CORRESPONDENCE
feel there is an industrial relationship or may be, I always indicate this in my report, and I have never been questioned by a lawyer or an insurance company, or asked to change my opinion. Dr. Drucker suggests that a panel of medical experts is not the answer, and indicates that the courts have found this approach does not work. My response is that these problems are medical problems and no one is more qualified to make these decisions than a panel of medical experts specialized in the particular field. I am sure that if Dr. Drucker develops chest pain he will call his doctor and not his lawyer. As I stated in my previous communication, if the panel cannot come to an agreement as to an industrial relationship or lack of same (I feel a small minority will end thusly), the legal process can supervene. When the legal process is, as is the case now, instituted from the beginning, it is long and costly, and each side in effect cancels the other out. In my experience, when there is evidence of injury the insurance companies make no complaints about
settling. Admittedly the solution is not perfect and clearly the causes of many medical ailments are multifactorial and obscure, but I believe these medical problems should be settled by medical experts and not lawyers who are trained to represent their clients in the best possible light, rather than seek the truth. ARTHUR S. WEISSBEIN, MD San Bernardino, California
Carnation Instant Breakfast TO THE EDITOR: The purpose of this letter is to call attention to some errors regarding Carnation Instant Breakfast (CIB) that were reported in Table 2 of the article entitled "The Challenge of Nutritional Maintenance in Cancer Patients" in the February 1979 issue. The normal dilution of our product should be one package of CIB mixed with 240 ml of whole milk, not water. Also, the product has undergone an instantizing process, eliminating the need to be mixed in a blender as stated in the table. Regarding the nutritional composition, CIB mixed with whole milk should provide 1,055 kilocalories and 132 grams of carbohydrate per liter rather than 967 kcal and 117 grams as shown. The values for protein and fat were correct. We also would like to point out that the col-
umn in Table 2 showing price per ounce is misleading. It would be better to do a price comparison of the products in the same physical form. For example, although one dry ounce of CIB pOWder does cost $0.17 as listed, one fluid ounce of CIB mixed with whole milk (which is the form the patient would be consuming) would'cost only $0.03, assuming a half gallon of whole milk costs $0.70. The cost figures as they appear in Table 2 make it seem as though the dry products are more expensive than the liquid canned products, which is incorrect in some cases. PATRICIA A. BEHM Nutrition Research Carnation Van Nuys, California
Charges for Emergency Services To THE EDITOR: We would like to underscore a point raised in a recent article and editorial (Allen and Teufel's "Organization of Emergency Services" and Schroeder's "The Increasing Use of Emergency Services-Why Has It Occurred? Is It a Problem?" in the January 1979 issue) regarding the high cost of emergency medical services. A concern was expressed that present emergency rooms are not ideal trauma centers and fall short when assessed against other alternatives for nonemergency services. As is universally recognized, emergency rooms are often utilized for services that could be rendered more efficiently in another setting. We are particularly concerned about the cost of these services as compared with those for visits to private physicians. We surveyed 456 consecutive charges for visits to private physicians for the diagnosis of tonsillitis, pharyngitis or upper respiratory infection. The average charge, not including laboratory or x-ray studies, for these diagnoses breaks down as shown in Table 1. In addition, we obtained the average charge for these diagnoses for 25 patient visits to a local hospital's drop-in clinic-$19.00-and for 30 patient visits to a local emergency room-$47.00. However, these latter two had a higher percentage of new patient visits and thus are not strictly comparable with the private physician data. In an effort to look at the reasons for the difference in charges between different specialties we looked at the distribution of RVS (Relative Value Studies) numbers used. The mode (the number used with the highest frequency) was Established THE WESTERN JOURNAL OF MEDICINE
465
CORRESPONDENCE TABLE 1.-Average Charges for Diagnosis of Tonsillitis, Pharyngitis or Upper Respiratory Infection Number of patients
General practitioners ...... ...... $15.03 Family physicians ...... ........ 15.19 Pediatricians .......... ......... 15.48 Internists ...................... 16.06 Ear, nose and throat physicians ... 22.60
211 56 152 23 14
Limited for the pediatricians, internists and ear, nose and throat specialists, and Established Brief for the general or family practitioners. The number of new patients did not explain the differences and was under 20 percent for all specialists. The least expensive visit for handling tonsillitis, pharyngitis or an upper respiratory infection is with private general or family practitioners, and this is a third the cost of a visit to an emergency room in our area. We expect comparable data are available in many locales. A family physician's private office seems the ideal place to care for patients with these illnesses. RICHARD C. BARNETT, MD Director, Family Practice Program Medical Director JONATHAN E. RODNICK, MD Assistant Director, Family Practice Program Communzity Hospital Santa Rosa, California
Rehabilitation Through Marathon Running TO THE EDITOR: Schroeder and Wagner1 have reported in this journal encouraging follow-up statistics on 81 patients with cardiac disease who have completed the 42-km Honolulu Marathon. This event has a medically supervised (noncompetitive) division for rehabilitated cardiac patients and wheelchair athletes at present. They are thinking of adding a "diabetic division" and a "chronic lung disease division" in the future. Interested physicians or their patients can write to J. A. Schroeder and J. 0. Wagner, Cardiac Rehabilitation Program, Central Branch YMCA, 401 Atkinson Drive, Honolulu, Hawaii 96814. In the course of running some 100 marathons myself, I have compiled a list of 131 marathoners with cardiac disease including 48 with previous myocardial infarction and 19 who have had coronary-bypass operations. Follow-up shows that 126 are alive and running after 500 patient-years. Of 466
MAY 1979 * 130 * 5
Figure 1.-Marathon runner's coronary artery showing atherosclerosis and thrombosis. This man, in his mid60's, chewed tobacco and swallowed all the juice. The pronounced inflammation is attributed to the angiotoxic material in tobacco juice. (H & E stain; reduced from X 10)
the five who have died, only one showed progressive atherosclerosis at autopsy (Figure 1). This elderly man continued to chew tobacco and swallowed all the juice from three boxes of chewing tobacco a week. The plaques were very inflamed. This suggests that tobacco juice contains highly angiotoxic material. Rehabilitation programs in Canada and the United States have been using marathon training as a tool for risk-factor modification for almost ten years. Six institutions have cooperated with my forensic surveillance over those athletes with cardiac disease who have reached the 42-km marathon distance. I have been very encouraged by the results. THOMAS J. BASSLER, MD Centinela Hospital
Inglewood, California REFERENCE 1. Schroeder JA, Wagner, JO: Marathon runners with cardiovascular disease (Correspondence). West J Med 129:241, Sep 1978
Theophylline Toxicity TO THE EDITOR: Recent reports on the frequency and severity of the toxic effects of theophylline in obese patients or those with hepatic cirrhosis, chronic lung disease or congestive heart failure, have shown a high morbidity in cases where the serum level exceeds 50 ,ug per ml-roughly twice the therapeutic level.'5 Optimism concerning the prognosis in these cases has been generated by
feel there is an industrial relationship or may be, I always indicate this in my report, and I have never been questioned by a lawyer or an insurance company, or asked to change my opinion. Dr. Drucker suggests that a panel of medical experts is not the answer, and indicates that the courts have found this approach does not work. My response is that these problems are medical problems and no one is more qualified to make these decisions than a panel of medical experts specialized in the particular field. I am sure that if Dr. Drucker develops chest pain he will call his doctor and not his lawyer. As I stated in my previous communication, if the panel cannot come to an agreement as to an industrial relationship or lack of same (I feel a small minority will end thusly), the legal process can supervene. When the legal process is, as is the case now, instituted from the beginning, it is long and costly, and each side in effect cancels the other out. In my experience, when there is evidence of injury the insurance companies make no complaints about
settling. Admittedly the solution is not perfect and clearly the causes of many medical ailments are multifactorial and obscure, but I believe these medical problems should be settled by medical experts and not lawyers who are trained to represent their clients in the best possible light, rather than seek the truth. ARTHUR S. WEISSBEIN, MD San Bernardino, California
Carnation Instant Breakfast TO THE EDITOR: The purpose of this letter is to call attention to some errors regarding Carnation Instant Breakfast (CIB) that were reported in Table 2 of the article entitled "The Challenge of Nutritional Maintenance in Cancer Patients" in the February 1979 issue. The normal dilution of our product should be one package of CIB mixed with 240 ml of whole milk, not water. Also, the product has undergone an instantizing process, eliminating the need to be mixed in a blender as stated in the table. Regarding the nutritional composition, CIB mixed with whole milk should provide 1,055 kilocalories and 132 grams of carbohydrate per liter rather than 967 kcal and 117 grams as shown. The values for protein and fat were correct. We also would like to point out that the col-
umn in Table 2 showing price per ounce is misleading. It would be better to do a price comparison of the products in the same physical form. For example, although one dry ounce of CIB pOWder does cost $0.17 as listed, one fluid ounce of CIB mixed with whole milk (which is the form the patient would be consuming) would'cost only $0.03, assuming a half gallon of whole milk costs $0.70. The cost figures as they appear in Table 2 make it seem as though the dry products are more expensive than the liquid canned products, which is incorrect in some cases. PATRICIA A. BEHM Nutrition Research Carnation Van Nuys, California
Charges for Emergency Services To THE EDITOR: We would like to underscore a point raised in a recent article and editorial (Allen and Teufel's "Organization of Emergency Services" and Schroeder's "The Increasing Use of Emergency Services-Why Has It Occurred? Is It a Problem?" in the January 1979 issue) regarding the high cost of emergency medical services. A concern was expressed that present emergency rooms are not ideal trauma centers and fall short when assessed against other alternatives for nonemergency services. As is universally recognized, emergency rooms are often utilized for services that could be rendered more efficiently in another setting. We are particularly concerned about the cost of these services as compared with those for visits to private physicians. We surveyed 456 consecutive charges for visits to private physicians for the diagnosis of tonsillitis, pharyngitis or upper respiratory infection. The average charge, not including laboratory or x-ray studies, for these diagnoses breaks down as shown in Table 1. In addition, we obtained the average charge for these diagnoses for 25 patient visits to a local hospital's drop-in clinic-$19.00-and for 30 patient visits to a local emergency room-$47.00. However, these latter two had a higher percentage of new patient visits and thus are not strictly comparable with the private physician data. In an effort to look at the reasons for the difference in charges between different specialties we looked at the distribution of RVS (Relative Value Studies) numbers used. The mode (the number used with the highest frequency) was Established THE WESTERN JOURNAL OF MEDICINE
465
CORRESPONDENCE TABLE 1.-Average Charges for Diagnosis of Tonsillitis, Pharyngitis or Upper Respiratory Infection Number of patients
General practitioners ...... ...... $15.03 Family physicians ...... ........ 15.19 Pediatricians .......... ......... 15.48 Internists ...................... 16.06 Ear, nose and throat physicians ... 22.60
211 56 152 23 14
Limited for the pediatricians, internists and ear, nose and throat specialists, and Established Brief for the general or family practitioners. The number of new patients did not explain the differences and was under 20 percent for all specialists. The least expensive visit for handling tonsillitis, pharyngitis or an upper respiratory infection is with private general or family practitioners, and this is a third the cost of a visit to an emergency room in our area. We expect comparable data are available in many locales. A family physician's private office seems the ideal place to care for patients with these illnesses. RICHARD C. BARNETT, MD Director, Family Practice Program Medical Director JONATHAN E. RODNICK, MD Assistant Director, Family Practice Program Communzity Hospital Santa Rosa, California
Rehabilitation Through Marathon Running TO THE EDITOR: Schroeder and Wagner1 have reported in this journal encouraging follow-up statistics on 81 patients with cardiac disease who have completed the 42-km Honolulu Marathon. This event has a medically supervised (noncompetitive) division for rehabilitated cardiac patients and wheelchair athletes at present. They are thinking of adding a "diabetic division" and a "chronic lung disease division" in the future. Interested physicians or their patients can write to J. A. Schroeder and J. 0. Wagner, Cardiac Rehabilitation Program, Central Branch YMCA, 401 Atkinson Drive, Honolulu, Hawaii 96814. In the course of running some 100 marathons myself, I have compiled a list of 131 marathoners with cardiac disease including 48 with previous myocardial infarction and 19 who have had coronary-bypass operations. Follow-up shows that 126 are alive and running after 500 patient-years. Of 466
MAY 1979 * 130 * 5
Figure 1.-Marathon runner's coronary artery showing atherosclerosis and thrombosis. This man, in his mid60's, chewed tobacco and swallowed all the juice. The pronounced inflammation is attributed to the angiotoxic material in tobacco juice. (H & E stain; reduced from X 10)
the five who have died, only one showed progressive atherosclerosis at autopsy (Figure 1). This elderly man continued to chew tobacco and swallowed all the juice from three boxes of chewing tobacco a week. The plaques were very inflamed. This suggests that tobacco juice contains highly angiotoxic material. Rehabilitation programs in Canada and the United States have been using marathon training as a tool for risk-factor modification for almost ten years. Six institutions have cooperated with my forensic surveillance over those athletes with cardiac disease who have reached the 42-km marathon distance. I have been very encouraged by the results. THOMAS J. BASSLER, MD Centinela Hospital
Inglewood, California REFERENCE 1. Schroeder JA, Wagner, JO: Marathon runners with cardiovascular disease (Correspondence). West J Med 129:241, Sep 1978
Theophylline Toxicity TO THE EDITOR: Recent reports on the frequency and severity of the toxic effects of theophylline in obese patients or those with hepatic cirrhosis, chronic lung disease or congestive heart failure, have shown a high morbidity in cases where the serum level exceeds 50 ,ug per ml-roughly twice the therapeutic level.'5 Optimism concerning the prognosis in these cases has been generated by
