EDITORIALS
178 178
EIOIL
orders associated with damage to prefrontal cortex have only just begun. Further studies will certainly illuminate how this area contributes to memory function. ARTHUR P. SHIMAMURA, PhD Department of Psychology University of California, Berkeley REFERENCES 1. Amaral DJ: Memory: The anatomical organization of candidate brain regions, In Plum F (Ed): Handbook of Physiology: Higher Functions of the Nervous
System. New York, Oxford University Press, 1987 2. Kandel ER, Schwartz JH: Molecular biology of learning: Modification of transmitter release. Science 1982; 218:433-442 3. Lynch G: Synapses, Circuits and the Beginnings of Memory. Cambridge, Mass, MIT Press, 1986 4. Mishkin M: A memory system in the monkey, In Broadbent DE, Weiskrantz L (Eds): The Neuropsychology of Cognitive Function. London, The Royal Society, 1982, pp 85-95 5. Squire LR: Memory and Brain. New York, Oxford University Press, 1987 6. Shimamura AP: Disorders of memory: The cognitive science perspective, chap 2, In Boller F, Grafman J (Eds): Handbook of Neuropsychology, Vol 3. Amsterdam, Elsevier Publishers, 1989, pp 35-73 7. Schacter DL: Implicit memory: History and current status. J Exp Psychol [Learn Mem Cogn] 1987; 13:501-518 8. Shimamura AP: Priming effects in amnesia: Evidence for a dissociable memory function. Q J Exp Psychol 1986; 38A:619-644 9. Cohen NJ, Squire LR: Preserved learning and retention of pattern-analyzing skill in amnesia: Dissociation of knowing how and knowing that. Science 1980; 210:207-210 10. Squire LR, Zola-Morgan S: Memory: Brain systems and behavior. Trends Neurosci 1988; 11:170-175 11. Andreason NC: Brain imaging: Applications in psychiatry. Science 1988; 239:1381-1388 12. Press GA, Amaral DG, Squire LR: Hippocampal abnormalities in amnesic patients revealed by high-resolution magnetic resonance imaging. Nature 1989; 341:54-57 13. Olverman HJ, Jones AW, Watkins JC: L-Glutamate has higher affinity than other amino acids for [3H]-DAP5 binding sites in rat brain membranes. Nature 1984; 307:460-465 14. Collingridge GL: The role of NMDA receptors in learning and memory. Nature 1987; 330:604-605 15. Morris RGM, Anderson E, Lynch GS, et al: Selective impairment of learning and blockade of long-term potentiation by an N-methyl-D-aspartate receptorantagonist, AP5. Nature 1986; 319:774-776 16. McNaughton B, Morris RGM: Hippocampal synaptic enhancement and information storage within a distributed memory system. Trends Neurosci 1987; 10:408415 17. Rolls ET: Functions of neuronal networks in the hippocampus and neocortex in memory, In Byrne JH, Berry WO: Neural Models of Plasticity. San Diego, Calif, Academic Press, 1989, pp 240-265 18. Milner B, Petrides M: Behavioural effects of frontal-lobe lesions in man. Trends Neurosci 1984; 7:403-407 19. Shimamura AP, Squire LR, Janowsky JS: What is the role of the frontal lobes in amnesic disorders? In Levin HS, Eisenberg HM (Eds): Frontal Lobe Function and Injury. Oxford, Oxford University Press, in press
Occupational and Environmental Illness and the Poison Center
WITH THE PUBLICATION OF THE ARTICLE by Blanc and coworkers in this issue of THE WESTERN JOURNAL OF MEDI-
CINE, the literature now contains the complete cycle of this group's work analyzing occupational exposures reported to regional poison centers. 1.2 As such, their work deserves the scrutiny of all occupational physicians, toxicologists, and relevant government agencies with toxicologic responsibilities in the occupational, environmental, and health arenas. Compelling evidence is presented to confirm the inadequacy of current reporting systems for occupational exposures. Moreover, these studies highlight the disparity between increasing exposures, public awareness, and health professional inquiries and the paucity of institutions and trained specialists to provide knowledgeable counsel and care. Taken together, these findings have substantial medical, occupational, political, and public health import. Among the nearly half a million physicians in the United States today, only 1,378 have been certified in occupational
medicine since 1955 (even in 1988, only 121 physicians were newly certified [American Board of Preventive Medicine, Dayton, Ohio, written communication, September 1989]),
and fewer than 125 are certified in medical toxicology (only 15 in 1988).34 Moreover, only a handful are certified in both disciplines, and there are no formally recognized training or certifying procedures in environmental medicine. Data from the American Association of Poison Control Centers (AAPCC) indicate there are at least 86,000 occupational exposures to toxic substances each year in this country. (The AAPCC National Data Collection System documented 25,368 occupational exposure cases in 1988 from 63 % ofthe US population.5 In 1988 AAPCC used an extrapolation factor of 3.4 to estimate actual exposures compared to the 1,368,748 total reported exposures.) This may considerably underestimate occupational exposures due to a relative lack of awareness of poison centers' ability to assist in this area. Such a postulate is strongly supported by the magnitude of occupational illness in the United States, with estimates of the incidence of occupational illnesses and injuries ranging as high as 12 million cases per year.6 The incidence of exposure to chemical hazards has doubtlessly risen in our increasingly technological civilization, yet considerable but heretofore-occult occupational illness is likely surfacing in response to a promulgation of exposure standards, right-toknow legislation, and media-induced "toxic terror." The entire situation has attracted the formal attention of the National Academy of Science's Institute of Medicine and the National Research Council. These organizations have expressed profound concern over the shortage of trained physicians and resources to handle the growing number of occupational exposures and illnesses. I Few would dispute that occupational and environmental illnesses are widely underestimated and underreported, and Blanc and coauthors have demonstrated this phenomenon within the subset of occupational exposures. Using indirect and direct comparisons with extant reporting systems, they have found that the traditional and established reporting systems failed to capture 68 % to 92 % of occupational exposure cases-particularly clinically serious cases-reported to the regional poison center.2 This is especially remarkable as California, the site of the study, has perhaps the most extensive array of occupational and environmental exposure reporting systems of any state. Unquestionably there is a manifest role for the AAPCC-certified regional poison centers to supplement and validate current occupational illness reporting systems. According to the studies of Blanc and associates, patients concerned about occupational or environmental exposures will seek assistance from some combination of public health agencies, primary care physicians, the company or employer's physician, and poison centers. This fragmentation induces confusion and poses problems with the reporting, consultation, and follow-up of these patients. Ultimately, all exposures are fundamentally a medical problem with economic, occupational, and legal components; yet, the number of trained occupational physicians and medical toxicologists is clearly inadequate to address this need. Company physicians are perceived as insufficiently independent to serve as objective patient advocates, and primary care physicians are not trained to handle these problems. (The average US medical student will receive less than three hours of instruction in these areas over the four-year curriculum, and the vast ma-
THE WESTERN JOURNAL OF MEDICINE
THE
WESTERN
JOURNAL
OF
MEDICINE
o *
FEBRUARY 1990
FEBRUARY
1990
jority of primary care residency programs-internal, family, and emergency medicine-offer no formal experience in these areas.7) Public health agencies are understandably not oriented to interact with patients in a comprehensive, consistent, or individual manner. Where are these patients and their physicians to turn? Increasingly, it seems, it is to the regional poison center. Over the past five years the percentage of reports to poison centers of exposure that is occupational has nearly doubled, rising from 2,445 cases (0.97% of exposure consultations) in 19838 to 25,368 cases (1.85% in 1988),5 despite the fact that poison centers still focus on acute overdoses of pharmaceuticals and pediatric ingestions of household products, rather than adult occupational and environmental exposures in subacute and chronic circumstances. Nevertheless, because of their toxicologic expertise, information resources, concentrated experience, and awareness of prevention and treatment programs, regional poison centers are a compelling venue to orchestrate the provision of counseling, medical care, and exposure-site investigation of these cases. Patients, physicians, and governmental agencies have grown to trust regional poison centers to provide timely, knowledgeable advice with flexible, readily accessible human services-free phone calls, anonymity when requested, no user fees-and a full range of expert backup. Furthermore, health professionals appreciate that computerized access to informational data bases alone is inadequate, and they have come to depend, instead, on a poison center's ability to provide not only relevant information but also the interpretation and application of that information to specific clinical scenarios. Over the past decade, regional poison centers have become highly professional, sophisticated, and computerized operations, with extensive on-line resources, specialized toxicologic expertise, public and professional education programs, and consultation provided by trained and certified specialists in poison information and by clinical toxicologists. These established relations and familiarity with regional considerations-industry, location, climate, economics, and politics-often prove essential in dealing with an occupational exposure and illness. From a public health standpoint, regional poison centers have a proven data collection system able to accommodate a substantial increase in the number of occupational and environmental exposures. Adaptations of this AAPCC National Data Collection System would allow poison centers to provide ongoing surveillance with singular active attributeseducation, management, referral, and follow-up. Moreover, poison centers are likely sources of information regarding index cases of affected or exposed workers, and these sentinel cases can be of utmost importance in identifying multiple exposures, discovering the source, and initiating remediation-all in cooperation with local public health agencies. (Indeed, Bresnitz has found that such reports to regional poison control centers represent only the tip of the iceberg, with, on average, 12 additional workers being exposed for every inquiry or report [E. A. Bresnitz, "The Evaluation of Poison Control Centers as Surveillance Systems for Occupational Illness," unpublished data, 1989].) The regional poison center model has not only been embraced by the public, physicians, and government, it has had a highly costeffective impact9 10 on the use of medical resources while at the same time providing state-of-the-art guidance that likely leads to decreased morbidity and mortality. Finally, perhaps
9
*
152
152
-
*
2
2
179
179
the most enduring public health effect regional poison centers could have would be in the areas of education, informational data-base development, and research. Obviously, each inquiry or report is fundamentally an educational encounter for the caller, but regional poison centers can also be instru-
mental in promoting professional education for physicians, nurses, and pharmacists; training clinical toxicologists; developing useful resources; and stimulating research in this field. Regional poison centers already participate in the management of a significant (and apparently otherwise unrecognized) burden of occupational or environmental illness. They are uniquely able to provide an active surveillance system to supplement current reporting systems, guide the care, counseling, referral, and follow-up of patients, help educate the public and primary care physicians, assist employers and industries to contain and avoid toxic exposures, and encourage scientific and epidemiologic investigations of occupational and environmental exposures and illness. These capabilities expressly meet the agenda laid out in the recommendations of the Institute of Medicine report on occupational and environmental medicine. I Regional poison centers have a unique potential to evolve a system for the reporting, care, education, and research in environmental and occupational exposures. Logistically, however, these centers are not in a position to seriously expand into this field without the necessary financial and personnel resources. If these poison centers are to become broad-based toxicology resource centers, each center will have to expand its activities. Expertise in industrial hygiene and occupational and environmental toxicology needs to be brought on board. Current staffs need to be trained in these specialized areas. Operational protocols and comprehensive yet concise informational data bases need to be developed. National and local experts, response systems, and resources must be identified and combined into a network. Working protocols and relations with local, state, and federal agencies must be developed. Existing data collection systems must be expanded to active surveillance and ready detection of sentinel health events. Finally, the public, health professionals, and the work force need to be educated to an expanded role of regional poison centers as they become true toxicologic resource centers. State health departments and agencies with mandates in this field-the Agency for Toxic Substances and Disease Registry, the Environmental Protection Agency, the National Institute of Environmental Health Sciences, the National Institute for Occupational Safety and Health, and the Occupational Safety and Health Administration-need to cooperate with and encourage the regional poison centers and the AAPCC during this evolution. The opportunity to deal with occupational and environmental exposures in a coordinated, comprehensive, and capable manner through regional poison centers needs to be supported if the promise of regional poison and toxicology resource centers is to materialize. TOBY L. LITOVITZ, MD J. DOUGLAS WHITE, MD National Capital Poison Center Georgetown University Medical Center Washington, DC REFERENCES 1. Blanc P, Olson KR: Occupationally related illness reported to a regional poison control center. Am J Public Health 1986; 76:1303-1307 2. Blanc PD, Remple D, Maizlish N, et al: Occupational illness: Case detection by poison control surveillance. Ann Intern Med 1989; 1 1 1:238-244
180 EDITORIALS 18lDTOIL 3. Banner W: Minutes of the American Board of Medical Toxicology meeting of October 1, 1988, Baltimore, Maryland. Vet Hum Toxicol 1989; 31:83-84 4. Goldfrank L: Minutes of the American Board of Medical Toxicology annual meeting, September29, 1987, Vancouver, British Columbia. Vet Hum Toxicol 1987; 29:512-515 5. Litovitz TL, Schmitz BF, Holm KC: 1988 Annual report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1989; 7:495-545 6. Gould KG, Peterson KW: In search of occupational illness. Ann Intern Med 1989; 1 1 1: 195-197 7. Division of Health Promotion and Disease Prevention, Institute of Medicine: Role of the Primary Care Physician in Occupational and Environmental Medicine. Washington, DC, National Academy Press, 1988 8. Veltri JC, Litovitz TL: 1983 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1983; 2:420-443 9. Schleich C, McIntire M: Poison control and definitive cost containment. Vet HumToxicol 1984; 26:101-104 10. Chafee-Bahamon C, Lovejoy FH Jr: Effectiveness of a regional poison center in reducing excess emergency room visits for children's poisonings. Pediatrics 1983; 72:164-169
On Rocks and Hard Places DURING THEIR TRAINING, physicians study human biology and come to a degree of understanding of the human mind and body within the framework of biologic law in the natural world. There has been enormous progress in our degree of understanding, and, indeed, bioscience has been the foundation upon which modern medicine has been built. As this understanding has increased and the technology to apply it has advanced, medical care has become much more complex and costly, with results, to be sure, that are often spectacular. As interest in health and health care has grown, much of the new knowledge and technology has entered into the public consciousness, if not the public domain. This public interest has been intensified by concern and even alarm over rapidly rising costs. Because of this, third parties who pay the bills in both the public and private sectors have become increasingly involved in many aspects of health care delivery. A turning point that began the present era was passage of the Medicare law in 1965, and third party involvement in patient care has been progressing ever since. With the entry of these third parties, new expectations were introduced into patient care and health care delivery. Whereas physicians, by reason of their training, considered medical practice and patient care in terms of their understanding of biologic laws of nature as applied to health and illness, this was not so much the case with the new third parties, whose motives were based largely, though certainly not entirely, on their concern with economic realities. They soon began to introduce and apply the business and legal expertise of society to health care by fostering economic competition, enacting legislation to try to control costs, introducing administrative regulation, and indulging in litigation. So it comes about that there are now two standards or systems at work in health care that are in fundamental conflict. The biologic system is one created by nature and operates with its own natural laws. These are expressed in terms
of probabilities, and these probabilities are always accompanied by possibilities that are more or less probable but nevertheless equally real. Much of what is done in medical practice is determined by a physician's assessment of the probabilities and possibilities inherent in a given situation. This biologic fact of life is not readily recognized by the legal system. Laws created by society are artificial rather than natural. Yet they must be respected and obeyed in a human society governed by law. The differences come into focus especially when there is a medical injury accompanied by litigation. The legal system assumes that the injury should not have happened, but since it did, it seeks to affix blame and punishment and to give compensation to the aggrieved party. The trial is public, conducted with attorneys for the plaintiff and defendant jousting with one another in court, using their wits and knowledge of the rules of law created by humans as their weapons. The facts of the case are sought but used selectively as deemed best for the cause of prosecution or defense. Right or wrong is decided in light of whether or not there is compliance with more or less arbitrary rules established through legislation or by the courts. It is seldom recognized that guilt or innocence may exist in terms ofthe probabilities inherent in the biologic law that governs patient care. The biologic approach to an unfortunate medical happening is quite different. The approach is "no-fault." True to bioscience, it tries to get at the full truth of what really happened and why it happened and then to use this information positively with the view of gaining experience and preventing an unfortunate event from being repeated. The focus is on getting to the truth, wherever it may lie, but if there was genuine wrongdoing, it is understood that whatever blame, punishment, and compensation are appropriate should be meted out. The art and science of medicine clearly lie within the realm of biologic law, but practice must respond to legal as well as biologic standards. Physicians in daily practice cannot escape either rule. Their patients are governed by biologic law in their sickness and their health. Medical practice is increasingly governed by societal law and regulation. It is not surprising that physicians sometimes find themselves between rocks and hard places when the two systems conflict, as is often evident when a medical practice issue involving an untoward outcome is being adjudicated in the courts. But there may be a ray of hope. It was only during the last century that the fundamentally biologic nature of humans was finally recognized. The inescapable consequence-that human society itself is therefore fundamentally biologic in nature and behavior and subject to biologic law-has yet to be similarly recognized. Progress is slow, but sooner or later there has to be light at the end of the tunnel. In the meantime there will be many rocks and many hard places in a physician's practice. MSMW
178 178
EIOIL
orders associated with damage to prefrontal cortex have only just begun. Further studies will certainly illuminate how this area contributes to memory function. ARTHUR P. SHIMAMURA, PhD Department of Psychology University of California, Berkeley REFERENCES 1. Amaral DJ: Memory: The anatomical organization of candidate brain regions, In Plum F (Ed): Handbook of Physiology: Higher Functions of the Nervous
System. New York, Oxford University Press, 1987 2. Kandel ER, Schwartz JH: Molecular biology of learning: Modification of transmitter release. Science 1982; 218:433-442 3. Lynch G: Synapses, Circuits and the Beginnings of Memory. Cambridge, Mass, MIT Press, 1986 4. Mishkin M: A memory system in the monkey, In Broadbent DE, Weiskrantz L (Eds): The Neuropsychology of Cognitive Function. London, The Royal Society, 1982, pp 85-95 5. Squire LR: Memory and Brain. New York, Oxford University Press, 1987 6. Shimamura AP: Disorders of memory: The cognitive science perspective, chap 2, In Boller F, Grafman J (Eds): Handbook of Neuropsychology, Vol 3. Amsterdam, Elsevier Publishers, 1989, pp 35-73 7. Schacter DL: Implicit memory: History and current status. J Exp Psychol [Learn Mem Cogn] 1987; 13:501-518 8. Shimamura AP: Priming effects in amnesia: Evidence for a dissociable memory function. Q J Exp Psychol 1986; 38A:619-644 9. Cohen NJ, Squire LR: Preserved learning and retention of pattern-analyzing skill in amnesia: Dissociation of knowing how and knowing that. Science 1980; 210:207-210 10. Squire LR, Zola-Morgan S: Memory: Brain systems and behavior. Trends Neurosci 1988; 11:170-175 11. Andreason NC: Brain imaging: Applications in psychiatry. Science 1988; 239:1381-1388 12. Press GA, Amaral DG, Squire LR: Hippocampal abnormalities in amnesic patients revealed by high-resolution magnetic resonance imaging. Nature 1989; 341:54-57 13. Olverman HJ, Jones AW, Watkins JC: L-Glutamate has higher affinity than other amino acids for [3H]-DAP5 binding sites in rat brain membranes. Nature 1984; 307:460-465 14. Collingridge GL: The role of NMDA receptors in learning and memory. Nature 1987; 330:604-605 15. Morris RGM, Anderson E, Lynch GS, et al: Selective impairment of learning and blockade of long-term potentiation by an N-methyl-D-aspartate receptorantagonist, AP5. Nature 1986; 319:774-776 16. McNaughton B, Morris RGM: Hippocampal synaptic enhancement and information storage within a distributed memory system. Trends Neurosci 1987; 10:408415 17. Rolls ET: Functions of neuronal networks in the hippocampus and neocortex in memory, In Byrne JH, Berry WO: Neural Models of Plasticity. San Diego, Calif, Academic Press, 1989, pp 240-265 18. Milner B, Petrides M: Behavioural effects of frontal-lobe lesions in man. Trends Neurosci 1984; 7:403-407 19. Shimamura AP, Squire LR, Janowsky JS: What is the role of the frontal lobes in amnesic disorders? In Levin HS, Eisenberg HM (Eds): Frontal Lobe Function and Injury. Oxford, Oxford University Press, in press
Occupational and Environmental Illness and the Poison Center
WITH THE PUBLICATION OF THE ARTICLE by Blanc and coworkers in this issue of THE WESTERN JOURNAL OF MEDI-
CINE, the literature now contains the complete cycle of this group's work analyzing occupational exposures reported to regional poison centers. 1.2 As such, their work deserves the scrutiny of all occupational physicians, toxicologists, and relevant government agencies with toxicologic responsibilities in the occupational, environmental, and health arenas. Compelling evidence is presented to confirm the inadequacy of current reporting systems for occupational exposures. Moreover, these studies highlight the disparity between increasing exposures, public awareness, and health professional inquiries and the paucity of institutions and trained specialists to provide knowledgeable counsel and care. Taken together, these findings have substantial medical, occupational, political, and public health import. Among the nearly half a million physicians in the United States today, only 1,378 have been certified in occupational
medicine since 1955 (even in 1988, only 121 physicians were newly certified [American Board of Preventive Medicine, Dayton, Ohio, written communication, September 1989]),
and fewer than 125 are certified in medical toxicology (only 15 in 1988).34 Moreover, only a handful are certified in both disciplines, and there are no formally recognized training or certifying procedures in environmental medicine. Data from the American Association of Poison Control Centers (AAPCC) indicate there are at least 86,000 occupational exposures to toxic substances each year in this country. (The AAPCC National Data Collection System documented 25,368 occupational exposure cases in 1988 from 63 % ofthe US population.5 In 1988 AAPCC used an extrapolation factor of 3.4 to estimate actual exposures compared to the 1,368,748 total reported exposures.) This may considerably underestimate occupational exposures due to a relative lack of awareness of poison centers' ability to assist in this area. Such a postulate is strongly supported by the magnitude of occupational illness in the United States, with estimates of the incidence of occupational illnesses and injuries ranging as high as 12 million cases per year.6 The incidence of exposure to chemical hazards has doubtlessly risen in our increasingly technological civilization, yet considerable but heretofore-occult occupational illness is likely surfacing in response to a promulgation of exposure standards, right-toknow legislation, and media-induced "toxic terror." The entire situation has attracted the formal attention of the National Academy of Science's Institute of Medicine and the National Research Council. These organizations have expressed profound concern over the shortage of trained physicians and resources to handle the growing number of occupational exposures and illnesses. I Few would dispute that occupational and environmental illnesses are widely underestimated and underreported, and Blanc and coauthors have demonstrated this phenomenon within the subset of occupational exposures. Using indirect and direct comparisons with extant reporting systems, they have found that the traditional and established reporting systems failed to capture 68 % to 92 % of occupational exposure cases-particularly clinically serious cases-reported to the regional poison center.2 This is especially remarkable as California, the site of the study, has perhaps the most extensive array of occupational and environmental exposure reporting systems of any state. Unquestionably there is a manifest role for the AAPCC-certified regional poison centers to supplement and validate current occupational illness reporting systems. According to the studies of Blanc and associates, patients concerned about occupational or environmental exposures will seek assistance from some combination of public health agencies, primary care physicians, the company or employer's physician, and poison centers. This fragmentation induces confusion and poses problems with the reporting, consultation, and follow-up of these patients. Ultimately, all exposures are fundamentally a medical problem with economic, occupational, and legal components; yet, the number of trained occupational physicians and medical toxicologists is clearly inadequate to address this need. Company physicians are perceived as insufficiently independent to serve as objective patient advocates, and primary care physicians are not trained to handle these problems. (The average US medical student will receive less than three hours of instruction in these areas over the four-year curriculum, and the vast ma-
THE WESTERN JOURNAL OF MEDICINE
THE
WESTERN
JOURNAL
OF
MEDICINE
o *
FEBRUARY 1990
FEBRUARY
1990
jority of primary care residency programs-internal, family, and emergency medicine-offer no formal experience in these areas.7) Public health agencies are understandably not oriented to interact with patients in a comprehensive, consistent, or individual manner. Where are these patients and their physicians to turn? Increasingly, it seems, it is to the regional poison center. Over the past five years the percentage of reports to poison centers of exposure that is occupational has nearly doubled, rising from 2,445 cases (0.97% of exposure consultations) in 19838 to 25,368 cases (1.85% in 1988),5 despite the fact that poison centers still focus on acute overdoses of pharmaceuticals and pediatric ingestions of household products, rather than adult occupational and environmental exposures in subacute and chronic circumstances. Nevertheless, because of their toxicologic expertise, information resources, concentrated experience, and awareness of prevention and treatment programs, regional poison centers are a compelling venue to orchestrate the provision of counseling, medical care, and exposure-site investigation of these cases. Patients, physicians, and governmental agencies have grown to trust regional poison centers to provide timely, knowledgeable advice with flexible, readily accessible human services-free phone calls, anonymity when requested, no user fees-and a full range of expert backup. Furthermore, health professionals appreciate that computerized access to informational data bases alone is inadequate, and they have come to depend, instead, on a poison center's ability to provide not only relevant information but also the interpretation and application of that information to specific clinical scenarios. Over the past decade, regional poison centers have become highly professional, sophisticated, and computerized operations, with extensive on-line resources, specialized toxicologic expertise, public and professional education programs, and consultation provided by trained and certified specialists in poison information and by clinical toxicologists. These established relations and familiarity with regional considerations-industry, location, climate, economics, and politics-often prove essential in dealing with an occupational exposure and illness. From a public health standpoint, regional poison centers have a proven data collection system able to accommodate a substantial increase in the number of occupational and environmental exposures. Adaptations of this AAPCC National Data Collection System would allow poison centers to provide ongoing surveillance with singular active attributeseducation, management, referral, and follow-up. Moreover, poison centers are likely sources of information regarding index cases of affected or exposed workers, and these sentinel cases can be of utmost importance in identifying multiple exposures, discovering the source, and initiating remediation-all in cooperation with local public health agencies. (Indeed, Bresnitz has found that such reports to regional poison control centers represent only the tip of the iceberg, with, on average, 12 additional workers being exposed for every inquiry or report [E. A. Bresnitz, "The Evaluation of Poison Control Centers as Surveillance Systems for Occupational Illness," unpublished data, 1989].) The regional poison center model has not only been embraced by the public, physicians, and government, it has had a highly costeffective impact9 10 on the use of medical resources while at the same time providing state-of-the-art guidance that likely leads to decreased morbidity and mortality. Finally, perhaps
9
*
152
152
-
*
2
2
179
179
the most enduring public health effect regional poison centers could have would be in the areas of education, informational data-base development, and research. Obviously, each inquiry or report is fundamentally an educational encounter for the caller, but regional poison centers can also be instru-
mental in promoting professional education for physicians, nurses, and pharmacists; training clinical toxicologists; developing useful resources; and stimulating research in this field. Regional poison centers already participate in the management of a significant (and apparently otherwise unrecognized) burden of occupational or environmental illness. They are uniquely able to provide an active surveillance system to supplement current reporting systems, guide the care, counseling, referral, and follow-up of patients, help educate the public and primary care physicians, assist employers and industries to contain and avoid toxic exposures, and encourage scientific and epidemiologic investigations of occupational and environmental exposures and illness. These capabilities expressly meet the agenda laid out in the recommendations of the Institute of Medicine report on occupational and environmental medicine. I Regional poison centers have a unique potential to evolve a system for the reporting, care, education, and research in environmental and occupational exposures. Logistically, however, these centers are not in a position to seriously expand into this field without the necessary financial and personnel resources. If these poison centers are to become broad-based toxicology resource centers, each center will have to expand its activities. Expertise in industrial hygiene and occupational and environmental toxicology needs to be brought on board. Current staffs need to be trained in these specialized areas. Operational protocols and comprehensive yet concise informational data bases need to be developed. National and local experts, response systems, and resources must be identified and combined into a network. Working protocols and relations with local, state, and federal agencies must be developed. Existing data collection systems must be expanded to active surveillance and ready detection of sentinel health events. Finally, the public, health professionals, and the work force need to be educated to an expanded role of regional poison centers as they become true toxicologic resource centers. State health departments and agencies with mandates in this field-the Agency for Toxic Substances and Disease Registry, the Environmental Protection Agency, the National Institute of Environmental Health Sciences, the National Institute for Occupational Safety and Health, and the Occupational Safety and Health Administration-need to cooperate with and encourage the regional poison centers and the AAPCC during this evolution. The opportunity to deal with occupational and environmental exposures in a coordinated, comprehensive, and capable manner through regional poison centers needs to be supported if the promise of regional poison and toxicology resource centers is to materialize. TOBY L. LITOVITZ, MD J. DOUGLAS WHITE, MD National Capital Poison Center Georgetown University Medical Center Washington, DC REFERENCES 1. Blanc P, Olson KR: Occupationally related illness reported to a regional poison control center. Am J Public Health 1986; 76:1303-1307 2. Blanc PD, Remple D, Maizlish N, et al: Occupational illness: Case detection by poison control surveillance. Ann Intern Med 1989; 1 1 1:238-244
180 EDITORIALS 18lDTOIL 3. Banner W: Minutes of the American Board of Medical Toxicology meeting of October 1, 1988, Baltimore, Maryland. Vet Hum Toxicol 1989; 31:83-84 4. Goldfrank L: Minutes of the American Board of Medical Toxicology annual meeting, September29, 1987, Vancouver, British Columbia. Vet Hum Toxicol 1987; 29:512-515 5. Litovitz TL, Schmitz BF, Holm KC: 1988 Annual report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1989; 7:495-545 6. Gould KG, Peterson KW: In search of occupational illness. Ann Intern Med 1989; 1 1 1: 195-197 7. Division of Health Promotion and Disease Prevention, Institute of Medicine: Role of the Primary Care Physician in Occupational and Environmental Medicine. Washington, DC, National Academy Press, 1988 8. Veltri JC, Litovitz TL: 1983 Annual Report of the American Association of Poison Control Centers National Data Collection System. Am J Emerg Med 1983; 2:420-443 9. Schleich C, McIntire M: Poison control and definitive cost containment. Vet HumToxicol 1984; 26:101-104 10. Chafee-Bahamon C, Lovejoy FH Jr: Effectiveness of a regional poison center in reducing excess emergency room visits for children's poisonings. Pediatrics 1983; 72:164-169
On Rocks and Hard Places DURING THEIR TRAINING, physicians study human biology and come to a degree of understanding of the human mind and body within the framework of biologic law in the natural world. There has been enormous progress in our degree of understanding, and, indeed, bioscience has been the foundation upon which modern medicine has been built. As this understanding has increased and the technology to apply it has advanced, medical care has become much more complex and costly, with results, to be sure, that are often spectacular. As interest in health and health care has grown, much of the new knowledge and technology has entered into the public consciousness, if not the public domain. This public interest has been intensified by concern and even alarm over rapidly rising costs. Because of this, third parties who pay the bills in both the public and private sectors have become increasingly involved in many aspects of health care delivery. A turning point that began the present era was passage of the Medicare law in 1965, and third party involvement in patient care has been progressing ever since. With the entry of these third parties, new expectations were introduced into patient care and health care delivery. Whereas physicians, by reason of their training, considered medical practice and patient care in terms of their understanding of biologic laws of nature as applied to health and illness, this was not so much the case with the new third parties, whose motives were based largely, though certainly not entirely, on their concern with economic realities. They soon began to introduce and apply the business and legal expertise of society to health care by fostering economic competition, enacting legislation to try to control costs, introducing administrative regulation, and indulging in litigation. So it comes about that there are now two standards or systems at work in health care that are in fundamental conflict. The biologic system is one created by nature and operates with its own natural laws. These are expressed in terms
of probabilities, and these probabilities are always accompanied by possibilities that are more or less probable but nevertheless equally real. Much of what is done in medical practice is determined by a physician's assessment of the probabilities and possibilities inherent in a given situation. This biologic fact of life is not readily recognized by the legal system. Laws created by society are artificial rather than natural. Yet they must be respected and obeyed in a human society governed by law. The differences come into focus especially when there is a medical injury accompanied by litigation. The legal system assumes that the injury should not have happened, but since it did, it seeks to affix blame and punishment and to give compensation to the aggrieved party. The trial is public, conducted with attorneys for the plaintiff and defendant jousting with one another in court, using their wits and knowledge of the rules of law created by humans as their weapons. The facts of the case are sought but used selectively as deemed best for the cause of prosecution or defense. Right or wrong is decided in light of whether or not there is compliance with more or less arbitrary rules established through legislation or by the courts. It is seldom recognized that guilt or innocence may exist in terms ofthe probabilities inherent in the biologic law that governs patient care. The biologic approach to an unfortunate medical happening is quite different. The approach is "no-fault." True to bioscience, it tries to get at the full truth of what really happened and why it happened and then to use this information positively with the view of gaining experience and preventing an unfortunate event from being repeated. The focus is on getting to the truth, wherever it may lie, but if there was genuine wrongdoing, it is understood that whatever blame, punishment, and compensation are appropriate should be meted out. The art and science of medicine clearly lie within the realm of biologic law, but practice must respond to legal as well as biologic standards. Physicians in daily practice cannot escape either rule. Their patients are governed by biologic law in their sickness and their health. Medical practice is increasingly governed by societal law and regulation. It is not surprising that physicians sometimes find themselves between rocks and hard places when the two systems conflict, as is often evident when a medical practice issue involving an untoward outcome is being adjudicated in the courts. But there may be a ray of hope. It was only during the last century that the fundamentally biologic nature of humans was finally recognized. The inescapable consequence-that human society itself is therefore fundamentally biologic in nature and behavior and subject to biologic law-has yet to be similarly recognized. Progress is slow, but sooner or later there has to be light at the end of the tunnel. In the meantime there will be many rocks and many hard places in a physician's practice. MSMW
