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Primary Care Doctors Aren't Just GatekeepersI read...

THE BALTIMORE SUN

Primary Care Doctors Aren't Just Gatekeepers

I read Dr. R. Ben Dawson's testimonial (The Sun, Oct. 2) to specialty physicians with great interest. However, I think he misses the mark on a number of his conclusions.

My training has been in general internal medicine and I, like his "primary care" physician, was at the top of my class in medical school (Maryland) and was also picked to be chief resident at the University of Virginia Hospital.

However, I do not consider myself a mere "gatekeeper" and am skilled in the diagnoses and treatment of a great many illnesses, as are my colleagues.

I also have the advantage of knowing my patients well and, therefore, can guide them through the maze of specialists and technology to get the most appropriate care, or to help in the decision to withhold treatment.

Dr. Dawson claims that common and rare problems are best handled by a specialist. Specialists by nature have a narrow focus which at times can turn into tunnel vision (like so many blind men when asked to describe an elephant by the part their hands had touched).

He cites the example of chest pain which turned out to be an esophageal problem and had been exacerbated by the heart drug he was taking. Why is he still going to his cardiologist if there was no heart problem to begin with? Is it just to be sure that one doesn't develop? And, what is the cost of that?

In my own residency, I remember a man who saw a "super-specialist" (electrophysiologist) because he had a past history of a cardiac rhythm irregularity and had begun to feel quite ill. The specialist pronounced his heart in good working order and sent him on his way.

The next day he was brought to the emergency room near death and was diagnosed by his family physician as having a severe hemolytic anemia (unrelated to his heart), and appropriate treatment was rendered.

Efficiency in diagnosis was also an issue that Dr. Dawson raised. An ear, nose and throat physician quickly diagnosed his chronic sinus problem after his internist had been unsuccessful. No reasonable physician would argue that referral in that case was appropriate.

Nevertheless, most illnesses can be handled quite well at the generalist level with judicious referral to specialists for recalcitrant or difficult cases.

Further, initial contact with specialists may be expensive as they may frequently want to rule out more arcane causes of an illness.

Also, patients inevitably present multiple problems, and I have seen more than one person shuttled by referral from one special ist to multiple others. Frequently, these problems can be handled more efficiently and cheaply by one visit to a primary care doctor.

Finally, there are some patients who collect specialty physicians like many trophies, going initially to the neurologist for a headache, the orthopedist for a sprained wrist and the gastroenterologist for a "bellyache."

They also insist on every high-technology test, whether appropriate or not, and often specialists are loathe to refuse them. Is this really quality care? Maybe a good generalist could help the patient select a more appropriate approach. Obviously, this requires top-notch primary physicians, not mere gatekeepers.

To practice this type of high quality general medical care is difficult, demanding, requires long hours and, unfortunately, is not compensated very well.

However, it can be done, and the quality of medical care will be enhanced, not diminished, by the training of more generalists. While I would agree with Dr. Dawson that specialty is extremely important, I believe it has been over emphasized.

The change has to start with medical institutions and the funding they receive. Governmental and private agencies tend to give money to narrowly defined research projects, usually at the laboratory level. The dollars for clinical projects are rapidly drying up. In turn this serves as a disincentive for faculties of medicine to hire professors who cannot bring in this type of funding.

Thus, the mentors of today's students become more and more specialized, fostering the same attitudes and beliefs in their young charges.

Physicians, especially generalists, should be able to deliver quality care in an environment that does not reduce them to gatekeepers or insurance clerks. The primary care doctor should be a sophisticated and compassionate adviser to his or her patients and have the freedom to consult specialists when appropriate.

In that, I share Dr. Dawson's concern over managed care. Unfortunately, these institutions may introduce countless layers of bureaucracy and actually drive up the cost of medical care, while decreasing the amount provided. I don't like that, either.

Also, generalists need to be paid what they are worth. Previous attempts at that, including the oft-quoted relative value scale, have fallen short of the mark. If we are to have any hope of attracting the best and brightest to become primary physicians, this must be changed and changed now.

So, if we are to focus on the delivery of care, let's return the emphasis to the basic partnership of the patient and his or her family physician and minimize all of the extraneous bureaucratic nonsense.

Together this unit can carve out the most reasonable and cost effective approach with the rational and appropriate use of specialty services and technology.

Ali J. Afrookteh, M.D.

Frederick

Avoid Maryland

A recent article informed Sun readers that commuting to work in Maryland can only get worse.

No number of additional lanes on the beltway or on other roads, and no additional transit routes, can cope with the anticipated population growth. The quality of life, as it is affected by travel, can only be degraded.

No planners ever seem to consider the possibility of discouraging the in-migration that will steadily increase the number of people having to commute to work.

The anticipated increase will also pave over more land, fill most remaining open space with houses, increase the problems of waste disposal and pollution, and continue pressure on Chesapeake Bay.

Why not consider disincentives to moving into Maryland?

Until the United States adopts a population policy to maintain a balance between people and resources, states need to make a start at limiting their population growth.

Maryland already has a minor disincentive: the tax on out-of-state automobiles registered here. The state could invent several more.

There would have to be certain exemptions, such as an employee with certain needed skills allowed a rebate when accepting a job in Maryland, but those exemptions could be designed into a population policy.

Why is a population policy the last subject planners ever consider, if they consider one at all?

Carleton W. Brown

Elkton

Polish Refugees

I have to take exception to your staff writer Richard O'Mara ("Influx of World War II refugees brought thousands of war criminals into U.S.") lumping Poles with other nationalities who came to the United States as hidden collaborators.

Mr. O'Mara apparently is not aware that the majority of the Polish migration to the country came from the Polish servicemen who fought against Germany, who were stranded in the United Kingdom after the war since they were unable or unwilling to go back to a Soviet-dominated Poland.

In fact, the United States passed special enabling legislation (I believe in 1947-48) to allow these forced political exiles to come to this country.

Unless Mr. O'Mara can come up with one name of a Polish national who after arrival in the United States was found to have been implicated in Nazi collaboration, he should formally apologize.

Michael Alfred Peszke

Perry Point

The McMillion

Your editorial concerning the Maryland Million attributes that program to the late Frank DeFrancis.

You might check your publication's own history to find the true father of the Million.

Back in the 1940's a young fellow by the name of James McManus worked as a reporter for The Evening Sun. With the advent of WMAR-TV, he also did some television work.

When he moved up to the ABC network he changed his name to Jim McKay. You can call him McKay or McManus, but the "McMillion" is his baby.

W. K. Lester

Round Bay

Hazard's Talents

I want to congratulate The Sun for making use of the exceptional talents of Charles Hazard, whose drawings, in addition to always being topical, are works of art.

In a single picture he tells more than it would take 10,000 (not the usually misquoted 1,000) words to convey, according to ancient Chinese wisdom.

Stanislav Rembski

Baltimore

NAFTA Improves America's Competitiveness

Congress will face one of its most important votes this year when it decides the fate of the North American Free Trade Agreement.

By linking the United States, Mexico and Canada into the world's largest trading zone, NAFTA is an essential tool for generating economic growth, producing new U.S. jobs and allowing our companies to remain competitive into the 21st century.

Recently McCormick & Co. -- the world's largest manufacturer of spices and seasonings -- announced a new structuring of the company based on two basic principles: the growing importance of foreign markets to U.S. companies and their employees and the increasing tendency of nations to form regional trade partnerships rather than continue to go it alone in the global economy.

NAFTA is, in my view, the natural evolution of these two trends.

Our nation's economy has become increasingly dependent on exports to create good, new jobs for the American people.

Our trade relationship with Mexico is a good example of how exports can fuel the engine of economic growth and job creation.

Since Mexico began reducing its own tariffs and trade barriers in 1986, U.S. exports to Mexico have grown from $12.4 billion to $40.6 billion. About 700,000 U.S. jobs are now directly related to those exports and if NAFTA is approved, an additional 200,000 jobs will be created by 1995.

The international arena has been an important part of McCormick's past and will be a major factor in our future.

Approximately 35 percent of our sales are outside the U.S. market. In 1947, we established our first international operation in Mexico, the first of many joint ventures, affiliations and strategic alliances that now reach around the globe.

We remain convinced that our growth objectives can only be met by entering new markets, and making further inroads into existing ones.

From a strictly business standpoint, Mexico offers a market ripe for expansion.

Last year the average Mexican spent $450 on U.S. agricultural, manufactured or consumer goods.

That's more than the wealthier Japanese or Europeans spent on U.S.-made products.

It's in our interest -- McCormick's and the United States' -- to give Mexicans even greater access to U.S. products. Purchases made in Mexico support jobs in the U.S.

Our recent corporate structuring into three global markets reflects this movement toward increased partnering.

Our U.S. operations are now included in a division encompassing all of the Americas. The rest of our international operations are divided into European and Pacific markets. This, we feel, positions our company more strategically for future growth, and improves servicing our customers. Congress should approve NAFTA and start building a North American partnership for future growth.

Bailey A. Thomas

Sparks

The writer is chairman of the board and chief executive officer of McCormick & Co.

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