this lady — gets what we call 'caretaker fatigue.' That's when they show up in my office.
— Roy Overton, II, M.D.
UNLESS ALTERNATIVES TO nursing homes are developed, we will face a bur- geoning crisis in long-term care as baby boomers age, predicts Des Moines geriatri- cian Dr. Roy Overton, II.
Dr. Overton, who has a thriving geriat- rics practice, says there is already a shortage of physicians in his specialty. The situation is bound to get worse as the percentage of el- derly people grows and the Medicaid budget shrinks.
"Consider the person who has saved all their life for their old age. They go into a
Dr. Overton is vice president of the Iowa Association of Long-Term Care Facility Medical Directors.
nursing home as a private pay patient and their money lasts an average of 13 weeks. Even the cheaper nursing homes are $55 a day," relates Dr. Overton.
So what will be the solution to this grow- ing problem in the future?
"Before too long, 15-20% of our popula- tion will be geriatric. We're going to have to face the fact that more people will be staying in their homes instead of going into long- term care facilities," he says.
More physicians need more education on caring for elderly people. Dr. Overton be- lieves.
"Geriatric medicine is different, and we need more CME programs in geriatrics. There's a difference between normal aging and pathological aging," he explains. "Some people aren't just old, they're sick. Their symptoms aren't a part of the aging process."
When a physician is faced with a patient such as the one Dr. Overton described in the opening scenario, it is vitally important to do a complete geriatric evaluation before de- termining what should be done.
"Often, these situations may seem to be an emergency, but actually the problem devel- oped very gradually. Usually, caretaker fa- tigue is the reason the patient is brought to the doctor."
January 1993
9
(Continued next page)
To make a determination about what should be done. Dr. Overton does a “mini- mental health status" test which shows if the patient can tell time, if they know where they are and if they can reason. He checks for bruises and scrapes and he asks about the pa- tient's lifestyle. He also tries to find out what family members are willing to do.
'Sometimes, the only way to find out about their lifestyle is to make a house call. It doesn't hurt a physician to do that'
“We can keep lots of people in their homes if the families are willing to help out.
I have one elderly lady who has about 20 rel- atives who all take turns going to her house," he relates. “The most important things a doc- tor can do are to ask questions and observe.
If a patient says 'I don't feel good,' it may re- ally mean 'Help me,' “ he comments.
The amount of money a patient has also can help physicians make a decision on ap- propriate caretakers.
“There are services available to patients who can pay, such as temporary total care for elderly people whose family members are out of town," Dr. Overton relates. “The Medic Alert system has allowed a tremen- dous number of people to stay in their homes, but there is an extensive waiting list."
Despite complete geriatric evaluations, deciding whether a patient can remain at home is “almost always a judgment call," Dr. Overton admits. Patients with progressive dis- ease, patients who wander, patients who have no family and patients who carmot take medications correctly are obvious candidates for intermediate care facilities, he explains. However, he says urinary or fecal inconti- nence are common reasons why elderly peo- ple are sent to nursing homes.
“Elderly people who are endangering themselves must go to a care facility," he says. “Sometimes, the only way to find out about their lifestyle is to make a house call. It doesn't hurt a physician to do that."
New OBRA regulations requiring physi- cians to visit patients more often in intermedi- ate care facilities have been “harder on physi- cians here because Iowa has a high
percentage of these facilities," Dr. Overton says.
“Of course, some of these regulations came about because some doctors didn't do their jobs," he comments. “Now, because of restrictive regulations physicians are losing the opportunity to individualize for their pa- tients."
Contrary to popular belief, the nursing home situation is “not just an urban prob- lem," Dr. Overton insists.
“Older people from small towns follow their children to the nursing home in the city. Consequently, many of the elderly people in facilities in Des Moines are actually from ru- ral Iowa. Sometimes those elderly people would be better off if they stayed in the small towns where their friends are. Of course, I have some patients who have out- lived everyone — their children, most of their family and all their friends. I'm their only vis- itor."
There are many services available to help elderly people, relates Dr. Overton. He ad- vises physicians to contact their county nurse or the social worker in their local hospital for
'Geriatric medicine is different, and we need more CME pro- grams in geriatrics. There's a dif- ference between normal aging and pathological aging.'
information about services they may not be aware of. Physicians with elderly patients should also watch their local paper for no- tices about free clinics and medical services available to senior citizens.
There is a growing realization, says Dr. Overton, that it is financially and psychologi- cally undesirable to put so many people in nursing homes. He believes families will have to assume more responsibility in the care of aging relatives and that more pro- grams will focus on using Medicaid money to keep people in their homes rather than in a care facility. (See sidebar story.)
“The goal is for these patients to be as autonomous as possible, making their own decisions, mobile and free from pain," he con- cludes.
Iowa Medicine
10
New Medicaid program promotes caring for elderly at home
Anew state program offers a welcome al- ternative to nursing homes by promot- ing caring for elderly people in their homes. Under a waiver granted by the Health Care Financing Administration, the “Medicaid Home and Community Based Services Waiver Program for the Elderly" is available in the following counties: Cerro Gordo, Deca- tur, Fayette, Keokuk, Linn, Ringgold, Scott, Black Hawk, Howard, Dubuque, Johnson, Hamilton, Polk and Muscatine. Under the program, Medicaid will pay for selected home based services, including:
• Adult day services — Services provided in day care setting for elderly persons who need supervision and assistance.
• Emergency response systems — An elec- tronic monitoring system placed in the home of an elderly person which will alert medical personnel in case of an emergency.
• Home health services — Personal assis- tance and home health services not normally covered under a state Medicaid program, in- cluding assistance with bathing, dressing and a variety of other daily activities.
• Respite care service — Temporary care provided in a facility or the client's home to provide relief for the care giver.
• Nursing care services — Services pro- vided by licensed agency nurses to clients in the home. Nursing care services must be rea- sonable and necessary to the treatment of an illness or injury and included in a plan of treatment established by a physician.
• Homemaker services — Assistance with cleaning, meal preparation, shopping and other duties the client is unable to do for themselves.
To be eligible for the waiver program, the person must be 65 years old or older, a resident of one of the 15 counties already listed and eligible for Medicaid or meet eligi- bility guidelines for a person in a medical in- stitution (income, resources).
Other criteria include:
• The person must be certified as being in need of care in an intermediate care facil- ity or a skilled nursing facility, and must cur- rently reside outside of a medical institution or nursing facility.
• The person must receive case manage- ment services from the Case Management Project for the Frail Elderly (CMPFE).
• The total monthly cost of the elderly waiver services cannot exceed the cost of the recipient's care if it were provided by a skilled nursing facility or an intermediate care facility.
The program is limited to 200 persons at any one time; currently there are fewer than 30 participants.
If physicians in the listed counties are aware of someone who might be eligible for the program, the person may apply at the lo- cal Department of Human Services Office or the Case Management Program for the Frail and Elderly of the local Area Agency on Aging. The application process takes aproxi- mately one month for someone who is eligi- ble for Medicaid. The approval process is longer for those who must prove Medicaid el- igibility. Financial participation by the client may be necessary based upon ability to pay.
Physicians with questions about the pro- gram should call Mary Cogley in the Divi- sion of Medical Services of the Iowa Depart- ment of Human Services at 515/281-3002.
Is your marriage on the rocks?
Getting an alcoholic to admit he has a problem is the second step of treatment The first step is getting him into treatment
For 18 years, Mercy's Addictions Recovery Center - MARC - has provided successful and confidential treatment; helping many alcoholics and their families conquer alcoholism
Get in touch with the hospital that's in touch Mercy Hospital. 319-383-2799.
Mercy Hospital
In Touch.
1401 West Central Park • Davenport, Iowa
January 1993
11
Here’s the Complete Pension Package You Can Establish with Complete Confidence
Centurys Qualified Pension Program
As a professional, you are probably aware of how attractive a qualified pension plan can be to your organization. But you may have heard they are very complicated, full of red tape and too rigid.
That’s why you’ll appreciate the complete and flexible package from Century Pension Services, specialists in Tax-qualified Employee Benefit Plans for small to mid-size companies. With our turn-key approach to pensions, you will
never regret establishing one.
For more information on the complete pension package, call today.
Robert J. Grieser, LUTCF
Representative
3737 Westown Parkway, Suite E West Des Moines. lA 50265 (515) 224-0073
.lames E. Pede, Jr., CEP
Representative
3737 Westown Parkway. Suite E West Des Moines, lA 50265 (515) 224-0073
Stephen D. Roe
Pension Consultant 3737 Westown Parkway, Suite E West Des Moines. lA 50265 (515) 224-0073
Michael E. Diers, CEP, LUTCF
Representative 930 South Gilbert Street Iowa City, lA 52240 (319) 351-5388
Century Pension Services is a division of Century Life of America, Waverly, Iowa.
5 - PIA - 91
Advice to transplant patients? Ask questions
Organ transplantation has meant a miraculous prolongation of life for many lowans. However, this young man's story — sent unsol icitea to the editors of iowa medicine— illustrates what happens when a patient has unrealistic expectations of what life will be like after a transplant.
Brad Lofton
Bloomfield, Iowa
IN 1987 I RECEIVED A double transplant, a kid- ney and a pancreas. Technically, Tm doing fine. However, if I could turn back the clock I would not go through it again.
Unlike many other transplant patients, my problems didn't appear within a rela- tively short period of time. I had lived with diabetes since my early teens; when I reached my twenties many other things attributed to diabetes started going wrong.
First, poor circulation left my feet cold and numb. Then nerve deterioration caused me to lose normal feeling in my feet. Several times I injured my feet and, because I didn't feel pain, my injuries went unnoticed until in- fection set in. Next, I developed diabetic reti- nopathy, a disease which causes new veins to form in the eye. Because these veins are poorly formed, they can burst and cause blindness. As these things occurred my body weakened and my ability to work suffered. Each time I experienced a problem I was forced to take a lesser job at less pay.
As 1 reached 30, I couldn't walk more than a few yards and sometimes required a cane. My kidneys quit and I had to be put on dialysis, two and then three times weekly. That was an experience I will never go through again. I weighed 132 pounds after the excess fluids were removed from my sys-
tem. Each day I required two naps, each two hours long, besides a normal nights' sleep.
I had been interested in a pancreas trans- plant for some time but they were still experi- mental. After my kidneys failed, the possibil- ity of a transplant became greater as a body is more accepting of foreign organs when it is twice weakened. I underwent numerous tests for tissue typing and to see if my heart could take the strain of being on the operating table the necessary number of hours. My parents had helped me pay my health insurance all the years of my illness, so the pancreas trans- plant was covered. However, it had to be ap- plied for and approved in advance then reap- plied for every six months. The kidney transplant was covered by the Iowa Kidney Foundation.
In mid-1987 I was called early one morn- ing and told to come to the U. of I. Hospital immediately. I spent the next 10 weeks there being poked and filled with drugs. Conse- quently I'm somewhat nervous about any- thing more involved than a simple blood test.
I was released after I refused any new treatments. I figured if I wasn't well enough by then, 1 would never be. At my release, I was taking over 30 pills daily. I had to make repeated trips to Iowa City to make sure the organs were functioning properly. These things — plus the fact I wasn't getting back the strength I'd expected — led to a depres- sion that lasted almost two years. I slept odd (Continued next page)
January 1993
13
hours, ate little and tried to avoid taking my medications. This made me feel even worse because I wasn't strong enough physically or mentally not to take them.
Although everything now works and I have some strength back, 1 still need to nap, even after doing very little. I take 27 pills a day, many of which have side effects. Suscep- tibility to skin cancer, cataracts, short term memory loss, weight gain and puffiness in
'This type of thing changes your whole perspective on life. I hate when people say "At least you're alive." There is more to life than just being. '
the face are a few. 1 look like a cross between Charlie Brown and Homer Simpson.
These medicines cost over $600 a month. As of 1992 my private insurance costs over $275 per month, which I need should my medical benefits be canceled or cut. 1 receive assistance for these expenses and for housing. Basically Tm kept by taxpayers money, which more taxpayers are tired of providing.
The deterioration my body suffered be- fore has not halted, but merely slowed. For example, the recent collapse of a bone in my foot requires me to wear special shoes and supports to prevent further problems. Ev- erytime something seems unusual I call the doctors. I'm so afraid that something minor will become major and mean more drugs, tests and time in the hospital that I feel like a hypochondriac. I think I am merely dying a bit slower now. Maybe the way I was dying before would have been more merciful be- cause I would not have had such false hopes about returning to a normal life. I thought after the transplant I would be able to return and contribute to society.
This type of thing changes your whole perspective on life. I hate when people say "At least you're alive." There is more to life than just being. I find myself more under- standing of people who take their own life when they suffer serious medical problems.
On the other hand when I see a healthy person, especially a child who really seems to enjoy life, it does more for me than all the medicine they could give me. Children are
the biggest reason I go on because I hope they may benefit from my medical tribula- tions.
I don't want people to exclude the possi- bility of a transplant. In the years since mine new developments have arisen. But, patients must ask questions so as not to be disap- pointed. They should ask about the opera- tion, how they will have to change their life- style, what kind of help they may need (physically, financially, mentally), how it will effect other medical problems they may have and what kind of recovery they will experi- ence.
I've met several transplant patients and not many have the problems I have had. In- deed I am stronger than before my trans- plant, and I manage to take care of myself and do a little volunteer work. I also greatly enjoy being around children. But, I think peo- ple need to know they may not return to a normal way of life. They shouldn't get their hopes up too high as to the fullness of their recovery following a transplant.
Things are never as perfect as we might wish.
Northern Minnesota
Family Practice partnership opportunity in an 8 physician clinic Cloquet, Minnesota (pop. 14,000)
Cloquet offers:
• Spectacular natural beauty
• Excellent public schools, low teacher to student ratio
• Local community college, 2 universities and a 4-year private college within 20 miles
• Low, low crime rate
■ Affordable lakeside living
• Year round outdoor recreation
• Stable economy
What the Raiter Clinic offers:
• Financial strength (founded 1930)
■ Next to community hospital
• First year salary guaranty
• Generous and comprehensive benefit package
• Bonuses and incentives •Yearly CME
■ Manageable call schedule
• On site radiology, lab and pharmacy
• Eligibility for partnership after 2 years
Send CV in strictest confidence to:
John J. Turonie, Administrator The Raiter Clinic, Ltd.
417 Skyline Boulevard Cloquet, Minnesota 55720
equal opportunity employer
Iowa Medicine
14
I C A L
OFFICE
SOFTWARE
The Key To Information Is Access...
Practice Partner™ Patient Records Qives You Access
Designed by a physician, Patient Records software provides quick access to, and instant updating of your patient charts.
Quickly retrieve progress notes.
Pinpoint patient medications, allergies, lab data, vital signs, health maintenance and much more. Improve quality of care.
Enter data quickly and efficiently.
No computer expertise required. Runs on IBM PC'AT, PS/2 and compatibles. Ready for multi-user networking.
Other PRACTICE PARTNER Software:
Appointment Scheduler, Medical Billing, Medical Writer.
IOWA MEDICINE Interview
Logic
Paul Romans
and consistency needed in long-term care
Society faces some difficult decisions about long-term care, says the author, executive vice president of the Iowa Health Care Association.
What is the Iowa Health Care Association? What is the organization's primary goal?
The Iowa Health Care Association is a trade association representing Iowa long-term facili- ties. Our membership consists of 300 licensed profit and not-for-profit facilities, represent- ing over 22,000 long-term health care beds. The Iowa Health Care Association provides resources and education to help our members comply with laws and regulations and achieve the highest possible level of physical, mental and psychosocial well-being for facil- ity residents.
Iowa receives less federal money than other states for long-term care because we have a high percentage of intermediate facilities
rather than skilled nursing facilities. Why has this situation continued and what can be done to alter it?
It's true Iowa used to have a higher percent- age of intermediate care facilities compared to most other states. Today, however, we no longer have intermediate care facilities in Iowa or nationwide. OBRA 1987 mandated all intermediate care facilities upgrade their services to skilled care as of October, 1990.
All facilities that used to be called intermedi- ate care facilities are now called "nursing facilities."
The distinction between intermediate care facilities and skilled nursing facilities is primarily one of care philosophy. Generally, intermediate care facilities use a less expen-
lowa Medicine
16
sive “hospitality” model of care. The hospital- ity model focuses on “high touch" rather than “high tech." Skilled nursing facilities use a sub-acute care model, which requires more staff and specialized medical therapies.
Because we were primarily a state of in- termediate care facilities, which required less state spending, Iowa also received less fed- eral matching money than other states.
Along with mandating skilled care, the federal government charged the state with de- vising a reimbursement methodology to pay for it. Ultimately, the state decided to con- tinue its current system, which places a cap on total reimbursement to a facility.
Unfortunately, this system is unrespon- sive to actual costs, creates a disincentive for facilities to take “heavy care" Medicaid pa- tients and results in a low reimbursement rate to Iowa's nursing homes.
In order to correct this problem, the state should consider changing its reimbursement methodology to take into consideration the costs of the skilled care model, including pay- ing for specialized ancillary services.
How have OSHA and other government regu- lations affected Iowa's nursing homes?
OSHA recently began requiring long-term care facilities to offer all employees hepatitis vaccines at no charge and to implement occu- pational exposure plans. This was mandated in spite of the fact that infection by blood- borne contact is exceedingly rare in long-term facilities.
The OSHA regulation is a prime exam- ple of how the federal government often man- dates regulations without regard to cost or need. (The estimated cost to implement the OSHA rules is somewhere between $7,000- $15,000 per facility.)
The Iowa Health Care Association recog- nizes that our industry needs to be held ac- countable. However, we need to return some common sense into the law and rule-making process to better utilize limited resources.
Also, we must cut through the bureau- cracy barriers if we want to retain our profes- sional health care workers. The current regu- latory environment does not allow long-term care workers to use their professional judge- ment as they were trained and educated. Many of the industry's best and brightest, feeling stifled, are leaving long-term care work.
What is the biggest challenge facing Iowa's long-term care facilities in the future?
Our nation faces a quandary about our health care policy. We have used a reactionary ap- proach to setting policy for far too long.
Our population is aging. As a nation, we cannot afford to wait until the baby boomers need long-term care to develop a logical sys- tem and a consistent policy.
To determine what we want out of long- term care, as well as from health care in gen- eral, we must unify with the medical profes- sion, other health care providers, lawmakers and the public to begin making difficult ethi- cal choices.
In long-term care, if we desire the skilled model with emphasis on technological ser- vices and rehabilitation, we need to make our reimbursement system responsive to the cost demands. If we seek a return to the hospital- ity model, our regulatory environment must change to allow providers to work with the patients and family members toward this end.
No matter what we decide, we must achieve some consensus on what we want and what we can afford.
THE
B^WorRs.
Iowa’s Boating Superstore
Shop Now for
SPECTACULAR ’93 Boat Show Prices
VIP SPECTRUM MARIAH RINKER
CENTRAL IOWA’S LARGEST THE BOATWORKS
Open 7 days a week
515/288-6311 • 5795 N.W. 2nd Ave.
Des Moines
January 1993
17
General Surgery
Leave A Lot Behind As A Marshfield Clinic General Surgeon.
/Vt Marshfield Clinic, a 400-physician x \. multi- specialty practice, you’ll leave sixteen-hour workdays, time consuming business concerns, and the hassles of paperwork behind you!
Practice
I Here, you can concentrate
on General Surgery. We’ll put a staff of administrative experts behind you and a team of trained health care professionals beside you. Also, we’ll compensate you very well.
Localion/LHcslyle
This opportunity is available at our Satellite Clinic located in Park Falls, Wisconsin. This area is defined by beautiful woods and an abundance of lakes, rivers, and streams. It’s the chance to spend your days doing what
you do best — treating patients. And your nights - your family again.
- getting to know
If you would like to practice in a state-of-the-art healthcare setting, if you enjoy a life-style that’s rich with recreational diversity, and if you are seeking professional excellence in a family-oriented environment, contact David Draves at 1-800-782-8581, ext. 7-5376.
MARSHFIELDCLINIC
1000 North Oak Avenue Marshfield, WI 54449
EOE/AAM/F/H/V
The Lodge Is... Safe & Secure!
* 24 Hour Security * On-site RN
* Indoor Heated Garages * Gourmet Meals
* Wellness Center * Pull Size Kitchens
* Weekly Housekeeping * Indoor Pool/Spa
* Health Care Available - Fountain West Health Ctr.
Heritage Court
Assisted Living...
Excellence in Health Care for the 1990's
West Des Moines, Iowa S0265
Iowa's Finest Senior Living Community Locally owned by Colby Properties
Fountain West Health Center
(515) 224-4898
West Des Moines, Iowa
515-223-1223
BLISS
CANCER
CENTER
Offering
Oncology Treatment & Support Services
Xhe William R. Bliss Cancer Center, located at Mary Greeley Medical Center and McFarland Clinic P.C. in AmeS; is a comprehensive cancer treatment center serving the communities of north central Iowa. It offers such services as radiation therapy, chemotherapy, cancer surgery, diagnosis and staging of malignancies, and a specialized inpatient oncology unit.
MEDICAL ONCOLOGY
M. Michael Guffy, M.D.
Larry A. Otteman, M.D.
Elie P. Saikaly, M.D.
239-4401
RADIATION ONCOLOGY
Gregory Yee, M.D.
John Ptacek, M.D.
239-2411
8 a.m. to 5 p.m. Monday through Friday 8 a.m. to 12 noon Saturday
800-678-8661
HAE patients needed for U. of I. study
Two CLINICAL TRIALS WILL BEGIN in early 1993 for patients with Hereditary Angi- oedema (HAE), a rare disorder that results from congenital deficiency of the complement regulatory protein Cl inhibitor (CllNH). ClINH prevents uncontrolled classical path- way activation and low levels lead to comple- ment consumption and attacks of angi- oedema. The prevalence of CllNH deficiency may be as high as 1 in 50,000.
HAE is characterized by flares of angi- oedema, abdominal pain and throat swelling that may occur spontaneously or after trivial trauma. The average time from onset of symp- toms to recognition of this disorder is 21 years. A family history of HAE or sudden death due to choking may alert clinicians to consider this diagnosis but a positive family history is not necessary because CllNH gene mutations may occur spontaneously.
Patients may also present with an "acute abdomen" leading to multiple, unnecessary abdominal procedures before the diagnosis of HAE is made. C4 is virtually always de- pressed in patients with HAE due to low- grade chronic complement activation, and the level may be undetectable during acute flares. Antigenic CllNH levels may be nor- mal or depressed because about 15% of HAE patients produce antigenically normal CllNH that is non-functional. Thus, the diagnosis re- quires a low C4 and a low CllNH level (mea- sured either antigenically or functionally).
Patients with HAE are treated phylacti- cally with attenuated androgens for several days prior to surgical procedures. Patients with frequent spontaneous bouts of angi- oedema may also be treated chronically with androgens. Unfortunately, the management of acute flares of HAE is more difficult be- cause angioedema does not respond to epi- nephrine, corticosteroids or antihistamines as would be expected for idiopathic or allergic angioedema.
The two clinical trials planned for early 1993 will examine the safety and efficacy of CllNH concentrate in patients with HAE. If you have a patient with HAE, please contact Drs. Karen K. Maves (319/353-6077) and John M. Weiler (319/356-2114) of the UIHC Depart- ment of Internal Medicine.
January 1993
19
Maybe you think it*s OK to practice in Iowa without one of these.
Think again.
How does IOWA MEDICAL POLITICAL ACTION COMMITTEE work for your practice? Call toll free (800) 747-3070 and find out!
Contributions are not limited to the suggested amount. Neither the AMA nor the IMS will favor or disadvantage anyone based upon the amounts of or failure to make pac contributions. Contributions are subject to the limitations of FEC Regulations. (Federal Regulations require this notice.) Paid for by the Iowa Medical Political Action Committee, 1001 Grand Avenue, West Des Moines, lA 50265. Contributions to AMPAC and IMPAC are not deductible as charitable contributions for Federal Income Tax purposes. If your practice is incorporated, IMPAC and AMPAC voluntary political contributions should be written on a personal check.
College of Medicine Highlights
DR. JOHN ECKSTEIN, PROFESSOR OF IN- TERNAL MEDICINE AND LONGTIME DEAN of the UI College of Medicine, re- ceived the American Medical Association Dis- tinguished Service Award for 1992. The award recognizes meritorious service in the science and art of medicine and was one of six major honors presented at the AMA an- nual convention in June.
FORMER UI INTERIM PRESIDENT RICH- ARD REMINGTON died July 26, 1992. He was UI Foundation Distinguished Professor of Preventive Medicine and Environmental Health and former vice president for aca- demic affairs and dean of the faculties.
DR. DAVID SKORTON, INTERNAL MEDI- CINE, was named UI vice president for re- search, effective August 1. As vice president, he heads the UI research program, which at- tracted $150 million in grants, gifts and con- tracts for the 1992 fiscal year. Skorton will also continue as director of the Cardiovascu- lar Research Center's Specialized Center for Research in Coronary and Vascular Diseases, a multidisciplinary center funded by the NIH.
FACTORS INFLUENCING WHERE FAM- ILY PHYSICIANS LOCATE THEIR PRAC- TICES have changed over the past two dec- ades, says Roger Tracy, Office of Community-Based Programs. Tracy was lead investigator of a study of family physicians who completed three years of specialty train- ing in Iowa's Statewide Family Practice Train- ing Program. Compared to graduates in the 1970s, today's new family physicians are more interested in the quality of local schools, income guarantees, the cost of buy- ing into a group practice, the presence of other family physicians, and employment op- portunities for spouses. Several other factors have remained consistently important: size of the community, opportunities for group prac- tice, perceived compatibility with physicians in the group, perceived quality of the local hospital, on-call schedule, and availability of specialists such as general surgeons and ob- stetricians. The demand for family physicians remains high across Iowa, the Midwest and the nation, Tracy says.
THE UI HAS JOINED THE NIH AIDS CLINICAL TRIALS GROUP PROGRAM
that tests new therapies for people infected with the AIDS virus. UI researchers will par- ticipate as a subunit of the AIDS Clinical Tri- als Unit at the University of Minnesota. “The approval of our site is good news for all of our patients," said Dr. Jack Stapleton, inter- nal medicine, director of the HIV program at UI Hospitals and Clinics. “It means we will have an opportunity to participate in both clinical and laboratory studies that will ex- pand our understanding of this disease." Co- investigators include Dr. Bryan Volpp, inter- nal medicine, who is director of the Iowa City VA Medical Center HIV Clinic.
HONORS: Arthur Benton, neurology, won
the Gold Medal Award for Life Achievement in the Application of Psychology, presented by the American Psychological Foundation. Benton was cited for contributions made dur- ing his 60-year career as a neuropsychologist, including pioneering clinical studies of brain- behavior relations. . . . Charles Davis, preven- tive medicine and environmental health, is the 1992 recipient of the College of Medi- cine's Lewis D. Holloway Award for research in health science education. Davis, a biostatis- tician, developed a program to teach data analysis to medical students. . . . Dr. Robert Pick Jr., internal medicine, was recognized by the Iowa Lung Association as the out- standing volunteer for the state. Fick was pre- sented the 1992 Frances Brophy Award in Des Moines. . . . Dr. Hansjoerg Kolder, oph- thalmology, won the Dr. Ernest Theilen Clini- cal Teaching and Service Award. The award honors the late Dr. Theilen's contributions to the College of Medicine. Kolder, who con- ducts research in the electrodiagnosis of eye diseases, maintains an extensive clinical prac- tice and teaches in cataract surgery. . . . Dr. John Strauss, dermatology, has been elected to a five-year term as president of the Interna- tional League of Dermatological Societies. He will also serve as president of the Interna- tional Committee of Dermatology. . . . Dr. Richard Wenzel, internal medicine, has been appointed to the editorial board of the New England Journal of Medicine. The NEJM is the oldest continuously published journal in the world and has more than 230,000 subscribers. Wenzel is the first Iowan to be appointed to the journal's board.
January 1993
21
About IMS Members
Larry Beaty, M.D., has been named Director of Family Practice and Associate Director of Medical Educa- tion at Broadlawns Medical Center, Des Moines.
Timothy Blair, M.D., family practice, has joined a medi- cal practice which serves Keosauqua, Bonaparte and Farmington.
Jeffrey Bebensee, M.D., has joined Iowa Physicians Clinic Family Practice, Des Moines.
Donald Young, M.D., Iowa City and Stephen Van Houten, M.D., Ames, have been named fellows of the American College of Radiology.
James Duggan, D.O., Dale Wassmuth, M.D. and Ger- ald Brooks, M.D., all of Sioux City, have received the National Alliance for the Mentally 111 "Exem- plary Psychiatrist" Award.
George Aurand, M.D., Clinton, received an award in recognition of his contributions to and the initia- tion of Women's Health Services of Clinton.
Nidal Harb, M.D., Clinton, has been selected by Duke University Medical Center to take part in the largest cardiovascular medicine study ever con- ducted in the U.S.
Harold Eklund, M.D., Des Moines, has been elected president of the Iowa Academy of Family Physi- cians. Other officers include: Laine Dvorak, M.D., Humboldt, president-elect; A. Clinton MacKinney,
M.D., Cresco, vice president and Thomas Evans, M.D., Des Moines, secretary/treasurer.
Marian Barnes, M.D., Cedar Rapids, has been named 1992 Iowa Family Doctor of the Year by the Iowa Academy of Family Physicians.
Charles Driscoll, M.D., Iowa City, has been selected as the 1992 Iowa Academy of Family Physicians Edu- cator of the Year.
The governing boards of St. Joseph Mercy Hospital and North Iowa Medical Center, Mason City, re- cently approved a Memorandum of Understand- ing, specifying the intent of the two organizations to consolidate into one hospital. It is hoped the for- mal documents will be signed by June 1, 1993.
Terry Dynes, M.D., has been appointed medical direc- tor of the Decorah Clinic.
The following physicians have joined Medical Associ- ates Clinic, P.C. in Dubuque; Peter Tinsman, M.D., Frederick Hamly, M.D. and Yasyn Lee, M.D. All three physicians are new to Iowa.
News items for this column should be sent to "About IMS Members" c/o IOWA MEDICINE 1001 Grand Avenue West Des Moines, Iowa 50265
RUN A SPECIAL PRACTICE.
Today’s Air Force has special opportuni- ties for qualified physicians and physi- cian specialists. To pursue medical excel- lence without the overhead of a private practice, talk to an Air Force medical pro- gram manager about the quality lifestyle, quality benefits and 30 days of vacation with pay each year that are part of a medical career with the Air Force. Dis- cover how special an Air Force practice can be. Call
USAF HEALTH PROFESSIONS TOLL FREE 1-800-423-USAF
Iowa Medicine
22
YOCON*
YOHIMBINE HCI
Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-16a-car- boxyiic acid methyi ester. The aikaioid is found in Rubaceae and reiated trees. Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolalkyiamine alkaloid with chemical similarity to reserpine. It is a crystalline powder, odorless. Each compressed tablet contains (1/12 gr.) 5.4 mg of Yohimbine Hydrochloride.
Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors. Its action on peripheral blood vessels resembles that of reserpine, though it is weaker and of short duration. Yohimbine’s peripheral autonomic nervous system effect is to increase parasympathetic (cholinergic) and decrease sympathetic (adrenergic) activity. It is to be noted that in male sexual performance, erection is linked to cholinergic activity and to alpha-2 ad- renergic blockade which may theoretically result in increased penile inflow, decreased penile outflow or both.
Yohimbine exerts a stimulating action on the mood and may increase anxiety. Such actions have not been adequately studied or related to dosage although they appear to require high doses of the drug . Yohimbine has a mild anti-diuretic action, probably via stimulation of hypothalmic centers and release of posterior pituitary hormone.
Reportedly, Yohimbine exerts no significant influence on cardiac stimula- tion and other effects mediated by B-adrenergic receptors, its effect on blood pressure, if any, would be to lower it; however no adequate studies are at hand to quantitate this effect in terms of Yohimbine dosage.
Indications: Yocon® is indicated as a sympathicolytic and mydriatric. It may have activity as an aphrodisiac.
Contraindications: Renal diseases, and patient's sensitive to the drug. In view of the limited and inadequate information at hand, no precise tabulation can be offered of additional contraindications.
Warning: Generally, this drug is not proposed for use in females and certainly must not be used during pregnancy. Neither is this drug proposed tor use in pediatric, geriatric or cardio-renal patients with gastric or duodenal ulcer history. Nor should it be used in conjunction with mood-modifying drugs such as antidepressants, or in psychiatric patients in general.
Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a complex pattern of responses in lower doses than required to produce periph- eral a-adrenergic blockade. These include, anti-diuresis, a general picture of central excitation including elevation of blood pressure and heart rate, in- creased motor activity, irritability and tremor. Sweating, nausea and vomiting are common after parenteral administration of the drug.T? Also dtoiness, headache, skin flushing reported when used orally. T3 Dosage and Administration: Experimental dosage reported in treatment of erectile impotence. T3.4 i tablet (5.4 mg) 3 times a day, to adult males taken orally. Occasional side effects reported with this dosage are nausea, dizziness or nervousness. In the event of side effects dosage to be reduced to 'k tablet 3 times a day, followed by gradual increases to 1 tablet 3 times a day. Reported therapy not more than 10 weeks.3 How ^plied: Oral tablets of Yocon® 1/12 gr. 5,4 mg in bottles of 100’s NDC 53159-001-01 and 1000’s NDC 53159-001-10.
References:
1. A. Morales et al.. New England Journal of Medi- cine: 1221 . November 12, 1981 .
2. Goodman, Gilman — The Pharmacological basis of Therapeutics 6th ed., p. 176-188.
McMillan December Rev. 1/85,
3. Weekly Urological Clinical letter, 27:2, July 4,
1983.
4. A. Morales etal. , The Journal of Urology 128:
45-47, 1982.
Rev. 1/85
AVAILABLE AT PHARMACIES NATIONWIDE
PALISADES
PHARMACEUTICALS, INC.
21 9 County Road Tenafly, New Jersey 07670
(201) 569-8502 1-800-237-9083
"I’m practicing medicine the way I think it should be practiced, sans the paperwork and administrative overload.’’
Owen Brodie, MD, joined CompHealth’s locum tenens medical staif in 1989, after 21 years m private practice. Since then he’s worked in temporary assignments in state facilities, filled in for attending physicians, covered for private practitioners across the country.
A pilot. A historian. A board-certified psychiatrist. Southern to a fault. Owen Brodie knows...
It s a great way to practice medicine
CompHealth
Locum Tenens
1-800-453-3030
Salt Lake City ■ Atlanta ■ Grand Rapids, Mich.
>MERCY
Training Health Professionals
about
Smoking Cessation Techniques
A program of the National Cancer Institute*
Saturday, January 23, 1993
9 a.m.-4 p.m.
Mercy Education Center, Fifth & University, Des Moines
Co-sponsored by
AMERICAN
LUNG ASSOCIATION
AMERICAN
I*
Registration: $10 (includes lunch, materials).
Deadline to register is Friday, January 15. Continuing Education Credits: 6.5 CME credits approved in Category I of the Physicians’ Recognition Award. .7 CEUs for nurses. CEUs applied for with the Iowa Board of Dental Examiners.
For more information or to register: Call
Dianne Woods, Mercy Foundation, 515/247-3248.
*The NCI wants to assist health professionals and the public to reduce tobacco use by persons age 20 and older to no more than 15% by the year 2000. By participating in this program, individuals agree to help train their peers and to use the information and materials provided.
lanuary 1993
23
Because One Size Doesn’t Fit All...
New Humulin 50/50 is the tailor-made answer to individual patient needs. A unique combination of equal amounts of Regular human insulin and NPH human insulin, it will be useful in situations in which a greater initial insulin response is desirable for greater glycemic control.
Like Humulin 70/301 new Humulin 50/50 offers the convenience and accuracy of a premia. And it can be used in conjunction with an existing 70/30 regimen.
New 50/
Humulin X50
50% human insulin isophane suspension 50% human insulin Injection (recombinant DNA origin)
The Newest Option in Insulin Therapy
WARNING: Any change of insulin should be made cautiously and only under medical supervision.
* Humulin * 70/30 (70% human insulin isophane suspension, 30% human insulin injection |recombinant DNA origin] ].
Global Excellence in Diabetes Care
Eli Lilly and Company
Indianapolis, Indiana 46285
HI-791 1-B-249343 ®
JD COMPANY
Suburethral sling — an old procedure revisited
This procedure is increasing in popular- ity for certain patients.
Larry Lindell, M.D.
Des Moines
The suburethral sling procedure has been used to treat urinary incontinence since 1907.^ Despite multiple modifications of the procedure, it has the stigmas of technical difficulty and high morbidity. The list of re- ported complications include urinary retention requiring sling revision, voiding difficulties, urethral irritation, urethral necrosis from exces- sive sling tension, rejection of synthetic mate- rial and infection requiring removal of a syn- thetic sling. Therefore, this procedure has generally been used only to treat recurrent stress incontinence, usually as a last resort.
Despite this history, the popularity of the suburethral sling as treatment of stress urinary incontinence seems to be rising.
There are several factors that contribute to its rise in popularity. The first of these is a better understanding of the association be- tween surgical failures and the presence of a low urethral closure pressure (LUCP). Sands showed that the Burch procedure fails 54% of the time in women with a LUCP.^ In other words, a large percentage of women with LUCP are incontinent, even though their ur- ethrovesical junction is restored to its retropu- bic position.
Dr. Lindell practices obstetrics/gynecology in Des Moines.
The prevalence of LUCP in women with genuine stress incontinence is higher than ex- pected. Horbach noted in a recent retrospective review of 220 patients with stress incontinence that 49% had LUCP; the older patients had the highest incidence of LUCP.^ The same investi- gator found that being 50 years old or older was the only clinical finding predictive of LUCP in women with stress incontinence.
Prior incontinence surgery is also associ- ated with LUCP. McGuire found a 13% inci- dence of LUCP in patients with stress inconti- nence and no prior surgery compared to a 75% incidence in women who had failed previous incontinence surgical procedures.^
A suburethral sling procedure seems to be more effective in achieving continence in pa- tients with stress incontinence and LUCP than the retropubic or vaginal urethropexies. In a group with incontinence and LUCP, Horbach showed that surgical cure was obtained in 80% by performing a suburethral sling procedure compared to a 35% cure rate in a matched group who had a Burch colposuspension.^ Summit showed that 93% of patients with stress incontinence, a LUCP and urethral hy- permobility as defined by the Q-tip test, were cured after a suburethral sling procedure.^ This information suggests a suburethral sling is the indicated surgical procedure for pa- tients with LUCP, even if they have had no prior surgery. There are patients with normal urethral closure pressures who should also be
THE IMS EDUCATION FUND HAS DESIGNATED THIS ARTICLE AS THE HENRY ALBERT SCIENTIFIC PRESENTATION AWARD FOR JANUARY 1993
January 1993
25
considered for this procedure. Those who have failed other incontinence procedures and still have urethral mobility are good candidates. Those who have other risk factors for failing an incontinence procedure — obesity, chronic cough, lifestyle containing excessive physical strain — should also be considered.
This expansion of indications for a sub- urethral sling has been the main reason for its rise in popularity, but several modifications in the technique which seem to decrease morbid- ity have also contributed. One modification is
'A suburethral sling procedure seems to be more effective in achieving continence in patients with stress incontinence and LUCPthan the retropubic or vagi- nal urethropexies/
to use a wider strip of material for the sling. Strips of fascia for the sling are usually only 1- 2 cm wide and they tended to roll and act more like a rope than a hammock of support. This narrow band of support can create problems with urethral obstruction, irritation and pres- sure necrosis. A wider strip of material, (2-3 cm at the place of contact with the urethra), creates a wider distribution of pressure on the urethra with fewer obstructive problems and certainly less erosion into the urethra.
Synthetic products are required for wider strips since harvesting wide strips of fascia is very difficult. Polypropylene mesh (Marlex), which has been used extensively in abdominal wall reconstruction, is one possible material for suburethral slings. It is strong, host tissues seem to accept it well and fibrous tissue readily incorporates into its pores. Microporous poly- tetrafluorethylene (Gore-Tex), which is used as a vascular prosthetic material, is gaining wide- spread use in sling procedures. Bacteria adhere to it less than to Marlex in the presence of infec- tion so it does not have to be removed in the presence of operative bed infection.^ It also pro- duces fewer adhesions, making it easier to re- move.
Horbach et al describe a technique for the suburethral sling procedure which seems to de- crease the procedure's morbidity.® One im-
provement is to plicate the urogenital dia- phragm over the urethrovesical junction (Kelly plication stitch) before placing the sling. This not only places an extra layer of tissue between the urethra and the graft which helps prevent erosion, but it elevates the urethrovesicle junc- tion so less tension is necessary on the sling to keep this junction in a retropubic position. With this technique, the sling is not acting as the main support of the urethrovesicle junction in the static situation. Rather, it is an immobile shelf against which the urethra is pushed when the patient coughs, hence closing the urethra and maintaining continence.
The purpose of the sling is not primarily to increase the static intraurethral pressure but to increase the pressure in situations of abdom- inal pressure such as coughing and sneezing. This results in less constant extrinsic pressure being exerted on the urethra and fewer prob- lems with urethral obstruction, irritation and erosion.
Horbach's article also describes using the vaginal finger in the retropubic space to guide the movement of the forceps from the abdomi- nal incision through the retropubic space into the vaginal field. These forceps are used to bring the ends of the sling from the vagina into the abdominal field. By guiding the placement of these forceps with the vaginal finger, rather than "blind" placement, trauma to the bladder can be greatly reduced.
An acceptably low morbidity can be achieved when these technical modifications and inert synthetic materials are used. A proce- dure used only as a last resort in patients who have failed all other surgical procedures is now becoming a procedure used with little reserva- tion and may be used primarily in patients with stress incontinence and LUCP.
References
1. Hofheufellner, R and Petre, E: Sling procedures, Surgery of Female Incontinence. Edited by SL Stanton, E Tanagho. Heidilburg, Springer-Ver- lag, 1980;69-76.
2. Sand, PK, et ah The low pressure urethra as a factor in failed retropubic urethropexy. Obstetric & Gynecology 1987;69:399.
3. Horbach, NS, et ah The low pressure urethra in patients with genuine stress incontinence: clinical and urodynamic characteristics. Unpublished.
4. McGuire, EJ: Urodynamic findings in patients after failure of stress incontinence operations. Prog Clin Biol Res 1981;78:351.
5. Horbach, NS, et ah A comparison of retropubic urethropexy and subur- ethral sling procedure for the treatment of stress incontinence and the low pressure urethra. Unpublished.
6. Summit!, RL, et al: Stress incontinence and low urethral closure pressure. Journal of Reproductive Medicine 1990;35:877.
7. Brown, GL, et al: Comparison of prosthetic materials of abdominal wall reconstruction in the presence of contamination and infection, Ann Surgery 1985;201:705.
8. Horbach, NS, et al: A suburethral sling procedure with polytetraflu- oroethylene for the treatment of genuine stress incontinence in patients with low urethral closure pressure. Obstetric & Gynecology 1988;71:648.
Iowa Medicine
26
DOCTOR:
Put Our
To Work For You!
Filing claims electronically!!
A crucicd need — if not an absolute necessity — for Iowa medical practices.
Now, we can put our computerized ARMS around your claims — and file them electronically for you!!
We can do it not only ELECTRONICALLY, but also EFFICIENTLY and ECONOMICALLY.
ARMS is the newest Iowa Medical Society-sponsored practice support program from IMS SERVICES. It stands
for ACCOUNTS RECEIVABLE MANAGEMENT SERVICES.
In short, ARMS is a mechanism through which claims con be submitted to third party payers by electronic means. It furnishes participating offices/clinics both technology and expertise. And ARMS has much greater potential — to help any practice achieve operational efficiency.
A coll or card to ARMS/IMS SERVICES will bring you more information. Ask for Barbara Cannon, Jane Stongl or Don Neumann; the numbers ore 515/223-2816 or 800/728-5398.
is a program offered by
SERVICES
1001 Grand Avenue West Des Moines, Iowa 50265
Wi give Iowa Physicians the “Lowe” down on health, disability, life, and other insurance
IMS-endorsed insurance coverages are available in various essential areas - health, accident and disability, life, etc.
As the IMS insurance administrator, we work year-round with IMS SERVICES to address your inquiries. Our team of Bernie Lowe, Ruth Clare, Terri DeGroot and Sandy Wheeler is anxious to serve you at any time. Please contact us.
BERNIE LBWE 6^ A55BEIATE5. INE.
/A SUCCESSOR TO THE PROUTY COMPANY ^700 WB^town Parkway, Suite -41D West Des Moines. Iowa 5D2B5-1411 515-222-DBn 1-BDD-942-47IB FAX 515-222-D315
At the new Bernie Lowe & Associates, Inc., we give Iowa Medical Society member physicians quality insurance counsel. We have done so for 40 years under The Prouty Company banner.
Newly named in 1992, Bernie Lowe & Associates, Inc., is dedicated to supplying you and your colleagues with state-of-the-art insurance protection.
The Art of Medicine
Want to be a technician?
Richard M. Caplan^ M.D.
//ly^ OST DOCTORS DON'T WANT to make iVXhard moral choices. They just want to be technicians."
Ouch! I read that statement recently, but it made me so angry I promptly repressed the source, which reveals how emotional reac- tions can interfere with being "scholarly." With the passage of a little time I now reflect calmly on the question, liberating myself from the bias of having been socialized for about 40 years into thinking that my medical colleagues and I were professionals, some- thing different — and better — than being a technician. That sounds pretty arrogant and denigrating to technical work and those who perform it. Such work is vital to modern life and those doing it deserve respect and ap- preciation. But there are differences worth considering.
The quotation above sounds as if techni- cians are indeed free of hard moral choices. An argument against that assertion comes to mind at once: honesty, integrity, pride-in- work-well-done are surely high order moral attributes. Even so, physicians carry responsi- bilities that are different — maybe not in kind, if one uses abstract terms like honesty, but surely different in frequency and magnitude, if one thinks of the encounter between pa- tient and doctor, its frequency, its eye-to-eye directness and its gravity for both doctors and patients — not merely as a "possible sce- nario" that one may probe one's imagination to produce, but as events happening many times daily.
What would cause a (probably) intelli- gent person to make the claim in my opening quotation? Does that writer really think doc- tors don't want to encounter the pain and dis-
tress of patients' lives rather than bodies; that doctors want to avoid conflict, tension, dilem- mas; that doctors want to function as automa- tons, addressing problems in a standardized way that means no challenge, no strain, no rush of adrenalin, no responsibility — and be higher paid all the while? Might that (proba- bly) intelligent person have made such a claim because of direct personal experience of doctors who convey that impression? If such an impression is indeed faulty — grievously faulty — does it arise because the public is angry, confused, paranoid? Or because doc- tors spend too little time considering criti- cally their individual and collective behavior. Some of each, maybe?
Robert Burns wished that people might have the power "to see oursels as ithers see us." What if we accepted, as an opening as- sumption, that the criticisms are largely cor- rect, instead of largely incorrect? Because de- fensiveness clouds vision and judgement, especially of oneself, it's easier, if we do admit imperfections in doctorly behavior, to concede them as coming from some small fraction of other doctors. To introspect about one's own weaknesses usually stimulates lots of denial. To break through that protective crust to reveal ourselves as others perceive us can certainly feel painful. That surely ex- plains some of the negative responses among physicians toward efforts named "medical audit," "peer review" or "quality assessment and improvement."
What can or should physicians do who want to be part of the solution rather than part of the problem? Reading and listening to the critical voices with an open mind could be a good beginning. After absorbing the spirit of the critique, and perhaps a few of the details and examples, make the effort to assess one's own behavior and the environ- ment we each control. It's hard. It needs do- ing, though.
Dr. Caplan is Coordinator, Propam in Medical Humaiuties at the Uni- versity of Iowa College of Medicine.
January 1993
29
rthopedic Surgery (General)
Leave A Lot Behind As A Marshfield Clinic Orthopedic Surgeon.
t Marshfield Clinic, a 400-physician A. multi-specialty practice, you’ll leave sixteen-hour workdays, time consuming business concerns, and the hassles of paperwork behind you!
Practice
I Here, you can concentrate
on Orthopedic Surgery. We’ll put a staff of administrative experts behind you and a team of trained health care professionals beside you. Also, we’ll compensate you very well. Currently, practice opponunities are available at our Lakeland Center (Minoqua/ WoodrufO and Main Clinic (Marshfield).
Location/Lifestyl
I These opportunities offer
a safe friendly environment with an emphasis on education, family and quality of life. It’s the chance to spend your days doing
what you do best — treating patients. And your nights — getting to know your family again.
If you would like to practice in a state-of-the-art healthcare setting, and if you enjoy a life- style that’s rich with recreational diversity, if you are seeking professional excellence in a family-oriented environment, contact David Draves at 1-800-782-8581, ext. 7-5376.
MARSHFIELDCLINIC
1000 North Oak Avenue Marshfield, W1 54449
EOE/AAM/F/H/V
ONE. Order, Shipment, Supplier
Why waste valuable staff time coordinating orders, shipments, and supplies with multiple vendors when Hawkeye Medical Supply, Inc. does it all?
ONE ORDER: All medical supplies and office supplies, everything you need from Hawkeye Medical. Just think of us as your storeroom. Thousands of items to choose from. Save time and money by ordering what you need when you need it. No minimum orders and toll free phone lines make ordering easy!
ONE SHIPMENT: Hawkeye Medical Supply ships most orders the same day. You can inventory only what you need by using us as an extension of your storeroom and not tie up your dollars in inventory!
ONE SUPPLIER: With Hawkeye Medical Supply as your single supplier for medical and office supply products, you can reduce your transaction costs with fewer orders to receive, fewer phone calls, which results in more efficient use of your personnel!
Our knowledgeable, experienced, and dependable sales and customer service organization stand behind every product that we sell!
For more information, contact your local salesperson or call us;
HOME OFFICE: 225 E. PRENTISS STREET, IOWA CITY, IOWA 52244 (319) 337-3121
BRANCH OFFICES: 7212 UNIVERSITY AVENUE, DES MOINES, IOWA 50311 (5 15) 274-4015
901 E. KIMBERLY ROAD, DAVENPORT, IOWA 52807 (319) 386-1345
ilMff
HAWKEYE MEDICAL SUPPLY, INC.
Toll Free 1-800-272-6448
Practice Management
Shared management
WITH EACH INVOICE that crosses the desk and each check that's mailed, clinic ad- ministrators say it's becoming increasingly difficult to maintain a winning edge. One year ago I was given an opportunity to sharpen my strategy in battling those every- day economics of the business.
Already the administrator of a Des Moines ophthalmology clinic, I was offered the chance to manage a second ophthalmol- ogy clinic in Ames, 40 miles away. I ap- proached my physician employers with the topic of "shared management" and was im- pressed by their open-mindedness. Little did I realize the full impact this arrangement would have on both clinics. Shared manage- ment has opened the door for me to combine resources and pursue volume discounts that directly affect the entire office overhead.
How it works
I spend IV2 days in Des Moines and 2V2 days in Ames each week. My salary is paid equally by both groups but my check, bene- fits, profit sharing and pension are handled through one clinic. Both groups are single specialty ophthalmology, which means they both have a great deal in common as far as medical supplies and equipment utilization.
First year advantages
One of the top priorities was upgrading the computer system. Fortunately, both clinics
This article was written by Randy Eckard, clinic administrator for Des Moines Eye Surgeons, Des Moines, and Iowa Eye Care Physicians, P.C., Ames. He is a member of the Iowa Medical Group Management Associ- ation.
had the same system and both were open to the idea of upgrading. By sharing acquisition of a computer system, each group got a $6,000 discount savings. In addition, patient registration, billing, scheduling and word pro- cessing was shared by each group which al- lowed for improvement of joint operations. Subsequently, computerized payroll and ac- counts payable were completed with similar findings.
Both groups were able to combine vol- ume discount rates on routine office supplies 35% below what they had been paying.
Another area of expansion included the need for an ophthalmic technologist. Each group had only part-time openings, but through combining the two groups, we were able to attract a qualified individual to share job duties at both clinics.
Do the practices compete?
A major concern in shared management is each clinic's drawing area and the extent to which the practices actually compete. Shared management would not be advisable for prac- tices in direct competition because of the ad- ministrator's role in increasing market share. In these cases, a merger would be more ap- propriate.
There are also regional political issues that occasionally arise. These have been re- solved by physician interaction.
I'm not saying shared management is the only desirable clinic management plan, but I endorse it whole-heartedly. The economic re- wards enjoyed by the clinics prove shared management is a wise investment.
January 1993
31
Caring For lowans For More Than 50 Years.
The changes in health care and health coverage in the last five decades have been tremendous. And, through it all, Blue Cross and Blue Shield of Iowa has helped set the pace.
All the while, we have worked diligently to help our customers get the most out of their health care dollars, to provide excel- lence in service and to give our members cost-efficient, quality benefits. Like Total Health Network of Iowa and Family Health Plan, our Innovative health mainte- nance organizations ... and ALLIANCE Select, our preferred provider program.
We've worked with the providers of health care for 50 years to assure lowans of affordable, high-quality coverage. And you can be sure that we'll be doing the same for another 50 years. It's a tradition we're proud of ... and one you can con- tinue to count on.
Blue Cross Blue Shield
Biomedical Ethics
Nonautonomous patients
Robert Weir, Ph.D.
WE DISCUSSED AUTONOMOUS PATIENTS in
the October column, noting that the lan- guage of "autonomous /nonautonomous" pa- tients is preferable for several reasons to the traditional language of "competent /incompe- tent" patients. For patients to be autonomous in a general sense, they must have the capaci- ties for understanding, deliberation and vol- untariness in decision making. If they are be- ing asked to make a high-stakes decision, such as a decision to accept or refuse life-sus- taining treatment, they need additionally to have the capacities for authenticity, communi- cation and appreciation of the personal signif- icance of the decision.
One of the advantages of using the newer language is simple: autonomy is a flex- ible concept that fits the diversity of medical reality better than does the language of com- petency. Many patients possess all of the capacities mentioned above and are clearly autonomous. Other patients lack these deci- sion-making capacities and therefore are non- autonomous. An unknown number of pa- tients fall in the middle of the autonomous/ nonautonomous spectrum and are described as having underdeveloped autonomy (some adolescent patients), fluctuating autonomy (some psychiatric patients, some geriatric pa- tients) or diminished autonomy (some pa- tients with depression, patients with mild de- mentia, some geriatric patients and some confused patients).
Nonautonomous patients can be classi- fied according to the type of incapacity. Such a classification scheme should distinguish among patients in at least the following cate- gories: patients who are nonautonomous in relation to important health decisions because
Dr. Weir is director of the program in biomedical ethics for the University of Iowa College of Medicine.
of young age and immaturity (typically, pedi- atric patients under the age of 14), patients with substantial incapacity to make decisions because of severe to profound mental retarda- tion, brain damage or the complications of multiple-organ failure and patients with per- manent loss of consciousness. Adult patients who have fluctuating or diminished capacity to make decisions (because of mental illness, shock or organic brain syndrome) often end up as examples of a fourth category, at least when decisions in individual cases require an either /or determination by the attending phy- sician of a patient's decision-making capacity.
The importance of determining whether a patient is autonomous or nonautonomous is obvious. An adult patient who is autono- mous has the moral and legal right to con- sent to recommended medical treatment and to refuse any medical treatment (including life-sustaining treatment), regardless of views held to the contrary by the patient's physi- cian(s) or family.
A previously autonomous adult patient who now lacks decision-making capacity re- tains the moral and legal right to refuse treat- ment, but the refusal has to be communicated through the patient's earlier known prefer- ences (preferably an advance directive) or by a surrogate making a decision based on the patient's best interests. For adult patients who have never been autonomous, the only acceptable standard for abating life-sus- taining treatment is a determination by the patient's surrogate that such treatment is con- trary to the patient's best interests. For nonau- tonomous patients who have no surrogate, any decision not to initiate or continue life- sustaining treatment should be based on the patient's best interests and made with great care, either by a multidisciplinary care com- mittee or an institutional ethics committee. In some institutions, the appointment of a guard- ian may be deemed necessary.
January 1993
33
classified Advertising
CLASSIFIED ADVERTISING RATE— $3 per line, $30 minimum per insertion. Special rate of $20 per insertion for Iowa Medical Society members. Copy deadline — 1st of the month preceding publication.
ASSISTANT DIRECTOR FAMILY PRACTICE RESIDENCY— Established, community-based. University-affiliated, unopposed 6-6-6 residency enjoys strong hospital and medical community support. We seek a residency-trained, board-certified physician. Prior practice expe- rience, including obstetrics, preferred. Position includes teaching and patient care. Administrative responsibilites commensurate with experi- ence. Competitive salary and benefits. Send CV to John Sutherland, M.D., Waterloo FP Residency Program, 441 E. San Maman, Waterloo, Iowa 50702; 319/234-4419.
FP/PEDS/IM — One position needed immediately for a modem 360-bed intermediate care facility for mentally retarded clients at the Woodward State Hospital and School; located 30 miles from Des Moines. Competi- tive salary and benefits. Licensure by Iowa Board of Medical Examiners required. Salary range $70,782.40 to $89,460.80. Send CV to S. Lerd, M.D., Woodward State Hospital School, 1251 334th Street, Woodward, Iowa 50276. An Equal Opportunity/Affirmative Action Employer.
ACCESSIBLE DOWNTOWN MEDICAL OFFICE— Currently a doctor's office. Nice reception area, small play area for children, large business office, restroom, lab, 5 treatment rooms, large personal office and addi- tional large room for meetings/lunchroom/miscellaneous. 100 Court Av- enue Building, near new skywalk connection; visitor and monthly park- ing available; affordable rent; 2200 square feet. Call 515/282-2106.
MEDICAL DIRECTOR — Part-time position available. For more infor- mation call or write Dale Weaver, Administrator, Cresco Care Center, Route 2, Box 44, Cresco, Iowa 52136; 319/547-3580.
FOR SALE — Medical office furnishings. Office closing December 31, 1992. Contact Cedar Rapids Pediatric Clinic, P.C., 1030 5th Avenue SE, Cedar Rapids, Iowa 52403; 319/365-8661.
TIRED OF THE RAT RACE? — Anxious about entering private practice with the attendant risks and demands of the 90s? Why not consider emergency medicine. If you are trained in family practice or emergency medicine and are looking for a career with fixed hours, guaranteed
income free of financial risks and other practice hassles, please give me a call. Kenneth P. Schultheis, D.O., President, Emergency Physicians Services, P.C., do Mercy Hospital Medical Center, Des Moines, Iowa; 515/247-4445.
WISCONSIN — Growing southern Wisconsin, 47-physician, multispe- cialty group is seeking an endocrinologist, general surgeon, internist, neurologist, ob-gyn, ortho surgeon, physiatrist and rheumatologist. Guaranteed salary with incentive plus full benefit package. Excellent family environment in college community of 50,000+. Send CV to J.F. Ruethling, Administrator, Beloit Clinic, S.C., 1905 Huebbe Parkway, Beloit, Wisconsin 53511 or call 608/364-2200.
EMERGENCY PHYSICIAN— Full or part-time. BE/BC in primary care specialty or emergency medicine. Competitive salary and benefit pack- age. Call 515/263-5263 or write: Larry J. Baker, D.O., FACEP, Medical Director, Emergency Department, Iowa Lutheran Hospital, University at Penn, Des Moines, Iowa 50316.
MANKATO CLINIC, LTD — A progressive group practice is seeking BE/BC physicians in the following specialties; dermatology, family prac- tice, gastroenterology, invasive cardiology, oncology/hematology, pedi- atrics, urology, orthopedic surgery, pulmonology and general internal practice. The Mankato Clinic is a 50-doctor multispecialty group practice in south central Minnesota with a trade area population of +250,000. Guaranteed salary first year, incentive thereafter with full range of benefits and liberal time off. For more information, call Roger Greenwald, Executive Vice President or Dr. B.C. McGregor, President at 507/625-1811 or write 501 Holly Lane, Mankato, Minnesota 56001.
PRACTICE TRIALS, LOCUM TENENS, PERMANENT PLACE- MENT— Primary care physicians — you know all the benefits of locum tenens medicine. Join the one company that specializes in primary care. We put together "temporary solutions" and "lasting relationships." Great income, reasonable hours and travel opportunities. Call 800/925- 2144 or send CV to Interim Physicians Network, 10735 S. Cicero Ave., Suite 200, Oak Lawn, Illinois 60453.
Iowa Medicine
34
ACUTE CARE, INC. — Seeking full and part-time emergency physicians and medical directors for the following Iowa communities. Democratic group, excellent compensation, paid malpractice, excellent benefit package/bonuses to full-time physicians. Other locations available. Ames, Audubon, Carroll, Chariton, Charles City, Creston, Denison, Dy- ersville, Pocahontas, Sioux City and Winterset. Contact Acute Care, Inc., P.O. Box 515, Ankeny, Iowa 50021. Phone 1-800/729-7813 or 515/964-2772.
FAMILY PRACTICE, SOUTHWEST IOWA— Family PracHce (2), BC/ BE, excellent opportunity for 2 FPs to join multispecialty clinic in Cres- ton, Iowa, with limited call duty. Competitive salary and benefit pack- age, progressive community and 83-bed modem hospital. Contact Mike Brentnall, Administrator, Creston Medical Clinic, P.C., 526 New York Avenue, Creston, Iowa 50801, 515/782-2131.
INTERNAL MEDICINE — Large, multispecialty group in the Minneapolis/St. Paul area seeks additional BE/BC general internists. Busy, established primary care practice with focus on ambulatory geriat- rics; competitive guaranteed base salary and full benefit package; no practice buy-in. Send vitae to Nancy Borgstrom, Aspen Medical Group, 1021 Bandana Boulevard East #200, St. Paul, Minnesota 55108. EOE.
MIDWEST — Established, ethical, urologist seeks physician to share practice overhead. Practice affiliated with 176-bed hospital. 20-25 patients/day, 5 TURs, 10 cystoscopies/year. 1:2 call coverage. $140K in- come guarantee and many extra benefits. Suburban community 45 min- utes from capital city of 200,000. Call Darlene 1-800/669-9822.
MIDWEST — Join 3 highly qualified physicians in growing internal medicine practice. 25+ patients/day, 1:4 call coverage. Affiliated with 176-bed hospital. $100K with full benefits along with partnership oppor- tunity. Beautiful community with low cost of living. Call Darlene 1-800/ 669-9822.
MIDWEST — Three physician orthopedic group, run by 2, seeks associ- ate to complete practice. Full case load within 90 days. $200K+ produc- tivity, excellent benefits, one year to partnership. Call Darlene 1-800/ 669-9822.
COGLEY MEDICAL ASSOCIATES, P.C.— A progressive multispe- cialty group practice is seeking BE/BC physicians in the following spe- cialties: family practice, internal medicine and general surgery. CMA is a 14-doctor group with complete laboratory, radiology and physical therapy services. First year salary guarantee, full range of benefits and attractive buy-in option after first year. For more information, contact Richard F. Lehigh, Administrator, Cogley Medical Associates, P.C., 715 Harmony, Council Bluffs, Iowa 51503; 712/328-1801.
URGENT CARE — Marshfield Clinic is seeking several additional phy- sicians trained and certified in Primary Care (including family practice, internal medicine or pediatrics) to join its expanding urgent care practice section. As a 400-physician multispecialty group, Marshfield Clinic is at the forefront of today's medical practice. You would be joining top professionals committed to advancing health care services while en- joying full on-site medical and surgical support of one of the nation's premier groups. If you would like to practice in a state-of-the-art health care environment and if you enjoy a lifestyle that's rich with recreational diversity and if you would like to call "one of the best small cities in the midwest" home, contact: John P. Folz, Assistant Director, Marshfield Clinic, 1000 North Oaks Avenue, Marshfield, Wisconsin 54449 or call collect at 715/387-5181.
WISCONSIN, MICHIGAN — What are your prerequisites for a practice? Strelcheck & Associates, an extension of our clients' recruiting depart- ments, has several opportunities which might be of interest to you. We currently represent our clients in the areas of dermatology, emergency medicine, neurosurgery, occupational medicine, oncology, orthopedics, orthopedics-hand, otolaryngology, psychiatry and urology. Locations in metropolitan areas, mid-size cities, on lakes, streams or near forests — you choose. To discuss your practice preferences and these opportuni- ties, please call our toll-free number, 1-800/243-4353 or send your CV to Strelcheck & Associates, Inc., 10624 N. Port Washington Road, Mequon, Wisconsin 53092.
INTERNAL MEDICINE, FAMILY PRACTICE, URGENT CARE, OB/ GYN AND ACADEMICS — Locations from the lakes, rivers and forests of the Great Lakes area to the rolling plains of the Heartland to the Lone Star State. Whether you prefer a cosmopolitan lifestyle, a city
surrounded by nature and the beauty of the 4 seasons, the peaceful rolling farm country, or perhaps life in historic villages — there is some- thing for everyone. Positions with single and multispecialty clinics or solo with call coverage are available. Please call our toll-free number, 1-800/243-4353 or send your CV to Strelcheck & Associates, Inc., 10624 N. Port Washington Road, Mequon, Wisconsin 53092.
EMERGENCY MEDICINE — Progressive, physician-owned emergency group seeking primary care trained or experienced emergency physician for full-time position in Clinton, Iowa. Moderate volume in a challeng- ing emergency department offers an excellent compensation package. This Mississippi riverfront community offers a variety of leisure activi- ties, affordable housing, top-notch schools and quality living condi- tions. Call today: Sheila Jorgensen, 1-800/458-5003 or write Emergency Practice Associates, P.O. Box 1260, Waterloo, Iowa 50704.
EMERGENCY MEDICINE — Outstanding, professional opportunities in emergency medicine available in a variety of great Iowa locations. Quality lifestyles in family oriented communities. Comprehensive com- pensation packages for primary care trained or experienced emergency physicians. Administrative and staff positions with a progressive, phy- sician owned contract staffing group. For immediate consideration call Sheila Jorgensen at 1-800/458-5003 or mail CV to Emergency Practice Associates, P.O. Box 1260, Waterloo, Iowa 50704.
EMERGENCY MEDICINE— Full-time opening for a Board Certified/ Eligible emergency physician at Finley Hospital, Dubuque, Iowa. This is your chance to get control of your schedule, have some quality leisure and family time. Be a part of a progressive, professional, team oriented group. Outstanding financial package for a career oriented emergency physician. Compensation in excess of $200,000. A prosperous lifestyle in a picturesque, historical community. Call today: Sheila Jorgensen, 1- 800/458-5003 or write. Emergency Practice Associates, P.O. Box 1260, Waterloo, Iowa 50704.
Thanks to Our Advertisers
Bernie Lowe & Associates 28
Betts Lexus 4
Blue Cross/ Blue Shield 32
Boatworks, Inc 17
Bristol-Myers Squibb Company 39, 40
Cedar Rapids Heart Symposium 6
Century Pension Services 12
CompHealth 23
Entre Information Systems 38
Hawkeye Medical Supply, Inc 30
IMPAC 20
IMS Services /ARMS 27
IPMIT 2
Lilly, Eli & Company 24
Lodge of Ashworth 18
Marshfield Clinic 18, 30
Mary Greeley Medical Center 19
Mercy Hospital, Davenport 11
Mercy Hospital Medical Center 23
Medical Protective Company 8
Palisades Pharamceuticals 23
Raiter Clinic, Ltd 14
U.S. Air Force 22
Wahl & Wahl of Iowa, Inc 15
January 1993
35
Physicians' Directory
Physician members of the Iowa Medical Society may advertise in this directory. Monthly rates are as follows: $10.00 first 3 lines; $2.00 each additional line. Billed yearly; may be prorated.
ALLERGY
PEDIATRIC AND ADULT ALLERGY, P.C. VELJKO K. ZIVKOVICH, M.D.
ROBERT A. COLMAN, M.D.
1212 PLEASANT, SUITE 110 DES MOINES 50309 515/244-7229
ASTHMA, ALLERGY & IMMUNOLOGY
ALLERGY INSTITUTE, P.C.
A. Y. AL-SHASH, M.D.
1701 22ND STREET, SUITE 207 WEST DES MOINES 50265 515/223-8622
JOHN A. CAFFREY, M.D., P.C.
1212 PLEASANT, SUITE 106 DES MOINES 50309 515/243-0590
ALLERGY & IMMUNOLOGY
BREAST DISEASES
DIAGNOSTIC BREAST CENTER FAHIMA QALBANI, M.D.
440 UNITED FEDERAL PLAZA SIOUX CITY 51101 712/252-0135
BOARD CERTIFIED RADIOLOGIST
|. WILLIAM HOLTZE, M.D., P.C.
1221 PLEASANT, SUITE 500 DES MOINES 50309 515/241-8660
DERMATOLOGY, DERMATOLOGIC SURGERY, MOHS' SURGERY FOR SKIN CANCER AND LASER SURGERY
FAMILY PRACTICE
ACUTE CARE, INC.
P.O. BOX 515 ANKENY 50021
515/964-2772 OR 1-800/729-7813
LOCUM TENENS DOCTOR ON CALL
ELECTRODIAGNOSIS
JOHN MILNER-BRAGE, M.D.
208 ST. FRANCIS PROFESSIONAL BUILDING
WATERLOO 50702
319/234-6446
ELECTROMYOGRAPHY & NERVE CONDUCTION STUDIES CERTIFIED BY AMERICAN BOARD OF ELECTRODIAGNOSTIC MEDICINE
INFECTIOUS DISEASES
CHEST, INFECTIOUS DISEASES & CRITICAL CARE ASSOCIATES, P.C.
DANIEL H. GERVICH, M.D.
DANIEL J. SCHROEDER, M.D.
RAVI K. VEMURI, M.D.
INFECTIOUS DISEASES 1601 NW114TH, SUITE 347 DES MOINES 50325-7072 24 HOUR 515/224-1777
EMERGENCY MEDICINE
DERMATOLOGY
ROBERT J. BARRY, M.D.
1030 FIFTH AVE., S.E.
CEDAR RAPIDS 52403 319/366-7541
PRACTICE LIMITED TO DISEASES, CANCER AND SURGERY OF SKIN
DERMATOLOGY ASSOCIATES ROGER I. CEILLEY, M.D., P.C. ANDREW K. BEAN, M.D.
6000 UNIVERSITY, SUITE 450 WEST DES MOINES 50266 515/241-2000
ACUTE CARE, INC.
P.O. BOX 515 ANKENY 50021
515/964-2772 OR 1-800/729-7813
COMPREHENSIVE EMERGENCY CARE CONTRACTING, LOCUM TENENS, DOCTOR ON CALL
EMERGENCY PRACTICE ASSOCIATES P.O. BOX 1260 WATERLOO 50704 1/800/458-5003 SPECIALISTS IN EMERGENCY STAFFING & EMERGENCY DEPARTMENT SERVICES
I
Iowa Medicine
36
NEUROLOGY
IOWA MEDICAL CLINIC NEUROLOGY ANDREW C. PETERSON, M.D. LAURENCE S. KRAIN, M.D.
600 7TH STREET S.E.
CEDAR RAPIDS 52401 319/398-1721
NEUROLOGY, EEG, EMG &
EVOKED POTENTIALS
NEUROSURGERY
DES MOINES NEUROSURGEONS, P.C. ROBERT C. jONES, M.D.
S. RANDY WINSTON, M.D.
DOUGLAS R. KOONTZ, M.D.
SCOTT C. ERWOOD, M.D.
2600 GRAND AVENUE, SUITE 210 DES MOINES 50312 515/283-2217
1221 PLEASANT, SUITE 570 DES MOINES 50309 515/283-0189
PRACTICE LIMITED TO NEUROSURGERY
IOWA MEDICAL CLINIC
NEUROSURGERY
JAMES R. LAMORGESE, M.D.
600 7TH STREET, S.E.
CEDAR RAPIDS 52401 319/366-0481
PRACTICE LIMITED TO NEUROSURGERY
HOSUNG CHUNG, M.D.
SCHOITZ MEDICAL ARTS CENTER 2600 St. Francis Dr., Suite 401 WATERLOO 50702 319/232-8756
PRACTICE LIMITED TO NEUROSURGERY
EUGENE E. HERZBERGER, M.D.
300 NORTH GRANDVIEW DUBUQUE 52001 319/557-1550
PRACTICE LIMITED TO NEUROSURGERY
ROBERT A. HAYNE, M.D.
THOMAS A. CARLSTROM, M.D.
DAVID J. BOARINI, M.D.
1215 PLEASANT, SUITE 608 DES MOINES 50309 515/283-5760 NEUROLOGICAL SURGERY
OPHTHALMOLOGY
NORTH IOWA EYE CLINIC, P.C. ADDISON W. BROWN, JR., M.D. MICHAEL L. LONG, M.D.
BRADLEY L. ISAAK, M.D.
RANDALL S. BRENTON, M.D.
JAMES L. DUMMETT, M.D.
3121 4TH STREET, S.W.
P.O. BOX 1877 MASON CITY 50401 515/423-8861
WOLFE CLINIC, P.C.
OTIS D. WOLFE, M.D.
RUSSELL H. WATT, M.D.
JOHN M. GRAETHER, M.D.
RUSSELL R. WIDNER, M.D.
GILBERT W. HARRIS, M.D.
JAMES A. DAVISON, M.D.
NORMAN F. WOODLIEF, M.D.
ERIC W. BLIGARD, M.D.
DAVID D. SAGGAU, M.D.
STEVEN C. JOHNSON, M.D.
309 EAST CHURCH MARSHALLTOWN 50158 515/754-6200 SATELLITE OFFICES:
4800 WESTOWN PARKWAY REGENCY #3 WEST DES MOINES 50265 515/223-8685
300 SOUTH KENYON ROAD FORT DODGE 50501 515/576-7777
516 SOUTH DIVISION STREET CEDAR FALLS 50613 319/277-0103
OPHTHALMIC ASSOCIATES, P.C. ROBERT D. WHINERY, M.D.
STEPHEN H. WOLKEN, M.D.
ROBERT B. GOFFSTEIN, M.D.
LYSE S. STRNAD, M.D.
540 E. JEFFERSON, SUITE 201 IOWA CITY 52245 319/338-3623 FOX EYE INSTITUTE LEE BIRCHANSKY, M.D.
1953 1ST AVE., CEDAR RAPIDS 52402 1400 7TH AVE. MARION 52302 1-800-1 SEE YOU TIMOTHY F. MORAN, JR., M.D.
2800 PIERCE, SUITE 106 SIOUX CITY 51104 712/252-4333
GENERAL OPHTHALMOLOGY
OTOLARYNGOLOGY
DUBUQUE OTOLARYNGOLOGY SERVICE, P.C. THOMAS J. BENDA, M.D.
JAMES W. WHITE, M.D.
CRAIG C. HERTHER, M.D.
310 NORTH GRANDVIEW DUBUQUE 52001 319/588-0506
IOWA HEAD AND NECK ASSOCIATES, P.C. ROBERT T. BROWN, M.D.
EUGENE PETERSON, M.D.
RICHARD B. MERRICK, M.D.
3901 INGERSOLL DES MOINES 50312 515/274-9135
OTO. — HEAD & NECK SURGICAL ASSOCIATES, P.C.
THOMAS A. ERICSON, M.D.
STEVEN R. HERWIG, D.O.
MARK K. ZLAB, M.D.
1215 PLEASANT, SUITE 408 DES MOINES 50309 515/241-5780 1/800/248-4443
EAR, NOSE AND THROAT SURGERY,
EACIAL PLASTIC SURGERY, HEAD AND NECK SURGERY
WOLFE CLINIC, P.C.
MICHAEL W. HILL, M.D.
DANIEL J. BLUM, M.D.
309 EAST CHURCH MARSHALLTOWN 50158 515/752-1566 WOLFE CLINIC, P.C.
4800 WESTOWN PARKWAY REGENCY #3 WEST DES MOINES 50265 515/223-8685
OTOLARYNGOLOGY-HEAD AND NECK SURGERY, FACIAL PLASTIC SURGERY, ALLERGY
PHILLIP A. LINQUIST, D.O., P.C.
1000 ILLINOIS DES MOINES 50314 515/244-5225
EAR, NOSE AND THROAT SURGERY,
FACIAL PLASTIC SURGERY, HEAD AND NECK SURGERY
ROBERT G. SMITS, M.D., P.C.
1040 5TH AVENUE DES MOINES 50314 515/244-8152 1/800/622-0002
EAR, NOSE AND THROAT SURGERY,
FACIAL PLASTIC SURGERY AND HEAD AND NECK SURGERY
^
January 1993
37
PATHOLOGY
NICHOLS INSTITUTE LCM PATHOLOGISTS, P.C.
DAVID W. GAUGER, M.D.
ROBERT L. MAAS, M.D.
L. JEFFREY RISSMAN, M.D.
11380 AURORA AVENUE DES MOINES 50322 515/276-8402 CLINICAL CHEMISTRY, RADIOIMMUNOASSAY, MICROBIOLOGY, CYTOPATHOLOGY, HEMATOLOGY, SURGICAL AND FORENSIC PATHOLOGY
PHYSICAL MEDICINE & REHABILITATION
REHABILITATION MEDICINE ASSOCIATES WILLIAM D. DEGRAVELLES, JR., M.D.
CHARLES F. DENHART, M.D.
MARVIN M. HURD, M.D.
WILLIAM C. KOENIG, JR., M.D.
KAREN KIENKER, M.D.
YOUNKER REHABILITATION CENTER
IOWA METHODIST MEDICAL CENTER 1200 PLEASANT DES MOINES 50308 515/283-6434
MERCY'S REGIONAL REHABILITATION CENTER MERCY HOSPITAL
1401 WEST CENTRAL PARK AVENUE DAVENPORT 52804-1769 319/383-1466
MAURICE D. SCHNELL, M.D.
BOGDAN E. KRYSZTOFIAK, M.D.
ARTHUR B. SEARLE, M.D.
FAREEDUDDIN AHMED, M.D.
PULMONARY MEDICINE
CHEST, INFECTIOUS DISEASES & CRITICAL CARE ASSOCIATES, P.C.
ROGER T. LIU, M.D.
STEVEN G. BERRY, M.D.
DONALD L. BURROWS, M.D.
MICHAEL WITTE, D.O.
GERARD A. MATYSIK, D.O.
RONALD L. RAINS, M.D.
PULMONARY DISEASES 1601 NW 114TH, SUITE 347 DES MOINES 50325-7072 24 HOUR 515/224-1777
SURGERY
JOHN G. GANSKE, M.D.
1301 PENNSYLVANIA, SUITE 312 DES MOINES 50316 515/266-6558
PLASTIC, RECONSTRUCTIVE AND HAND SURGERY
SINESIO MISOL, M.D.
411 LAUREL, SUITE 3300 DES MOINES 50314 515/247-8400
ORTHOPEDIC SURGERY, SURGERY OF THE HAND
WENDELL DOWNING, M.D.
1212 PLEASANT STREET, SUITE 410 DES MOINES 50309 515/241-5767
DISEASES AND SURGERY OF THE COLON AND RECTUM
i
Are You Spending Too Much Time Managing Your Practice?
Entre Information Systems can help. More than 60,000 physicians manage the business end of medicine with The Medical Manager Practice Management Software. Entre will help your practice take advantage of the many benefits of The Medical Manager including;
• Easy to Use • Electronic Access to Hospital Information
• Electronic Claims Submission • Complete Accounts Receivable Management
Here's what other practices have to sav about The Medical Manager:
'WithneMedicalManagerwehavereducedourofficeoverheadexpensesasaresultofimproveclemployeeefficiency.Myofficemanager,
whohad never usedacomputerbefore, can ‘tlive without it!"
Sally M. Knox, M.D., Dallas, Texas
"Afteragreatdeaiofsoftwareshopping'thedecisionwasmadetopurchaseTheMedicalManager. Thiswiseinvestmenthasproventoincrease productivityandcashflowasweiiastogiveusgreaterefficiencyinscheduling. Thisuser-friendiyproductisgivenmyhighestrecommendation."
Joyce Abell, Practice Manager Harrisburg, Illinois
To find out more about the software system that physicians in over 70 different specialities are using, call Becky Oyler at (319) 366-3600.
ENTRE Information Systems
1229 First Ave, S.E., Cedar Rapids, lA (319) 366-3600
President's Privilege
William Eversmann, Jr., M.D.
What's in a name?
And the best and the worst of this is that neither is most to blame If you have forgotten my kisses and 1 have forgotten your name
— An Interlude by Swinburne, 1866
AS SWINBURNE POINTS OUT to US, remember- ing a name can be important. All the more vital if the name is easily confused with others.
Such was the circumstance with the for- mer name of the IMS Education Fund which was all too often confused with the other foundation.
During nearly 40 years of existence, the IMS Education Fund has been the source of loans to 743 medical students totaling $2.2 million. It represents the largest source of non-governmental funding for medical stu- dents at the University of Iowa but certainly is not limited to that institution.
During the most recent academic year, the IMS Education Fund provided $178,220 in loans to 43 medical students. The work of the Education Fund, however, is not limited to medical education. The Dr. Henry Albert Physician Benevolence and Public Health Fund which has received over $316,000 from its source since the mid-1960s continues to
make money available to needy physicians and their widows and supports programs such as the IMS Assistance Program for Trou- bled Physicians, the Hawkeye Science Fair and a variety of other educational and public health projects. As Iowa physicians, we con- tinue to be a primary source of funding for these activities through the IMS Education Fund and the Iowa Medical Society. In 1991, 424 physicians contributed over $21,000 to the IMS Education Fund. It is only through the generous support of physicians that this vital work can continue.
Realizing that physicians several times each year are asked to contribute to a variety of worthy causes, it seems even more im- portant now that there be no confusion con- cerning the name or purpose of the charitable organization associated with our medical soci- ety. I ask all of you — if you have not already done so with the renewal of your member- ship to the Iowa Medical Society — to support the IMS Education Fund and its vital work of medical education, support of needy physi- cians and their widows as well as a variety of health-related education projects and public health projects. That's what's in the name, IMS Education Fund. We the physicians of Iowa are its support.
February 1993
45
Here’s the Complete Pension Package You Can Establish with Complete Confidence
Centurys Qualified Pension ^ogram
As a professional, you are probably aware of how attractive a qualified pension plan can be to your organization. But you may have heard they are very complicated, full of red tape and too rigid.
That’s why you’ll appreciate the complete and flexible package from Century Pension Services, specialists in Tax-qualified Employee Benefit Plans for small to mid-size companies. With our turn-key approach to pensions, you will
never regret establishing one.
|
w \ntvv4\ \ ^ if 1 Swtiv p |
Plan Design |
.‘1500s Schedule B |
B ^^nding mS Instru- j jB nients 1 |
|
Ifonsul-M 1 lalion g |
Plan 1 Aniend- R ments |
Comput-P erized J Vulua- g lions S |
3 Plan / Lnstalla-/ 1 lion / |
For more information on the complete pension package, call today.
Robert J. Grieser, LUTCF
Representative
3737 Westown Parkway. Suite E West Des Moines. lA 50265 (515) 224-0073
James E. Pede, Jr., CFP
Representative
3737 Westown Parkway. Suite E West Des Moines. lA 50265 (515) 224-0073
Stephen D. Roe
Pension Consultant 3737 Westown Parkway. Suite E West Des Moines. lA 50265 (515) 224-0073
Michael E. Diers, CFP, LUTCF Representative 930 South Gilbert Street Iowa City, lA 52240 (319) 351-5388
Century Pension Services is a division of Century Life of America, Waverly, Iowa.
5 - PIA - 91
The Editor Comments
Marion E. Alberts^ M.D.
There Is hope
As I REFLECT UPON MY PAST pediatrics prac- tice I am sure that the most difficult part was to inform a child's parents of an unfavor- able diagnosis. Whether a deformity of a new- born infant, a serious illness, an incurable ma- lignancy or death, the task was never easy and it never became easier through the years. Physicians are often pictured as being cold about such events. Inside we are as upset as the child's family.
My first encounter with this experience was as a resident physician during the polio- myelitis epidemics of the late 1940s and early 1950s. I still have visions of a beautiful little girl, ill only a day or so, who entered the hos- pital in the morning afflicted with severe bul- bar poliomyelitis. Measures available at that time were ineffective; she died later the same day. I learned that it is a tremendous test of faith to accept such a tragedy.
Timothy was another child who remains in my memory. He was a failure to thrive in- fant. Yet, the mother with hope in her voice noted that Timothy was gaining weight — his abdomen was fatter. There was enormous en- largement of both kidneys; bilateral Wilms' tumors. He did not survive exploratory sur- gery.
Danny was an attractive young boy brought to me for evaluation of a limp. Exam- ination revealed a markedly enlarged liver.
Surgical exploration demonstrated a far-ad- vanced hepatoma. Danny died on the op- erating table.
Another child was seen in the emergency room because while on vacation she seemed less active. Her color was waxen and pale. Within an hour or so the diagnosis was evi- dent— acute lymphatic leukemia. The parents were unwilling to accept the diagnosis at first. Fortunately the child responded to medi- cal treatment.
So much for reflections of the past. This issue of IOWA MEDICINE features the subject of cancer. Much can be done for victims of can- cer, as well as other serious illnesses. I am for- tunate that I had the opportunity to practice medicine during an era of tremendous ad- vances in technology in the fields of diagno- sis and treatment. We have the means avail- able to diagnose more quickly and accurately; we have the therapeutic agents; we have the knowledge. We can provide more assurance of successful management. But, the fact re- mains that early diagnosis is the key to suc- cessful treatment. We must continually edu- cate our patients of the early signs and symptoms; we must be alert to the possibilit- ies. Our protocols of therapy are improving each year. The children upon whom I have re- flected would have had a better chance today to live and be well.
February 1993
47
MERCY HOSPITAL MEDICAL CENTER
DES MOINES, IOWA PRESENTS
ORTHOPEDIC UPDATE IN PRIMARY CARE
MARCH 24, 1993
TOPICS
GUEST FACULTY
FRANK SCHMID, M.D.
PROFESSOR OF MEDICINE DIVISION OF RHEUMATOLOGY NORTHWESTERN UNIVERSITY MEDICAL SCHOOL CHICAGO, ILLINOIS
ROBERT COFIELD, M.D.
ASSOCIATE PROFESSOR OF MEDICINE MAYO MEDICAL SCHOOL ROCHESTER, MINNESOTA
FRED DIETZ, M.D.
ASSOCIATE PROFESSOR, ORTHOPEDIC SURGERY UNIVERSITY OF IOWA HOSPITALS/CLINICS IOWA CITY, IOWA
ERNEST FOUND, M.D.
ASSOCIATE PROFESSOR, ORTHOPEDIC SURGERY UNIVERSITY OF IOWA HOSPITALS/CLINICS IOWA CITY, IOWA
BRUCE BARTIE, D.O.
STAFF SURGEON METROPOLITAN SPINE GROUP FAIRVIEW RIVERSIDE MEDICAL CENTER MINNEAPOLIS, MINNESOTA
“INFECTIOUS DISEASES OF BONE, JOINTS AND BURSAE”
“ARTHRITIS OF THE SHOULDER”
“ADOLESCENT LEG PAIN”
“LOW BACK PAIN”
“SURGICAL TREATMENT OF ADULT AND PEDIATRIC SCOLIOSIS”
Approved by Mercy Hospital Medical Center, an IMS-ac- credited CME organization, for 4 hours Category 1/A.M.A. Physicians’ Recognition Award.
Nursing CEU’s: 0.5 (5 contact hours)
Application has been made for additional accreditations.
Physicians $40.00
Physicians’ Assistants $20.00
Registered Nurses $20.00
Paramedicals $20.00
Residents and Medical Students Are Complimentary. ADVANCED REGISTRATION REQUESTED!
THE SEMINAR WILL BE HELD IN THE MERCY EDUCATION CENTER AT FIFTH STREET AND UNIVERSITY AVENUE IN DES MOINES, IOWA. PARKING IS AVAILABLE ADJACENT TO THE EDUCATION CENTER.
CONTACT: DEPARTMENT OF MEDICAL EDUCATION MERCY HOSPITAL MEDICAL CENTER SIXTH AND UNIVERSITY DES MOINES, IOWA 50314 515/247-3042
Patients benefit if cancer specialists^ family physicians communicate
Cancer patients often have needs the specialist can't fill. This oncologist discusses the special role family physicians can play when their patients are undergoing treatment for cancer.
PRIMARY CARE PHYSICIANS SHOULD not be relegated to the background when their patients are being treated for cancer, says an Iowa oncologist.
"A patient benefits greatly if the primary care physician and the specialist work to- gether during the cancer treatment," com- ments Dean Gesme, M.D., a Cedar Rapids on- cologist and president of the Iowa Division, American Cancer Society. "We specialists look to family physicians to remain involved in several key areas."
The first and most crucial is in the area of emotional support for patients dealing with the disbelief, anger and anxiety that ac- company a diagnosis of cancer.
"Cancer patients need so much emo- tional support and their family physician is often in the best position to offer it," says Dr. Gesme. "Some patients get very angry and stay that way. Others don't get angry at all. Some are disbelieving. There are patients who, for weeks and weeks, deny the diagno- sis. Every patient reacts differently and the patient's family physician is in the best posi- tion to know how a patient will cope with this disease and what resources they have in this time of stress."
The patient's primary care physician can help a patient "redirect the anxiety and de- nial in a productive way," adds Dr. Gesme.
"It's human nature to want to find out what caused a problem and what we can do
to fix it. A diagnosis of cancer goes against common sense and can evoke some emotions that can be very difficult to deal with."
Emotion-filled atmosphere
Family physicians can also play a key role as mediators in helping patients understand their diagnosis and treatment plans.
"A specialist probably doesn't know the patient very well and might overestimate their level of understanding. Also, the atmo- sphere is so emotion-filled that it often pre- vents a clear understanding of what the oncol- ogist is saying," adds Dr. Gesme. "When patients are told they have cancer, it's diffi- cult for them to assimilate huge amounts of information about their diagnosis and progno- sis."
Consequently, the patient may go back to the family physician later for a second ex- planation or further information.
"Talking to their family physician is a great way for the patient to reinforce what they have heard or be reassured about cer- tain treatment options," he says. "The patient is closer to the family physician and that phy- sician's word probably carries more weight. That physician is in a better position to help educate the patient and redirect their emo- tions."
Though Dr. Gesme says miscommunica- tion between family physicians and oncolo-
( Continued next page)
February 1993
49
gists is "infrequent," he believes patients would benefit if communications were more open. The problem, he explains, is not know- ing how involved the primary care physician wants to be in the cancer treatment.
"It's a matter of being sensitive to the de- sires of the individual doctor and reaching a compromise. Some family physicians want daily reports on a patient's status; others are comfortable being less involved. Some of us consultants do a better job of communicating than others. Problems arise when assump- tions are made which probably shouldn't be made."
Complex situations arise quickly
One problem, he says, is that family physi- cians sometimes don't feel qualified to deal with a patient being treated for cancer.
"Sometimes the family physician can end up having to care for the patient when complications arise. Cancer treatment can cause severe situations such as acute infec- tions or allergic reactions that develop very quickly," he explains.
This situation can be even more problem- atic when the patient lives in a rural area far from the specialist.
"Maybe the patient has had cancer treat- ment the day before, and the family physi- cian doesn't even know what the treatment entailed." Dr. Gesme says. "It's important for the physician to have the knowledge to deter- mine whether it's the treatment or the cancer that's causing the problem."
In some states, there are courses for pri- mary care physicians in rural areas on how to deal with cancer and cancer treatment com- plications in their patients and Dr. Gesme be- lieves there should be more emphasis on this subject in physician training.
Dr. Gesme's feels strongly that the pri- mary care physician and the specialist should be able to communicate freely about their pa- tient.
"The patient's family physician should make use of the oncologist at any time for any reason to the full extent of their needs. They should ask questions and be persistent. If a family physician wants to continue pro- viding medical care for the patient, they should tell the specialist. If they want to turn it over to us, they need to let us know that, too. We need to make use of each other's abil- ities."
BLISS
CANCER
CENTER
Offering
Oncology Treatment & Support Services
The William R. Bliss Cancer Center, located at Mary Greeley Medical Center and McFarland Clinic P.C. in Ames, is a comprehensive cancer treatment center serving the communities of north central Iowa. It offers such services as radiation therapy, chemotherapy, cancer surgery, diagnosis and staging of malignancies, and a specialized inpatient oncology unit.
MEDICAL ONCOLOGY
M. Michael Guffy, M.D.
Larry A. Otteman, M.D.
Elie P. Saikaly, M.D.
239-4401
RADIATION ONCOLOGY
Gregory Yee, M.D.
John Ptacek, M.D.
239-2411
8 a.m. to 5 p.m. Monday through Friday 8 a.m. to 12 noon Saturday
800-678-8661
Iowa Medicine
50
DOCTOR,
YOUR PRACTICE REQUIRES MORE THAN GUESSWORK.
Whether it’s a regulatory complexity, a human resources challenge or a reimbursement issue, your medical practice faces choices and hundreds of decisions.
Now is no time for guesswork.
You need to know about the Iowa Medical Group Management Association (IMGMA). It’s an organization that promotes and upholds high standards of medical management. And, through its membership, IMGMA represents nearly 80% of Iowa’s active physicians.
IMGMA is a source of valuable information — through Spring and Fall education programs, quarterly newsletters, salary surveys, etc.
Encourage your management staff to become active within the IMGMA membership. It can mean the difference between certainty and guesswork in your medical practice.
Doctor, we’re in the game with you.
IOWA MEDICAL GROUP MANAGEMENT ASSOCIATION
1001 Grand Avenue, West Des Moines, lA 50265 Phone: 515/223-2816 or toll-free 1-800-728-5398
1
9
9
3
5TH ANNUAL CEDAR RAPIDS
SYMPOSIUM
FOR THE PRACTICING PRIMARY CARE PHYSICIAN
February 26, 1 993 COLLINS PLAZA HOTEL CEDAR RAPIDS, IOWA Keynote speakers
Ronald M. Lauer Robert L. Replogle
Keynote Speakers
Greg C. Flaker, M.D. Michael D. Winniford, M.D.
Course Objectives and Intended Audience
This course is designed to provide family practitioners, internists, other primary care physicians and nurses with practical approaches to common cardiovascular disorders. The course will emphasize diagnostic evaluation, treatment modalities and day-to-day management of these disorders from the perspective of the primary care physician.
Accreditation
Credit hours have been applied for through the following organizations:
American Academy of Family Physicians American Osteopathic Association CME’s by Cedar Rapids Medical Education Program CEU’s by Mercy Medical Center
Registration Fees:
• Physicians $50.00
' Nurses and Residents $25.00 [includes course materials, breakfast, lunch and 'efreshments)
■ Registration Deadline is February 18, 1993.
■ Registration is limited. For registration information,
; Dlease contact June Zenisek, R.N., Symposium
; Coordinator, 31 9-362-51 1 8 or 1 -800-728-51 1 8.
Agenda
8:30 Registration
9:00 Opening Remarks — Dr. Ersin Atay
9:15 Atrial Fibrillation: New Ideas on an Old Arrhythm' Dr. Greg Flaker
10:00 Interventional Cardiology in the 90’s —
Dr. Michael Winniford 10:45 Break
1 1 :00 Healthcare in the 90’s: Cost versus Technology- Dr. Robert L. Replogle 1 1 :45 Ouestion Session 12:15 Lunch
1:15 The Significance of Cholesterol in Childhood — Dr. Ronald M. Lauer
2:00 Break
Concurrent Workshops
2:15 — Mitral Valve Prolapse — Dr. Todd Langager
— Peripheral Vascular Disease — Dr. Kevin Kopei — Rehabilitation of the Cardiac Patient — '
Dr. David Rater
3:00 Break
3:15 — Echocardiograms in Congenital Heart Diseasi |'
Dr. Stephen Roth j
— Innocent Heart Murmurs — Dr. Ronald Lauer — Medical Case Studies — Dr. Richard Fleming ^
4:00 Evaluations
IOWA MEDICINE Interview
Cancer rates and treatment options both increase for lowans
Cancer rates among lowans have increased in the past 20 years, but so have possible treatments for people diagnosed with certain types of cancer, say two experts from the University of lowans Department of Internal Medicine.
Gerald Clamon, M.D.
Charles Lynch, M.D., Ph.D.
Iowa City, Iowa
What are the most significant recent develop- ments in radiation and chemotherapy treat- ments for cancer?
New advances include the development of new agents for the treatment of cancer: Flu- darabine for chronic lymphocytic leukemia, Chlorodeoxyadenosine for hairy cell leuke- mia and Taxol for ovarian cancer. Taxol may also be promising in breast cancer, melanoma and lung cancer.
Other new drugs showing promise in- clude Camptothecan and related drugs for treatment of a broad range of tumors.
In colon cancer, 5 Fluorouracil and Leva- misole as adjuvant therapy for patients with resected Dukes C colon cancer have demon- strated that recurrence rates can be decreased with therapy. Patients with Dukes C disease and selected patients with Dukes B2 disease (either with a colon or rectal cancer primary) should be considered for adjuvant therapy.
For selected patients with node negative breast cancer, adjuvant therapy with Tamoxi- fen or chemotherapy may also reduce the re-
lapse rate. Patients with an excellent progno- sis— such as women with tumors under 1 cm — do not need such adjuvant therapy.
In radiation therapy, there are indica- tions twice daily therapy may be an improve- ment in the control of some cancers. In pa- tients with locally advanced head and neck cancer and in some patients with limited small cell lung cancer, BID fraction radiation therapy may be important in disease control. Ongoing studies will likely further define the utility of such therapy.
An important advance in cancer therapy falls in the area of supportive care. Use of erythropoietin, G-CSF and GM-CSF to im- prove blood counts post therapy has made it possible for patients to tolerate intensive ther- apies with less risk of neutropenic infection or anemia. Newer growth factors are under experimental trial and will likely be an im- provement since they will also support plate- let recovery. IL-3 is one such new growth fac- tor under investigation.
What types of cancer are showing the highest treatment success rate?
Hodgkins disease, non-Hodgkins lympho- mas, choriocarcinoma and testicular carci-
February 1993
53
(Continued next page)
noma remain among the most curable, even in patients with advanced disease. Hairy cell leukemia is now a potentially curable disease with 2-chlorodeoxyadenosine.
For patients with common epithelial can- cers such as colon cancer, lung cancer, blad- der cancer, and breast cancer, combinations of surgery, adjuvant or neo-adjuvant therapy and radiation therapy have proved successful in patients who were not surgically resect- able. The use of such neoadjuvant therapy (chemotherapy to reduce a tumor prior to sur- gery) is being tested in national trials.
Intensive chemotherapy with autologous bone marrow transplant to rescue from the side effects of chemotherapy can be a cura- tive therapy in patients with acute leukemia, chronic myelogenous leukemia, refractory Hodgkins and non-Hodgkins lymphomas and perhaps breast cancer.
Are more lowans getting cancer?
Since 1973, the cancer experience of lowans has been monitored through the State Health Registry of Iowa. The number of lowans an- nually diagnosed with cancer has been in- creasing. In 1973, the number of malignant cancers diagnosed was 10,100. This increased to 13,000 in 1990.
During this time period Iowa's total pop- ulation and age-distribution have changed. Because of this, a mechanism has been estab- lished to obtain age-adjusted cancer rates per
100.000 population. These rates allow for a better assessment of population changes in cancer frequency over time.
In 1973, this rate for all malignant can- cers in Iowa was 307.4. The rate increased to
355.0 in 1990. Between 1973 and 1990, the rate for malignant cancer in Iowa increased 15.5%. The increase has occurred in a steady and gradual manner among men and women.
What role does the patient's primary care phy- sician play in radiation or chemotherapy treat- ment? How can the specialist help the pa- tient's family physician in educating the patient about the effects of these treatments?
The majority of cancer care is likely given by the patient's primary care physician. From the beginning, the close relationship between the patient and physician leads many pa- tients to ask their primary physician if they should take therapy.
The primary physician can help the pa- tient consider the goal of the therapy. Is the specialist offering a potentially curative ther- apy? Is the proposed therapy possibly going to prolong life? Is the therapy apt to amelio- rate any side effects of the cancer? If the goal of therapy is to ameliorate side effects but not cure or prolong life, the patient may want to weigh the risks of therapy versus the symptoms being treated.
In a patient under chemotherapy, control of nausea or vomiting once the patient goes home is often a major problem. In patients who have received chemotherapy recently, nausea or vomiting may be controlled with Ondansetron 0.15 mg/kg every 4 hours if standard anti-emetics have not worked.
Patients who have a neutrophil count un- der 1000 and any significant infection or tem- perature over 100, must be hospitalized for broad spectrum antibiotics after cultures are obtained.
For almost all patients with petechiae, ep- istaxis or other bleeding and a platelet count under 20,000 or falling, platelet transfusions will be needed.
w.
hen I completed my residency it was tough paying back college loans. Today, the Air Force Reserve offers a monthly stipend to residents in general and orthopedic surgery and anesthesiology. Additionally, through the loan repayment program, you may qualify for repayment of out- standing student loans. This program allows repayment of loons up to $3,000 a year, and $20,000 overall.
Examine the oppor- tunities as part of this world- class operation. Because while they're giving you the green, you won't be singing the blues.
Call: (512)369-3245 Or Write To: RSH-3 Bldg 2900 Beigslfom AFB Austin, TX 78743-6002
JtIR FORCE RCSERVC
A GREAT WAY TO SERVE
Iowa Medicine
54
Are You Spending Too Much Time Managing Your Practice?
Entre Information Systems can help. More than 60,000 physicians manage the business end of medicine with The Medical Manager Practice Management Software. Entre will help your practice take advantage of the many benefits of The Medical Manager including:
• Easy to Use • Electronic Access to Hospital Information
• Electronic Claims Submission • Complete Accounts Receivable Management
Here's what other practices have to sav about The Medical Manager:
"WithTheMedicalManagerwehavereducedourofficeoverheadexpensesasaresultofimprovedemployeeefficiency.Myofficemanager,
''Afteragreatdealof'softwareshopping'thedecisionwasmadetopurchaseTheMedicalManager. Thiswise investmenthasprovento increase productivityandcashfiowasweliastogiveusgreaterefficiencyinscheduiing.Thisuser-friendiyproductisgivenmyhighestrecommendation."
Joyce Abell, Practice Manager Harrisburg, Illinois
To find out more about the software system that physicians in over 70 different specialities are using, caii Becky Oyier at (319) 366-3600.
ENTRE Information Systems
1229 First Ave, S.E., Cedar Rapids, lA (319) 366-3600
A
Top 5 reasons for not joining IMPAC
1* Politics bore me.
2* Let someone else do it.
3* I don’t have the money.
4« It doesn’t matter who gets elected. 5* Health Care Reform won’t affect me.
Political apathy. . . . a luxury you can’t afford
IMRIC
Iowa Medical Society Political Action Committee
Contributions are not limited to the suggested amount. Neither the AMA nor the IMS will favor or disadvantage anyone based upon the amounts of or failure to make pac contributions. Contributions are subject to the limitations of FEC Regulations. (Federal Regulations require this notice.) Paid for by the Iowa Medical Political Action Committee, 1001 Grand Avenue, West Des Moines, LA 50265. Contributions to AMP AC and IMPAC are not deductible as charitable contributions for Federal Income Tax purposes. If your practice is incorporated, IMPAC and AMPAC voluntary political contributions should be written on a personal check.
Letter to the Editor
Scott County was willing to accept small sacrifice
Dear Editor:
The Scott County Medical Society was disappointed to learn that HCFA has denied the IMS request that Iowa be converted to a single statewide payment area for Medicare reimbursement. Reason for the denial, ac- cording to HCFA, was that 70% of the “los- ing" physicians in areas 01 and 05 opposed the change.
We want the physicians of Iowa to know that the Scott County Medical Society voted in May, 1992 to support the single payment area, even though it would mean a decrease
in Medicare reimbursement for those of us in area 01. In the interest of fairness we were willing to accept a slight reimbursement de- crease if it meant fairer reimbursement for the hard-pressed physicians who serve rural Iowa.
The government is seeking to reduce the number of Medicare reimbursement areas in the nation, and this would have been a major step toward more regionalized rates.
If we truly believe in the goals of the Iowa Medical Society, it is apparent that some of us may have to sacrifice for the good of the many. The Scott County Medical Soci- ety voted to accept this small sacrifice in the interest of fairness and in the belief that a sin- gle Medicare reimbursement area would have long-term beneficial effects for Iowa physicians and our patients. — Mary Hoppa, M.D., Davenport
Tribute to a friend
Emmett Mathiasen, M.D.
Council Bluffs
Editor's note: Dr. Max Olsen, a family physician from Minden, died December 3, 1992. Dr. Olsen was very involved in organized medicine. He was a past president of the Pottawattamie-Mills County Medical Society and was also very active in the Iowa Medical Society. Dr. Olsen practiced 42 years, all of them in Minden. Dr. Mathiasen and Dr. Olsen were close friends of many years.
Max OLSEN WAS A CARING family physi- cian in a rural community, treating pa- tients of at least four generations. He helped bring about access to quality care through his work in the medical field and with the Iowa Medical Society.
Max touched people in numerous ways, having friends in all walks of life and proba- bly in every state in the country. He was a humble man who did not brag about all the things he did, letting his deeds speak for themselves.
His many loves, besides friends and pa- tients, included animals and farming, conser- vation (he planted hundreds of trees at West- fair in Pottawattamie County), woodworking
(including making gadgets for friends), 4-H work, fairs, going "shopping" at stores and auctions and best of all, visiting with anyone, always with a smile on his face.
As long-time friends. Art Sciortino and I will miss Max's almost daily phone calls, checking on our welfare and making plans for frequent lunches.
To change an old expression, under "friend" in the dictionary should be Max Olsen's picture.
He worked hard and long and now de- serves his rest.
.S-»;f|SPs3»
e give Iowa Physicians the “Lowe” down on heaith, disahiiity, iife, and other insurance
At the new Bernie Lowe & Associates, Inc., we give Iowa Medical Society member physicians quality insurance counsel. We have done so for 40 years under The Prouty Company banner.
Newly named in 1992, Bernie Lowe & Associates, Inc., is dedicated to supplying you and your colleagues with state-of-the-art insurance protection.
IMS-endorsed insurance coverages are available in various essential areas - health, accident and disability, life, etc.
As the IMS insurance administrator, we work year-round with IMS SERVICES to address your inquiries. Our team of Bernie Lowe, Ruth Clare, Terri DeGroot and Sandy Wheeler is anxious to serve you at any time. Please contact us.
BERNIE LOWE N ABBDEIATE5. INE.
A SUCCESSOR TO THE PROUTY COMPANY E7DD Westown Parkway. Suite 41D West Des Moines. Iowa 5DEB5-1411 515-EEE-DB11 l-BDD-g4E-471B FAX 51B-EEE-Dgi5
About IMS Members
i New members (as of January 21, 1993)
Eugene Wiemers, M.D., 81, life member, psychiatry, Davenport, died October 30 John Bakody, M.D., 78, life member, neurological surgery, Des Moines, died December 29
Robert Hinnen, M.D., family practice, Burlington Leroy Travers, M.D., radiology, Burlington Karl Kreder, M.D., urology, Iowa City f James McCoy, M.D., urology, Iowa City I Kevin Mulhern, M.D., cardiology, Iowa City Jerold Woodhead, M.D., pediatrics, Iowa City Gary Aragon, M.D., resident, Iowa City Steven Davis, M.D., resident, Iowa City Jennifer Palmer, M.D., resident, Iowa City I John Rogers, M.D., resident, Iowa City
Kaza Basavapunna, M.D., psychiatry, Clinton Louis Flores, M.D., family practice, Muscatine Barry Marun, M.D., orthopaedics, Muscatine Andrew Andersen, M.D., family practice, Bettendorf Mark litis, M.D., family practice, Bettendorf James Putman, M.D., family practice, Bettendorf Todd Ridenour, M.D., neurosurgery, Davenport Douglas Workman, M.D., family practice, Bettendorf Brent Feller, M.D., anesthesiology. Cedar Rapids Edwin Castaneda, M.D., orthopaedics, Dubuque John Lorenz, M.D., psychiatry, Dubuque Mark Moore, M.D., internal medicine. East Dubuque Charles Morrow, M.D., orthopaedics, Dubuque ! Mark Niemer, M.D., rheumatology, Dubuque i Leslie Riley, M.D., internal medicine, Dubuque I Peter Tinsman, M.D., obstetrics /gynecology, Dubuque j Rhett Eckmann, M.D., resident. Mason City ! Brian Hass, M.D., resident. Mason City j John Ingram, M.D., resident. Mason City I Paul Matthews, M.D., resident. Mason City I Djonggi Situmeang, M.D., resident. Mason City Jeffrey Wilwert, D.O., family practice, Oelwein Joan Harding, M.D., family practice. Belle Plaine Sushil Upadhyay, M.D., psychiatry. Independence Jerald Phipps, D.O., family practice, Boone Steven Hallberg, M.D., internal medicine, locum tenens
James Shehan, M.D., internal medicine, Albia Douglas Weedman, M.D., family practice, Ottumwa Caroline Boehnke, M.D., obstetrics/ gynecology. West Des Moines
Kent Kunze, M.D., child /adolescent psychiatry, Des Moines
Karla Cheney, M.D., resident, Des Moines Mark Schultz, D.O., family practice. Storm Lake Garth Purves, M.D., neurosurgery, Sioux City Roger Weste, M.D., resident, Sioux City
Deceased members
Dean Dutton, M.D., 84, life member, family practice. Van Horne, died December 23 Gerald Larson, M.D., 69, family practice. Elk Horn, died December 16
Patricia Hicks, M.D., 70, family practice /gynecology, Iowa City, died December 7 Aida Belarmino, M.D., 54, pediatrics, Davenport, died November 22
Max Olsen, M.D., 72, family practice, Minden, died December 3
Fortunato Neglia, M.D., 77, life member, family practice. Maxwell, died October 7
Items in this column are compiled from IMS membership department records. News from individual physicians, clinics and hospitals is welcomed. Send news items to: “About IMS Members" c/o IOWA MEDICINE, 1001 Grand Avenue, West Des Moines, Iowa 50265.
Miscellaneous
Nancy Andreasen, M.D., Iowa City, has been named editor of The American Journal of Psychiatry.
Douglas Dorner, M.D. and David Stubbs, M.D. were recently recertified in general vascular surgery by the American Board of Surgery.
College of Medicine Highlights
THE NUMBER OF HOSPITAL-ACQUIRED INFECTIONS could be reduced by 25% if health care workers washed their hands with chlorhexidine, an antimicrobial soap, instead of using soap and alcohol, report Drs. Rich- ard Wenzel and Bradley Doebbeling, inter- nal medicine. The results of their eight- month study that involved 1,894 adult pa- tients in three intensive care units were re- ported in the Neiv England Journal of Medicine. They reported 152 infections when chlorhexi- (Continued next page)
STEINWAY 6 SONS
The Artist Accepted Piano. The Finest In Craftsmanship And Materials For The Finest Sound.
KAWAI
Reflecting Rich Tone Quality And Technical Excellence.
Rx: yy\o)^t cv
2/1 qn q'
pen
86th & Douglas 515-278-4685
February 1993
59
dine was used versus 202 when the alcohol- soap combination was used. While the use of the antimicrobial soap helped reduce the inci- dence of hospital-acquired infections, such in- fections could be further reduced if health care workers washed their hands more often, as recommended under accepted protocols, the researchers noted.
THE GENE FOR BEST'S DISEASE, a rare, potentially blinding eye disease, has been mapped to chromosome 11 by College of Medicine researchers. The work is a major step toward isolating the Best's disease gene which the investigators hope will eventually provide clues to the cause of age-related mac- ular degeneration, the most common cause of legal blindness in older people. The study was directed by Dr. Edwin Stone, ophthal- mology; co-director was Dr. Val Sheffield, pediatrics. Dr. Alan Kimura, ophthalmol- ogy, collaborated on the project.
INJURIES SUCH AS BACK OR NECK PAIN, which build up over time instead of occurring in a single accident, are often not identified as work-related and may not be covered by workers' compensation, reports Thomas Cook, physical therapy and preven- tive medicine and environmental health. Cook is investigating the incidence of long- term cumulative injuries among construction workers as part of a joint program between the UI and the Eastern Iowa Construction Al- liance. While the construction industry has the fifth largest work force in the country and the third highest death rate, many con- struction workers are more likely to be af- fected by injuries resulting from cumulative traumatic effects of their work than from in- stantaneous injuries such as a fall. In a sur- vey of 536 construction workers in eastern Iowa, nearly four in five workers reported that low-back pain caused them to miss work in the 12-month period prior to the study.
RUN A SPECIAL PRACTICE.
Today’s Air Force has special opportuni- ties for qualified physicians and physi- cian specialists. To pursue medical excel- lence without the overhead of a private practice, talk to an Air Force medical pro- gram manager about the quality lifestyle, quality benefits and 30 days of vacation with pay each year that are part of a medical career with the Air Force. Dis- cover how special an Air Force practice can be. Call
USAF HEALTH PROFESSIONS TOLL FREE 1-800-423-USAF
Iowa Medicine
60
Family Medicine
Leave A Lot Behind As A Marshfield Clinic Family Practitioner.
At Marshfield Clinic, a 400-physician L multi-specialty practice, you’ll leave sixteen-hour workdays, time consuming business concerns, and the hassles of paperwork behind you!
Practice
I Here, you can concentrate
on Family Medicine. We’ll put a staff of administrative experts behind you and a team of trained health care professionals beside you. Also, we’ll compensate you very well.
Location/Lifestyle
I These opportunities are available at our Lakeland Center located in Minoqua/Woodruff, Wisconsin. This area is defined by beautiful woods and an abundance of lakes, rivers, and streams. It’s the chance to spend
your days doing what you do best — treating patients. And your nights — getting to know your family again.
If you would like to practice in a state-of-the-art healthcare setting, if you enjoy a life-style that’s rich with recreational diversity, and if you are seeking professional excellence in a family- oriented environment, contact David Draves at 1-800-782-8581, ext. 7-5376.
% MARSHFIELDCLINIC
1000 North Oak Avenue Marshfield, WI 54449
EOE/AAM/F/H/V
ONE, Order, Shipment, Supplier
Why waste valuable staff time coordinating orders, shipments, and supplies with multiple vendors when Hawkeye Medical Supply, Inc. does it all?
ONE ORDER: All medical supplies and office supplies, everything you need from Hawkeye Medical. Just think of us as your storeroom. Thousands of items to choose from. Save time and money by ordering what you need when you need it. No minimum orders and toll free phone lines make ordering easy!
ONE SHIPMENT : Hawkeye Medical Supply ships most orders the same day. You can inventory only what you need by using us as an extension of your storeroom and not tie up your dollars in inventory!
ONE SUPPLIER; With Hawkeye Medical Supply as your single supplier for medical and office supply products, you can reduce your transaction costs with fewer orders to receive, fewer phone calls, which results in more efficient use of your personnel!
Our knowledgeable, experienced, and dependable sales and customer service organization stand behind every product that we sell!
For more information, contact your local salesperson or call us:
HOME OFFICE: 225 E. PRENTISS STREET, IOWA CITY, IOWA 52244 (319) 337-3121
BRANCH OFFICES: 7212 UNIVERSITY AVENUE, DES MOINES, IOWA 5031 1 (515) 274-4015
901 E. KIMBERLY ROAD, DAVENPORT, IOWA 52807 (319) 386-1345
HAWKEYE MEDICAL SUPPLY, INC.
Toll Free 1-800-272-6448
February 1993
61
elOWA METHODIST MEDICAL CENTER
The Throckmorton Surgical Society and Iowa Academy of Surgery Spring Meetings
April 30-May 1, 1993 Jester Auditorium Iowa Methodist Medical Center Des Moines, Iowa
Friday, April 30, 1993: The Throckmorton Surgical Symposium on Breast Cancer
Society
John M. Bedwinek, M.D.
Director, Radiation Oncology St. joseph's Hospital Cancer Center St. Louis, Missouri
Blake Cady, M.D.
Professor of Surgery Harvard Medical School Chief of Surgical Oncology New England Deaconess Hospital Boston, Massachusetts
Guest Faculty
Frank E. Gump, M.D.
Chief, Surgical Service Department of Veterans Affairs Professor of Surgery UMDN)/New Jersey Medical School East Orange, New jersey
Peter R. Jochimsen, M.D.
Professor, Surgery
University of Iowa College of Medicine Director, Surgical Oncology University of Iowa Hospitals and Clinics Iowa City, Iowa
Karl G. Kardinal, M.D.
Ochner Clinic
New Orleans, Louisiana
Richard J. Field, M.D.
General Surgeon Centreville, Mississippi
Topics
• Postmastectomy Irridation: What is Its Role Today?
• Limitations of Mammographic Screening
• Breast Conservation Surgery: Patient Selection
• Treatment of Noninvasive Breast Cancer
• Contemporary Therapy of Early Breast Cancer
• Management of the High Risk Breast Patient
• Tamoxifen Breast Cancer Prevention Trial
• Pitfalls of Needle Localization and Sterotactic Techniques
• Rationale for and Status of the NSABP Prevention Trial
• Management of Locally Advanced and Inflammatory Breast Cancer
• Update on Adjuvant Therapy of Breast Cancer
• Surgery in Rural America
Saturday, May 1, 1993: Iowa Academy of Surgery Meeting
William W. Eversmann, Jr., M.D.
President, Iowa Medical Society Orthopedic Surgeon Cedar Rapids, Iowa
Speakers
Roger D. Tracy
Assistant to the Dean/Director,
Office of Community-Based Programs University of Iowa Hospitals and Clinics Iowa City, Iowa
Daniel K. Zismer, Ph.D.
Principal, Director and Co-Founder of Partners Consulting Group, Ltd. Minneapolis, Minnesota
Topics
• Presentation of Resident Competition Papers and • Hospital-Physician Relationship in the '90s
Awards at the Scientific and Clinical Session
• The Future of Health Care Reform In Iowa:
Where is Iowa Going?
• The Future of Rural Medical Care in Iowa
• Panel Discussion: Where is the Solo Physician Going? Crystal Ball Predictions
FEES: Physicians $150.00
Residents $ 35.00
As an organization accredited for Continuing Medical Education, the Iowa Methodist Medical Center certifies that this CME program meets the criteria in Category 1 of the Physicians Recognition Award of the AMA.
FACTS ABOUT CANCER IN IOWA
During 1993, cancer will cause one of every four deaths
During 1993, lowans will develop 14,000 new cancers
live out of six cancers occur in lowans 55 and older
The University of Iowa 100 Westlawn Bldg. S Iowa City, lA 52242-1100 (319) 335-8609
lung cancer causes one in four deaths
Prostate cancer will comprise one-fourth of the new cancer cases in men
Breast cancer will comprise 30 percent of all new cancer cases in women
in 1993, an estimated 6,350 lowans will die from
cancer, ten times the number caused by auto fatalities. These projections are based on data from the State Health Registry of Iowa. The registry has been recording the occurrence of cancer in Iowa since 1973.
As one of ten registries in the country funded by the National Cancer Institute (NCI), Iowa represents the rural and Midwestern populations and provides data found in many NCI publications.
CANCER PROJECTIONS FOR 1993
Cancer occurs throughout the state and affects lowans of all ages and in every walk of life. In 1 993, cancer will strike four out of every 1,000 lowans and bring death to two of them.
The State Health Registry of Iowa is located at The University of Iowa in the College of Medicine's Department of Preventive Medicine and Environmental Health. The staff includes more than 50 people. Half of them, situated throughout the state, regularly visit hospitals, clinics, and medical laboratories in Iowa and neighboring states. In 1993, data will be collected on 14,000 new cases among Iowa residents. A follow-up pro- gram tracks more than 97 percent of the 250,000 lowans diagnosed with cancer since 1973. This program provides regular updates to keep the data current and useful.
This excerpt provides information from the State Health Registry's annual publication Cancer in Iowa.
ESTIMATED NUMBER OF NEW CANCERS IN IOWA FOR 1 993
ESTIMATED NUMBER OF CANCER DEATHS IN IOWA FOR 1 993
.1
Among women, cancers of the reproductive organs, including breast, ovary, uterus, and cervix, comprise more than 40 percent of all new cancers. Lung cancer is on the rise as the leading cause of cancer deaths.
Prostate cancer comprises over one- fourth of all new cancers in men and continues a decade-long rise in occurrence. Lung cancer causes one- third of all cancer deaths in men.
TOP 1 0 TYPES OF CANCER IN IOWA ESTIMATED FOR 1 993
New Cancer in Femoles
SITE # OF CASES % OF TOM
|
_Blf.AST_, |
2181 |
29.6 |
|
COLON a RECTUM |
1080 |
15.4 |
|
LUN6 |
710 |
10.1 |
|
UTERUS |
430 |
6.1 |
|
OVARY |
350 |
5.0 |
|
NON-HODGKIN'S LYMPH. |
300 |
4.3 |
|
LEUKEMIA |
170 |
2.4 |
|
PANCREAS |
170 |
2.4 |
|
SKIN MEUNOMA |
165 |
2.4 |
|
CERVIX |
155 |
2.2 |
|
ALL OTHERS |
1410 |
20.1 |
|
iTOlAl’ ^ ' |
7020 |
^ J ' i ■ |
|
PROSTATE |
1870 |
26.8 |
|
LUNS_ .. : |
1450 |
20.8 |
|
COLONS RECTUM |
1030 |
14.8 |
|
NON-HODGKIN'S LYMPH. |
275 |
3.9 |
|
BLADDER |
255 |
3.7 |
|
LEUKEMIA |
230 |
3.3 |
|
KIDNEYS RENAL PELVIS |
190 |
2.7 |
|
SKIN MELANOMA |
175 |
2.5 |
|
PANCREAS |
155 |
2.2 |
|
ORAL CAVITY |
150 |
2.1 |
|
ALL OTHERS |
1200 |
17.2 |
|
i TOTAL |
6980 |
"I |
KIDNEY & RENAL PELVIS 80 2.6
BRAIN 70 2.3
UTERUS 65 2.1
ALL OTHERS 625 20.5
|
LUNG |
1100 |
33.3 I |
|
PROSTATE |
445 |
13.5 |
|
COLON S REOUM |
390 |
11.8 |
|
PANCREAS |
150 |
4.5 |
|
NON-HODGKIN'S LYMPH. |
140 |
4.2 |
|
LEUKEMIA |
135 |
4.1 |
|
BLADDER |
95 |
2.9 |
|
ESOPHAGUS |
80 |
2.4 |
|
BRAIN |
80 |
2.4 |
|
KIDNEY S RENAL PELVIS |
80 |
2.4 |
|
ALL OTHERS |
605 |
18.3 |
|
1 TOTAL |
3300 |
TOP 1 O CAUSES OF DEATH IN IOWA ESTIMATED FOR 1 993
Cancer remains the second most common cause of death. Over the past 25 years, deaths from heart disease have markedly decreased while cancer has continued a steady increase. If these trends continue, cancer will become the leading cause of death early in the next century.
Cancer occurs in people of all ages, although more than 80 percent of the cases occur in those 55 and older. Among children, leukemia and brain cancer are most common, while lung, colon and rectum, breast, and prostate cancer occur with greatest frequency among older lowans.
CAUSE
HEART DISEASE CANCER
CEREBROVASCULAR DISEASE
CHRONIC OBSTRUCTIVE & PULMONARY
PNEUMONIA
ACCIDENTS
DIABETES
ARTERIOSCLEROSIS OTHER ARTERIAL DISEASES SUICIDES
ALL OTHER CAUSES
NO. PERCENT
9000 32.7
6350 23.1
2050 7.5
1250 4.5
1200 4.4
1150 4.2
600 2.2
480 1.7
385 1.4
310 1.1
4725 17.2
TOP 3 TYPES OF NEW CANCER IN IOWA ESTIMATED FOR 1 993: Females & Males by Age Group
SITE # OF CASES
|
Ages 75+ |
♦ |
SHI COLON & RECTUM 545 LUNG 200 |
|
t |
LUNG 465 COLONS. RECTUM 410 |
|
|
Ages 55-74 |
♦ |
^ ■■■" 7“”'^ COLON & RECTUM 4M LUNG 430 |
|
t |
LUNG 820 COLON & RECTUM _ 525 |
|
|
Ages 35-54 |
f |
r; IHI' : BREAST 510 OVARY 80 LUNG 75 |
|
t |
wm - : LUNG 120 COLON & RECTUM 85 SKIN MELANOMA 55 |
|
|
Ages 15-34 |
BREAST 40 THYROID 35 SKIN MEUNOMA 30 |
|
|
TESTIS 45 SKIN MELANOMA 20 HODGKIN'S DISEASE 20 |
||
|
Ages Under 15 |
♦ t |
* LEUKEMIA 15 BRAIN 15 SOR TISSUE 5 |
|
LEUKEMIA 15 BRAIN 15 NON-HODGKIN'S LYMPH. 5 |
Fortunately for lowans, the chances of being diagnosed with many types of cancer can be reduced through positive health practices such as smoking cessation and healthful dietary habits. Early detection through self-examination and regular health check-ups can dramatically improve cancer treatment and survival. During the 1990s preventive measures and early detection should show positive changes in the cancer statistics reported by the registry.
i
Primary cancer of the head and neck
One hundred and seventy-eight cases of squamous cell carcinoma of the head and neck were reviewed. The incidence of second malignant neoplasms was 15%. The authors conclude that envi- ronmental and life-style factors con- tributed to the development of a sec- ond malignancy.
William Reynolds, D.D.S., M.D.
Richard Firkins, M.D.
Susan Aguiar, M.D.
Des Moines, Iowa
SURGERY HAS BEEN UNIQUELY involved with reported cases of second malignant neo- plasms since Billroth stated that some patients can develop a second malignant neoplasm si- multaneously and independently of a first ma- lignant neoplasm.^ Many tumors reported late in the 19th and early in the 20th century were metastatic disease or misclassifications of tu- mors near the primary.
Billroth suggests second malignant neo- plasms should be considered a second malig- nant neoplasm when a separate organ system is involved and/or the histopathology is differ- ent. Clearly, some of the second malignant neo- plasms described by Billroth in different organ systems were metastasis to that organ system and others were not.
Furthermore, Billroth observed that a sec- ond malignant neoplasm can develop after a
The authors are associated with the Department of Surgery and the Section of Otolaryngology, Department of Veterans Affairs Medical Center in Des Moines.
first malignant neoplasm has been treated. He was referring to cancers treated surgically in the late 1800s and this has relevance today in light of the known carcinogenic effects of che- motherapy, radiation and environmental fac- tors.
Interest in second malignant neoplasms continued into the 20th century. Warren and Gates reported 1,259 cases from the world liter- ature in 1932.^ Again in 1953, Watson reviewed 1,171 cases of multiple primaries.^ Moertel re- ported in 1961 that more than 10,000 cases of multiple primary malignant cancers had been reported in the literature by several hundred authors.^ This probably represents the in- creased awareness by clinicians to look for sec- ond malignant neoplasms in their patients. Moertel points out that with modern medicine (surgery, radiation, chemotherapy) second ma- lignant neoplasms can result from therapeutic intervention.
This is seen most recently in the NCI report on the Wilm's Tumor Study in which children successfully treated with chemotherapy and ra- diation therapy after 10-15 years develop sec- ond malignant neoplasms at a rate higher than predicted.^ Also, the carcinogenic effects of ra- diation are well known from the work with the atomic bomb survivors and patients receiving
THE IMS EDUCATION FUND HAS DESIGNATED THIS ARTICLE AS THE HENRY ALBERT SCIENTIFIC PRESENTATION AWARD FOR FEBRUARY 1993
February 1993
63
exposure to low dose radiation or to high dose radiation therapy.^®
Recently, the reported incidence rate of second malignant neoplasms for all cancers seems to range from 1% to 3% to
It is helpful to define second malignant neoplasm occurrence relative to time from the diagnosis of first malignant neoplasm. Simulta- neous malignancies are discovered at the initial presentation. Synchronous malignancies are discovered any time within six months of each other and include simultaneous malignancies. Tumors discovered beyond the six month inter- val are referred to as metachronous (Hordijk 1983).''
This paper is concerned with squamous cell carcinomas of the head and neck reviewed retrospectively from 1974-1983 at Veterans Ad- ministration Medical Center in Des Moines, Iowa. All head and neck cancers were re- viewed. All cases with a second malignant neo- plasm were reviewed.
Study results
There were 26 cases of a head and neck squa- mous cell carcinoma which had second malig- nant neoplasms between 1973-1984. Of these, five cases had an existing second malignant neoplasm at the time the first malignant neo- plasm was diagnosed; 22 cases developed a second malignant neoplasm after primary treatment.
The overall incidence of a second malig- nant neoplasm was 15%. The incidence rate of simultaneous second malignant neoplasm was 3% (5/178) and the incidence rate of a metach- ronous second malignant neoplasm after treat- ment was 12% (22/178). Development of a sec- ond malignant neoplasm after treatment occurred within a range of 5-113 months.
The most common site of a second malig- nant neoplasm was lung (8 squamous cell carci- nomas and 3 adenocarcinomas), followed by prostate (4 cases of adenocarcinomas), esopha- gus (2 cases of squamous cell carcinomas), pan- creas (2 cases of adenocarcinomas) and trachea (2 cases of squamous cell carcinomas). The re- mainder of the cases occurred in the bladder, colon, rectum, parotid, epiglottis, base of tongue and nasal cavity. None of the second malignant neoplasms occurring in the head and neck were contiguous to the first malig- nant neoplasms.
The most common histopathology of sec- ond malignant neoplasm was squamous cell
carcinoma (16 patients) and adenocarcinoma (11 patients). There was one transitional cell carcinoma of the bladder and one mixed malig- nant tumor of the parotid. One patient had three simultaneous cancers located in the floor of the mouth, tonsil and nasopharynx. Within 10 months, this patient had developed an ade- nocarcinoma of the prostate. Three patients had more than one second malignant neo- plasm.
The average age of diagnosis of the first malignant neoplasm was 61 years (range 39-
79) . The average age of diagnosis of the second malignant neoplasm was 63 years (range 45-
80) . The average duration between first malig- nant neoplasm and second malignant neo- plasm was 32 months (range 5-113 months). The average number of months of survival from the diagnosis of the second malignant neoplasm to death was six months (range 1-47 months).
The most common locations of the first malignant neoplasm were larynx (8), orophar- ynx (6), floor of the mouth (6), hypopharynx (3), then buccal mucosa, nasopharynx and lip (1 each).
Treatment of the first malignant neoplasm included surgery alone (6), surgery and radia- tion (5), radiation alone (8) and chemotherapy and radiation (6). For surgery various resec- tions were performed based on the clinical situ- ation. All radiation was given in doses greater than 5000 rads. Chemotherapy included meth- otrexate and bleomycin, mitomycin and 5-FU, methotrexate, cis-platinum and bleomycin, 5- FU and mithramycin, and 5-FU and DDF.
Simultaneous malignant neoplasms
Five patients had simultaneous second malig- nant neoplasms. One patient had a squamous cell carcinoma of the floor of the mouth. The second malignant neoplasm was a squamous cell carcinoma of the lungs. Death occurred within two months. Another had three simulta- neous neoplasms in the head and neck. The patient died within 10 months having devel- oped an adenocarcinoma of the prostate. One patient had a squamous cell carcinoma of the hypopharynx and a squamous cell carcinoma of the lungs. The patient died within one month during treatment with radiation. Another was a carcinoma in situ at the base of the tongue. The second malignant neoplasm was an adeno- carcinoma of the lung. The patient died within two months. Another had squamous cell carci-
lowa Medicine
64
noma of the larynx and adenocarcinoma of the colon, and died within two months.
There were 13 patients who smoked, three patients who drank, four patients who smoked and drank and six patients whose records did not indicate if smoking and drinking were risk factors.
High incidence
The small number of patients in this study pre- cludes a statement that the first malignant neo- plasm or its treatment dispose the patients to certain second malignant neoplasms. How- ever, the incidence of second malignant neo- plasm seems uncommonly high for such a small population.
In this study, the upper aerodigestive tract has been exposed to the carcinogens in tobacco. Alcohol, though not a carcinogen, may enhance the carcinogenic effects of tobacco. The second malignant neoplasms involving the lung, tra- chea, esophagus, floor of mouth, base of tongue and epiglottis are easy to explain because of the concept of field cancerization; however, second malignant neoplasms involving the prostate, bladder, rectum, colon and parotid are not as
easily conceptualized. Would these patients have developed a cancer in the locations of the second malignant neoplasm had no first malig- nant neoplasm developed? Did chemotherapy contribute to the development of a second ma- lignant neoplasm in these five patients? These are questions that larger case studies may an- swer.
What is clinically important is the aware- ness that other tumors can exist synchronously or metachronously with a first malignant neo- plasm. For head and neck cancers the role of panendoscopy cannot be over emphasized. Gluckman, Maisel, Vrabec and Grossman clearly show the importance of panendosco-
Py_13-16
Surgeons are intimately involved in the care of the head and neck cancer patient from the early stages of care. The surgeon's aware- ness that a second malignant primary may exist will benefit the patient. It is also consistent with the teachings of Billroth.
References
References are available from the authors or the editors of lOWA medicine.
General Internal Medicine
Leave A Lot Behind As A Marsheield Clinic General Internist.
t Marshfield Clinic, a 400-physician J. \. multi- specialty practice, you’ll leave sixteen-hour workdays, time consuming business concerns, and the hassles of paperwork behind you!
Practice
I Here, you can concentrate on Internal Medicine. We’ll put a staff of administrative experts behind you and a team of trained health care professionals beside you. Also, we’ll compensate you very well.
Localion/Lifostyle
I These opportunities are located at our Lakeland Center in MinoquaAVoodruff, Wisconsin. This area is defined by beautiful woods and an abundance of lakes, rivers, and streams. It’s the chance to spend your days doing what
you do best — treating patients. And your nights — getting to know your family again.
If you would like to practice in a state-of-the-art healthcare setting, if you enjoy a life-style that’s rich with recreational diversity, and if you are seeking professional excellence in a family-oriented environment, contact David Draves at 1-800-782-8581, ext. 7-5376.
MARSHFIELDCLINIC
1000 North Oak Avenue Marshfield, WI 54449
EOE/AAM/F/H/V
February 1993
65
SUPER SAUE
SOLARIUMS • PATIO ROOMS SCREEN ENCLOSURES • SKYLIGHTS WINDOWS • DOORS
Outdoor Living . . . Indoors®
*SALE ENDS MARCH 1, 1993 SYSTEM 4, 6, 9, 330 ONLY.
STATEWIDE
SERVICE & INSTALLATION 5328 N.W. 2nd Avenue, Des Moines, I A 50313 (515) 289-1749
INDEPENDENTLY OWNED & OPERATED
.year-round?
o
The
affordable way to enjoy outdoor living
We’re celebrating our expanded product line by offering you great savings on our new patio rooms and modular solariums — plus — savings on some of our other popular solariums.
Enjoy outdoor fun, relaxation and entertaining — regardless of the weather!
The things you like to do outside will never be spoiled by the weather if you own a Four Seasons patio enclosure. Better than an open porch or an awning, a patio enclosure really protects you from the elements.
On windy days, you can relax and read the newspaper without the pages flying away. And how about when mosquitos are a problem on hot summer nights? Our patio enclosures are screened so they keep the insects out and the cool breezes coming in.
WINTER
FOUR SEASONS
SUNROOMS
A patient with 56 primary malignancies
This very unusual case involves a 70- year-old white male who was within 50 miles of atomic bomb testing in the Mo- have Desert and had 56 primary malig- nancies from 1 946 to 1 992. Major cyto- genetic abnormalities sometimes found m patients with apparent genetic sus- ceptibility for developing solid tumors are reviewed.
Ahmed Ghouri, M.D.
Carl Peterson, M.D.
Richard Firkins, M.D.
Lester Dragstedt, II, M.D.
Des Moines, Iowa
This 70-year-old patient has been followed by the Department of Surgery at the VA Medical Center in Des Moines since 1969. Oth- erwise healthy, he has been surgically treated for numerous basal cell carcinomas of the skin, squamous cell carcinoma of the skin and Duke's B adenocarcinoma of the colon. He re- ported that he was in the Mohave Desert (Ne- vada) from 1942-44, within 50 miles of several above-ground atomic bomb explosions. There is a history of repeated contact with fallout ma- terial and he believes this exposure may be responsible for his recurrent malignancies.
Apart from neoplasia, his only other medi- cal problem is mild degenerative joint disease affecting his right hip, for which he takes na- proxen 375 mg tid prn. He takes no other medi- cations. His non-oncologic surgical history is significant for appendectomy in 1964, hemorr- hoidectomy in 1961 and cholecystectomy in 1979 for symptomatic cholelithiasis.
The authors are with the Veterans Administration Department of Surgery in Des Moines.
His family history is extensive. His father died of pancreatic cancer at age 81, his brother had melanoma, his uncle had colon cancer and his grandfather died of squamous cell cancer invading the jugular vein. He denies alcohol use, but has smoked a pack of cigarettes per day for approximately 54 years. He is an alert, well-nourished, elderly white male. Apart from numerous well-healed surgical scars, the phys- ical examination is unremarkable.
Mr. PS's first malignancy was a posterior- auricular basal cell carcinoma of the skin diag- nosed in 1946. Subsequently, he has presented with 53 basal cell cancers, each apparently a new primary. His tumors have typically pre- sented as non-healing skin lesions, oftentimes ulcerated or bleeding. Table 1 shows an impres- sive list of the anatomical sites involved. Of particular note, many have occurred on non- sun-exposed areas. Each time, the lesions have been removed as an excisional biopsy, with negative margins and without local recurrence.
In 1981 Mr. PS was admitted to our hospi- tal for workup of chronic diarrhea with hema- tochezia. Flexible sigmoidoscopy demon- strated a friable mass lesion at 18 cm, which was found to be well-differentiated adenocarci- noma. He subsequently underwent rectosig- moid colectomy with end-to-end anastomosis and pathological examination revealed Duke's (Continued next page)
February 1993
67
B adenocarcinoma. The margins were negative and the procedure was curative. In 1985, he was found to have a 1 cm X 1 cm squamous cell cancer involving the skin of the face. This was cured by surgical excision.
In June 1992, peripheral blood was ob- tained from Mr. PS and sent to MetPath labora- tories (Teterboro, New Jersey) for investiga- tional chromosomal and cytogenetic analysis. Unfortunately, no pathological specimens of actual tumor were available for study. PHA- stimulated lymphocytes and Giemsa-trypsin stained (G-banded) metaphases showed ran- dom loss of chromosomes in 34% of cells (a positive but non-specific finding). The re- maining cells revealed a normal-appearing 46, XY male chromosome complement. No in- creased breakage or other abnormalities were observed.
TABLE 1
SKIN LESIONS FOUND TO BE CANCER
|
Anatomical location |
No. primary lesions excised |
|
left angle of mandible |
2 |
|
left neck |
3 |
|
left posterior auricular region |
2 |
|
left pre-auricular region |
4 |
|
left ear |
2 |
|
left temple |
2 |
|
left nose |
2 |
|
left naso-labial groove |
1 |
|
left forehead |
3 |
|
left cheek |
2 |
|
left chin |
1 |
|
left shoulder |
1 |
|
left suprasternal notch |
1 |
|
left shoulder |
1 |
|
left back |
2 |
|
left scrotum |
1 |
|
left perianal region |
1 |
|
right upper cheek |
1 |
|
right lower cheek |
1 |
|
right submandibular region |
1 |
|
right forehead |
3 |
|
right zygomatic region |
1 |
|
right external auditory canal |
1 |
|
right ear |
1 |
|
right posterior auricular region |
3 |
|
right pre-auricular region |
2 |
|
right concha |
1 |
|
right neck |
2 |
|
right nose |
1 |
|
right sternum |
1 |
|
right back |
2 |
|
right axilla |
1 |
|
right suprapubic region |
1 |
|
right perianal region |
1 |
Comment
Only three decades have passed since the num- ber of human chromosomes was determined, but great advances have been made in our un- derstanding of genetics and its role in malig- nant disease. The field of cancer cytogenetics has been growing exponentially: more and more chromosomal abnormalities are being shown to be of importance in carcinogenesis. Indeed, oncogenes and tumor suppressor genes and the consequences of their molecular abberation have contributed greatly to our un- derstanding of cancer.
While the study of hematological malig- nancies has produced much data, for most solid tumors our knowledge is very rudimen- tary. A principal reason is that metaphase cells obtained