Faculty Bibliography

Marc Siegel comments on caring for a hospitalized patient with heart disease without ever having met her face to face.

The House recently passed a $4.6 billion bill that arranges for sprucing up CDC facilities and bringing the CDC to the forefront of the bioterror response. Further, the bill addresses the need for a rapid gearing-up of hospitals and laboratories throughout the country in the event of a catastrophe. But even if the overseeing agencies modernize their equipment and change their orientation toward terror, the FBI still is not in the business of public health. And the public-health-oriented scientists of the CDC, no matter how many computer links and sparkling new bioterror labs they get, still are not accustomed to being leaders at a time of crisis

Blood bank screening for hepatitis has brought several previously hidden cases to my office door. Some privacy has been forsaken for the more important goal of keeping our blood supply safe. A doctor must be able to communicate a patient's information to another doctor, provided the patient has authorized this referral. This method has always been used and it must continue. No additional written consent for expert consultation or chart notes passed among physicians is possible without gumming up the works. And a patient should want a consulting doctor to know his history and be able to pass a comprehensive evaluation back to the primary physician. This routine optimizes care

Which is why the president was right to make it clear in his speech yesterday that he was not recommending the old smallpox vaccine for the entire population. Doing so would have limited the ability of doctors to counsel their patients on whether they should subject themselves to a somewhat risky vaccine. In my experience, if people know that a vaccine or a treatment is out there, they are probably going to want it -- whether it will be helpful or not. With new, safer vaccines around the corner, doctors should be in as strong a position as possible to persuade people who are not at risk from using the live vaccine

Since President Bush announced the smallpox vaccine would likely be made available to the American public in 2004, my patients have all been asking me the same question: Should they get the smallpox vaccine? Which is why President Bush's intention to make the old smallpox vaccine available to the entire population by 2004 might not be so wise. It could raise false hopes because there's no way to vaccinate everyone overnight. It could also limit the ability of doctors to counsel their patients on whether they should subject themselves to a somewhat risky vaccine. Smallpox is one of our oldest scourges. It should scare us. But we would do well to remember that even before there was a vaccine, smallpox never took over a whole region the way polio or influenza did. And smallpox isn't about to do that now

A surgeon might favor surgery, while a nonsurgical neurologist might say that because some of the damage to the cord was irreversible, Why take the chance of scarring and inflammation from the surgery? On the other hand, doing nothing meant living with the unremitting pain, not to mention leaving the spinal cord vulnerable to further damage. The day before the surgery was scheduled, a routine blood test found a low sodium count. That meant an automatic delay because of the increased risk of seizure from low salt. Plus, the low sodium could be caused by dehydration, which would be compounded by blood loss during surgery. That sudden aberration before surgery seemed to be a warning that something else might go wrong. Weeks later, she arrived again at my office, not with tap-dancing shoes, as I had imagined, but unaided, without even a walker or a cane. She was calm and pleasant, and I could see her vitality starting to return. She was already walking better and feeling stronger than she did before the operation. As if to underline her full recovery, her blood tests were all normal, including the sodium, an indication that she had truly been dehydrated before surgery. Any other cause would not have gone away for good with just saline

Medicare has always provided compensation for 80 percent of what it sets as the bill, an amount that, if no longer gilded, still compensates doctors adequately. And as long as it pays the bills, Medicare is preferable to the strictures of most health maintenance organizations. It allows us to choose what tests we order and to refer our patients to specialists as we think is necessary. For doctors, Medicare is usually free of the problems that plague many H.M.O.'s -- the excess paperwork, the referral requests, the insurance-company arbiter who has the power to deny essential tests. With Medicare covering 80 percent of the bill, the greater difficulty often lies in collecting the remaining 20 percent from the patient or his secondary insurance

The risk of smallpox appearing in the United States is still theoretical. But ever since Ken Alibek, the former deputy director of Biopreparat, the Soviet biological weapons apparatus, freely admitted to extensive amounts of smallpox existing in the Soviet Union, there is every reason to believe that some of the stockpiled virus may have found its way into the hands of rogue dictators or terrorists. And smallpox may be aerosolized -- if it is sprayed, it could infect hundreds of victims right off the bat. The fear associated with smallpox is much more contagious than the disease. Smallpox is one of our ancient scourges, and it captures the dark side of our imaginations. Schoolchildren learn of smallpox as the first bioweapon, distributed in blankets to Native American tribes by British troops during the French and Indian wars of the 1750s. Vague memories of our earliest immunizations against smallpox haunt many of us. This antiquated vaccine is not safe when given to people who have certain skin conditions, are immuno-compromised or pregnant. Unfortunately, these conditions may be hidden. The one recent death from the smallpox vaccine occurred in a military recruit who unknowingly was HIV-positive

We health-care workers comfort and support one another, working as a unit. Firefighters and EMS workers ranging deeper into the rubble than they should have their eyes washed free of smoke by doting surgeons, and everyone who is injured in the cause is whisked away to St. Vincent's hospital or Bellevue for emergency treatment. Sign-up lists are filled with the names of nurses who work their regular shifts at the hospital and then volunteer to staff emergency centers in their free hours. Doctors fill the emergency rooms and help patrol Ground Zero without regard to previous rank or position in the medical community. There has been an overwhelming response to requests to the public to donate blood

Siegel comments on the exorbitant costs of prescription drugs. He discusses the current system's inability to consistently provide for a patient's medical needs.