EDITORIALS
If we are ever to bring this epidemic under control, health providers must improve the quality of their diagnoses, report diagnosed cases more faithfully, manage them more appropriately using the most effective treatment regimes, and insure that both male and female cases return for posttreatment culture. Providers must be made aware that failure to conduct contact investigation as part of the management of an infected patient can incur the risk of malpractice charges as surely as neglect of the patient in other areas of patient care.9 Only through better epidemiological practice and sounder patient management can we hope to make a significant impact on the current epidemic of gonorrhea.
PAULINE 0. ROBERTS, MD, MPH
Address reprint requests to Dr. Pauline 0. Roberts, Chief, VD Control Program, Los Angeles County Health Department, 12838 Erickson Avenue, Downey, CA 90242. Dr. Roberts is a member of the Journal Editorial Board.
REFERENCES 1. Gale, J. L., and Hinds, M. W. Male urethritis in King County, Washington, 1974-1975, I. Incidence. Am. J. Public Health 68:20-25, 1978. 2. Hinds, M. W., and Gale, J. L. Male urethritis in King County, Washington, 1974-1975, II. Diagnosis and treatment. Am. J. Public Health 68:26-30, 1978. 3. VD Fact Sheet 1976: U.S. Dept. of H.E.W., Public Health Service, Center for Disease Control. 4. Venereal Diseases, Los Angeles County 1976: County of Los An-
geles Department of Health Services. 5. Eschenbach, D. A. and Holmes, K. K. Acute pelvic inflammatory disease: Current concepts of pathogenesis, etiology and management. Clinical Obstetrics and Gynecology, Vol. 18, No. 1, March 1975. 6. VD Fact Sheet 1976: Summary of Research and Evaluation of Studies. U.S. Dept. of H.E.W., Public Health Service, Center for Disease Control. 7. Pariser, H.: Asymptomatic gonorrhea in the male. South. Med. J. 57:688 (June) 1964. 8. Pariser, H.: Asymptomatic gonorrhea. Medical Clinics of North America, Vol. 56, September 1972. 9. Handsfield, H. H. et al: Asymptomatic gonorrhea in men. N. Eng. J. Medicine: 290:117-123, 1974
From House Calls to Telephone Calls "Mr. Watson, come here, I want you!" When I was a little girl, I-like most of my generationlearned American history at the movies. I remember it distinctly: with those seven words, Don Ameche not only invented the telephone, but also gave us yet another example of the ingenuity and inventiveness which made this, The Greatest Country on Earth. While the Hollywood version of history may be apocryphal, in fact, the invention of the telephone does represent one of the earliest examples of the impact of technology on the delivery of health care. The telephone has become as much a part of our standard equipment as our stethoscopes. Practicing pediatricians, in particular, find themselves attached to the umbilical cord of the telephone. Indeed, most pediatricians in self defense have created the "telephone hour" in an attempt to manage the volume of their calls from worried parents; in many ways, the telephone call has replaced the almost extinct house call of long ago. Yet, the immense and growing importance of the telephone to our daily practice has gone virtually unnoticed by medical care researchers, medical educators, and health care planners. Recently, all of these groups have become excited about "technology transfer." A national debate has erupted over the use of high cost technology in medical practice with the CAT scanner providing the dramatic symbol of the debate. While I agree that the location and use of high cost machines deserves our attention, I cannot help but wonder if a portion of our energies should not be directed toward some of the humbler and more widespread technical innovations in medical care. If, until recently, we have ignored the telephone as an important variable in the health care delivery 14
system, surely other mundane technological advances in medical practice also need our attention. For example, over the past 30 years, plastics have gradually invaded every aspect of our lives to the extent that future historians may well label ours as the Age of Plastic. Medical practice, as other segments of national life, has experienced the impact of this technological innovation. Plastic disposable syringes, procedure trays, and culture tubes have replaced the lowly sterilizer once found in every physician's office. Yet, this revolution in practice has occurred almost without comment, certainly without a national or professional debate about its long range implications, cost benefits, or environmental impact. Ironically, while some states are enacting laws to control the spread of disposable bottles, we who proclaim our concern for the public's health and the environment continue to make our own contribution to the solid waste disposal problem. Perhaps the time has come to begin to reexamine the technological innovations which we have simply taken in stride and for granted. In their study of telephone usage in pediatric practice, published in this issue of the Journal, Dr. Katz and his colleagues have provided us with a model of research into the everyday of medical practice.' The study, instituted to assess the quality of their practice's telephone system, demonstrates that physicians can delegate a significant proportion of their telephone calls from patients to properly trained health assistants. These authors quite rightly emphasize that one needs some education and training to answer the telephone in a clinical setting. Unfortunately, medical and nursing educators seem unaware that much of the practice of medicine takes place over the telephone and that the teleAJPH January, 1978, Vol. 68, No. 1
EDITORIALS
phone interview differs in approach and technique from the face to face interaction. If physicians and nurses have received little formal training in the clinical use of the telephone, the personnel in physician's answering services have received even less. Across the country, a network of telephone operators answer calls to physicians with only the most general guidelines to help them respond to anxious patients. Those of us in practice should look again at the information these operators provide our patients; those of us responsible for the evaluation of the medical care system should begin to develop methods for monitoring the quality of information and advice provided by these services. Indeed, there is some urgency in this matter. If we are not careful, technology will steal another march on us; the human telephone operator may be completely replaced by the inhumane, automatic tape recorded message. Dr. Katz and his co-authors provide us with another lesson. Medical care researchers, relatively new arrivals on the scene of medical scholarship, continue to struggle to define the goals, content, and methods of their research. Given the difficulties of this form of research, they have understandably tended to study matters from the safety of the academic setting. For that reason, we have few examples of research which have investigated the mysteries of private practice. Most of the available data come from institutional forms of practice usually involving the delivery of medical care to low income groups. To begin to develop an under-
standing of the process, structure, and outcome of our national health system, a coalition between researchers from the academic commuqity and their colleagues in private practice must be formed. The Columbia Medical Plan and the Johns Hopkins University represent such a partnership. There are considerable secondary gains for both partners in these efforts. Academics who venture into the unknown world of private practice will find that their teaching improves as they gain an understanding of the realities of the daily practice of medicine. Practitioners will begin to understand the intellectual satisfaction of critical inquiries into the daily issues of their professional lives. Who knows, if collaborative efforts begin to flourish, we may find we have the solution to the proverbial "town and gown" problem. If both sides work together, we may not be able to tell who is who without a scorecard.
MARGARET C. HEAGARTY, MD Address reprint requests to Dr. Margaret C. Heagarty, Director, Division of Pediatric Ambulatory Care, The New York Hospital-Cornell Medical Center, 525 East 68th St., New York, NY 10021.
REFERENCE 1. Katz, H. P., Pozen, J., and Mushlin, A. I. Quality assessment of a telephone care system utilizing non-physician personnel. Am. J. Public Health 68:31-38, 1978.
Prevention and the Power of Consumers Everyone concerned with the promotion of health practices that lead to the prevention of disease is aware of the importance of consumers and their increased interest in health affairs. Consumers can be aggressive in their demands for more and better health services; they can also exert their influence by challenging scientific findings and recommendations. For these reasons, public health personnel have a clear cut responsibility to present health promoting information to the public in a manner which is understandable to them and pertinent to their needs. The commentary which appears in this issue of the Journal, dealing with statewide antifluoridation initiatives, brings this responsibility clearly into focus and points quite properly to the potential challenges in other health areas.' It should be abundantly clear that if disease prevention and health promotion are to be achieved, the acceptance and support of the consumer as well as the provider are necessary. The history of public health during the past two centuries demonstrates dramatically that to control devastating communicable diseases and to improve sanitation it was necessary to overcome strong opposition. Such landmark achievements as inoculation against smallpox, the pasteurization of milk, and the chlorination of public water supplies AJPH January, 1978, Vol. 68, No. 1
were bitterly fought by both the medical profession and the public for periods of many years. It is now about 30 years since the evidence has accumulated to show that the ingestion of the fluoride ion in potable water is an effective and safe prophylactic against the onset of dental caries in children, and that this protection continues into adult life among those who continue to drink fluoridated water.2 The optimum concentration for most areas in the United States is 1.0-1.2 ppm F. Yet, as of December 31, 1973, only 59.3 per cent of persons living in communities served with public water supplies were receiving the benefits of water-borne fluorides. While dental caries is not a dramatic disease from which people become seriously ill, caries and its concomitant effects are of such mangitude that virtually the entire population suffers from it. Unfortunately, many go without treatment for a variety of reasons so that all too frequently, dental caries is the forerunner of tooth loss. Caries starts early in life and the hazard continues as long as natural teeth are present in the mouth, unless they are fortified against it by the only known effective prophylactic we have today, that is, the ingestion of the optimpm concentration of the fluoride ion. Because the risk of caries is almost universal and because of 15
If we are ever to bring this epidemic under control, health providers must improve the quality of their diagnoses, report diagnosed cases more faithfully, manage them more appropriately using the most effective treatment regimes, and insure that both male and female cases return for posttreatment culture. Providers must be made aware that failure to conduct contact investigation as part of the management of an infected patient can incur the risk of malpractice charges as surely as neglect of the patient in other areas of patient care.9 Only through better epidemiological practice and sounder patient management can we hope to make a significant impact on the current epidemic of gonorrhea.
PAULINE 0. ROBERTS, MD, MPH
Address reprint requests to Dr. Pauline 0. Roberts, Chief, VD Control Program, Los Angeles County Health Department, 12838 Erickson Avenue, Downey, CA 90242. Dr. Roberts is a member of the Journal Editorial Board.
REFERENCES 1. Gale, J. L., and Hinds, M. W. Male urethritis in King County, Washington, 1974-1975, I. Incidence. Am. J. Public Health 68:20-25, 1978. 2. Hinds, M. W., and Gale, J. L. Male urethritis in King County, Washington, 1974-1975, II. Diagnosis and treatment. Am. J. Public Health 68:26-30, 1978. 3. VD Fact Sheet 1976: U.S. Dept. of H.E.W., Public Health Service, Center for Disease Control. 4. Venereal Diseases, Los Angeles County 1976: County of Los An-
geles Department of Health Services. 5. Eschenbach, D. A. and Holmes, K. K. Acute pelvic inflammatory disease: Current concepts of pathogenesis, etiology and management. Clinical Obstetrics and Gynecology, Vol. 18, No. 1, March 1975. 6. VD Fact Sheet 1976: Summary of Research and Evaluation of Studies. U.S. Dept. of H.E.W., Public Health Service, Center for Disease Control. 7. Pariser, H.: Asymptomatic gonorrhea in the male. South. Med. J. 57:688 (June) 1964. 8. Pariser, H.: Asymptomatic gonorrhea. Medical Clinics of North America, Vol. 56, September 1972. 9. Handsfield, H. H. et al: Asymptomatic gonorrhea in men. N. Eng. J. Medicine: 290:117-123, 1974
From House Calls to Telephone Calls "Mr. Watson, come here, I want you!" When I was a little girl, I-like most of my generationlearned American history at the movies. I remember it distinctly: with those seven words, Don Ameche not only invented the telephone, but also gave us yet another example of the ingenuity and inventiveness which made this, The Greatest Country on Earth. While the Hollywood version of history may be apocryphal, in fact, the invention of the telephone does represent one of the earliest examples of the impact of technology on the delivery of health care. The telephone has become as much a part of our standard equipment as our stethoscopes. Practicing pediatricians, in particular, find themselves attached to the umbilical cord of the telephone. Indeed, most pediatricians in self defense have created the "telephone hour" in an attempt to manage the volume of their calls from worried parents; in many ways, the telephone call has replaced the almost extinct house call of long ago. Yet, the immense and growing importance of the telephone to our daily practice has gone virtually unnoticed by medical care researchers, medical educators, and health care planners. Recently, all of these groups have become excited about "technology transfer." A national debate has erupted over the use of high cost technology in medical practice with the CAT scanner providing the dramatic symbol of the debate. While I agree that the location and use of high cost machines deserves our attention, I cannot help but wonder if a portion of our energies should not be directed toward some of the humbler and more widespread technical innovations in medical care. If, until recently, we have ignored the telephone as an important variable in the health care delivery 14
system, surely other mundane technological advances in medical practice also need our attention. For example, over the past 30 years, plastics have gradually invaded every aspect of our lives to the extent that future historians may well label ours as the Age of Plastic. Medical practice, as other segments of national life, has experienced the impact of this technological innovation. Plastic disposable syringes, procedure trays, and culture tubes have replaced the lowly sterilizer once found in every physician's office. Yet, this revolution in practice has occurred almost without comment, certainly without a national or professional debate about its long range implications, cost benefits, or environmental impact. Ironically, while some states are enacting laws to control the spread of disposable bottles, we who proclaim our concern for the public's health and the environment continue to make our own contribution to the solid waste disposal problem. Perhaps the time has come to begin to reexamine the technological innovations which we have simply taken in stride and for granted. In their study of telephone usage in pediatric practice, published in this issue of the Journal, Dr. Katz and his colleagues have provided us with a model of research into the everyday of medical practice.' The study, instituted to assess the quality of their practice's telephone system, demonstrates that physicians can delegate a significant proportion of their telephone calls from patients to properly trained health assistants. These authors quite rightly emphasize that one needs some education and training to answer the telephone in a clinical setting. Unfortunately, medical and nursing educators seem unaware that much of the practice of medicine takes place over the telephone and that the teleAJPH January, 1978, Vol. 68, No. 1
EDITORIALS
phone interview differs in approach and technique from the face to face interaction. If physicians and nurses have received little formal training in the clinical use of the telephone, the personnel in physician's answering services have received even less. Across the country, a network of telephone operators answer calls to physicians with only the most general guidelines to help them respond to anxious patients. Those of us in practice should look again at the information these operators provide our patients; those of us responsible for the evaluation of the medical care system should begin to develop methods for monitoring the quality of information and advice provided by these services. Indeed, there is some urgency in this matter. If we are not careful, technology will steal another march on us; the human telephone operator may be completely replaced by the inhumane, automatic tape recorded message. Dr. Katz and his co-authors provide us with another lesson. Medical care researchers, relatively new arrivals on the scene of medical scholarship, continue to struggle to define the goals, content, and methods of their research. Given the difficulties of this form of research, they have understandably tended to study matters from the safety of the academic setting. For that reason, we have few examples of research which have investigated the mysteries of private practice. Most of the available data come from institutional forms of practice usually involving the delivery of medical care to low income groups. To begin to develop an under-
standing of the process, structure, and outcome of our national health system, a coalition between researchers from the academic commuqity and their colleagues in private practice must be formed. The Columbia Medical Plan and the Johns Hopkins University represent such a partnership. There are considerable secondary gains for both partners in these efforts. Academics who venture into the unknown world of private practice will find that their teaching improves as they gain an understanding of the realities of the daily practice of medicine. Practitioners will begin to understand the intellectual satisfaction of critical inquiries into the daily issues of their professional lives. Who knows, if collaborative efforts begin to flourish, we may find we have the solution to the proverbial "town and gown" problem. If both sides work together, we may not be able to tell who is who without a scorecard.
MARGARET C. HEAGARTY, MD Address reprint requests to Dr. Margaret C. Heagarty, Director, Division of Pediatric Ambulatory Care, The New York Hospital-Cornell Medical Center, 525 East 68th St., New York, NY 10021.
REFERENCE 1. Katz, H. P., Pozen, J., and Mushlin, A. I. Quality assessment of a telephone care system utilizing non-physician personnel. Am. J. Public Health 68:31-38, 1978.
Prevention and the Power of Consumers Everyone concerned with the promotion of health practices that lead to the prevention of disease is aware of the importance of consumers and their increased interest in health affairs. Consumers can be aggressive in their demands for more and better health services; they can also exert their influence by challenging scientific findings and recommendations. For these reasons, public health personnel have a clear cut responsibility to present health promoting information to the public in a manner which is understandable to them and pertinent to their needs. The commentary which appears in this issue of the Journal, dealing with statewide antifluoridation initiatives, brings this responsibility clearly into focus and points quite properly to the potential challenges in other health areas.' It should be abundantly clear that if disease prevention and health promotion are to be achieved, the acceptance and support of the consumer as well as the provider are necessary. The history of public health during the past two centuries demonstrates dramatically that to control devastating communicable diseases and to improve sanitation it was necessary to overcome strong opposition. Such landmark achievements as inoculation against smallpox, the pasteurization of milk, and the chlorination of public water supplies AJPH January, 1978, Vol. 68, No. 1
were bitterly fought by both the medical profession and the public for periods of many years. It is now about 30 years since the evidence has accumulated to show that the ingestion of the fluoride ion in potable water is an effective and safe prophylactic against the onset of dental caries in children, and that this protection continues into adult life among those who continue to drink fluoridated water.2 The optimum concentration for most areas in the United States is 1.0-1.2 ppm F. Yet, as of December 31, 1973, only 59.3 per cent of persons living in communities served with public water supplies were receiving the benefits of water-borne fluorides. While dental caries is not a dramatic disease from which people become seriously ill, caries and its concomitant effects are of such mangitude that virtually the entire population suffers from it. Unfortunately, many go without treatment for a variety of reasons so that all too frequently, dental caries is the forerunner of tooth loss. Caries starts early in life and the hazard continues as long as natural teeth are present in the mouth, unless they are fortified against it by the only known effective prophylactic we have today, that is, the ingestion of the optimpm concentration of the fluoride ion. Because the risk of caries is almost universal and because of 15
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