AL ISSUE:

>SIONAL LIABILITY )UTH CAROLINA

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IVERSITY OF MARYLAND BALTIMORE

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3818 River Drive • Columbia, South Carolina 29203

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2900 Sunset Blvd. West Columbia, SC 29171 803/796-9911

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(in SC)

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139)

VOLUME 85	JANUARY 1989	NUMBER 1

EDITOR

Charles S. Bryan, M.D.

SCMA, P. 0. Box 11188 Columbia, S. C. 2921 1

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia, Editor Emeritus

Charles N. Still, M.D., Columbia

Thomas M. LeLand, M.D., Charleston

W. Curtis Worthington, Jr., M.D., Charleston

Arthur F. DiSalvo, M.D., Columbia

Frederick L. Greene, M.D., Columbia

Albert Cannon, M.D., Charleston

J, Sidney Fulmer, M.D., Spartanburg

Hunter R. Stokes, M.D., Florence

E. Conyers O'Bryan, M.D., Florence

Robert Mallin, M.D., Columbia

William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Thomas C. Rowland, Jr., M.D., President Daniel W. Brake, M.D., President-Elect Carol S. Nichols, M.D., Secretary Bartolo M. Barone, M.D., Treasurer 0. Marion Burton, M.D., Speaker of the House Benjamin E. Nicholson, Jr., M.D.,

Vice Speaker of the House Charles R. Duncan, Jr., M.D., Past President

TRUSTEES

John C. Hawk, III, M.D., First District, Chairman John B. Johnston, M.D., First District Edward W. Catalano, M.D., Second District Frank W. Young, M.D., Second District Richard M. Carter, M.D., Third District James B. Page, M.D., Fourth District William J. Goudelock, M.D., Fourth District Terry L. Dodge, M.D., Fifth District James M. Lindsey, Jr., M.D., Sixth District Stephen A. Imbeau, M.D., Sixth District S. Perry Davis, M.D., Seventh District John W. Rheney, Jr., M.D., Eighth District John W. Simmons, M.D., Ninth District

DELEGATES TO THE AMA

John C. Hawk, Jr., M.D., Delegate Donald G. Kilgore, Jr., M.D., Delegate Randolph D. Smoak, Jr., M.D., Delegate Charles R. Duncan, Jr., M.D., Alternate J. Gavin Appleby, M.D., Alternate Walter J. Roberts, Jr., M.D., Alternate

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

SPECIAL ISSUE:

PROFESSIONAL LIABILITY IN SOUTH CAROLINA

Introduction — Euta M. Colvin, M.D 5

Glancing Back — William F. Fairey, M.D 6

South Carolina Medical Malpractice Joint Underwriting

Association — Bartolo M. Barone, M.D 7

South Carolina Medical Malpractice Patients’ Compensation

Fund — Donald G. Kilgore, Jr., C. Tucker Weston, M.D 10

JUA Claims Functions — Boyce M. Lawton, Jr., M.D 11

The South Carolina Medical Association/Joint Underwriting Association Risk Management Program — Euta M. Colvin,

M.D 16

The SCHA Loss Control Program: Reduction in Liability Exposures

for Hospitals and Physicians — Cheryl Koob, Jane Bryant 25

The South Carolina Dental Association and the S. C. Medical

Malpractice JUA — James H. Gaines, D.M.D 33

Malpractice Prophylaxis — John R. Hunt, M.D 36

So You are the Defendant in a Malpractice Action — Donald V.

Richardson, Esquire 39

The Deposition — The Doctor, The Lawyer — William F. Fairey,

M.D., LL.B 43

SPECIAL ARTICLE

A Report of the AMA Interim Meeting — John C. Hawk, Jr., M.D. . 19

EDITORIALS

Quality Assurance, Quality Management, Risk Management and Other Buzz Words of the Eighties — How do we Use Them? —

R. L. Skinner, Jr., M.D 46

Risk Management — Euta M. Colvin, M.D 47

FEATURES

51

48

48

3

ASSOCIATION

Gray Matter 49

Information for Authors 52

SCMA Newsletter 29

THE JOURNAL SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139) — Published monthly by the South Carolina Medical Association Business office: 3210 Lernandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 11188 Capitol Station, Columbia, SC 29211.

Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box 11188, Columbia, South Carolina 29211.

Auxiliary Page Letter to the Editor

On the Cover

President’s Page . . .

The views expressed in this publication are those of the writers and do not necessarily reflect the opinions of the South Carolina Medical Association.

INFORMATION FOR AUTHORS

Authors should refer to the detailed instructions in the January issue. Manuscripts and other correspondence should be addressed: The Editor, JOURNAL OF THE SOUTH CAROLINA MEDICAL ASSOCIATION, Post Office Box 1 1 1 88, Columbia, S. C. 2921 1 .

All manuscripts should be accompanied by a transmittal letter with the following paragraph: "This original work has not been submitted or published elsewhere, in entirety or in part. I (we) hereby transfer, assign, or otherwise convey all copyright ownership to the South Carolina Medical Association in the event that this work is published by the SCMA."

We request that manuscripts be concise (no longer than 8 typewritten pages, double-spaced), with no more than ten references. These should be cited in the text in superscript, e.g., “Bottsford, et al.3", and should conform to the following style: "3. Bottsford JE, Bearden RC, Bottsford JG: A ten year community hospital experience with abdominal aorta aneurysms. JSC Med Assoc 79: 57-62, 1983." Ordinarily, publication of four small illustrations or tables or the equivalent will be paid for by The Journal. Manuscripts should be submitted in duplicate. Reprints will be made available by the publisher.

4

The Journal of the South Carolina Medical Association

We have all heard for all of our lives that South Carolina ranks lowest in this or that state ranking. Well! We now rank lowest in malpractice premiums — at least in OB-GYN — of ail the states, and that is great! The national average malpractice premium for OB-GYNs in the United States is $37,000 per year, or an average of $206 per delivery. In South Carolina the JUA plus PCF premium in 1988 was about $9,000 or $54 per delivery — the lowest premium in the country. Our neighboring southern states are not nearly so fortunate. Georgia’s premium for OB-GYNs is about $50,000 per year; in North Carolina the premium is about $30,000; and even in Mississippi the premium is more than twice that in South Carolina. The rates for other specialties are relatively the same.

The malpractice climate in South Carolina is much better than in most other parts of the United States. Our JUA has been much more successful than most similar organizations in the country. After a recent actuarial review the JUA board recommends no increase in our JUA premiums this year.

Why have we had such a favorable experience with our JUA in South Carolina? The obvious answer I would like to give you is that we have the best doctors, the best defense attorneys, and the nicest patients in the country.

I can enumerate several reasons for the better malpractice climate in our home state. First, South Carolina is a small and very provincial state with a total population of about three million. There are about 5000 licensed physicians in the state, only about 3000 of whom are doing private practice. Our cities are small and for the most part our population is fairly stable. The people of South Carolina are fairly conservative. I truly believe that our patients and our juries are basically honest and conservative. Lack of communication between physician and patient is the basic ingredient to most malpractice lawsuits. We know our patients and they know us — much different from large metropolitan areas. Our juries have been, for the most part, educable and fair.

The JUA has assumed a very firm stand under the capable leadership of Cal Stewart. The JUA has a reputation of standing firm for trial if the experts feel a claim is defensible. The trial bar has learned not to bring nuisance suits in hopes of an easy settlement.

The S.C. Medical Association has developed a very impressive risk management program. We have developed a panel of experts in all specialties that review claims and records and later serve as experts — much more credibly than the “Hired Guns”! Dr. Euta Colvin has had numerous risk management CME programs that have all played before “Standing Room Only” crowds.

We have developed a small cadre of expert defense attorneys who have a tremendous record of courthouse victories. We also have a group of self-trained expert witnesses in South Carolina who continue to out-perform “experts” from out of town.

Tort reform I mention last because it has had little to do with the present situation. However, when one considers the charitable immunity law, the amendment to the tort claims act, in addition to the tort reform bill, we have had significant reform. We may never get caps on non-economic damages and if we did, they would probably prove unconstitutional in our judiciary system.

South Carolina physicians are in the most enviable position in the U.S. as far as malpractice is concerned. Communication, accessibility and quality care are most important traits of a good physician. Good physicians, not necessarily good doctors, will have the fewest malpractice litigations.

J)t ^a1

Thomas C. Rowland, Jr., M.D.

President

January 1989

3

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139)

VOLUME 85	FEBRUARY 1989	NUMBER 2

EDITOR

Charles S. Bryan, M.D.

SCMA, P. O. Box 11188 Columbia, S. C. 2921 1

EDITORIAL BOARD

Edward E. Kimbrough, M.D , Columbia, Editor Emeritus

Charles N. Still, M.D., Columbia

Thomas M. LeLand, M.D., Charleston

W. Curtis Worthington, Jr., M.D., Charleston

Arthur F. DiSalvo, M.D., Columbia

Frederick L. Greene, M.D., Columbia

Albert Cannon, M.D., Charleston

J. Sidney Fulmer, M.D., Spartanburg

Hunter R. Stokes, M.D., Florence

E. Conyers O'Bryan, M.D., Florence

Robert Mallin, M.D., Columbia

William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Thomas C. Rowland, Jr., M.D., President Daniel W. Brake, M.D., President-Elect Carol S. Nichols, M.D., Secretary Bartolo M. Barone, M.D., Treasurer 0. Marion Burton, M.D., Speaker of the House Benjamin E. Nicholson, Jr., M.D.,

Vice Speaker, of the House Charles R. Duncan, Jr., M.D., Past President

TRUSTEES

John C. Hawk, III, M.D., First District, Chairman John B. Johnston, M.D., First District Edward W. Catalano, M.D., Second District Frank W. Young, M.D., Second District Richard M. Carter, M.D., Third District James B. Page, M.D., Fourth District William J. Goudelock, M.D., Fourth District Terry L. Dodge, M.D., Fifth District James M. Lindsey, Jr., M.D., Sixth District Stephen A. Imbeau, M.D., Sixth District S. Perry Davis, M.D., Seventh District John W. Rheney, Jr., M.D., Eighth District John W. Simmons, M.D., Ninth District

DELEGATES TO THE AMA

John C. Hawk, Jr., M.D., Delegate Donald G. Kilgore, Jr., M.D., Delegate Randolph D. Smoak, Jr., M.D., Delegate Charles R. Duncan, Jr., M.D., Alternate J. Gavin Appleby, M.D., Alternate Walter J. Roberts, Jr., M.D., Alternate

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

ORIGINAL SCIENTIFIC ARTICLES

Gamete Intrafallopian Transfer (GIFT): The South Carolina

Experience — Gary Holtz, M.D., Grant W. Patton, Jr.,

M.D 59

Update on Hospitalized Pesticide Poisonings in South

Carolina, 1983-1987 — Stanley H. Schuman, M.D., Dr.

P.H., Norris H. Whitlock, M.S., Samuel T. Caldwell,

M.A., Paul M. Horton, Ph.D 62

Chronic Hepatitis and Indolent Cirrhosis Due to

Methyldopa: the Bottom of the Iceberg? — William M.

Lee, M.D., William T. Denton, M.D 75

SPECIAL ARTICLE

Health Promotion Beliefs and Attitudes of Physicians:

A Survey of Two Communities in South Carolina — Frances C. Wheeler, Ph.D., Daniel T. Lackland,

M.S.P.H., John V. Rullan, M.D., M.P.H 80

EDITORIALS

Beliefs, Attitudes and Health Promotion — Charles S. Bryan,

M.D 84

Slow Poisons? — Charles S. Bryan, M.D 86

FEATURES

Auxiliary Page 91

On the Cover 89

President’s Page 57

ASSOCIATION

Gray Matter 87

Physician Recognition Award 79

SCMA Newsletter 71

THE JOURNAL SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139) — Published monthly by the South Carolina Medical Association Business office: 3210 Fernandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 11188 Capitol Station, Columbia, SC 29211.

Subscription price to non-members S25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association , P. O. Box 11188, Columbia, South Carolina 29211.

The views expressed in this publication are those of the writers and do not necessarily reflect the opinions of the South Carolina Medical Association.

INFORMATION FOR AUTHORS

Authors should refer to the detailed instructions in the January issue. Manuscripts and other correspondence should be addressed: The Editor, JOURNAL OF THE SOUTH CAROLINA MEDICAL ASSOCIATION, Post Office Box 11188, Columbia, S. C. 29211.

All manuscripts should be accompanied by a transmittal letter with the following paragraph: "This original work has not been submitted or published elsewhere, in entirety or in part. I (we) hereby transfer, assign, or otherwise convey all copyright ownership to the South Carolina Medical Association in the event that this work is published by the SCMA."

We request that manuscripts be concise (no longer than 8 typewritten pages, double-spaced), with no more than ten references. These should be cited in the text in superscript, eg, "Bottsford, et al.3", and should conform to the following style: "3. Bottsford JE, Bearden RC, Bottsford JG: A ten year community hospital experience with abdominal aorta aneurysms. JSC Med Assoc 79: 57-62, 1 983. ' ' Ordinarily, publication of four small illustrations or tables or the equivalent will be paid for by The Journal. Manuscripts should be submitted in duplicate. Reprints will be made available by the publisher.

The Journal of the South Carolina Medical Association

58

A SALUTE TO THE SOUTH CAROLINA BOARD OF MEDICAL EXAMINERS

In May 1988, House Bill #4101 was passed by an overwhelming majority with a definite threat to override a gubernatorial veto. This Bill was amended to reduce the FLEX examination score required for physician licensure to 74 for any day and an overall average of 75. The efforts of our state house staff resulted in changing the original amendment from a score of 70 for any part of the exam. All of this was done for the purpose of licensing a single physician to practice medicine in S.C.

The physician in question is probably very well qualified as he had specialty and subspecialty training and came highly recommended. He had been strongly recruited by the hospital and the community in which he practices. The county medical association in that community sought SCMA help in getting him licensed.

Many members of the legislature, many of our colleagues and even some ranking political officials of our state have asked me what SCMA was going to do about the Board of Medical Examiners and their unbending stature which required legislation to license needed physicians. Of course my first answer is to remind them that the Supreme Court of South Carolina in 1985 asked the SCMA to butt out of the Board of Medical Examiners’ business.

Recently three SCMA officers met with three officers of the S.C. State Board of Medical Examiners for an open discussion of our differences of opinion. Since your president and the president of the Board have been close friends for some 35 years, you can be assured that the discussion was very frank and open.

The following data has been reviewed from the last three years’ work of the Board. Of the 1,529 physicians licensed, 82% were based on national board exams or old State Board exams. Only 18% were based on FLEX scores. Of these, only 14% were U.S. graduates. The total number of applicants for licensure in S.C. who were rejected for not meeting minimum standards of the Board were 44 or 2.8% in this three-year period. SPEX, a new exam for physicians entering S.C., is designed for the practicing physician who has been out of school for some time. Reportedly it is passed without special preparation by most physicians in active practice. A recent graduate of any good medical school should score in the mid to high 80s on the FLEX exam.

South Carolina is a very attractive place to settle. It is certainly a very attractive place to practice medicine. The malpractice climate is much more favorable than that in even our neighboring states. We are developing rapidly in industrial and economic stature. Our mountains, coast and climate are attracting a great number of retirees. We want and can have capable, well-trained and properly motivated physicians in South Carolina. Let’s not lower our standards even to get lesser qualified doctors in poorly served rural areas. Our citizens are better served by good transportation.

I understand that there are several other less than qualified young physicians who were educated in off- shore medical schools standing in the wings waiting for their chance at “Legislative Licensure” this next session. Qualifications for licensure to practice medicine are best not legislated by well-meaning politi- cians— regardless of the stature of the candidate’s parents or friends!!

We should salute our Board of Medical Examiners for keeping the standards and quality of our practicing physicians at a high level. This best serves the citizens of our great state.

Sincerely,

Thomas C. Rowland, Jr., M.D.

President

February 1989

57

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139)

VOLUME 85 MARCH 1989 NUMBER 3

EDITOR

Charles S. Bryan, M.D.

SCMA, P. O. Box 11188 Columbia, S. C. 2921 1

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia, Editor Emeritus

Charles N. Still, M.D., Columbia

Thomas M. LeLand, M.D., Charleston

W. Curtis Worthington, Jr., M.D., Charleston

Arthur F. DiSalvo, M.D., Columbia

Frederick L. Greene, M.D., Columbia

Albert Cannon, M.D., Charleston

J. Sidney Fulmer, M.D., Spartanburg

Hunter R. Stokes, M.D., Florence

E. Conyers O'Bryan, M.D., Florence

Robert Mallin, M.D., Columbia

William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Thomas C. Rowland, Jr., M.D., President Daniel W. Brake, M.D., President-Elect Carol S. Nichols, M.D., Secretary Bartolo M. Barone, M.D., Treasurer 0. Marion Burton, M.D., Speaker of the House Benjamin E. Nicholson, Jr., M.D.,

Vice Speaker of the House Charles R. Duncan, Jr., M.D., Past President

TRUSTEES

John C. Hawk, III, M.D., First District, Chairman John B. Johnston, M.D., First District Edward W. Catalano, M.D., Second District Frank W. Young, M.D., Second District Richard M. Carter, M.D., Third District James B. Page, M.D., Fourth District William J. Goudelock, M.D., Fourth District Terry L. Dodge, M.D., Fifth District James M. Lindsey, Jr., M.D., Sixth District Stephen A. Imbeau, M.D., Sixth District S. Perry Davis, M.D., Seventh District John W. Rheney, Jr., M.D., Eighth District John W. Simmons, M.D., Ninth District

DELEGATES TO THE AMA

John C. Hawk, Jr., M.D., Delegate Donald G. Kilgore, Jr., M.D., Delegate Randolph D. Smoak, Jr., M.D., Delegate Charles R. Duncan, Jr., M.D., Alternate J. Gavin Appleby, M.D., Alternate Walter J. Roberts, Jr., M.D., Alternate

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

ORIGINAL SCIENTIFIC ARTICLES

Clinical Experience with Ciprofloxacin: Analysis of a Multi- Practice Study — C. P. Dunbar, M.D., Ronald L. Ashton, M.D., Larry Atkinson, M.D., Henry F. Crotwell, M.D., Henry M. Faris, M.D., Howard G. Royal, Jr., M.D., Duncan W. Tyson, M.D., Charles H.

White, Jr., M.D 97

Seroprevalence of Human Immunodeficiency Virus in Mental Health Patients — Walter K. Clair, M.D.,

G. Paul Eleazer, M.D., Linda Jean Hazlett, B.A.,

B. Ann Morales, B.A., Judith M. Sercy, B.S., Lee V.

Woodbury, M.D 103

Lymphomatoid Papulosis: Mostly Benign but Potentially Malignant — A Case Report with a Fatal Outcome —

Larry H. Parrott, M.D 113

Project Readiness II: Some Results from a Physicial Fitness and Health Enhancement Program for Law Enforcement Personnel — Stanley J. LeProtti, M.Ed.,

Warren K. Giese, Ph.D., John H. Spurgeon, Ph.D.,

James A. Keith, Ph.D., Stanley S. Juk, Jr., M.D.,

Clarence G. Robinson, M.D., Sandor Molnar, Ph.D.,

J. David Branch, M.S 119

EDITORIAL

Ciprofloxacin: Panacea or Blunder Drug? — Charles S.

Bryan, M.D 131

FEATURES

Auxiliary Page 138

On the Cover 133

President’s Page 95

ASSOCIATION

CME Calendar 127

Gray Matter 135

SCMA Newsletter 109

THE JOURNAL SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139) — Published monthly by the South Carolina Medical Association Business office: 3210 Lernandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 11188 Capitol Station, Columbia, SC 29211.

Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box 11188, Columbia, South Carolina 29211.

The views expressed in this publication are those of the writers and do not necessarily reflect the opinions of the South Carolina Medical Association.

INFORMATION FOR AUTHORS

Authors should refer to the detailed instructions in the January issue. Manuscripts and other correspondence should be addressed: The Editor, JOURNAL OF THE SOUTH CAROLINA MEDICAL ASSOCIATION, Post Office Box 1 1 1 88, Columbia, S. C. 2921 1 .

All manuscripts should be accompanied by a transmittal letter with the following paragraph: “This original work has not been submitted or published elsewhere, in entirety or in part. I (we) hereby transfer, assign, or otherwise convey all copyright ownership to the South Carolina Medical Association in the event that this work is published by the SCMA."

We request that manuscripts be concise (no longer than 8 typewritten pages, double-spaced), with no more than ten references. These should be cited in the text in superscript, e.g., “Bottsford, et al.3", and should conform to the following style "3. Bottsford JE, Bearden RC, Bottsford JG: A ten year community hospital experience with abdominal aorta aneurysms. JSC Med Assoc 79: 57-62, 1 983. ' ’ Ordinarily, publication of four small illustrations or tables or the equivalent will be paid for by The Journal. Manuscripts should be submitted in duplicate. Reprints will be made available by the publisher.

96

The Journal of the South Carolina Medical Association

A SALUTE TO MIKE AND ANDY

Having been reared in the modest home of a public school teacher and having worked hard to obtain my medical education, and having worked hard to accumulate whatever worldly goods I have acquired, I can assure you that I have very little time for freeloaders, bureaucratic intrusion, and socialism in our medical system. However, there are two persons in South Carolina who are involved in the bureaucracy who have become my good friends and good friends of medicine in South Carolina during my term as your president. I would like to take this opportunity to recognize and thank them both.

Mike Jarrett, Commissioner of DHEC, is doing an outstanding job for the well-being of our citizens. He is very involved in improving the perinatal health in S. C. (which may be the worst in the world). He is dealing with toxic and other waste disposal problems in an orderly manner, and he constantly seeks consultation of your president and other officers and staff of the SCMA before making decisions which affect our practices. Mike is always available to SCMA for advice or help with any mutual problem.

Dr. Andy Laurent is the Executive Director of the State Health and Human Services Finance Commission — put simply, he is in charge of Medicaid reimbursement in South Carolina. Early after his appointment, Andy met with SCMA leadership in an effort to determine why so many physicians refused to care for Medicaid patients. Of course he knew that fees were low, but we must be reminded that these are poor people — patients who traditionally have had free care — or at least they usually did not pay anything for it. Fees have been increased. Medicaid reimbursement in South Carolina exceeds Medicare payments in some cases. Andy also heard our complaints of returned claims, stymied cash flow, negative attitudes, poor access of patients to the system and the “program integrity’’ or audit system problems. He has solicited all our complaints both individually and collectively.

Not only has he heard our problems, but he is doing something about them. Andy has personally worked through the claims process and has identified the most common causes for rejection. He is educating his people to positive attitudes and is trying to improve and simplify access for patients. He has discovered a lot of errors on our part and will educate us, if we ask for help.

Mike and Andy are combining forces to find innovative ways to get more funds and patients into the system. They are both sincerely interested in good health and good health care for these less fortunate South Carolinians. They both are motivated to help us provide this care with the least hassle and with reasonable reimbursement.

We physicians must remember that those of us who received our medical education in South Carolina did so at a cost of some $50,000 to $60,000 a year to our state. We owe something back for this help. Part of our debt is to provide care for our less fortunate. It disturbs me, Andy, Mike, the Governor and our Legislators to hear of a physician, especially a young physician, publicly refusing to accept Medicaid patients.

I salute my new friends Mike and Andy and thank them on behalf of our association for the services they are providing which many times seem thankless, I am sure. I implore you all to share the load, and it will not be too heavy for any of us. We must voluntarily help care for these less fortunate people or their care will surely be mandated.

Sincerely,

Thomas C. Rowland, Jr., M.D., President

March 1989

95

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139)

VOLUME 85 APRIL 1989 NUMBER 4

EDITOR

Charles S. Bryan, M.D.

SCMA, P. 0. Box 11188 Columbia, S. C. 2921 1

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia, Editor Emeritus

Charles N. Still, M.D., Columbia

Thomas M. LeLand, M.D., Charleston

W. Curtis Worthington, Jr., M.D., Charleston

Arthur F. DiSalvo, M.D., Columbia

Frederick L. Greene, M.D., Columbia

Albert Cannon, M.D., Charleston

J. Sidney Fulmer, M.D., Spartanburg

Hunter R. Stokes, M.D., Florence

E. Conyers O’Bryan, M.D., Florence

Robert Mallin, M.D., Columbia

William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Thomas C. Rowland, Jr., M.D., President Daniel W. Brake, M.D., President-Elect Carol S. Nichols, M.D., Secretary Bartolo M. Barone, M.D., Treasurer 0. Marion Burton, M.D., Speaker of the House Benjamin E. Nicholson, Jr., M.D.,

Vice Speaker of the House Charles R. Duncan, Jr., M.D., Past President

TRUSTEES

John C. Hawk, III, M.D., First District, Chairman John B. Johnston, M.D., First District Edward W. Catalano, M.D., Second District Frank W. Young, M.D., Second District Richard M. Carter, M.D., Third District James B. Page, M.D., Fourth District William J. Goudelock, M.D., Fourth District Terry L. Dodge, M.D., Fifth District James M. Lindsey, Jr., M.D., Sixth District Stephen A. Imbeau, M.D., Sixth District S. Perry Davis, M.D., Seventh District John W. Rheney, Jr., M.D., Eighth District John W. Simmons, M.D., Ninth District

DELEGATES TO THE AMA

John C. Hawk, Jr., M.D., Delegate Donald G. Kilgore, Jr., M.D., Delegate Randolph D. Smoak, Jr., M.D., Delegate Charles R. Duncan, Jr., M.D., Alternate J. Gavin Appleby, M.D., Alternate Walter J. Roberts, Jr., M.D., Alternate

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

ONE HUNDRED FORTY-FIRST ANNUAL MEETING

Introduction 145

Schedule of Events 146

Delegates and Alternates 161

Officer Reports 167

Trustee Reports 179

Committee Reports 186

Report of the Executive Vice President 196

SCMA Delegation to the AMA Report 198

Report of the Editor 199

SCMA Members’ Insurance Trust Report 199

SCIMER Report 200

SOCPAC Report 200

Report of the S. C. Medical Care Foundation 201

Report of the S. C. Department of Health &

Environmental Control 201

Report of the S. C. State Board of Medical Examiners 205

Resolutions 206

AMA Special Guest 206

SOCPAC Luncheon Speaker 207

Leonard W. Douglas, M.D., Memorial Lecture Speaker .... 207

Exhibitors 214

Acknowledgments 215

EDITORIALS

Newborn Screening for HIV Antibody — Arthur F. DiSalvo,

M.D., William B. Gamble, M.D 208

Peer Review Where It Counts — Charles S. Bryan, M.D 209

FEATURES

Auxiliary Page 212

On the Cover 211

President’s Page 143

ASSOCIATION

Gray Matter 203

SCMA Newsletter 175

THE JOURNAL SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139) — Published monthly by the South Carolina Medical Association Business office: 3210 Fernandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 11188 Capitol Station, Columbia, SC 29211.

Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box 11188, Columbia, South Carolina 29211.

The views expressed in this publication are those of the writers and do not necessarily reflect the opinions of the South Carolina Medical Association.

INFORMATION FOR AUTHORS

Authors should refer to the detailed instructions in the January issue. Manuscripts and other correspondence should be addressed: The Editor. JOURNAL OF THE SOUTH CAROLINA MEDICAL ASSOCIATION, Post Office Box 11188, Columbia, S. C. 29211.

All manuscripts should be accompanied by a transmittal letter with the following paragraph: "This original work has not been submitted or published elsewhere, in entirety or in part. I (we) hereby transfer, assign, or otherwise convey all copyright ownership to the South Carolina Medical Association in the event that this work is published by the SCMA.”

We request that manuscripts be concise (no longer than 8 typewritten pages, double-spaced), with no more than ten references. These should be cited in the text in superscript, e.g., "Bottsford, et al.3", and should conform to the following style: "3. Bottsford JE, Bearden RC, Bottsford JG: A ten year community hospital experience with abdominal aorta aneurysms. JSC Med Assoc 79: 57-62, 1 983. ' ' Ordinarily, publication of four small illustrations or tables or the equivalent will be paid for by The Journal. Manuscripts should be submitted in duplicate. Reprints will be made available by the publisher.

144

The Journal of the South Carolina Medical Association

THANK YOU AND FAREWELL

It is hard to believe that my year as President of the SCMA will be over this month. It seems like such a short time and so little has been accomplished. On the other hand, I am not sure how much more one could stand!

I have certainly enjoyed the privilege of being your President for the past year. I have enjoyed representing you in national forums, our legislature, and the state agencies. I have enjoyed the hospitality of many county societies and regret that time did not allow a visit to all of them. My relationship with the media has been pleasant and I hope positive for our association and the profession. The turf battles and the changing PRO have been challenges in which we have prevailed. My rapport with our auxiliary has been good, and I am proud to see “The Van” on the road. I have especially enjoyed this page — a true luxury to be able to express one’s thoughts to an open forum. I have even enjoyed the chicken dinners!

I would like to take this last page to thank all the people who have made my year so pleasant. Dan Brake, President-Elect, and Chris Hawk, Chairman of the SCMA Board, have been very supportive throughout the year. They will provide excellent leadership for the SCMA in the future. The members of the Board of Trustees of the SCMA have all been very supportive. They have offered good advice and have made wise decisions for the good of all. The members of the AM A Delegation have always offered wise counsel and support in more ways than I can enumerate. To all of the SCMA leadership, I say thank you!

Bill Mahon has been chauffeur, advisor and friend. He has provided support far beyond the require- ments of his job description. The other members of the SCMA staff are fantastic. The cohesiveness and cooperation of all our staff members are outstanding. I can honestly say that I have not heard of an unpleasant situation at SCMA Headquarters this entire year. Thanks to all of you for a job well done, and for making my job so easy.

I must take this opportunity to publicly thank Isabelle, my wife and good friend, for tolerating my schedule and supporting my projects. I must also thank my partners, Nat Salley, Dave Postles, and Jimmy Stands for all their support and toleration of my many absences from my office. Special thanks to Lisa Bishop, my secretary, for keeping me “on track” during the year. I must not forget to thank my patients who have remained loyal in spite of missed and changed appointments.

Last and most important, I would like to thank you — the membership. You have my sincere apprecia- tion for the confidence and support you have given me that has made my year of service successful. Thank you for the privilege of becoming “one of a hundred. ” SCMA can only have 100 presidents per century and I am very proud to have been elected to this group. As I complete my year as your president, I will join other members of my class for our 30th MUSC class reunion. What a way to end the year!

Thank you for the greatest honor of my life — to have served as your President!

Sincerely.

Thomas C. Rowland, Jr., M.D. President

April 1989

143

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION

(ISSN 0038-3139)

VOLUME 85 MAY 1989 NUMBER 5

EDITOR

Charles S. Bryan, M.D.

SCMA, P. 0. Box 11188 Columbia, S. C. 2921 1

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia, Editor Emeritus

Charles N. Still, M.D., Columbia

Thomas M. LeLand, M.D., Charleston

W. Curtis Worthington, Jr., M.D., Charleston

Arthur F. DiSalvo, M.D., Columbia

Frederick L. Greene, M.D., Columbia

Albert Cannon, M.D., Charleston

J. Sidney Fulmer, M.D., Spartanburg

Hunter R. Stokes, M.D., Florence

E. Conyers O’Bryan, M.D., Florence

Robert Mallin, M.D., Columbia

William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Thomas C. Rowland, Jr., M.D., President Daniel W. Brake, M.D., President-Elect Carol S. Nichols, M.D., Secretary Bartolo M. Barone, M.D., Treasurer 0. Marion Burton, M.D., Speaker of the House Benjamin E. Nicholson, Jr., M.D.,

Vice Speaker of the House Charles R. Duncan, Jr., M.D., Past President

TRUSTEES

John C. Hawk, III, M.D., First District, Chairman John B. Johnston, M.D., First District Edward W. Catalano, M.D., Second District Frank W. Young, M.D., Second District Richard M. Carter, M.D., Third District James B. Page, M.D., Fourth District William J. Goudelock, M.D., Fourth District Terry L. Dodge, M.D., Fifth District James M. Lindsey, Jr., M.D., Sixth District Stephen A. Imbeau, M.D., Sixth District S. Perry Davis, M.D., Seventh District John W. Rheney, Jr., M.D., Eighth District John W. Simmons, M.D., Ninth District

DELEGATES TO THE AMA

John C. Hawk, Jr., M.D., Delegate Donald G. Kilgore, Jr., M.D., Delegate Randolph D. Smoak, Jr., M.D., Delegate Charles R. Duncan, Jr., M.D., Alternate J. Gavin Appleby, M.D., Alternate Walter J. Roberts, Jr., M.D., Alternate

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

ORIGINAL SCIENTIFIC ARTICLES

The Non-Operative Care of the Vascular Surgical Patient —

Gilbert B. Bradham, M.D 221

Utility of Lesser Saphenous Vein as a Substitute Conduit — Arthur Grimball, M.D., B. Randolph Bradham, M.D.,

F. Reid Locklair, M.D 226

Takayasu’s Arteritis — John T. Tolhurst, M.D., Grady H.

Hendrix, M.D 234

SPECIAL ARTICLE

Physician Manpower and Graduate Medical Education: A Review with Implications for State Policy Development — Julie Johnson McGowan, G. Dean Cleghorn, Ed.D 239

EDITORIALS

Policy Development for Medical Education in South

Carolina — G. William Bates, M.D 247

Working Together Makes Sense and Progress — J. O’Neal

Humphries, M.D 248

FEATURES

Auxiliary Pages 257

On The Cover 250

President’s Pages 253

ASSOCIATION

Gray Matter 251

Physician Recognition Award 249

SCMA Newsletter 229

THE JOURNAL SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139) — Published monthly by the South Carolina Medical Association Business office: 3210 Fernandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 11188 Capitol Station, Columbia, SC 29211.

Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box 11188, Columbia, South Carolina 29211.

The views expressed in this publication are those of the writers and do not necessarily reflect the opinions of the South Carolina Medical Association.

INFORMATION FOR AUTHORS

Authors should refer to the detailed instructions in the January issue. Manuscripts and other correspondence should be addressed: The Editor, JOURNAL OF THE SOUTH CAROLINA MEDICAL ASSOCIATION, Post Office Box 11188, Columbia, S. C. 29211.

All manuscripts should be accompanied by a transmittal letter with the following paragraph: "This original work has not been submitted or published elsewhere, in entirety or in part. I (we) hereby transfer, assign, or otherwise convey all copyright ownership to the South Carolina Medical Association in the event that this work is published by the SCMA."

We request that manuscripts be concise (no longer than 8 typewritten pages, double-spaced), with no more than ten references. These should be cited in the text in superscript, e.g., "Bottsford, et al.3”, and should conform to the following style: “3. Bottsford JE, Bearden RC, Bottsford JG: A ten year community hospital experience with abdominal aorta aneurysms. JSC Med Assoc 79: 57-62, 1 983. ' ' Ordinarily, publication of four small illustrations or tables or the equivalent will be paid for by The Journal. Manuscripts should be submitted in duplicate. Reprints will be made available by the publisher.

220

The Journal of the South Carolina Medical Association

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VOLUME 85 JUNE 1989 NUMBER 6

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION

Contents

Original Scientific Articles

267 Trends in Cardiovascular Mortality and Risk Factor Levels in South Carolina: Significance for Prevention

Carlton A. Homung, Ph.D., Ernest P. McCutcheon, M.D.

275 Advances in the Treatment of Supraventricular Tachycardia

Paul C. Gillette, M.D., Fred A. Cranford, M.D., Derek A. Fyfe, M.D., Ashby B. Taylor, M.D., Henry B. Wiles, M.D.

283 Descending Thoracic Aorta to Femoral Artery Bypass

R. Randolph Bradham, M.D., P. Reid Locklair, Jr., M.D., Arthur Grim ball, M.D.

292 Myasthenia Gravis Presenting as Respiratory Failure: Confusion with a Psychiatric Illness

C. Bryan Jordan, II, M.D., Harold G. Morse, M.D., Larry

S. Atkinson, M.D.

THE JOURNAL SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139) — Published monthly by the South Carolina Medical Association Business office: 3210 Femandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 11188 Capitol Station, Columbia, SC 29211.

Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box 11188, Columbia, South Carolina 29211.

Editorial

296 True (Palmetto) Blue

Charles S. Bry an, M.D.

Features

301 Auxiliary Page

297 On The Cover 262 President’s Page

Association

287 CME Calendar

299 Gray Matter

294 Physician Recognition Awards 279 SCMA Newsletter

The views expressed in this publication are those of the writers and do not necessarily reflect the opinions of the South Carolina Medical Association.

INFORMATION FOR AUTHORS

Authors should refer to the detailed instructions in the January issue. Manuscripts and other correspondence should be addressed: The Editor, JOURNAL OF THE SOUTH CAROLINA MEDICAL ASSOCIATION, Post Office Box 11188, Columbia, S. C. 29211.

All manuscripts should be accompanied by a transmittal letter with the following paragraph: "This original work has not been submitted or published elsewhere, in entirety or in part. I (we) hereby transfer, assign, or otherwise convey all copyright ownership to the South Carolina Medical Association in the event that this work is published by the SCMA."

We request that manuscripts be concise (no longer than 8 typewritten pages, double-spaced), with no more than ten references. These should be cited in the text in superscript, e g., "Bottsford, et al.3", and should conform to the following style: "3. Bottsford JE, Bearden RC, Bottsford JG: A ten year community hospital experience with abdominal aorta aneurysms. J S C Med Assoc 79: 57-62, 1983." Ordinarily, publication of four small illustrations or tables or the equivalent will be paid for by The Journal. Manuscripts should be submitted in duplicate. Reprints will be made available by the publisher.

EDITOR

Charles S. Bryan, M.D.

SCMA, P. O. Box 11188 Columbia, S. C. 29211

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia, Editor Emeritus

Charles N. Still, M.D., Columbia Thomas M. LeLand, M.D., Charleston W. Curtis Worthington, Jr., M.D., Charleston Arthur F. DiSalvo, M.D., Columbia Frederick L. Greene, M.D., Columbia Albert Cannon, M.D., Charleston J. Sidney Fulmer, M.D., Spartanburg Flunter R. Stokes, M.D., Florence E. Conyers O'Bryan, M.D., Florence Robert Mallin, M.D., Columbia William H. Flunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Daniel W. Brake, M.D., President

John W. Simmons, M.D., President-Elect

Bartolo M. Barone, M.D., Secretary

John W. Rheney, Jr., M.D., Treasurer

O. Marion Burton, M.D., Speaker of the House

Benjamin E. Nicholson, Jr., M.D.,

Vice Speaker of the House Thomas C. Rowland, Jr., M.D., Past President

TRUSTEES

J. Chris Hawk, III, M.D., First District, Chairman John B. Johnston, M.D., First District Edward W. Catalano, M.D., Second District Frank W. Young, M.D., Second District Richard M. Carter, M.D., Third District James B. Page, M.D., Fourth District

William J. Goudelock, M.D., Fourth District Roger Gaddy, M.D., Fifth District James M. Lindsey, Jr., M.D., Sixth District Stephen A. Imbeau, M.D., Sixth District J. Capers Hiott, M.D., Seventh District Dallas W. Lovelace, III, M.D., Eighth District Carol S. Nichols, M.D., Ninth District

DELEGATES TO THE AMA

John C. Hawk, Jr., M.D., Delegate Donald G. Kilgore, Jr., M.D., Delegate Randolph D. Smoak, Jr., M.D., Delegate Charles R. Duncan, Jr., M.D., Alternate J. Gavin Appleby, M.D., Alternate Walter J. Roberts, Jr., M.D., Alternate

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

264

The Journal of the South Carolina Medical Association

Your SCMA Board of Trustees and staff get frequent complaints from physicians throughout the state who are upset about problems they are having in their practice and want us to help. We have not denied help to physicians who are not members of the SCMA, but you would be amazed at the number of complainers who have not paid their dues to the SCMA and the AMA. They are the “free-riders” we have been talking about on our membership posters. These free-riders are mostly good, caring physicians, but often in a three-man group, for example, one member of the group joins and the other members of the group get a free ride. This is totally unfair to the paying members of this association. As you know, last year the House of Delegates approved the first dues increase in ten years. This increase would not be necessary if we could get all the “free-riders” to pay their fair share. You can help! The delegates from your county have a list of those who are not members. Urge those non-members to join and become involved!

As I stated at the House of Delegates I really am looking forward to coming to your county medical society meetings. Having graduated from Wofford College and MUSC, I have old friends in every county in this state that I have not seen for a long time. I look forward to renewing old friendships. I will be wearing the SCMA medallion in honor of John Dessaussure Gilland, III. I hope it will be an inspiration to you, as it is to me, to follow Dr. Gilland’s example of involvement and commitment to our profession and the patients we serve.

Daniel W. Brake, M.D. President

June 1989

263

VOLUME 85 JULY 1989 NUMBER 7

^Journal ?,

THE SOUTH CAROLINA MEDICAL ASSOCIATION

Contents

Original Scientific Articles Special Articles

311 Lyme and Other Tick-Borne Diseases Acquired in South Carolina in 1988: A Survey of 1,331 Physicians

Stanley H. Schuman, M.D., Dr. P.H., Samuel T. Caldwell, M.D.

317 Acute Pancreatitis in a Five-Year-Old Male

Timothy J. Mader, M.D., Jeter P. Taylor, M.D., Terrance P. McHugh, M.D.

327 Marfan Syndrome in the Parturient

M. K. Bailey, M.D., R. Hwu-Yun, M.D., J. D. Baker, III, M.D., J. E. Cooke, M.D., J. M. Conroy, M.D.

323 The Annual Meeting of the AMA: Report of the SCMA Delegation

John C. Hawk, Jr., M.D.

331 Eradication of Filariasis in South Carolina: A Historical Perspective

Wade D. Reynolds, M.P.H., Francisco S. Sy, M.D., Ph.D.

Features

349 Auxiliary Page 347 Letter to the Editor 344 On The Cover 307 President’s Page

Association

Editorial

341 Ticks, Terrorism and Tetracyclines

Charles S. Bryan, M.D.

345 Gray Matter 323 SCMA Newsletter

THE JOURNAL SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139) — Published monthly by the South Carolina Medical Association Business office: 3210 Fernandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 11188 Capitol Station, Columbia, SC 29211.

Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box 11188, Columbia, South Carolina 29211.

The views expressed in this publication are those of the writers and do not necessarily reflect the opinions of the South Carolina Medical Association.

INFORMATION FOR AUTHORS

Authors should refer to the detailed instructions in the January issue. Manuscripts and other correspondence should be addressed: The Editor, JOURNAL OF THE SOUTH CAROLINA MEDICAL ASSOCIATION, Post Office Box 11188, Columbia, S. C. 29211.

All manuscripts should be accompanied by a transmittal letter with the following paragraph: "This original work has not been submitted or published elsewhere, in entirety or in part. I (we) hereby transfer, assign, or otherwise convey all copyright ownership to the South Carolina Medical Association in the event that this work is published by the SCMA."

We request that manuscripts be concise (no longer than 8 typewritten pages, double-spaced), with no more than ten references. These should be cited in the text in superscript, e.g., "Bottsford, et al.3", and should conform to the following style: "3. Bottsford JE, Bearden RC, Bottsford JG: A ten year community hospital experience with abdominal aorta aneurysms. JSC Med Assoc 79: 57-62, 1 983. ' ' Ordinarily, publication of four small illustrations or tables or the equivalent will be paid for by The Journal. Manuscripts should be submitted in duplicate. Reprints will be made available by the publisher.

EDITOR

Charles S. Bryan, M.D.

SCMA, P. O. Box 11188 Columbia, S. C. 29211

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia, Editor Emeritus

Charles N. Still, M.D., Columbia Thomas M. LeLand, M.D., Charleston W. Curtis Worthington, Jr., M.D., Charleston Arthur F. DiSalvo, M.D., Columbia Frederick L. Greene, M.D., Columbia Albert Cannon, M.D., Charleston J. Sidney Fulmer, M.D., Spartanburg Hunter R. Stokes, M.D., Florence E. Conyers O'Bryan, M.D., Florence Robert Mallin, M.D., Columbia William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Daniel W. Brake, M.D., President

John W. Simmons, M.D., President-Elect

Bartolo M. Barone, M.D., Secretary

John W. Rheney, Jr., M.D., Treasurer

O. Marion Burton, M.D., Speaker of the House

Benjamin E. Nicholson, Jr., M.D.,

Vice Speaker of the House Thomas C. Rowland, Jr., M.D., Past President

TRUSTEES

J. Chris Hawk, III, M.D., First District, Chairman John B. Johnston, M.D., First District Edward W. Catalano, M.D., Second District Frank W. Young, M.D., Second District Richard M. Carter, M.D., Third District James B. Page, M.D., Fourth District

William J. Goudelock, M.D., Fourth District Roger Gaddy, M.D., Fifth District James M. Lindsey, Jr., M.D., Sixth District Stephen A. Imbeau, M.D., Sixth District J. Capers Hiott, M.D., Seventh District Dallas W. Lovelace, III, M.D., Eighth District Carol S. Nichols, M.D., Ninth District

DELEGATES TO THE AMA

John C. Hawk, Jr., M.D., Delegate Donald G. Kilgore, Jr., M.D., Delegate Randolph D. Smoak, Jr., M.D., Delegate Charles R. Duncan, Jr., M.D., Alternate J. Gavin Appleby, M.D., Alternate Walter J. Roberts, Jr., M.D., Alternate

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

308

The Journal of the South Carolina Medical Association

At the May meeting of the SCMA Board of Trustees, we reaffirmed the previous position, originally set in 1984, which stated that the SCMA go on record as “opposing the UCR reimbursement system in its current form because it is discriminatory against patients and physicians alike, and the SCMA supports equal reimbursement by third party payors for equal services, with no mandatory assignment, the freedom to balance bill and an upgrade of reimbursement schedules every six months.”

To understand this position, it might be worthwhile to review the circumstances in 1984 which led to its adoption. First, the UCR (usual, customary and reasonable) which Medicare utilizes in South Carolina is not usual and customary — and it certainly is not reasonable. The principle was to utilize physicians’ fees to arrive at the 75th percentile to determine the Medicare allowable charge. However, each physician and each specialty had different fees, so this system rewarded the physician who charged the highest rates and penalized the physician who tried to keep his fees down. For example, if a patient went to one surgeon for a procedure, the charge and the UCR may be the same — $300; but suppose another patient went to a different surgeon for the identical procedure, this surgeon’s fee could be $300 and his UCR only $200. So, one patient may have an out- of-pocket cost of $100, although both patients paid the same insurance premium.

The specialty differentiation at times would also be humorous if it weren’t so sad. For example, guess which specialty was reimbursed the highest fee for a sigmoidoscopy. If you guessed the gastroenterologist, you guessed wrong. Ophthalmologists were paid more than gastroenterologists for a sigmoidoscopy because only a few ophthalmologists filed that code and their fees and resulting UCRs were higher. The only fair system, then, would be to allow the physician to set a reasonable fee for his service and an insurance company reimburse all patients the same fee for that service. Then the patient could pay the physician the balance, allowing all patients to receive the same amount for the same procedure regardless of the physician who provided the service. Sounds simple enough, doesn’t it?

In 1983, the SC Academy of Family Physicians wrote the Insurance Commissioner stating that the UCR reimbursement system discriminated against patients and physicians alike, and that Blue Cross and Blue Shield should eliminate the UCR with specialty prevailings and calculate one allowable charge for each code. The carrier responded to the Insurance Commission that since this would affect all of the state’s physicians, they could not consider such a major change without the endorsement of the SCMA. At about the same time, at the AMA Interim Meeting, the AMA House of Delegates voted to change the AMA policy on physician reimbursement from the UCR concept to the indemnity method. Thus, on January 13, 1984, after consider- ation by a subcommittee and after careful deliberation, the SCMA Council voted to adopt the position stated above. It was further adopted by the SCMA House of Delegates.

Blue Cross and Blue Shield implemented a prevailing fee schedule July 1, 1984 and eliminated the “customary” charge schedule, further requesting that HCFA allow them to implement the same schedule for Medicare patients. A decision was deferred because of a pending lawsuit in the state of Michigan on the same subject. In April of this year, Senator Hugh Leatherman, working with our congressional delegation to eliminate unreasonable Medicare payment differentials, requested Blue Cross and Blue Shield to urge HCFA to implement a prevailing charge screen with no specialty differentiation. This, then, resulted in the SCMA’s reaffirming its previous position in support of eliminating the UCR reimbursement system.

If, indeed, this concept is implemented by HCFA, it will have NO effect on your current charges to Medicare patients. There will be only one fee (or Medicare allowed charge) for each CPT code for all physicians, and all patients will be reimbursed the same fee for the same service regardless of their physician. This will serve two purposes: ( 1 ) it will standardize the charge for a procedure so that all Medicare patients will receive the same amount of reimbursement for that procedure; and (2) it will unite us as one and hopefully prevent any specialty group from pulling out and trying to negotiate separate contracts with Medicare. This would be nonproductive, divide our organization and destroy our private practice of medicine. United we stand!

Daniel W. Brake, M.D. President

July 1989

307

VOLUME 85 AUGUST 1989 NUMBER 8

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION

Contents

Original Scientific Articles

357 Regionalized Perinatal Care in South Carolina

Thomas C. Hulsey, MSPH, Sc.D., Henry C. Heins, M.D., Terry A. Marshall, M.D., Mary Lou Martin, MSN, R.N., Tom W. McGee, M.A.T., Marie C. Meglen, MS, C.N.M., Susie F. Peden, BSN, M.H.S.A., William B. Pittard, M.D., David H. Wells, M.D.

Features Editorial

395 Auxiliary Page 393 On The Cover 353 President’s Page

389 The Essential Healer

Charles G. Sasser, M.D.

Association

387 Gray Matter 371 SCMA Newsletter

THE JOURNAL SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139) — Published monthly by the South Carolina Medical Association Business office: 3210 Fernandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 11188 Capitol Station, Columbia, SC 29211.

Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box 11188, Columbia, South Carolina 29211.

EDITOR

Charles S. Bryan, M.D.

SCMA, P. O. Box 11188 Columbia, S. C. 29211

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia, Editor Emeritus

Charles N. Still, M.D., Columbia Thomas M. LeLand, M.D., Charleston W. Curtis Worthington, Jr., M.D., Charleston Arthur F. DiSalvo, M.D., Columbia Frederick L. Greene, M.D., Columbia Albert Cannon, M.D., Charleston J. Sidney Fulmer, M.D., Spartanburg Hunter R. Stokes, M.D., Florence E. Conyers O’Bryan, M.D., Florence Robert Mallin, M.D., Columbia William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Daniel W. Brake, M.D., President

John W. Simmons, M.D., President-Elect

Bartolo M. Barone, M.D., Secretary

John W. Rheney, Jr., M.D., Treasurer

O. Marion Burton, M.D., Speaker of the House

Benjamin E. Nicholson, Jr., M.D.,

Vice Speaker of the House Thomas C. Rowland, Jr., M.D., Past President

TRUSTEES

J. Chris Hawk, III, M.D., First District, Chairman John B. Johnston, M.D., First District Edward W. Catalano, M.D., Second District Frank W. Young, M.D., Second District Richard M. Carter, M.D., Third District James B. Page, M.D., Fourth District

William J. Goudelock, M.D., Fourth District Roger Gaddy, M.D., Fifth District James M. Lindsey, Jr., M.D., Sixth District Stephen A. Imbeau, M.D., Sixth District J. Capers Hiott, M.D., Seventh District Dallas W. Lovelace, III, M.D., Eighth District Carol S. Nichols, M.D., Ninth District

DELEGATES TO THE AMA

John C. Hawk, Jr., M.D., Delegate Donald G. Kilgore, Jr., M.D., Delegate Randolph D. Smoak, Jr., M.D., Delegate Charles R. Duncan, Jr., M.D., Alternate J. Gavin Appleby, M.D., Alternate Walter J. Roberts, Jr., M.D., Alternate

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

354

The Journal of the South Carolina Medical Association

President's Page

LET’S GET IT TOGETHER

Not too many years ago doctors were concerned about the growing number of patients who were inadequately insured. To try to help these people the physicians founded Blue Shield. They agreed to accept the allowed charge as payment in full. In those days, the allowed charge was reasonable and most physicians were “participating” physicians. The Blue Cross and Blue Shield Board of Trustees was made up of lay people plus a number of physicians. As the years have passed, we have seen our numbers decrease to one physician on the board. We have also seen an attitude change, as reflected in a recent newspaper article interviewing Blue Cross and Blue Shield President, M. Edward Sellers, and Chairman of the Board, Joe Sullivan. If this negative philosophy persists, there can be only more problems for the patients, the doctors, the hospitals and, eventually, for Blue Cross and Blue Shield.

When Blue Cross and Blue Shield began serving as the intermediary for Medicare they began denying claims retroactively. They also began retroactive denials for their private insurance company. It was interesting that other insurance companies were not utilizing the same retroactive denial procedure as Blue Cross and Blue Shield. Before long it was difficult to tell the difference between Blue Cross and Blue Shield and Medicare. In the 1970s the SCMA fought to stop the retroactive denial process and tried to establish a concurrent review system. We worked with Blue Cross and Blue Shield and tried to improve the quality of reviewers who were denying claims. Blue Cross and Blue Shield also worked with us and we were able to find competent, practicing physicians to do their review work.

It is interesting to note that Blue Cross and Blue Shield recently got the contract for CHAMPUS and the SCMA is starting to get complaints about denials of CHAMPUS claims. This was not a problem with the previous intermediary, but Blue Cross and Blue Shield might say that the former intermediary was not denying enough claims. We also continue to get complaints about Medicare and about Blue Cross and Blue Shield as a private company and, again, most of these complaints deal with denied claims. Some of these denials are legitimate, but there are also claims which are denied inappropriately. In these situations either the patient pays out of pocket for the service or the physician provides a service for which he is not paid. Either way, Blue Cross and Blue Shield gets the premium from the patient and doesn’t have to pay the claim. How many thousands or millions of dollars of claims are denied each year? Only Blue Cross and Blue Shield can answer that question.

This problem needs to be addressed. One possible solution would be to set up a liaison committee between the physicians and Blue Cross and Blue Shield for their private company as well as Medicare and CHAMPUS. I’ve already met with representatives from Medicare and Blue Cross and will meet with representatives from CHAMPUS to try to improve relations. For me to effectively discuss the problems with the carrier requires that you notify us of any claims that are denied inappropriately. This will allow SCMA to document the severity of the problem. Hopefully, Blue Cross and Blue Shield will be receptive to our patient and physician problems and we can work to insure true peer review and effective claims administration.

<L

Daniel W. Brake, M.D.

President

August 1989

353

VOLUME 85 SEPTEMBER 1989 NUMBER 9

^Journal t,

THE SOUTH CAROLINA MEDICAL ASSOCIATION

Contents

SYMPOSIUM: Otolaryngology and Head and Neck Surgery

GUEST EDITORS: J. David Osguthorpe , M.D., F. Johnson Putney , M.D.

441 Dizziness: Current Evaluation

Warren Y. Adkins, M.D., William J. Frarel, M.D.

444 Hearing Conservation and New Techniques in Rehabilitation

403 Indications for Tonsillectomy and Adenoidectomy

Richard M. Carter, M.D., J. Capers Hiott, M.D.

405 Current Techniques in Evaluation of a Neck Mass

Robert C. Jordan, M.D., Augustus J. Goforth, in, M.D.

409 Multimodality Treatment of Advanced Head and Neck Carcinoma

L. S. Carlson, M.D., R. Stuart, M.D., J. D. Osguthorpe, M.D.

415 Inhalant Allergies: Skin Versus In Vitro Testing

Gien Hoang, M.D., Robert G. Mahon, Jr., M.D.

417 Endoscopic Technique for Sinus Surgery

Juan A. Brown, M.D., L. Ronald Hurst, M.D.

425 External Rhinoplasty

William R. Lomax, M.D., Kenneth A. Bronn,

M. D.

429 Adjunctive Procedures in Surgery of the Aging Face

Paul T. Davis, M.D., Calhoun D. Cunningham, M.D.

R. Stewart Bauknight, M.D., Robert C. Waters, M.D., Robert M. Poland, M.A.

447 Management of Post-Intubation and Post- Traumatic Airway Stenosis

Lucinda A. Halstead, M.D., James T. Bowles, M.D.

Editorial

450 Otolaryngology— Head and Neck Surgery

F. Johnson Putney, M.D.

Features

451 Auxiliary Page 449 On The Cover 399 President’s Page

Association

437 CME Calendar 427 Gray Matter 443 Physician Recognition Award 421 SCMA Newsletter

THE JOURNAL OF THE SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139) — Published monthly by the South Carolina Medical Association Business office: 3210 Femandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 11188 Capitol Station, Columbia, SC 29211.

Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box 11188, Columbia, South Carolina 29211.

EDITOR

Charles S. Bryan, M.D.

SCMA, P. O. Box 11188 Columbia, S. C. 2921 1

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia, Editor Emeritus

Charles N. Still, M.D., Columbia Thomas M. LeLand, M.D., Charleston W. Curtis Worthington, Jr., M.D., Charleston Arthur F. DiSalvo, M.D., Columbia Frederick L. Greene, M.D., Columbia Albert Cannon, M.D., Charleston J. Sidney Fulmer, M.D., Spartanburg Hunter R. Stokes, M.D., Florence E. Conyers O'Bryan, M.D., Florence Robert Mallin, M.D., Columbia William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Daniel W. Brake, M.D., President

John W. Simmons, M.D., President-Elect

Bartolo M. Barone, M.D., Secretary

John W. Rheney, Jr., M.D., Treasurer

O. Marion Burton, M.D., Speaker of the House

Benjamin E. Nicholson, Jr., M.D.,

Vice Speaker of the House Thomas C. Rowland, Jr., M.D., Past President

TRUSTEES

J. Chris Hawk, III, M.D., First District, Chairman John B. Johnston, M.D., First District Edward W. Catalano, M.D., Second District Frank W. Young, M.D., Second District Richard M. Carter, M.D., Third District James B. Page, M.D., Fourth District

William J. Goudelock, M.D., Fourth District Roger Gaddy, M.D., Fifth District James M. Lindsey, Jr., M.D., Sixth District Stephen A. Imbeau, M.D., Sixth District J. Capers Hiott, M.D., Seventh District Dallas W. Lovelace, III, M.D., Eighth District Carol S. Nichols, M.D., Ninth District

DELEGATES TO THE AMA

John C. Hawk, Jr., M.D., Delegate Donald G. Kilgore, Jr., M.D., Delegate Randolph D. Smoak, Jr., M.D., Delegate Charles R. Duncan, Jr., M.D., Alternate J. Gavin Appleby, M.D., Alternate Walter J. Roberts, Jr., M.D., Alternate

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

400

The Journal of the South Carolina Medical Association

HEALTHCARE 2000

At our Annual Meeting I promised to form an ad hoc committee to study our healthcare system. We had our first meeting in July and I feel confident we will bring some constructive recommenda- tions to our House of Delegates next year. Our committee consists of representatives from government, Medicare, Medicaid, hospitals, physicians, nurses, nursing homes. Medicare recip- ients (AARP), private business, private insurance companies and the legal profession. After our first meeting it is quite evident that we will have to address two major problems: ( 1 ) how to cut medical costs without affecting quality; and (2) how to redistribute the total healthcare dollar so that everyone is paying their fair share according to their ability to pay. These arc tough questions. Some of the decisions that will follow to address costs will have to include a closer look at heroics (in medicine), such as performing CPR on a patient who has been in a nursing home with a stroke, being tube fed, with no mental responses. We also will have to look at neonatal nurseries. There are many patients we keep alive with respirators, etc., for days to weeks at tremendous financial and emotional expense to the families. We will have to include our medical ethics committee as well as the legal profession in discussing these problems.

In discussing the distribution of the total healthcare dollar we will accumulate data on exactly what percent is paid by all the recipients. For example, the healthcare dollar is paid by ( 1 ) Medicare/ Medicaid — but they frequently do not pay a full dollar for a dollar’s worth of service; (2) the uninsured or inadequately insured — these also do not pay a full dollar for a dollar’s worth of service; (3) private patients and private business — usually pay in full plus they pay for the deficit created by Medicare/Medicaid and the uninsured and inadequately insured. The percent of private paying patients continues to decrease but the percent they pay of the healthcare dollar continues to increase. We cannot continue in this direction.

We will need to look closely at businesses Medicare has created such as nursing homes, home healthcare services and medical supplies. We need to address how physicians can become more cost conscious about practicing medicine without affecting the quality of care we give our patients. We also need to address some physicians’ charges as well as look at socialized medicine as practiced in other countries. These are a few issues we will have to address over the next year.

You may be interested in knowing that we are not the only people concerned about healthcare costs. Senators Hugh Leatherman and Ed Salceby have formed separate committees to address this issue and these committees have begun their work.

I can assure you of a dramatic change in the current healthcare system by the year 2000. Hopefully, the change will be what’s best for the American people. I promise to dedicate my time and energies to attempt to correct the flaws in our current system rather than allowing our country to move toward socialized medicine.

Daniel W. Brake, M.D. President

September 1989

399

VOLUME 85 OCTOBER 1989 NUMBER 10

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION

Contents

Original Scientific Articles

459 How Good (or Bad) is the Pap Smear?

William T. Creasman, M.D.

463 Utilization of Amniocentesis and Chorionic Villus Sampling by South Carolina Women 35 Years of Age and Older

Cam Knutson, M.S., S. R. Young, Ph.D., Ronald V. Wade, M.D., and Robert G. Best, Ph.D.

469 Idiopathic Arteriovenous Renal Vascular Malformation Treated by Ex Vivo Repair

William R. Morgan, M.D., James A. Majeski, M.D., Ph.D.

Special Article

481 Knowledge, Perceived Risk, and Beliefs about AIDS among High School and College Students in South Carolina

Francisco S. Sy, M.D., Dr.P.H., Yvonne Freeze-McFJwee, M.S.P.H., Carol Z. Garrison, Ph.D., and Kirby L. Jackson, B.A.

Editorials

494 Tick Distribution in South Carolina

Arthur F. DiSalvo, M.D.

495 Regionalized Perinatal Care: The Next Step

C. Warren Derrick, Jr., M.D.

Features

497 Auxiliary Page

495 Letter to the Editor

496 On The Cover 455 President’s Page

Association

489 Gray Matter

473 SCMA Newsletter

THE JOURNAL OF THE SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3 1 39) — Published monthly by the South Carolina Medical Association Business office: 3210 Fernandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 1 1 188 Capitol Station, Columbia, SC 2921 1.

Copyright © 1 989 by the South Carolina Medical Association. All rights reserved. The views expressed in this publication arc those of the writers and do not necessarily reflect the opinions of the South Carolina Medical Association.

Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box 11188, Columbia, South Carolina 2921 1.

EDITOR

Charles S. Bryan, M.D.

SCMA, P. O. Box 11188 Columbia, S. C. 2921 1

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia, Editor Emeritus

Charles N. Still, M.D., Columbia Thomas M. LeLand, M.D., Charleston W. Curtis Worthington, Jr., M.D., Charleston Arthur F. DiSalvo, M.D., Columbia Frederick L. Greene, M.D., Columbia Albert Cannon, M.D., Charleston J. Sidney Fulmer, M.D., Spartanburg Hunter R. Stokes, M.D., Florence E. Conyers O'Bryan, M.D., Florence Robert Mallin, M.D., Columbia William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Daniel W. Brake, M.D., President

John W. Simmons, M.D., President-Elect

Bartolo M. Barone, M.D., Secretary

John W. Rheney, Jr., M.D., Treasurer

O. Marion Burton, M.D., Speaker of the House

Benjamin E. Nicholson, Jr., M.D.,

Vice Speaker of the House Thomas C. Rowland, Jr., M.D., Past President

TRUSTEES

J. Chris Hawk, III, M.D., First District, Chairman John B. Johnston, M.D., First District Edward W. Catalano, M.D., Second District Frank W. Young, M.D., Second District Richard M. Carter, M.D., Third District James B. Page, M.D., Fourth District

William J. Goudelock, M.D., Fourth District Roger Gaddy, M.D., Fifth District James M. Lindsey, Jr., M.D., Sixth District Stephen A. Imbeau, M.D., Sixth District J. Capers Hiott, M.D., Seventh District Dallas W. Lovelace, III, M.D., Eighth District Carol S. Nichols, M.D., Ninth District

DELEGATES TO THE AMA

John C. Hawk, Jr., M.D., Delegate Donald G. Kilgore, Jr., M.D., Delegate Randolph D. Smoak, Jr., M.D., Delegate Charles R. Duncan, Jr. , M.D., Alternate J. Gavin Appleby, M.D., Alternate Walter J. Roberts, Jr., M.D., Alternate

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

456

The Journal of the South Carolina Medical Association

Rising health care costs are of great concern to both health care providers and consumers alike. The reduction of health care expenditures must occur but in a manner so as not to jeopardize the quality of care available to patients.

Upon taking the office of the presidency of the South Carolina Medical Association in April of this year, I stressed three primary points to my colleagues in my inaugural address: first, to provide quality medical care for the sick; second, to discipline ourselves to insure that quality; and third, to be an observer and spokesman for health care and guarantee access to quality care for all Americans.

Each of these responsibilities addresses the issue of quality of care for our patients. I believe it is the responsibility of organized medicine to protect the availability of quality care for our patients from the bureaucratic attempts to control health care expenditures.

One area of health care spending of utmost concern today is Medicare — a federal promise to provide health care services which was made to elderly Americans 26 years ago.

Certainly, no one would quarrel with the idea of controlling Medicare costs, but the proposal to impose expenditure targets (ETs) on Medicare payments is very simply wrong. The idea of capping the total amount of Medicare dollars available each year is a “solution” which would work a great hardship on patients by severely restricting their access to necessary medical services. What Congress and the Bush Administration are talking about is RATIONING of health care. Due to new technology and longer life span, the demand for health care is growing. To couple that demand with shrinking resources would put an unbearable pressure on physicians to do less for patient welfare. Under ETs, the government would be asking physicians to figure out how NOT to treat their patients instead of how to treat them. This is a situation physicians could never accept. By any name, expenditure targets are simply an attempt by Congress and the current administration to balance the budget on the backs of America’s elderly.

The real message of ETs is that the government cannot control the Medicare program. There are many areas that could be considered to decrease Medicare costs. Instead of reasoned approaches to specific problem areas, the government is throwing up its hands and abdicating responsibility to a process that has resulted in rationed care in other countries. For example, the Canadian system progressed from access to care for everyone to long waiting periods for hip prostheses, coronary bypass and other procedures. We are seeing America go through the same process with Medicare. With Congress’ proposed ETs we have now reached the final step to rationing care as we have seen in the socialized systems.

Ironically, these targets aren’t even necessary. The Ways and Means Health Subcommittee has already met its Graham-Rudman-Hollings target for 1990, so there is no short-term justification for Medicare expenditure targets.

The reason Part B (physician) payments have risen faster than Part A (hospitals) is not because of “overutilization” by physicians. When the government clamped down on hospital admissions five years ago, more procedures had to be done on an outpatient basis, resulting in an average growth of outpatient services of 30 percent per year. In comparison, physician services grew only 13 percent from 1980 to 1988. Outpatient charges grew from 18 percent of Part B spending in 1984 to 28 percent in 1988. At the same time, physician services decreased from 72 percent of Part B spending to 61 percent.

In commenting on ETs, a June editorial in The Washington Post concluded that “normally, it would be wrong to impose a change as vast as this in the budget process, where the focus is on the short term rather than the long and less on substance than on dollars.” We believe this would always be wrong.

The South Carolina Medical Association and American Medical Association believe that areas such as practice guidelines would be more appropriate — and more effective — than ETs in controlling physicians’ charges. The number of practice guidelines in existence today is small, but there are enough of them to demonstrate their usefulness in reducing the cost of medical care. Practice guildelines work. More importantly, they control costs by reducing the amount of inappropriate care. On the other hand, however, expenditure targets control costs by limiting appropriate as well as inappropriate care.

The SCMA and AMA are committed to working with Congress to address budget requirements, while maintaining the promise of the access to quality care for all patients. Rationing in the guise of expenditure targets would betray that promise. Physicians will not abandon their role as the patients’ advocate in order to provide the government a quick and dirty fix to a budget problem which neither the elderly nor the physicians created. .

Daniel W. Brake, M.D.

VOLUME 85 NOVEMBER 1989 NUMBER 11

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION

Contents

Original Scientific Articles

503 Intravenous Streptokinase Therapy for Acute Myocardial Infarction in a Community Hospital: Effect on Ventricular Function and Mortality

Joseph L. Trask, M.D., Neil W. Trask, III, M.D., William J. Cushing, M.D., Harvey E. Butler, Jr., M.D., Bruce W. Usher, M.D.

509 Schizophrenia: Promising New Directions in South Carolina

Alberto B. Santos, Jr., M.D., Paul A. Deci, M.D.

522 Dynamic Auscultation

Richard S. Pollitzer, M.D., Stephen L. Watkins, M.D., Timothy S. Llewelyn, M.D.

Special Articles

527 Online Information Management: Who Needs It?

Nancy C. McKeehan, M.S.L.S.

529 Access to Online Information: The Hardware Connection

Nancy Smith, M.L.S.

Editorials

533 Into The Fray: The Community Hospital Treatment of Acute Myocardial Infarction

E. Conyers O'Bryan, Jr., M.D.

534 SCHIN and GRATEFUL MED (or Computers to the Rescue!)

Charles S. Bryan, M.D.

Features

539 Auxiliary Page

535 On the Cover 501 President’s Page

Association

531 Gray Matter

536 In Memoriam

537 Physicians’ Advocacy and Assistance Committee 517 SCMA Newsletter

THE JOURNAL OF THE SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139) — Published monthly by the South Carolina Medical Association Business office: 3210 Fernandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 11188 Capitol Station, Columbia, SC 29211.

Copyright © 1989 by the South Carolina Medical Association. All rights reserved. The views expressed in this publication are those of the writers and do not necessarily reflect the opinions of the South Carolina Medical Association.

Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box 11188, Columbia, South Carolina 29211.

EDITOR

Charles S. Bryan, M.D.

SCMA, P. O. Box 11188 Columbia, S. C. 2921 1

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia, Editor Emeritus

Charles N. Still, M.D., Columbia Thomas M. LeLand, M.D., Charleston W. Curtis Worthington, Jr., M.D., Charleston Arthur F. DiSalvo, M.D., Columbia Frederick L. Greene, M.D., Columbia Albert Cannon, M.D., Charleston J. Sidney Fulmer, M.D., Spartanburg Hunter R. Stokes, M.D., Florence E. Conyers O'Bryan, M.D., Florence Robert Mallin, M.D., Columbia William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Daniel W. Brake, M.D., President

John W. Simmons, M.D., President-Elect

Bartolo M. Barone, M.D., Secretary

John W. Rheney, Jr., M.D., Treasurer

O. Marion Burton, M.D., Speaker of the House

Benjamin E. Nicholson, Jr., M.D.,

Vice Speaker of the House Thomas C. Rowland, Jr., M.D., Past President

TRUSTEES

J. Chris Hawk, III, M.D., First District, Chairman John B. Johnston, M.D., First District Edward W. Catalano, M.D., Second District Frank W. Young, M.D., Second District Richard M. Carter, M.D., Third District James B. Page, M.D., Fourth District

William J. Goudelock, M.D., Fourth District Roger Gaddy, M.D., Fifth District James M. Lindsey, Jr., M.D., Sixth District Stephen A. Imbeau, M.D., Sixth District J. Capers Hiott, M.D., Seventh District Dallas W. Lovelace, III, M.D., Eighth District Carol S. Nichols, M.D., Ninth District

DELEGATES TO THE AMA

John C. Hawk, Jr., M.D., Delegate Donald G. Kilgore, Jr., M.D., Delegate Randolph D. Smoak, Jr., M.D., Delegate Charles R. Duncan, Jr., M.D., Alternate J. Gavin Appleby, M.D., Alternate Walter J. Roberts, Jr., M.D., Alternate

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

502

The Journal of the South Carolina Medical Association

HUGO VS. SOUTH CAROLINA

Hurricane Hugo hit the coast of South Carolina on Thursday, September 21 and struck a fierce blow to our state that night. The word “devastating” has been used so much that we are tired of it, but it certainly describes Hugo’s effect on South Carolina. After the shock, we started to put our lives back together.

My medical office now has electricity and we are getting back to normal at work, but I still have 1 4 trees on my garage, deck and house and no electricity at home. I must admit that the SCMA has been pushed down on my priority list since Hugo. I had to cancel a trip to Washington the week of October 6 but I resumed my duties the following week, with a trip to Georgetown on October 9, and on to Hickory Knob to meet with the House Labor, Commerce and Industry Committee, and then the Pickens County Medical Society on October 10. Because of the magnitude of the effects of the hurricane, I think it is certainly appropriate to dedicate this President’s Page to Hugo.

I would like to commend the doctors, nurses, paramedics, emergency personnel, electricians and telephone personnel who neglected their personal needs to give their time to the rest of us. Many physicians and medical personnel have gone out to rural areas to care for the sick and injured. As a result of Hugo, our interpersonal relationships have undergone changes. For example, Hugo has made us more honest. If you ask someone, “How are you doing?” most people would reply, “Fine,” pre-Hugo days. Now they say, “Not so good,” “It’s getting better,” “I got electricity today,” or “Not worth a damn.” I have noticed a definite improvement in attitudes and spirit when the electricity comes on and you can take a hot shower and shave. I’m still waiting. I complained to a doctor in the hospital about my problems and his answer was, “I knew a man who complained because he had no windows until he met a man with no walls.” I stopped complaining.

This hurricane has certainly brought a lot of us closer together. We have seen neighbors working to help each other clean their yards, when before Hugo they did not even know each other’s names. With no electricity — therefore no television — and a curfew, our families have had to stay in and talk to one another, resulting in closer family relationships. Disasters frequently bring out the best in us. We have seen a tremendous outpouring of supplies and money from all over the country. It has reinforced my belief that we are better off caring for ourselves than depending on government to care for us. A typical example is the 38 truckloads of goods donated by private sources and delivered to McClellanville, while the government (FEMA) tried to figure out how to get money from Washington to the needy people in South Carolina. They still haven’t figured it out! It’s quite obvious that whether we are talking about medicine or a disaster like Hugo, the more we care for ourselves with as little government involvement as possible, the better off we are.

We realize that a number of physicians have lost their offices and are having financial problems as a result of Hugo. The SCMA has offered $500,000 to set up low interest loans to needy physicians, and the AM A is providing an additional $500,000. If you are having financial problems as a result of Hugo, send your application in to the South Carolina Medical Association and we will try to assist you.

I’m happy to report that, although badly damaged, Charleston has not lost its charm. The spirit I see in the people all over South Carolina assures me that Charleston and the other areas will rebuild. Charleston has withstood revolutionary and civil wars, fire and earthquake, and it will certainly withstand Hugo. So you can count on our Annual Meeting, April 1990, in Charleston. All in all, Hugo struck a mighty blow, but South Carolina will come back stronger than ever, having learned another lesson from nature. ^

Daniel W. Brake, M.D.

President

VOLUME 85 DECEMBER 1989 NUMBER 12

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION

Contents

Editorials

Original Scientific Articles

549 The Surgical-Prosthetic Method of Cleft Lip and Palate Care: Development of a Comprehensive Program

Robert F. Hagerty, M.D., Richard C. Hagerty, M.D.,

Warren L. Gould, M.D., and the Staff of the Carolina Cleft Lip and Palate Center

554 Identification and Intervention for Alcohol Abuse

Stephen Holt, M.B.

560 Recurrence of Node-Negative Breast Cancer in Patients Treated in a Community Hospital

Betty M. Hahneman, M.D., M.P.H., Shirley J. Thompson, Ph.D., William H. Babcock, M.D., Susan Salters, B.A., C.T.R.

577 Trends in Public Knowledge and Attitudes about AIDS, South Carolina, 1987-1988

Jeffrey L. Jones, M.D., M.P.H., Daniel T. Lackland, M.S.P.H., Lynda D. Kettinger, M.P.H., William B. Gamble, Jr., M.D., M.P.H.

580 Peace and Good Will

Charles S. Bryan, M.D.

582 Tackling the Alcohol Problem: The Case for Secondary Prevention

Stephen Holt, M.B.

Features

589 Auxiliary Page 587 On The Cover 545 President’s Page

Association

573 CME Calendar

585 Gray Matter

590 Index to Volume 85

586 Physician Recognition Awards 565 SCMA Newsletter

THE JOURNAL OF THE SOUTH CAROLINA MEDICAL ASSOCIATION (ISSN 0038-3139) — Published monthly by the South Carolina Medical Association Business office: 3210 Femandina Road, Columbia, S. C. 29210. Mailing address: P. O. Box 11188 Capitol Station, Columbia, SC 29211.

Copyright © 1 989 by the South Carolina Medical Association. All rights reserved. The views expressed in this publication are those of the writers and do not necessarily reflect the opinions of the South Carolina Medical Association.

Subscription price to non-members $25.00. SCMA members’ subscription cost ($15.00) included with payment of annual dues. Second class postage paid at Columbia, S. C. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box 11188, Columbia, South Carolina 29211.

EDITOR

Charles S. Bryan, M.D.

SCMA, P. O. Box 11188 Columbia, S. C. 2921 1

EDITORIAL BOARD

Edward E. Kimbrough, M.D., Columbia, Editor Emeritus

Charles N. Still, M.D., Columbia Thomas M. LeLand, M.D., Charleston W. Curtis Worthington, Jr., M.D., Charleston Arthur F. DiSalvo, M.D., Columbia Frederick L. Greene, M.D., Columbia Albert Cannon, M.D., Charleston J. Sidney Fulmer, M.D., Spartanburg Hunter R. Stokes, M.D., Florence E. Conyers O’Bryan, M.D., Florence Robert Mallin, M.D., Columbia William H. Hunter, M.D., Clemson

MANAGING EDITOR

Joy Drennen

SCMA OFFICERS

Daniel W. Brake, M.D., President

John W. Simmons, M.D., President-Elect

Bartolo M. Barone, M.D., Secretary

John W. Rheney, Jr., M.D., Treasurer

O. Marion Burton, M.D., Speaker of the House

Benjamin E. Nicholson, Jr., M.D.,

Vice Speaker of the House Thomas C. Rowland, Jr., M.D., Past President

TRUSTEES

J. Chris Hawk, III, M.D., First District, Chairman John B. Johnston, M.D., First District Edward W. Catalano, M.D., Second District Frank W. Young, M.D., Second District Richard M. Carter, M.D., Third District James B. Page, M.D., Fourth District

William J. Goudelock, M.D., Fourth District Roger Gaddy, M.D., Fifth District James M. Lindsey, Jr., M.D., Sixth District Stephen A. Imbeau, M.D., Sixth District J. Capers Hiott, M.D., Seventh District Dallas W. Lovelace, III, M.D., Eighth District Carol S. Nichols, M.D., Ninth District

DELEGATES TO THE AMA

John C. Hawk, Jr., M.D., Delegate Donald G. Kilgore, Jr., M.D., Delegate Randolph D. Smoak, Jr., M.D., Delegate Charles R. Duncan, Jr., M.D., Alternate J. Gavin Appleby, M.D., Alternate Walter J. Roberts, Jr., M.D., Alternate

EXECUTIVE VICE PRESIDENT

Mr. William F. Mahon

ASSOCIATE EXECUTIVE VICE PRESIDENT

Mrs. Barbara Whittaker

546

The Journal of the South Carolina Medical Association

WE OWE IT TO FUTURE GENERATIONS

In a previous President’s Page, I told you about Healthcare 2000, our committee to address the healthcare crisis. To treat our diseased healthcare system I have asked the members of Healthcare 2000 to take off their special interest hats and do what’s best for America. Healthcare 2000 is looking at all aspects of the healthcare system, Medicare, Medicaid, the uninsured and the inadequately insured.

Medicare and Medicaid account for over 50 percent of our hospital days and do not pay a full dollar for the dollar of services received. Another 10 to 15 percent of hospital days are used by the uninsured and inadequately insured. Obviously, they are not paying in full for the services received. That leaves only 35 percent of patients paying in full the services received as well as picking up the cost of services received by Medicare/Medicaid, the uninsured, and the inadequately insured. Healthcare 2000 is addressing the healthcare issue by dividing it into two areas: (1) addressing the total cost of healthcare by trying to discover ways to control the cost without affecting the quality of care; and (2) redistributing the healthcare dollar so that everyone is paying what they can afford to pay and letting the government take care of those patients that are unable to pay for themselves. One thing is clear, it is important that the government programs pay in full for the services received so that we can stop the burden of cost shifting to that 35 percent of patients who are paying in full.

On future President’s Pages I will discuss other aspects of our healthcare system, but for this page I would like to take a look at Medicare. In America we find retired parents who are financially secure offering assistance to their children. We also find children offering financial assistance to their parents. This is the way our American system works. But with Medicare, we have wealthy parents receiving benefits while some young people in financial trouble are having to pay for the cost shifting in Medicare. One solution to this problem is to require everyone with the financial means to pay their fair share of healthcare costs. This would require a means test in Medicare to put it on the road to becoming fiscally sound. Medicare should also start paying in full for the services received and thus eliminate the cost shift.

I really do not believe the U. S. Congress realizes the burden they are putting on future generations of Americans when they approve more Medicare benefits without increased contribu- tions to Medicare. Certainly refinancing Medicare will not solve all the problems but it would go a long way toward alleviating them. We all need to work together to correct the inequities in our healthcare system. Medicare is only one of the problems.

<L

Daniel W. Brake, M.D. President

December 1989

545

OF THE SOUTH CAROLINA MEDICAL ASSOCIATION VOLUME 85 JANUARY 1989 NUMBER 1

PROFESSIONAL LIABILITY IN SOUTH CAROLINA

INTRODUCTION

This issue of The Journal of the South Carolina Medical Association is a milestone for the South Carolina Medical Association/Joint Underwriting Association Risk Management Program. Members of the committee who have contributed so much over the past six or more years have provided articles for this publication. Our hope is that it will be a permanent record or manual of the accom- plishments of what those of us involved believe is a very successful endeavor. The thrust of the pro- gram has always been and continues to be positive. The concept of the program originated in the minds of thinkers and doers in our Associa- tion. We were faced with a pending crisis in medical liability — everyone told us we were just behind the rest of the country but that the prob- lem would overtake us and we would be in trouble just as Florida, New York, California and others were.

When all the malpractice insurers pulled out of the state in the mid 70’s, SCMA leadership worked with the South Carolina General Assembly and the Joint Underwriting Association was created. Later the Patients’ Compensation Fund was es- tablished. These are relatively permanent entities, being functional until there is “no longer a need for them.”

The JUA and the PCF have very adequately met the needs of South Carolina physicians as well as other healthcare providers. SCMA tried once to bring a private insurer back into the state but this carrier could not compete with the JUA’s rate structure and soon pulled out.

There has been good and helpful cooperation

GUEST EDITORS PROFESSIONAL LIABILITY IN SOUTH CAROLINA

EUTA M. COLVIN, M.D. WILLIAM L. FAIREY, M.D. JOHN R. HUNT, M.D. ROLAND L. SKINNER, JR., M.D. BARTOLO M. BARONE, M.D. B. DANIEL PAYSINGER, M.D. JOHN W. BROWN, M.D.

from the state Insurance Department through the Commissioners, John Lindsey, Roger Smith and now John Richards. SCMA, as well as other health professional groups, is well represented on the Board of Directors of both the JUA and the PCF.

This special issue of The Journal of the South Carolina Medical Association is dedicated to the many individuals who have contributed to the success of our medical liability efforts in South Carolina — to the leadership of SCMA, the South Carolina General Assembly, the South Carolina Insurance Department, JUA Defense Attorneys and UAC Investigators, the staff of the South Carolina Medical Association, the Physicians Risk Management Committee and particularly to the many South Carolina physicians who have given freely and willingly of their time and abilities.

With this support our efforts will continue to “eliminate the negative” and “accentuate the positive” in medical professional liability in South Carolina. □

January 1989

5

GLANCING BACK

WILLIAM F. FAIREY, M.D.*

It is of historical interest that a “Medical Mal- practice Survey” was taken of the South Carolina physicians in 1971 by this author, who reported the results in The Journal of the South Carolina Medical Association in January 1972. The closing paragraphs of this article are as follows:

“As a result of this survey and its conclusions, it would seem appropriate at this time for orga- nized medicine in South Carolina to form a “Malpractice Committee” to avail themselves of the status of malpractice cases and insurance as revealed by this study, to keep abreast of increased rates as are periodically requested by the insurance companies and for represen- tatives of the Committee to attend such open hearings as are made available by law to ques- tion critically the basis for such increases; to determine some means of notification by the insurance companies of the outcome of each malpractice claim or case which is brought in South Carolina; and further to consider the possibilities of obtaining a single insurance company which would offer to insure the phy- sicians of South Carolina in a fair, consistent and realistic manner, and by this pooling of malpractice data, information can be readily and constantly available as the malpractice sit- uation predictably becomes more critical.

Consideration may even be given to the for- mation of a panel of physicians (or doctors and lawyers) to evaluate on behalf of the individual doctor against whom a claim is made to deter- mine whether it is a valid claim as has been done in other states with the cooperation of an insurance company. In this way, the insurance company can keep its doctors constantly alerted to the pitfalls and can provide prophylactic measures by which the physician can avoid legal entanglements.

Education of the physician is needed by hav- ing nationally recognized legal experts to speak to the Medical Association and to the county

societies, by formation of medical-legal panels locally to discuss their respective disciplines and to seek common ground of understanding. It is to be noted that the Medical College has adopted as a part of its new curriculum a re- quired 22 hour course on medical jurispru- dence which stimulates the students early so that they pursue a continual, interested study of malpractice cases throughout their training, on a sound and relatively objective basis.

Although the malpractice picture in South Carolina has not reached the critical stage, as one reads the individual letters from the physi- cians who have been threatened or involved in a malpractice suit, the only conclusion is that the situation is serious enough and potentially dan- gerous enough to warrant an official interest by organized medicine in this State. The goal at the present time should be primarily that of finding a means by which the physicians might stay informed on a year to year basis as to what malpractice suits are being brought and to be reassured that the rates are reasonably tied in with the malpractice experience.”

During the past 17 years, organized medicine has responded well to the concerns expressed by the physicians in this 1971 survey. The physicians’ survey reflected a certain helplessness, dismay, and even outrage relative to their plight and to the discernable malpractice crisis which was begin- ning to unfold.

Due to enlightened leadership of the South Carolina Medical Association, uniquely bringing together the strengths of the state government combined with that of the insurance industry, South Carolina has responded well to the chal- lenge of the medical malpractice crises of the 70 s and 80 s. As a profession and as an association, it is vital that we continue to work together to address the medical malpractice problems/crises as they arise in the coming years. □

P. O. Box 188, Pawleys Island, SC 29585.

6 The Journal of the South Carolina Medical Association

SOUTH CAROLINA MEDICAL MALPRACTICE JOINT UNDERWRITING ASSOCIATION

BARTOLO M. BARONE, M.D.*

In early 1974 and in 1975, the private insurance carriers announced they would no longer write medical malpractice coverage in South Carolina. Consequent to this impending availability crisis, the South Carolina Medical Association worked to maintain an occurrence basis rather than a claims- made market for professional liability insurance. Through the expert help of Mr. Calvin Stewart and the South Carolina Department of Insurance, the SCMA appealed to the legislature for the enabling legislation, and the South Carolina Medi- cal Malpractice Liability Joint Underwriting As- sociation came into being in 1975, with Mr. Calvin Stewart as the Manager and the Chief Insurance Commissioner of the South Carolina Department of Insurance as the Chairman of the JUA Board.

Only three major changes have been made in the JUA law during its entire lifetime. The first major change in 1976 removed the provision which made the JUA the exclusive medical mal- practice insurer in South Carolina, and this change permitted the private insurance com- panies to sell medical malpractice insurance in South Carolina. The second major change also occurred in 1976 when the JUA law was changed to limit the amount of coverage provided by the JUA to $100,000 per claim and $300,000 aggre- gate of all claims in one year. This change made the JUA a basic insurer and the Patients’ Compen- sation Fund (PCF) became the source of the ex- cess medical malpractice coverage. The third major change occurred in 1983 when the JUA law was changed to make the JUA a permanent opera- tion. Prior to this time the JUA law expired every year or two and it was necessary to pass new legislation to extend the JUA’s authorization to operate. With the exception of these three changes, the JUA currently operates as it did in the beginning on July 1, 1975.

The JUA operates exactly like a mutual insur- ance company in that it provides all of the casu-

° 315 Calhoun St., Charleston, SC 29401.

alty insurance services that are provided by insurance companies. The JUA issues insurance policies, collects and invests insurance premiums, handles claims, defends suits and provides loss control and risk management services to its pol- icyholders. The JUA operates under the direction of its Board of Directors and through the JUA manager and servicing carriers. The Board con- tracts with the servicing carriers to provide the necessary policy, claims, loss control and risk man- agement functions. This has proven to be a very satisfactory and economical method of operation. Most private insurance companies’ total expenses are at least 30% of each premium dollar while the JUA’s total expenses are less than 15% of each premium dollar. The JUA is able to specialize in specific areas in a manner that private insurers are unable to do in that it contracts with the South Carolina Medical Association to provide a very comprehensive physician risk management pro- gram and it contracts with the South Carolina Hospital Association to provide an extensive hos- pital loss control program. The JUA is also able to contract with a company which specializes in claims and a company which specializes in policy administration.

The JUA was the exclusive medical malpractice insurer from July 1, 1975 through September 27, 1976 and insured all of the nongovernment physi- cians during this period. Although private insur- ance companies started to insure South Carolina physicians again on July 1, 1977, the private insur- ance companies have never made any significant market penetration and the JUA has been the state’s major medical malpractice insurer since its inception. The JUA currently insures more than three thousand physicians and a thousand P.A.s. There are a number of reasons for the JUA’s popularity with physicians including occurrence type coverage at an affordable cost, good service, and strong legal defense; however, the most important reason is the physicians’ confidence in the JUA. As a result of the very extensive physi-

January 1989

THE JUA

cian participation in the operation of the JUA, physicians are aware of the true medical malprac- tice conditions in South Carolina and the neces- sary costs of insuring South Carolina physicians for their medical malpractice exposures. Not only do our physicians know that the JUA is being operated in their best interests, they also know that no one will make a profit from its operation. They know that the JUA will continue to be available to them and that physicians will con- tinue to have a major role in the operation of the JUA.

It is quite clear that the medical malpractice crisis of the seventies is still with us in the eighties and that it will probably be with us for a long, long time in the future. Most states have passed a tremendous amount of legislation in an attempt to improve the medical malpractice conditions. Some 37 states have passed very extensive medical malpractice tort reform laws and there has been no measurable improvement. In fact, medical malpractice conditions seem to be getting worse in many parts of the country. For example, Vir- ginia and Minnesota have activated JUAs in the last year or so and recently the last two major medical malpractice private insurance companies pulled out of Kansas. The private insurer market is extremely restricted here in South Carolina and the major private insurance company has not insured any new physicians, except new members of insured groups, for over two years. Along with the restricted availability of medical malpractice insurance here and in other states, there has been a tremendous increase in the cost of medical mal- practice insurance. While South Carolina’s in- creases have been substantial (class I rate in 1975

was $250 and class I rate in 1988 is $1,226), our state has not experienced increases which com- pare with the increases in other states. We are all familiar with the horror stories of $100,000 or $200,000 annual malpractice premiums for physi- cians in Florida and New York; however, you may not be aware of the fact that in 1987 a Georgia OB-GYN paid five times as much for $1,000,000 claims made coverage than a South Carolina OB- GYN paid for unlimited occurrence coverage through the JUA and PCF. The North Carolina OB-GYN paid almost three times more than his South Carolina counterpart and only has $1,000,000 claims made coverage. There is no question that South Carolina medical malpractice costs are among the lowest in the entire country.

In an effort to determine why South Carolina enjoyed this favorable medical malpractice posi- tion among the various states, comparisons were made in the medical malpractice insurance opera- tions in other states with JUAs and physician owned medical malpractice insurance companies. The only factor which could be identified as being different is the extensive and direct involvement of physicians in the entire South Carolina medical malpractice process. Physicians serve on the JUA and PCF Boards and Committees as well as the Physician Risk Management Committee. Over 1,000 South Carolina physicians participate in the Physician Risk Management program. Credit for South Carolina medical malpractice success must go to all of the South Carolina physicians and particularly to the leaders of the South Carolina Medical Association who had the foresight to de- velop the JUA and the PCF and the fortitude and persistence to make them work. □

The Journal of the South Carolina Medical Association

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January 1989

9

SOUTH CAROLINA MEDICAL MALPRACTICE PATIENTS' COMPENSATION FUND

DONALD G. KILGORE, JR., M.D.*

C. TUCKER WESTON, M.D.**

In 1975 the South Carolina General Assembly passed legislation which created the South Caro- lina Medical Injury Insurance Reparations Ad- visory Committee to perform a comprehensive study of medical malpractice conditions in South Carolina and to recommend remedial legislation to improve these conditions. This was a Blue Rib- bon committee whose 17 members included sen- ators, representatives, physicians, dentists, hospi- tal officials, defense attorneys, plaintiff attorneys, insurance agents and members of the general public. This committee was jointly chaired by Chief Insurance Commissioner John W. Lindsay and the Commissioner of Health & Environmen- tal Control, E. Kenneth Aycock, M.D. The Com- mittee drafted proposed legislation creating the PCF which was adopted by the General Assembly in 1976. The PCF became operational on July 1, 1977.

The PCF operates in a manner similar to an excess insurance company and provides unlimited coverage that is identical to the basic malpractice insurance. The PCF does not provide any of the malpractice insurance services; it does not issue policies since it actually extends the limits of cov- erage of the basic malpractice insurance policy; it does not handle claims or defend suits since the PCF law requires the basic insurer “to provide an adequate defense on any claim filed that poten- tially affects the Fund;’’ nor does the PCF provide any loss control or risk management services which are provided by the basic insurer. The PCF’s function is to monitor potential claims and to make payments on settlements which it consid- ers to be appropriate or to pay its share of court awards.

The PCF operates under the direction of a Board of Governors and through the PCF staff. PCF members deal directly with the PCF staff

° 8 Memorial Medical Ct., Greenville, SC 29605. P. O. Box B, Columbia SC 29202.

10

and no other organizations or agents are involved in the PCF’s operation. The PCF is able to operate with a very small staff and the total operation costs of the PCF are approximately two percent of its revenues. This means that over 98% of each PCF fee dollar goes into the state treasury where it earns interest until such time as it is needed to pay claims. The PCF is totally funded by its members.

Economy is only one of the important features of the PCF. The low cost of protection is very important; however, the amount of protection provided by the PCF may be even more impor- tant. The PCF provides unlimited coverage in excess of the member s basic malpractice insur- ance. This extensive protection is particularly important in the many claims which involve sev- eral permanent injuries and huge expenses. The unlimited coverage provides the PCF member with the opportunity to defend himself without jeopardizing his personal assets. Since the entire costs of the PCF are shared by all PCF members, the individual PCF member’s exposures are spread over the entire PCF membership of over 4,600 physicians, dentists, hopsitals and others. This broad spread of risk reduces everyone’s per- sonal risk while they enjoy the maximum protec- tion. Some question thas been raised as to the feasibility of unlimited coverage and actuarial studies were made to determine the cost of lower amounts of coverage. When this study showed that a PCF coverage limit of $5,000,000 would only result in a six percent savings, the PCF Board of Governors did not feel a reduction of coverage was worthwile.

One of the most misunderstood provisions of the PCF law is the optional payment provision which permits the PCF Board to pay as little as $100,000.00 per claim per year. Some have inter- preted this provision to mean that the PCF could only pay $100,000.00 per year on any claim. This is completely incorrect and there is no limitation on the amount the PCF can and will pay on any

The Journal of the South Carolina Medical Association

claim. Since the PCF is responsible to the PCF member for the entire amount of the award which is in excess of the basic medical malpractice insur- ance, plus 14% interest on the unpaid award, it is not in the PCF’s best interest nor the members’ best interest for the PCF payment to be limited to $100,000.00 per year if the PCF has the money to pay the award. The PCF has never paid less than the entire award during its eleven plus years of operation. At one time the size of the PCF was limited to four million dollars and the danger of depletion of the entire fund was real. Now the PCF has more than $23 million in the state treas- ury plus the ability to raise much more if neces-

sary, and there is no reason to be concerned with the PCF’s ability to deal with a large award.

After more than eleven years of operation, the PCF has proven to be successful beyond all expec- tations. It is providing unlimited medical mal- practice protection to the great majority of South Carolina physicians, hospitals and dentists and the cost of this protection is remarkably low. This is essentially a “do it yourself” organization and its success is the result of the extensive involvement and support of the state’s physicians and particu- larly the current and former leaders of the South Carolina Medical Association. □

JUA CLAIMS FUNCTIONS

BOYCE M. LAWTON, JR., M.D.*

WHAT HAPPENS WHEN A CLAIM IS RECEIVED BY THE JUA?

Initially, it is referred to UAC (Underwriters Adjustment Corp.), our claims administrators, who do the initial investigative work. This is usu- ally accomplished in the first 30 days. Their find- ings determine how the claim will be handled:

(1) A decision may be made to engage an at- torney for the defendant. JUA manager, Cal Stewart, is primarily responsible for selection of the lawyer, from a list of expert defense lawyers;

(2) UAC may decide to do nothing and await developments, especially if they feel claim is non-meritorious; or

(3) UAC may push for resolution when the claim is highly defensible.

Our claims administrators will oversee progres- sion of the case and assist in settlement if indicated.

Legally, your JUA policy gives the JUA author- ity to select the defendant lawyer. Traditionally, we have frequently acquiesced and permitted the defendant to use the lawyer of his choice if he had

strong feelings about the matter. Recently, we have initiated a new policy of selecting the lawyer we feel can achieve the best results, regardless of where the defendant and lawyer live in the state.

Our claims committee’s main function is to insure the adequacy of reserves for pending cases and cases in suit. Files are periodically reviewed by our committee.

During the course of our review, we occasion- ally come upon instances of gross negligence, and/or individuals with multiple claims. These individuals are reported to the S.C. Board of Med- ical Examiners. They, in turn, initiate their own investigation to determine if any of the Medical Practice Laws of South Carolina or Rules and Regulations of the State Board of Medical Exam- iners have been broken.

We feel we have a very aggressive defense, skilled and dedicated claims people and excellent defense attorneys which have resulted in our win- ning 91% of our suits over the last three years and 97% in 1987. " □

° P.O. Box 366, Cameron, SC 29030.

January 1989

11

YOCON

YOHIMBINE HCI

Description: Yohimbine is a 3a-15a-20B-17a-hydroxy Yohimbine-16a-car- boxytic acid methyl ester. The alkaloid is found in Rubaceae and related trees. Also in Rauwolfia Serpentina (L) Benth. Yohimbine is an indolalkylamine alkaloid with chemical similarity to reserpine. It is a crystalline powder, odorless. Each compressed tablet contains (1/12 gr.) 5.4 mg of Yohimbine Hydrochloride.

Action: Yohimbine blocks presynaptic alpha-2 adrenergic receptors. Its action on peripheral blood vessels resembles that of reserpine, though it is weaker and of short duration. Yohimbine’s peripheral autonomic nervous system effect is to increase parasympathetic (cholinergic) and decrease sympathetic (adrenergic) activity. It is to be noted that in male sexual performance, erection is linked to cholinergic activity and to alpha-2 ad- renergic blockade which may theoretically result in increased penile inflow, decreased penile outflow or both.

Yohimbine exerts a stimulating action on the mood and may increase anxiety. Such actions have not been adequately studied or related to dosage although they appear to require high doses of the drug . Yohimbine has a mild anti-diuretic action, probably via stimulation of hypothalmic centers and release of posterior pituitary hormone.

Reportedly, Yohimbine exerts no significant influence on cardiac stimula- tion and other effects mediated by B-adrenergic receptors, its effect on blood pressure, if any, would be to lower it; however no adequate studies are at hand to quantitate this effect in terms of Yohimbine dosage.

Indications: Yocorr is indicated as a sympathicolytic and mydriatric. It may have activity as an aphrodisiac.

Contraindications: Renal diseases, and patient's sensitive to the drug. In view of the limited and inadequate information at hand, no precise tabulation can be offered of additional contraindications.

Warning: Generally, this drug is not proposed for use in females and certainly must not be used during pregnancy. Neither is this drug proposed for use in pediatric, geriatric or cardio-renal patients with gastric or duodenal ulcer history. Nor should it be used in conjunction with mood-modifying drugs such as antidepressants, or in psychiatric patients in general.

Adverse Reactions: Yohimbine readily penetrates the (CNS) and produces a complex pattern of responses in lower doses than required to produce periph- eral a-adrenergic blockade. These include, anti-diuresis, a general picture of central excitation including elevation of blood pressure and heart rate, in- creased motor activity, irritability and tremor. Sweating, nausea and vomiting are common after parenteral administration of the drug.12 Also dizziness, headache, skin flushing reported when used orally.13 Dosage and Administration: Experimental dosage reported in treatment of erectile impotence. 1 '3 4 1 tablet (5.4 mg) 3 times a day, to adult males taken orally. Occasional side effects reported with this dosage are nausea, dizziness or nervousness. In the event of side effects dosage to be reduced to Vi tablet 3 times a day, followed by gradual increases to 1 tablet 3 times a day. Reported therapy not more than 10 weeks.3 How Supplied: Oral tablets of YoconT 1/12 gr. 5.4 mg in bottles of 100’s NDC 53159-001-01 and 1000’s NDC 53159-001-10.

References:

1. A. Morales et al., New England Journal of Medi- cine: 1221 . November 12, 1981 .

2. Goodman, Gilman — The Pharmacological basis of Therapeutics 6th ed., p. 176-188.

McMillan December Rev. 1/85.

3. Weekly Urological Clinical letter, 27:2, July 4,

1983.

4. A. Morales et at. , The Journal of Urology 1 28:

45-47, 1982.

Rev. 1/85

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BRIEF SUMMARY

CONTRAINDICATIONS

There are no known contraindications to the use of sucralfate.

PRECAUTIONS

Duodenal ulcer is a chronic recurrent disease. While short-term treatment with sucralfate can result in complete healing of the ulcer a successful course of treatment with sucralfate should not be expected to alter the post-healing frequency or severity of duodenal ulceration.

Drug Interactions: Animal studies have shown that simultaneous admin- istration of CARAFATE (sucralfate) with tetracycline, phenytoin, digoxin, or cimetidine will result in a statistically significant reduction in the bioavailability of these agents. The bioavailability of these agents may be restored simply by separating the administration of these agents from that of CARAFATE by two hours. This interaction appears to be nonsystemic in origin, presumably result- ing from these agents being bound by CARAFATE in the gastrointestinal tract The clinical significance of these animal studies is yet to be defined. However because of the potential of CARAFATE to alter the absorption of some drugs from the gastrointestinal tract the separate administration of CARAFATE from that of other agents should be considered when alterations in bioavailability are felt to be critical for concomitantly administered drugs.

Carcinogenesis, Mutagenesis, Impairment of Fertility: Chronic oral toxicity studies of 24 months' duration were conducted in mice and rats at doses up to 1 gm/kg (12 times the human dose). There was no evidence of drug-related tumorigenicity. A reproduction study in rats at doses up to 38 times the human dose did not reveal any indication of fertility impairment Mutagenicity studies were not conducted.

Pregnancy: Teratogenic effects. Pregnancy Category B. Teratogenicity studies have been performed in mice, rats, and rabbits at doses up to 50 times the human dose and have revealed no evidence of harm to the fetus due to sucralfate. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always pre- dictive of human response, this drug should be used during pregnancy only rf clearly needed.

Nursing Mothers: It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when sucralfate is administered to a nursing woman.

Pediatric Use: Safety and effectiveness in children have not been established.

ADVERSE REACTIONS

Adverse reactions to sucralfate in clinical trials were minor and only rarely led to discontinuation of the drug. In studies involving over 2,500 patients treated with sucralfate, adverse effects were reported in 121 (4.7%).

Constipation was the most frequent complaint (2.2%). Other adverse effects, reported in no more than one of every 350 patients, were diarrhea, nausea, gastric discomfort, indigestion, dry mouth, rash, pruritus, back pain, dizziness, sleepiness, and vertigo.

OVERDOSAGE

There is no experience in humans with overdosage. Acute oral toxicity studies in animals, however, using doses up to 1 2 gm/kg body weight could not find a lethal dose. Risks associated with overdosage should, therefore, be minimal.

DOSAGE AND ADMINISTRATION

The recommended adult oral dosage for duodenal ulcer is 1 gm four times a day on an empty stomach.

Antacids may be prescribed as needed for relief of pain but should not be taken within one-half hour before or after sucralfate.

While healing with sucralfate may occur during the first week or two, treatment should be continued for 4 to 8 weeks unless healing has been demonstrated by x-ray or endoscopic examination.

HOW SUPPLIED

CARAFATE (sucralfate) 1-gm tablets are supplied in bottles of 100 (NDC 0088-171 2-47) and in Unit Dose Identification Paks of 1 00 (NDC 0088- 1 71 2-49). Light pink scored oblong tablets are embossed with CARAFATE on one side and 1 71 2 bracketed by C's on the other. Issued 1 /87

Reference:

1 . Eliakim R, Ophir M, Rachmilewitz D: J Clin Gastroenterol 1987, 9{A):39S-399

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The Journal of the South Carolina Medical Association

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January 1989

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THE SOUTH CAROLINA MEDICAL ASSOCIATION/JOINT UNDERWRITING ASSOCIATION RISK MANAGEMENT PROGRAM

EUTA M. COLVIN, M.D.*

Discussion regarding the establishment of a physician’s risk management program began in the early days of the Joint Underwriting Associa- tion when the suggestion of this type activity was brought before the Council of the South Carolina Medical Association by the SCMA Professional Liability Committee, chaired by Frank Biggers, M.D., in early 1976. The committee had based the idea on the fact that the South Carolina Hospital Association had a similar program under contract with the JUA. The SCMA Council and the Profes- sional Liability Committee felt that the SCHA program, while benefiting institutions, did little for physicians covered under the JUA. It was their consensus that a risk management program for physicians and their office staffs was needed to minimize professional liability risk and lessen the volatility of the medical liability environment.

The SCMA Council studied the idea over the next several years and the officers had various meetings with insurance people and risk manage- ment and loss prevention specialists, discussing the possibility of contracting for an outside group to handle the program, much as the South Caro- lina Hospital Association had done. With the help of Charlie Johnson and Blake Williams of SCMA staff, a proposal was developed with the idea that we could do a better job ourselves than the groups who had presented plans to us. The conclusion that we had the interest and the ability in the South Carolina Medical Association’s mem- bership, leadership and staff was enthusiastically recognized. We were encouraged in this thinking by Cal Stewart of the State Insurance Department who was our staunch supporter.

I recall a meeting that the Executive Commit- tee of Council had with the four physicians serv- ing on the JUA Board — Boyce Lawton, John Sutton, Bart Barone and Walt Roberts. They were

Department of Surgery, Spartanburg Regional Medical Cen- ter, 101 E. Wood Street, Spartanburg, SC 29303.

very receptive to the idea and agreed to present it to the JUA Board and to encourage its approval.

The proposal was presented to the Honorable John W. Lindsey, Commissioner of the South Carolina Department of Insurance and Chairman of the JUA Board, in a letter from Halstead Stone in November, 1980. There continued to be discus- sions and encouragement and on January 8, 1982, at a meeting of the JUA Servicing Carrier Com- mittee, chaired by Bart Barone, acceptance of the program was recommended to the full JUA Board and was approved with the following objectives:

1. Four regional meetings co-sponsored by SCMA and various county medical societies, and one statewide meeting to be held at the SCMA Annual Meeting.

2. Periodic newsletters on South Carolina med- ical malpractice claims development.

3. Recruiting and maintaining a comprehen- sive panel of physicians to review and testify on JUA claims.

A quote from the SCMA proposal seems to be pertinent and is as follows:

“The South Carolina Medical Association will, on an ongoing basis, continue its efforts for additional tort reform with hopes of as- suring a more stable insurance marketplace for all South Carolina health care pro- fessionals.

The SCMA recognizes the fact that tort reform alone will not assure the creation nor the stabilization of the medical liability work place. The SCMA believes that the funda- mental natures of risk must be minimized to lessen the volatility of the medical liability environment.

Therefore, the SCMA would propose to develop and administer, in cooperation with the South Carolina Medical Practice Lia- bility Insurance Joint Underwriting Associa- tion, a program of risk management and loss

16

The Journal of the South Carolina Medical Association

SCMA/JUA RISK MANAGEMENT PROGRAM

prevention for physicians and their office staffs.

The SCMA proposes to provide educa- tional and informational services directed to- ward the physicians and their office staffs in an effort to support loss prevention pro- grams. The SCMA is prepared to develop and support meaningful programs in this area, programs that should be beneficial to both the JUA and the physician.”

The first program on risk management was held in Charleston on April 22, 1982. The follow- ing is a quote from the invitational letter to physi- cians written by Frank Biggers, Chairman of the Professional Liability Committee. “This may be our last opportunity to have some positive effect on this growing malpractice problem.” Subse- quent meetings were held in Greenville, Florence and Columbia.

The original members of the Risk Management subcommittee were John Hunt of Anderson, Danny Paysinger of Columbia, Roy Skinner of Florence and Bart Barone of Charleston. Their time was largely devoted to reviewing charts and then locating an area physician to review in depth and give advice concerning the defensibility of the case. They also presented programs locally and regionally on the subject of risk management. They did an outstanding job and continue to do so. John Brown of Columbia was added to the com- mittee later because of the number of cases in the midlands area. The author was appointed in early 1983 by Randy Smoak and was designated as Chairman, with the objective of expanding the project and trying to attain the original goals of the program. Billy Fairey of Pawleys Island and Georgetown was added to the committee about two years ago, and he has brought considerable expertise from both his medical and legal back- grounds. Each of these physicians is dedicated to the success of this effort.

The first official meeting of the SCMA/JUA Subcommittee on Risk Management was held on July 13, 1983, and the course of the present pro- gram was set. A questionnaire was sent out to all South Carolina physicians asking them to volun- teer to serve as chart reviewers, expert defense witnesses, moral supporters to physicians being sued, and generally to be supportive of the pro- gram with their suggestions. We had over 1,000

responses to that request and all were very positive.

At that meeting, the motto of the program, ‘‘Physicians Helping Physicians,” was chosen. Later, at a suggestion from a reader, it was changed to “South Carolina Physicians Helping Physicians. ” Also, plans were made to start pub- lishing a quarterly newsletter and the first issue came out in January, 1984. It was originally called the “Medical Malpractice Bulletin” but at the suggestion of one of our physicians it was changed to “Medical Liability Bulletin,” which is much more appropriate.

We have come a long way and I know that the program has had a very significant beneficial effect on the medical liability situation in South Carolina. Much, much credit goes to Cal Stewart, who has been our ardent supporter and very valu- able advisor from the very beginning. Joy Dren- nen of the SCMA staff provides outstanding support to the program and serves as the Editor of the Bulletin. She coordinates the program and has much to do with its success. Previously, we had excellent staff support from Robin Medlock and Mary Ann West.

I also want to acknowledge the tremendous contributions that Dr. Bill Cantey has made and continues to make to this program. His careful and constructive preliminary review of charts is most helpful to our regional committee members.

SCMA/JUA RISK MANAGEMENT PROGRAM CURRENT ACTIVITIES

— Review of malpractice claims by phy- sicians.

— Depositions and testimony for defense. — Publication of quarterly Risk Manage- ment Bulletin.

— Risk Management Programs:

— Statewide — Regional — Medical staffs

— Medical school faculty /students — SCMA Annual Meeting — Lending program — audiotapes, video- tapes

— Written materials on professional liability

January 1989

17

Now, with some improvement due to recent tort reform legislation, we are encouraged to con- tinue a full and even expanded program. Included in the table is a listing of the activities of the SCMA/JUA Risk Management Program. The real success of this endeavor is due to the cooperation of the physicians of our state, who have taken seriously our motto, “South Carolina Physicians Helping Physicians.” □

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THE INTERIM MEETING OF THE AMA

REPORT OF THE SCMA DELEGATION

JOHN C. HAWK, JR., M.D.

RBRVS

It was a foregone conclusion that the most important and contentious issue at the Interim Meeting of the AMA House of Delegates at Dallas, Texas (December 2-7, 1988) would be the Resource Based Relative Value Scale (RBRVS) , developed by William H. Hsiao at Harvard University, and funded through a cooperative agreement with the Health Care Financing Administration in response to a congressional mandate to the Secretary of Health and Human Services. The AMA served as a subcontractor in the Harvard Study, as described in several previous reports from the Board of Trustees.

The Board of Trustees, in addition to a preliminary report N, submitted to the House Report AA, a comprehensive 57-page evaluation of the RBRVS. The report by the Harvard group had been released on September 28, 1988, and simultaneously the studies, methods and results were published in the New England Journal of Medicine, with an accompanying editorial by HCFA Administrator, William Roper, M.D. Also the entire October 28th issue of the Journal of the American Medical Association (JAMA) was devoted exclusively to the Harvard Study. Additional material had been submitted in advance to the various state associations .

At the meeting there were a total of nine resolutions which addressed the RBRVS in one way or another. As expected, resolutions from the American College of Physicians, the American Society of Internal Medicine, and the American Academy of Family Physicians asked for support of the RBRVS and development of a gradual but definite phase-in of the program. The resolution from the American Academy of Ophthalmology requested withholding of any endorsement until approval of the methodology and conclusions by the AMA House of Delegates. A resolution from Dr. F. William Dowda asked for opposition to any implementation of the RBRVS. A resolution from the Utah delegation stressed the need for unity in the response to the RBRVS and also asked that the AMA analyze the impact on availability of care, cost of care, and the structure of the nation's health care system. The Hospital Medical Staff Section asked for a sense of restraint and responsibility, with a constant concern for what is best for the patient, and also asked the AMA to work diligently to minimize potential divisiveness. The Resident Physicians Section

CMTlO*‘

requested the AMA to study the effects of the RBRVS on funding of graduate medical education. Finally, in a late resolution accepted by the House, Dr. Joseph O'Donnell, delegate from Illinois, asked that the AMA withhold endorsement of the RBRVS until questions of its impact on patients and concerns about the technical aspects of the study are addressed.

The issue was assigned to Reference Committee A, and the speakers had taken the unprecedented step of arranging for Reference Committee A to meet on Sunday afternoon with no other conflicting meetings so that all delegates would have a chance to attend the hearings. The committee met for over three hours on Sunday afternoon, and then had to continue its hearings Monday morning. There were long lines at all of the microphones, and the testimony was diverse, conflicting, sometimes heated, and before the end was certainly quite repetitious. There was no time limit set on testimony, and everyone had a chance to speak.

The Reference Committee, chaired by Dr. John C. Nelson of Utah, did a monumental job of making appropriate recommendations for amendment of Report AA of the Board of Trustees and were highly complimented for their diligent work. The report emphasized that the AMA reaffirms its current policy in support -of a fair and equitable Medicare indemnity payment schedule under which physicians would determine their own fees and Medicare would establish its payments for physicians' services, using an appropriate RVS, an appropriate monetary conversion factor, and an appropriate set of conversion factor multipliers. It was noted that refinement and modifications of the RBRVS are necessary and a number of the problems were detailed. It was stated that there would have to be a blending transition period and that this should have an appropriate balance between minimizing disruptions for physicians and patients while also minimizing the complexity of the process. It was reaffirmed that this indemnity payment system should reflect valid and demonstrable geographic differences in practice costs, including professional liability insurance premiums. Emphasis was placed that geographic differentials should be addressed simultaneously with specialty differentials. Also it was felt that a method of adjusting payments to effectively remedy demonstrable access problems in specific geographic areas should be developed and implemented .

Probably the most important testimony centered on the following section which was revised to state "that the Association strongly oppose any attempt to use the initial implementation or subsequent use of any new Medicare payment system to freeze or cut Medicare expenditures for physicians' services in order to produce federal budget savings".

The House adopted Board of Trustees Report AA as amended with the proviso that the Board report back to the House on further developments regarding the Harvard RBRVS and other issues considered in Report AA at the 1989 Annual Meeting or sooner if

2

necessary. The House also adopted an added resolution from the Virginia delegation "that the AMA prepare at the earliest possible date informational material regarding the significance of the adoption of Board of Trustees Report AA" . It was requested that this material be "positive in nature, concise, readily understandable, and in a form suitable for presentation at informational meetings of hospital medical staffs, local and county medical societies, and specialty groups". The resolution asking that the AMA study the effects of the RBRVS on graduate education was amended to include undergraduate medical education.

I believe that nearly all delegates received a large number of communications both before and after the Interim Meeting, from individual physicians and societies, recommending adoption or rejection of the RBRVS. Obviously the AMA cannot please everyone completely. I personally believe that the final action of the House was about as satisfactory as could be obtained. Subsequently we received a "clean copy" of Report AA of the Board of Trustees, as revised by the House. The internists and family practitioners, including members of our own delegation, might wish for immediate implementation of the RBRVS, since it would increase payments to them. On the other hand, various surgical specialty groups and those internists who carry out various "procedures" would prefer that it be amended, delayed, or completely "killed". In my opinion the House of Delegates acted in a wise and judicious manner.

It should be noted that the House was considering tjiis matter under the implied, and perhaps actual, threat thatr if the AMA could not reach some sort of consensus about the RBRVS' that it might lead Congress to adopt a much more onerous capitation plan for all Medicare patients.

REGISTERED CARE TECHNOLOGISTS

The RCT program, which had been discussed at length at the Annual Meeting of the AMA, was again the subject of debate both in Reference Committee C and on the floor of the House. Testifying to the reference committee, the representative of the American Nurses Association indicated "that the dialogue between the AMA and ANA on the RCT was at an impasse, but that new constructive relationships between nursing and medicine were developing at the state and local levels". It should be noted that the ANA represents a relatively small percentage of all of the nurses, probably about 20% in our own state.

Before the House was an excellent Report Z from the Board of Trustees, describing implementation thus far of the program adopted by the House in June. This announced the Board's decision to evaluate one or more of the existing programs that are most similar to the proposed RCT program and to implement a pilot project to demonstrate and evaluate the training of RCTs. A resolution from Florida asked that the AMA "back off" and seek alternative proposals to the RCT program, and recognized the

3

concern of the ANA and other nursing organizations.

The reference committee, after hearing all testimony, provided a substitute resolution "that the American Medical Association continue to seek solutions to the problem of the shortage of bedside care givers, in addition to the Registered Care Technologists Program". Amendments from the New York delegation would have changed the title of the resolution from "Registered Care Technologists" to "Addressing the Nursing Shortage", would have eliminated the above Resolved, and would have added a Resolved which in effect asked for the AMA just to work with the ANA and other nursing organizations. This the AMA has done for many years, without complete success.

The motion to change the title and to delete the Resolve of the reference committee was defeated. I personally spoke to this, as I believe, from my personal experience as a patient, that there is a need for additional bedside care givers, who would be of assistance to the nurses, but would not have to have all of the training of nurses. The House agreed with the reference committee, but added the additional New York Resolve "that the American Medical Association, recognizing the concerns of our partners in health care, the nursing profession, work together with the American Nurses ' Association and other nursing organizations to address the nursing shortage and to continue to seek innovative ways to alleviate the acute shortage of bedside care providers, and that the Board of Trustees report to the House of Delegates at the Annual Meeting in 1989". I had received in advance a request from the President of the South Carolina Nurses Association to try to defeat the RCT program and had replied to her my personal feelings on this matter. The House of Delegates apparently agreed with my thoughts that this RTC program should be tried, as originally provided, to see whether it will be successful or not.

ADDRESS OF THE PRESIDENT

Undoubtedly the address of Dr. James E. Davis, AMA President, played a major role in the decision of the House to continue implementation of the RCT program. He called the AMA-proposed "Registered Care Technologists" an idea whose time has come and he urged that an opportunity be given to try it out in order to provide more bedside care givers.

In regard to the RBRVS , Dr. Davis urged physicians to "remain unified and not split into warring factions". He added "American Medicine cannot afford a divided profession. Indeed, if we divide, American Medicine will not survive as we know it today".

Dr. Davis also reported a very favorable response to the challenge given in his Inaugural Address for physicians "to tithe four hours a week to community service". He said he had received many favorable communications from physicians, medical organizations, and public groups, and stated "they tell me they

4

agree that physicians need to be more extensively perceived as caring individuals who take a vital part in community life".

SPEAKER ON ANTI-TRUST

An address by Charles F. Rule, head of the Anti-Trust Division of the U.S. Justice Department, Tuesday morning was an unexpected and unwelcome addition to an already crowded program. He warned the delegates that felony criminal charges will be leveled against competing physicians if they fix fees, allocate patient territories, or boycott insurers. He was at times pedantic, at other times threatening, and appeared to be trying to intimidate physicians into hiring lawyers to keep them out of trouble. The address was so poorly delivered that many of us would have paid little attention to it, except that the content was so offensive. Just before the midday break, a delegate from Houston, Texas, was recognized at microphone and gave a highly charged, emotional speech, which I think reflected the opinions of many of the delegates. He had gone to considerable trouble to get an early copy of the speech, and read excerpts from it with appropriate comments .

I had heard earlier that Mr. Rule was a self-invited guest, but later we were told by Dr. James Sammons, AMA EVP, that he had been invited to give this address because of problems that physicians in several areas of the country had incurred with alleged anti-trust violations, and in which the AMA had also been involved. This was intended to be an "educational" address, but it certainly was received as an attempt at intimidation.

At the midday break, I overheard a comment by Dr. Harry Schwartz (Ph.D.) who is a well-recognized medical commentator for the New York Times. Private Practice, and other publications, as well as the author of a book entitled The Case for American Medicine. Talking to Dr. George Alexander, the Houston Delegate, Schwartz said "George, you are the hero of this Convention". And indeed he was!

"MEDICALLY UNNECESSARY" STATEMENTS

The House commended the Board of Trustees for its activities on this important issue, but took notice that it is not yet completely resolved by adopting the following policies: (1) That the American Medical Association continue to call for the repeal of the "medically unnecessary" provisions of Section 9332 (c) of the Omnibus Budget Reconciliation Act of 1986; and (2) That until such time as repeal is achieved, the American Medical Association urge the Health Care Financing Administration to require that there be stated on the medically unnecessary notices mailed by carriers (a) the basis for the denial; (b) the name, position, and title of the person to be contacted regarding questions about the review; and (c) the screening criteria or parameter used in denying payment for the service.

5

PROFESSIONAL LIABILITY

The House received a report describing the work of AMA's Special Task Force on Professional Liability and Insurance and also the Advisory Panel on Professional Liability. A continuing study relating to expert medical witnesses was described. The House adopted policy calling on the AMA to establish a policy that each physician should be able to maintain what he or she determines to be an appropriate amount of liability insurance except where otherwise required by state law; and to support the policy that physicians not be required to divulge the exact amount of their professional liability coverage as a condition of hospital medical staff privileges but should be allowed to provide verification that the minimum level of coverage required by the medical staff bylaws is in effect.

SCMA RESOLUTION

As directed by the SCMA House of Delegates, our delegation submitted one resolution (Number 70) in regard to Hospitalization Review Requirements of Self-Insured Companies, pointing out that these companies are not subject to satisfactory standards, and that many of them have adopted review requirements that may be inconsistent with good medical care. Our resolution asked the AMA Board of Trustees to thoroughly investigate current governmental and/or other controls over self-insured companies to determine whether there is adequate uniformity of requirements for initial and continued hospitalization review and report to the House of Delegates on the feasibility of seeking such changes which would enhance the accountability of self-insured companies in the administration of their respective health insurance plans. The Reference Committee made minor changes in the Resolved, which included that the report back to the House be at the 1989 Interim meeting rather than the Annual Meeting. The amended resolution was adopted without dissent. Dr. Robert D. Burnett of Los Altos, California, member of the Council on Medical Service, and its former chairman, told me that he considered this the most important resolution submitted to the House.

OTHER IMPORTANT ITEMS

Actions of the House in regard to many other issues have already been reported in the AM News in the issues of December 16th and December 23/30. You are encouraged to read these two issues carefully.

COMPOSITION OF THE HOUSE

There were 423 delegates seated at this meeting, including one new specialty society, The American Academy of Pain Medicine, which was granted a voting delegate at this meeting. Two applying societies, both in the same field, the American Society for Surgery of the Hand (applying for the second time) and the American Association for Hand Surgery, were turned down by the

6

House, upon recommendation from the Board. There are now 7 7 delegates representing national medical societies, contrasted with 336 delegates representing state medical associations, and 10 Section and Service delegates.

The House considered 66 reports and 129 resolutions, a large volume of business, but not unusually so for an Interim Meeting. Of course the RBRVS, as discussed above, was of such importance as to be very time consuming.

HOUSE TAKES SHORTCUT

In mid-morning on Wednesday, with tight plane schedules staring them in the face, and with important commitments at home, the delegates adopted a very unusual procedure, unprecedented in my memory, to expedite the conclusion of scheduled business. After only the first item of Reference Committee F had been considered, and with two other committee reports to go, a motion was made to put the entire remainder of the committee report on the "Consent Calendar". This meant that for any item to be debated, there would have to be a request to extract it from the calendar. Otherwise the items were simply read by number, and the recommendation of the Reference Committee voted upon. The same procedure was utilized for the last two committee reports. Only a few items were extracted, and debate was limited.

I personally think that allowing this tactic was a mistake. Although all items of business had been debated in the Reference Committees, and then brought back to the House in well-considered written reports from the committees, there may have been some items which needed to be "aired" on the floor, which were passed over with such a hasty procedure. The most important items of business (as judged by those assigning the material to the committees) , had been discussed at length (and at times almost ad nauseam) in the consideration of the earlier committee reports. Despite a two-minute restriction on debate by any one person, there had been a considerable waste of time. The House had been embroiled in time-consuming hassles, points of order, and counted votes, and of course additional time was taken for the speech by Mr. Rule. I believe the House, under firm control by the Speakers which might at times appear restrictive, must discipline itself to more expeditious consideration of early items of business, to pace itself, so as to reserve adequate time for consideration of all of the items of business.

GUIDELINES FOR CAMPAIGN ACTIVITIES

At the Interim Meeting of 1987 the House adopted Resolution 61, designed to reduce campaign expenditures, and among other things restricting room size for campaign events. At Annual 88, this proved to have a number of problems, including fire hazards, overcrowding, etc. The A-88 reference committee recommended that this problem be addressed by the Convention Committee on Rules and Order of Business. I was asked to chair this committee. We

7

considered all of the problems in considerable detail, with extensive input from both of the Speakers. We brought in recommendations which were adopted by the House and which are essentially as follows:

1. That no state, specialty society, or coalition have more than two nights of hospitality, only one of which may be held in a public function room.

2. That no candidate shall have more than two nights of organized campaign activities (e.g. standing in a receiving line or distributing campaign paraphernalia) , only one of which may be held in a public function room.

3. That lavish and extravagant campaign events be eliminated.

4. That the state where the AMA meets should feel no obligation to sponsor a "host state party" and that host states are encouraged to make a charge to cover expenses for these non- campaign social events.

SMOAK ELECTED AMPAC CHAIRMAN

We were all highly gratified that the AMPAC Board, at its meeting on Friday, December 2nd, elected as its Chairman Randy Smoak, a Past President of the SCMA and Chairman of the SOCPAC Board. This is indeed a signal honor and a real accomplishment. We congratulate Randy on his achievement and know that he will do a splendid job during the coming year.

SCMA DELEGATION

The SCMA had a full delegation at the meeting, including Randy Smoak, Don Kilgore and John Hawk, delegates; Gavin Appleby, Charlie Duncan and Walt Roberts, alternate delegates; Tommy Rowland, President; Dan Brake, President-Elect; Chris Hawk,

Chairman of the Board of Trustees; Carol Nichols, Secretary; Roger Gaddy and Steve Hulecki, delegate and alternate delegate to the Young Physicians Section. Bill Mahon and Barbara Whittaker were present from the staff.

Also Bob Schwartz, Greenville, Young Physician delegate of the American Academy of Physical Medicine and Rehabilitation Therapy, attended some of our caucuses. Several students from both MUSC and the University of South Carolina attended the medical

students section. Mark Newberry, Vice-President of Academic

Affairs at MUSC, was also with us for part of the meeting.

Again, your delegation thanks the members of the Association for the privilege of representing you. We also invite you to meet with us, and to attend all South Carolina and Southeastern

Delegation functions at any AMA Annual or Interim Meeting.

8

THE SCHA LOSS CONTROL PROGRAM: REDUCTION IN LIABILITY EXPOSURES FOR HOSPITALS AND PHYSICIANS*

CHERYL KOOB**

JANE BRYANT***

Americans have been characterized as willing to sue anyone for any reason. Hospitals and physi- cians share concern over the increasing number of suits filed on health care related issues.

To reduce liability claims for hospitals and phy- sicians, the South Carolina Hospital Association (SCHA) developed the Loss Control Program in 1975. It is funded by the Joint Underwriting Asso- ciation (JUA) and the Insurance Reserve Fund (IRF) which currently insures 54 hospitals in the state.

In 1988, a representative from the South Caro- lina Medical Association was appointed to the SCHA Loss Control Task Force to ensure that physician perspectives are incorporated into the Loss Control Program.

The initial concept of the program was to re- duce liability exposures in member hospitals. Over the years, hospitals have been surveyed an- nually for risks of professional liability, premises liability exposure, and clinical apparatus liability exposure. The professional liability component is performed by a registered nurse Risk Manage- ment Consultant. The premises liability and clinical apparatus components are performed by a Clinical Engineer.

In the first 11 years of the program, a general survey was conducted of the entire hospital. As high risk areas, such as obstetrics, anesthesia, and emergency room, resulted in a greater proportion of malpractice claims, it was felt “focused” sur- veys would be more beneficial in decreasing lia- bility claims. Concentrating on areas where medical care had the most potential for having liability claims became the concept that is used at the present time.

° From the McNeary Insurance Consulting Services, Inc., and the SCHA Loss Control Task Force.

° Consultant, McNeary Insurance Consulting Services, Inc., PO Box 220926, Charlotte, NC 28222.

° Chairperson, SCHA Loss Control Task Force, and Risk Manager, Greenville Hospital System, 701 Grove Road, Greenville, SC 29605-4295.

The professional liability component consists of medical record reviews (to assess documentation practices), review of policies and procedures, re- view of the physician credentialling system, oc- currence reporting system, and the quality assur- ance and risk management programs. The prem- ises liability component consists of a review of the safety program, review of surveys performed by other agencies and reports, review of the haz- ardous materials program, review of the security program, and a general survey of the physical plant. The clinical apparatus component consists of a review of all clinical apparatus in the area to be surveyed, especially high risk equipment. Also, each year the previous years’ recommendations are monitored for progress.

The risk management consultants use state (i.e., DHEC) and national (i.e., Joint Commission, ACOG, ACEP, ASA, OSH A, EPA, etc.) standards, as well as sound risk management practices, as criteria when surveying a hospital. A written re- port with recommendations is provided each hos- pital and distributed to appropriate personnel after the annual survey. The risk management consultants provide assistance, if requested by the hospital, in correcting deficiencies. Hospitals are requested to respond to the recommendations made by the consultants within 30 days. Written responses are returned to the consultants and fol- low-up is performed if indicated.

Last year, the focus of the annual survey was obstetrics. Recommendations were given to hospi- tals across the state to bring them up to date with state and national standards in this area. This year emergency rooms were targeted because of the high frequency of liability claims in this area. Also, hazardous materials management programs were reviewed because of risk management con- cerns about hospital waste.

The most frequent recommendations in these areas have been in regard to documentation prac- tices in the emergency room and ways to improve or enhance hazardous materials management pro-

January 1989

25

SCHA LOSS CONTROL PROGRAM

gram$ to comply with federal and state regula- tions.

The risk management consultants and SCHA continually update hospitals, through memoran- dums, newsletters, and educational programs, on risk management issues and how to reduce lia- bility exposures for hospitals and their medical staffs. SCMA and SCHA are in the process of developing a joint educational program which will address the Loss Control survey findings re- lated to emergency rooms. Collaboration between hospitals and physicians is essential in ensuring that liability is reduced.

The Loss Control Program will continue in its effort to reduce liability exposures thereby miti- gating or reducing liability claims in the state of South Carolina. As other areas become identified as high risk, emphasis will be placed on control- ling risk in those areas. The very essence of the Loss Control Program is to assure that every pa- tient who enters the health care system is provided quality health care. As hospitals and physicians identify their risks and implement practices which reduce their liability, they can work to- gether more effectively in ensuring that high quality patient care is provided. □

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The Journal of the South Carolina Medical Association

NEWSLETTER

JANUARY 1989

MEDICARE UPDATE

Blue Cross and Blue Shield of SC held a series of workshops in December in order to explain the 1989 Medicare program. It was explained at the workshops that you should write Professional Reimbursement (BC/BS of SC, 1-20 and Alpine Road, Columbia, SC 29219) , if you wish to obtain a copy of the clinical laboratory fee schedule. It was also pointed out that there was a December Medicare Advisory planned which would explain the HCFA changes in Holter monitoring billing made since the October Advisory.

A special five percent bonus will be reimbursed quarterly to physicians who provide services in Classes I and II Health Manpower Shortage Areas (HMSAs) . The correct HMSA code should be included on each Medicare claim. BC/BS also instructs you to record the code for Classes III and IV HMSAs.

The following counties are entirely HMSA and the correct HMSA class is given after the county name. You should put the correct HMSA code on your claim:

ALLENDALE 3

BARNWELL 3

CALHOUN 1

CLARENDON 2

DILLON 4

FAIRFIELD 3

HAMPTON 4

JASPER 4

LEE 3

MCCORMICK 3

MARLBORO 4

SALUDA 3

UNION 2

WILLIAMSBURG 2

Parts of the following counties are designated as a HMSA:

( ) ABBEVILLE

( ) BAMBERG

( ) BEAUFORT

( ) CHESTER

( ) CHESTERFIELD

( ) COLLETON

( ) GEORGETOWN

( ) HORRY

( ) KERSHAW

( ) MARION

( ) SUMTER

( ) DARLINGTON

( ) GREENWOOD ( ) LANCASTER ( ) LAURENS ( ) ORANGEBURG

If you practice in one of these counties. Blue Cross & Blue Shield of SC will send you a map which shows which areas are designated as a HMSA and the correct code to use for your claims.

If you practice in a "split" county, you need to identify on the list each county where you practice and send it to: Attention:

Office of the Director, Medicare Service Center, Suite 1300, Fontaine Business Center, 300 Arbor Lake Drive. Columbia, SC 29223 .

MEDICAID UPDATE

AIDS Waiver Program

As of August 1, 1988, the State Health & Human Services Finance Commission initiated an AIDS Waiver Program approved by HCFA. This waiver will provide home and community-based services to eligible Medicaid recipients diagnosed with acquired immune deficiency syndrome and AIDS related complex.

Services which are covered as part of the waiver include: private duty nursing, day care services, personal care aide services and home delivered meals consisting of modified and therapeutic-diets. Services for counseling, foster care and hospice are also covered, as are traditional Medicaid Services (i.e., drugs, physicians, hospital).

Home and community-based services for recipients diagnosed with AIDS will offer the individual and the SC Medicaid program alternatives to institutional care.

South Carolina is one of five states in the country to receive funding for the AIDS Waiver Program. Specific policy guidelines are available from SCHHSFC.

Obstetric Care - Fee Updates

Effective January 1, 1989, fees for some charges of Obstetric care increased. The reimbursement for those procedure codes includes :

CPT Code

Fee Increase fas of 1/1/89)

59410-Vaginal Delivery 59400-Cesarean Section 59420-Antepartum care only 59430-Postpartum care only S1500-Initial OB exam

Emergency Room Visit Updates

$100.00 $100.00 $ 7.00

$ 7.00

$ 50.00

Effective January 1, 1989, Medicaid will follow Medicare's updated policy for use of the unusual or special services codes listed in the "Special Services and Reports" section of the CPT-4 coding manual.

Providers should submit charges for their normal services under the procedure code for the basic procedure performed, and if any

2

unusual service is performed, submit charges with one of the

special service procedure codes (99050 - 99065) .

In addition, non-hospital based physicians should begin using the 90500 - 90580 series of codes for ER visits, adding a 26 modifier

to the appropriate code. If the ER visit was after regular

office hours, the physician may also submit a charge for

procedure code 99064. This would be an additional charge to cover the special service of going to the hospital after normal working hours.

EXPANDED " PERSONAL CARE” PROGRAM

^Earlier this month the SCMA held a press conference to announce implementation of our newly revised "Personal Care" program. By now you should have received a mailing regarding the SCMA Personal Care program designed to assist non-participating physicians in better serving their Medicare patients. At the direction of the SCMA House of Delegates in 1988, the program has been revised to establish an eligibility certification protocol. Under the expanded program, local aging service providers will provide eligibility cards to qualifying Medicare patients (up to 150% of poverty - $8,250 for a one-person family or $11,100 for a two-person family) to be presented to the "Personal Care" physician. The physician retains the right to accept assignment on an individual basis regardless of whether or not the patient has been issued an eligibility card; however, the SCMA strongly encourages "Personal Care" physicians to accept assignment on these eligible patients.

We urge that you carefully study the information furnished in the mailing. Non-participating physicians who did not enroll earlier are encouraged to do so. Also, physicians who are changing their par status to non-par this year should seriously consider enrolling.

Ilf you have questions or need additional information, please call Barbara Whittaker or Melanie McLendon at SCMA Headquarters.

PRO UPDATE —

On December 1, HCFA contracted with Medical Review of North Carolina (MRNC) for Medicare review in SC. Actual Medicare review is expected to begin in February or March.

At the present time, MRNC is working with SCMA and all SC specialty societies in reviewing proposed licensing criteria and establishing a committee responsible for review in SC. MRNC has hired Blake Williams, formerly employed by SCMA and BC/BS of SC, to direct their review in SC.

Medical Review of NC, Inc., will conduct seminars for physicians' office staffs (especially those responsible for preadmission review) from 10:00 a.m. to noon as follows:

3

Wed. , Feb. 1 Thurs . , Feb . 2 Mon. , Feb. 6 Wed. , Feb. 8

Greenville Hilton, 1-385 at Heywood Rd. Columbia Marriott Holiday Inn at 1-95, Florence Mills House, Charleston

Your office will receive a letter from MRNC regarding these workshops. Workshops for hospital personnel will be conducted at these same locations in the afternoon.

NEWS FROM THE STATE HOUSE

Following are new chairmen of committees of the South Carolina House of Representatives: Donna Moss, Gaffney, - Medical

Affairs Committee, and Robert Brown, Florence - Labor, Commerce & Industry Committee. Sarah Manly, Greenville, has been elected to the House of Representatives to fill the unexpired term of Chick Rice (deceased) .

Chairmen of Senate committees remain virtually unchanged for 1989.

DOCTOR OF THE DAY

Volunteers are still needed for the Doctor of the Day for the 1989 session of the SC General Assembly. If you can serve as Doctor of the Day on a Tuesday, Wednesday or Thursday during March, April or May, please call Jan Maynard at SCMA Headquarters to schedule a date.

AIDS UPDATE

Additional Federal funding has been received by DHEC for the Retrovir Program. However, the amount of funding was only enough to allow DHEC to maintain its current case load plus add the applications already on hand. Therefore, DHEC is unable to accept any further applications. DHEC regrets this decision, but continues to suggest that physicians refer appropriate applicants to their local Department of Social Services for coverage under the Medicaid Waiver Program.

OCCUPATIONAL EXPOSURE TO BLOOD-BORNE DISEASES

The Occupational Safety and Health Division of the SC Department of Labor has issued an information memorandum, #88-x-77, which addresses enforcement procedures for occupational exposure to HBV, HIV and other blood-borne infectious agents in health care facilities .

The memorandum provides procedures and guidelines to follow when conducting inspections and issuing citations for health care workers potentially exposed to these infectious agents. Also included in the memorandum is the June 1988 update from the Centers for Disease Control regarding universal precautions for prevention of blood-borne pathogens in health-care settings and

4

checklist evaluations of employer training and education programs .

For further information, call Melanie McLendon or Kim Fox at SCMA Headquarters. To obtain a copy of the memorandum, contact the Office of Public Information of the SC Department of Labor at 734-9612 or 734-9661.

RED CROSS TRANSPLANT PROGRAM

Since 1985, the Southeastern Transplantation Services Division of the American Red Cross has been responsible for collecting human tissue used in some 5,000 transplants. Although less known than more publicized heart, lung and kidney transplants, bone grafts are second only to blood as the most transplanted human tissue. Nearly 200,000 patients require bone allografts each year in the U.S.

Bone transplantation is used to treat victims of osteosarcoma, scoliosis, disfiguring injuries, congential deformities and orthodontic diseases. Bones and tissue can be donated by males age 15-70 and females age 15-65, or on an individual basis for other age groups.

Bones and tissue can be extracted from a donor whose heartbeat and respiration have ceased, provided the surgery takes place within 24 hours of death and the body is refrigerated. One donor can benefit as many as 50 recipients.

To learn more about donation and transplantation, call the American Red Cross at 1-800-922-5986 or 251-6153 (statewide),

1989 CPT— 4 CODE BOOK AVAILABLE

Remember to purchase your 1989 Physician's Current Procedural Terminology (CPT-4) book. This book, revised and published on an annual basis, is a listing of descriptive terms and identifying codes for reporting medical services and procedures. Since medical nomenclature and procedural coding is a dynamically changing field, new procedures are developed and old procedures become obsolete, it is a good idea to keep a current book on hand.

To purchase your CPT-4 book, write to: Book and Pamphlet Fulfillment: OP-341/8 , American Medical Association. PO Box 10946, Chicago, IL 60610-0946. VISA and MasterCard orders may be placed by calling 1-800-621-8335. Copies are $25.60 for AMA members and $32.00 for non-members.

AMA/GM EDUCATIONAL EFFORT: SAFETY BELTS

Available on loan from the SCMA Library is the latest AMA/General Motors video project kit which is part of the continuing educational project promoting wider use of safety

5

belts. The kit contains a two-part videocassette and a teacher's guide. The two films on the videocassette were prepared for young students of specific ages. "Safety Belts: For Dummies or People" is designed for youngsters in the six-to-eight-year range and encourages them to use seat belts. "The Game of Life" is geared for students in junior high and demonstrates the effects of alcohol consumption on driving abilities. To obtain the kit on loan, contact Melanie McLendon or Kim Fox at SCMA.

AMA TELECONFERENCE VIDEOTAPES

The AMA announces the availability of two 90-minute videotapes containing full proceedings of HSN teleconferences on "Beyond Tort Reform: New Developments in Professional Liability" and "Health Legislation 1988: Update and a Look Toward 1989." Copies may be purchased for $7 5 each or you may request copies on loan for a seven-day period for a $25 shipping and handling fee. To place orders for either purchases or loan use, call Irene Foster. AMA Division of Television. Radio and Film Services. (312) 645-5102.

CONFERENCES TO BE HELD

The second annual Palmetto State Medical Student Conference will be held January 20-21, 1989 in Charleston. Registration is $15.00 per person. For further information, contact the MUSC Student Activities Office at (803) 792-2693.

A Joint Commission on Accreditation of Healthcare Organizations program to help hospitals with 1989 standards will be held February 16-17 at the Radisson Hotel in Columbia. This pre- survey tool will assist hospital personnel in interpreting and applying standards in the 1989 edition of the Accreditation Manual for Hospitals. For further information, contact Doris Clevenger, SCHA. 796-3080.

CAPSULES

Vasa W. Cate, M. D. , has joined the staff of Blue Cross and Blue Shield of South Carolina, Medicare Division, as part-time medical director. Dr. Cate will continue with his private practice in Lexington County.

Milton D. Sarlin, M. D. , was chosen the 1988 Medical Executive of the Year by the Medical Group Management Association.

Anne-Marie C. Leventis, M. D. , Family Practice resident at the Anderson Family Practice Center, is one of 25 residents in the country to receive the AMA/Burroughs Wellcome Leadership Award. She was cited for her volunteer work with a local "Doctors Ought to Care" group to counsel schoolchildren to shun drugs and alcohol and for assisting a teen pregnancy prevention council.

6

THE SOUTH CAROLINA DENTAL ASSOCIATION AND THE S.C. MEDICAL MALPRACTICE JUA

JAMES H. GAINES, D.M.D.*

The Legislature passed enabling legislation to allow the creation of the South Carolina Medical Malpractice Joint Underwriting Association (JUA) in 1975. At that time dentists in South Carolina were not nearly as concerned about this subject as were the physicians.

By and large, dentists had not then generally been discovered as targets for significant malprac- tice actions. As a result, we did not draw the immediate concern of the insurance industry that befell physicians and surgeons.

We are told that insurance companies back then generally had us lumped under something called “miscellaneous professional liability,” wherein a number of so-called low risk professions were put together for experience and rating pur- poses. Apparently this had been customary for a number of years. As a result, the insurance indus- try really didn’t know what the specific dental risk factors were, and consequently rates were low and availability was no problem.

The American Dental Association (ADA) was prophetically aware of the potentiality of coming problems in the malpractice area. Nineteen years ago they set a program of protection into motion with CHUBB as the carrier, which became known as the ADA Professional Protector Plan (P.P.P.).

This “package” policy combined all the areas of coverage normally needed in a dental office so far as property and liability protection was con- cerned. It automatically included professional lia- bility (as we preferred to call it) for at least $1,000.00.

As a result of this foresight, S.C.D. A. co-endors- ing The Professional Protector Plan provided our members with the availability of a first-class oc- currence professional liability policy at reasonable rates.

By 1978, except for the Association Plan, The South Carolina dental malpractice marketplace had largely dried up. Out of concern for our

° 870 Cleveland St., No. 2-C, Greenville, SC 29601.

fellow dentists who were non-members and the lack of a competitive market, we appealed to The Insurance Commission that an emergency did, in fact, exist. Subsequently members of the dental profession became eligible for JUA coverage and Dr. George P. Hoffman of Greenville became dentistry’s first JUA Board Member.

Most dentists are members of The South Caro- lina Dental Association. Since our sponsored cov- erage stayed on an occurrence basis and the rates remained reasonable, only a minimal number of South Carolina dentists became insured with the JUA. S.C.D. A. had a good program, well-admin- istered, providing many needed facets of cover- age, so there was no reason to leave it.

A few years ago storm clouds appeared and matters began to worsen. The insurance carrier (CHUBB) we had used for years decided for their own reasons they no longer would provide cover- age. A replacement carrier (CNA) was obtained with all hopes that it would work out.

After several uncertain years, the shoe fell. The new carrier unilaterally announced that coverage would only be provided on a claims-made basis and difficulties in continued negotiations as part- ners were appearing. For these reasons and others, the ADA withdrew endorsement leaving it to the state associations to determine their best course of action since the Professional Protector Plan (P.P.P.) would still be marketed.

The South Carolina Dental Association con- tinued to support the P.P.P. until the claims-made policy form was effectively filed in South Caro- lina. We then withdrew our endorsement.

We have always felt the occurrence form pro- vides the greatest measure of protection for our members for their premium dollar and commend the JUA and PCF for remaining on that preferred form over the years. With it there are no new questions of coverage, additional premiums or other contingencies down the road. Not so with the claims-made policy.

The particular claims-made policy we were

January 1989

33

THE DENTAL ASSOCIATION AND THE JUA

offered was, perhaps, as good as any on the mar- ket. There are, however, some built-in problems peculiar to such coverage. Great care is required at application time (annually) to adequately in- form the would-be carrier of any possibility of any known circumstances which may lead to claim. Failure to adequately inform the carrier (to their satisfaction) of any such happening would most likely lead them to not providing coverage for a claim which had its origins prior to the policy date. With an occurrence policy there are no such problems since the prior occurrence policy would defend against the claim.

Here in South Carolina we dentists are fortu- nate to have the availability of a reasonably priced occurrence form professional liability insurance policy through the JUA as an option in our insur- ance planning. It is a privilege not universally enjoyed.

LOSS PREVENTION

The old Professional Protector Plan provided loss prevention seminars, workshops and publica-

tions. They worked with sponsoring state associa- tions in these areas and through professional assessment committees of those state associations.

The South Carolina Dental Association has an on-going Dental Risk Management Committee. We publish a Risk Management periodical (sim- ilar to the one published for physicians by the S.C.M.A.) and utilize programs prepared by the American Dental Association, such as Risk Pre- vention Manuals, a series of video tapes which are regularly updated, and seminar-type programs available to both local and state dental associa- tions. The Oral Hygienists have developed on- going programs for their specialty inasmuch as their requirements differ from other dentists.

The JUA is now the principal provider of pro- fessional liability insurance for South Carolina dentists. We will work closely with the JUA in helping to continue to experience a low level of claims by providing a comprehensive dental risk management program as is being done with the South Carolina Medical Association and the South Carolina Hospital Association. □

Cheiron is the practice management system that combines the latest advances in high technology with a commitment to 'W 100% customer satisfaction.

We take pride in our ability to adapt /-A ^ '4 /a 'J each sYstem t0 W the particular

Wm w jff needs of the individual practice.

AVAILABLE FALL OF 1988

Call for more information.

Medical Software Management, Inc.

1157 Forsyth St.

Suite 110-B Macon, Georgia 31201 912-745-0040 1-800-521-8476

34

The Journal of the South Carolina Medical Association

Now America’s oldest professional

liability insurer has come to South Carolina.

The newest professional liability insurer in South Carolina is the oldest in the nation. The Medical Protective Company pioneered the concept of professional pro- tection before the turn of the century and has been serving doctors exclusively ever since. Through good times and bad.

With the current liability crisis escalating, you need to take a close look at your coverage and the company that stands behind it. Then take a close look at us. You’ll see we carry the highest

rating from A.M. Best, the firm that tracks the financial stability of insurance companies nation- wide. Beyond that, you’ll find complete protection at premium rates that are likely lower than you’re currently paying. Plus the personal attention and claims prevention assistance you deserve.

Contact Stu Mitchelson today at 704/541-8020. He’s the oldest company’s representative in its newest state. And he’s here to serve you.

ilia

Stuart Mitchelson, P.O. Box 13489 Charlotte, North Carolina 28211, (704) 541-8020

MALPRACTICE PROPHYLAXIS

JOHN R. HUNT, M.D.*

“I still can’t believe that my long-time doctor was sued for malpractice and the fact that he lost is even harder to comprehend,” confided a mu- tual patient and friend to me recently. As we discussed our mutual acquaintance, my friend was genuinely surprised to learn that nationwide, malpractice suits are on the rise as seven out of ten doctors have been or are being sued. While our experience in South Carolina is somewhat better than the national experience, malpractice actions are affecting you or me or our dedicated, compe- tent, devoted colleagues with striking regularity. Certainly most physicians today realize the litigious nature of the society in which we live and practice and have altered habits or taken precau- tions which they feel will be helpful in avoiding the circumstances which might lead to a malprac- tice suit. Yet it seems that the “Malpractice Crisis” continues as some doctors aren’t able to either act responsibly or fail to take adequate measures to protect themselves. Interestingly enough, about one-half of physicians sued have been the target of a previous liability claim. Whereas nationally, 70 percent of all malpractice claims were felt to be without merit and were closed without any pay- ment, 30 percent of the cases were felt to have grounds for suit. Could these cases be prevented by “Malpractice Prophylaxis?” Obviously, there are things that all doctors can and should do to prevent an action from happening in the first place. The purpose of this paper is to review seven areas which are frequent liability pitfalls.

1. Communication: We must talk with our patients and their families. We are criticized for taking on too much work, for being on too many committees, for seeing too many patients in too little time. As the proverb recounts, “Pay me now or pay me later,” we must give our patients enough time now or risk the prospect of devoting a tremendous amount of time and effort and anxiety defending ourselves from a legal action. If a physician has taken the time to talk and listen to the patient and the family, he will almost never be

° 703 N. Fant St., Anderson, SC 29621.

36

sued, no matter what the outcome. He is thought of almost as a member of the family.

Non-verbal communication is just as important as what is said. We must learn to avoid the “Rolex Bedside Manner.” Our patients need to see us as one of them. They need to feel that we are the “same kind of folks” as they are. If they feel that we are talking down to them, they will resent it. The resentment is just the fuel which is needed to provoke some patients or families to seek legal counsel if things don’t go as expected.

2. Referral of Hostile Patients: We must learn to refer patients we don’t feel good about. Within the first few minutes of interacting with a patient, most of us have very definite feelings about whether we like that individual and whether we will get along well. This requires that both patient and physician develop a trusting relationship with each other. If the “vibrations ” which we get are bad, we need to realize that the patient is probably getting a bad feeling about us also. We need to seriously consider referral of that case. We have no obligation, except in an emergency situation, to take a case about which we have uncomfortable feelings. Besides the fact that most of us don’t need additional patients, we certainly don’t need the hostile patient who is likely to cause us much grief down the road. Even though we are not getting along with a given patient, we must realize that the physician down the street may get along famously with that individual. Rather than just asking someone to “get out of my office,” it is much more honest to sit down and explain to a hostile patient that “we don’t communicate very well, and I don’t think I can give you the kind of service that I know you want and that your medi- cal condition deserves. I’m going to refer you somewhere else.”

Likewise, we should pay attention to our office nurse or receptionist. If they have a real person- ality conflict with a given patient if may be best to refer that patient.

3. Informed Consent: We need “informed consent” for anything we do that invades a pa- tient’s body. We should be in line with what others

The Journal of the South Carolina Medical Association

MALPRACTICE PROPHYLAXIS

in our area in the same speciality are doing in terms of written consents. However, for any invas- ive procedure, we, the physicians, must explain the situation such that an average “reasonable man” will understand the options he has, the probable outcomes and the potential complica- tions of any given choice which he makes. He, the patient, should make the choice to proceed with a given treatment plan. Most attorneys presently recommend that a formal consent be obtained for anything that is not “routine.” An explanation which has been suggested is that “the courts are responsible for making us have to get this formal consent.” Presently in South Carolina, it is not clear just how far one should go in obtaining a formal consent for any non-routine (IV’s, Subcla- vian lines, Blood Transfusions, etc.) procedure. Many physicians are concerned that too legalistic an approach may sensitize patients legally and make them more likely to think in terms of a legal solution to any perceived problems.

Many questions exist about what constitutes adequate informed consent. The patient and his physician decide what is adequate informed con- sent most of the time. When problems arise, how- ever, the court decides. The court’s job is greatly simplified if there is a document which spells out the consent. How far we in South Carolina should go in providing evidence of adequate informed consent for a possible future court action is not clear at present. Surgeons in Florida are presently being advised to obtain videotaped consents or at least audiotaped consents for most procedures. I do not feel this is necessary in my practice at present, and feel that in most cases it would be detrimental to the relationship of trust which I want to foster with my patients. In most cases, our hospitals prescribe a standard consent, but this does not relieve us individually of discussing pro- cedures and treatment plans with patients. One good suggestion is to draw the patient a picture on the back of the consent form. This then becomes a part of the permanent record.

4. Speak English, not Medical Jargon: Most patients are afraid as they sit in our office and hear us talk to them. If we use medical terms they will not understand, they won’t say they don’t under- stand then, but years later on the witness stand they will relate that they did not understand. It is our duty to take all of our medical jargon and translate it into plain English. The average educa-

tional level of a patient, and a juror, in South Carolina is approximately the eighth grade. Our discussion should be in terms that the average eighth grader can understand. At the same time we should be very careful to avoid a condescend- ing or “talking down” attitude.

5. Honesty is the Best Policy: If something bad happens, admit it! Tell the patient and the family the truth — exactly what happened and what you are going to do about it. Spend some time commu- ning with the family. Cry with the family or the patient if that is appropriate. Go to the funeral. Go to the home. Be involved just like a member of the family. Even if the patient has suffered damage as a result of something you have done, in 50% of the cases, you will not be sued if you are totally up front about what happened.

On the other hand, if you don’t talk with the patient/family, if you ignore their anxiety about a bad outcome, if you try to sweep it under the rug, or try to fix the chart to show that you didn’t do anything wrong, there is a high probability that you will be sued.

6. Shoppers: One of the significant items of the History of any new patient relates to the previous physicians. If you get the impression that this patient has left his prior physician under bad circumstances, be careful. Call and discuss the case with the prior physician. If this patient could not get along with your colleague, chances are that he will not be able to get along very well with you.

Another item of the History which you need to know and should not be afraid to ask about relates to the medicolegal history. You have every right to know if this patient has been a plaintiff in a lawsuit before. You should not ask “Have you ever sued a doctor before?” But rather ask whether this patient has been involved in litigation so that you might get a better idea of the total complex of the medical history. If the patient does have a history of litigation, and you don’t want to become in- volved, you have every right to decline to accept that patient.

7. Records: All attorneys agree that it is ex- tremely detrimental to your case if you don’t have legible office notes. In today’s environment, it is much more preferable to have typed office notes. With the availability of small portable pocket dictating machines, there is very little reason for

January 1989

37

MALPRACTICE PROPHYLAXIS

handwritten office notes. One can generally di- cate a better note more quickly than trying to write it by hand. I believe that the office note can usually be dictated in the presence of the patient. If the patient has any disagreement with anything that is said, he has an opportunity to say so. I also suspect that patients feel better knowing what is being said about them. A dictated note also pro- vides an immediate report to send back to the referring physician or other involved physicians in appropriate cases.

AREAS OF FREQUENT LIABILITY PITFALLS

1. Communication

2. Hostile Patients

3. Informed Consent

4. Medical Jargon

5. Ignoring/Denying Mistakes

6. Doctor Shoppers

7. Recordkeeping

Malpractice suits and “bad doctors” are not synonymous. The incompetent physician exists, but all major studies have found that these physi- cians represent only a minor element in the over- all picture of medical malpractice. Dedicated, competent, well-trained South Carolina physi- cians, who have lost rapport with their patients or patients’ families, represent the bulk of our local cases. Many of us can profit by using some of the suggestions we have mentioned to prophylax our own practice against the specter of a malpractice suit. □

MALPRACTICE PROPHYLAXIS RESOURCES

1. Mr. Richard Jones, Malpractice Defense Attorney; Gaines- ville, Fla.; Speech given, May, 1988 at the SCMA annual meeting in Charleston, S. C. Tape available from SCMA.

2. Malpractice: A Guide to Avoidance and Treatment, by Kenneth Brooten and Stuart Chapman. 1987. Grume.

3. Malpractice: A Guide to the Legal Rights of Doctors and Patients, by Donald J. Flaster. 1983. Scribner.

4. Malpractice: A Trial Lawyer's Advice for Physicians, by Walter G. Alton, Jr. 1977. Little.

5. Malpractice Depositions: Avoiding the Traps, by Ray- mond M. Fish and Melvin E. Ehrhardt. 1987. Medical Economics Books.

6. “Professional Liability in the 80s.” Chicago: American Medical Association Special Task Force on Professional Liability and Insurance, 1984.

7. “Response of the American Medical Association to the Association of Trial Lawyers of America Statements Re- garding the Professional Liability Crisis.” Chicago: Ameri- can Medical Association, Special Task Force of Professional Liability and Insurance, August, 1985.

38

The Journal of the South Carolina Medical Association

SO YOU ARE A DEFENDANT IN A MALPRACTICE ACTION

DONALD V. RICHARDSON, ESQUIRE*

Like rain, there seems to be a time in a physi- cian’s life when a medical malpractice action falls. This article is about what you may expect from your defense counsel in your defense.

As soon as you or your staff or family receive the suit papers (Summons and Complaint) in- stituting the action, you should note on the face of the Complaint the date and time they were re- ceived, and initial this notation. When the suit papers are sent to your insurance carrier, be sure that you also transmit everything you received. In a death case, a case involving a child, or a married couple, two separate suits are usually served at the same time. In a death case, you will not be able to tell the wrongful death action from the survival action unless it states on the face of the Complaint which action it is. If it does not so state, you can only determine the difference by the civil action number, which will be different on each Com- plaint. In the case of a child, there will be an action in the name of the parents and an action in the name of the child. In the case of the married couple, there will be an action in the name of the husband and an action in the name of the wife. Also, be sure that you were not served with Inter- rogatories or Requests for Production. It is a good practice to send everything you receive to your insurance company. Accordingly, if you receive anything other than the suit papers, you must also notify your insurance company of this fact. The additional documents should also be dated and initialed.

Upon the assignment of the defense attorney to represent your interests, a meeting should be es- tablished with him as soon as possible. At the meeting with the defense counsel, take all medical records you have in your possession concerning the patient. Be sure that your attorney has a complete copy of the original records, and that they are legible. If your attorney cannot read your

° Richardson, Plowden, Grier and Howser, 1600 Marion St., P.O. Drawer 7788, Columbia, SC 29202.

records, by all means have the records typed out in legible form for his use. This initial meeting should be for the purpose of introducing the medi- cal records to your attorney, reviewing those rec- ords with your attorney, and ascertaining what course of action you are to follow in the defense of the litigation.

It is imperative that medical research be con- ducted as soon as possible. The defense attorney and the physician should collaborate as to how this medical research should be best accomplished. The research will determine not only what your best defense is, but will also assist you in preparing for the attack that will surely be based upon the medical literature. Your attorney should be given copies of any literature search you perform. The literature search can also be used in meeting with treating physicians to refresh their memory on current medical practices.

Your attorney will secure by Subpoena all other medical records from treating physicians and hos- pitals. These records are immediately available by a Rule 45(b) Subpoena, which is simply prepared by the attorney and served on the particular in- stitution or physician. These records should be obtained very quickly, and you should be fur- nished with a copy for your immediate review.

After you have received all of the medical records of the attending physicians and hospitals, and have secured all of your office records, they should be reviewed. After you have reviewed these records, you and your defense attorney should determine the proper course of action. Hopefully, by the time you have reviewed the records you will also have the current literature and will be in a position to consider the services of an expert witness.

At some point in time, you will be advised that the Plaintiff’s attorney desires to take your deposi- tion. Hopefully, your attorney has already taken the depositions of the Plaintiffs and any other lay witnesses who relate to the history of the patient and to gather the facts and circumstances sur-

January 1989

39

A DEFENDANT IN A MALPRACTICE ACTION

rounding the alleged malpractice. It is imperative that the Plaintiffs be deposed promptly in order that' they cannot back-fill their history after your deposition had been taken. If you admit during your deposition that you would have done certain things if the patient had given a particular history, you can rest assured that this particular history will be provided by the Plaintiffs if they are deposed after you. Do not expect the truth as you perceive it to be to come from the patient. It would be startling if the patient admitted to the history as you have noted it in your records.

Once you are notified that you are to be de- posed, you should meet with your attorney, who should explain to you the purpose of the deposi- tion and the use of the deposition at trial by the opposing counsel. You should be fully and com- pletely prepared for your deposition, just as if you were going to trial. You should understand the records completely, including everything from the nurse’s notes to the laboratory data. You should never attempt to practice law, but should practice medicine at the time of your deposition. You should answer any questions fully and com- pletely in a medical context. If you have an opin- ion concerning causation or your treatment, do not hesitate to give it. In short, when your deposi- tion is taken, you should be the very best of friends with your attorney. If your attorney does not give you this service, you should demand it. In all probability, your case will be won or lost at the time your deposition is taken. It is rare that a physician can overcome at the time of trial his unpreparedness at his deposition.

Once your deposition is taken, you then serve as a consultant for your attorney. You should know what is going on in your litigation at all times. You should help your attorney digest any medical records that may be discovered, interpret any medical literature that may be obtained, and assist him in responding to new facts as revealed by the attending physicians. Hopefully, by the time you are deposed, your attorney has already started discussing the medical records of the treating physicians with you so that you may be fully informed of the significance of these records and the opinions contained therein.

When your attorney receives Interrogatories, you should assist your attorney in drafting re- sponses to them. A review by you of the answers proposed by your attorney will be very helpful in maintaining a good medical perspective. Please

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take the time to read any of the attorney’s pro- posed Answers to Interrogatories and help him draft the correct medical response. At all times you should strive to be medically correct in any response that you give to the court.

You will not have a confrontation with oppos- ing counsel again until the time of trial. Generally, there are only two times the physician will be directly confronted by opposing counsel in any adversarial proceedings. The first is when your deposition is taken by Plaintiff’s counsel, and the second is when the case is tried in court.

If you learn that other attending physicians are to be deposed by the Plaintiff ’s attorney, be sure to discuss this with your attorney to be sure that he has already discussed the case with the attending physician and has ascertained what the attending physician is going to testify to in advance. Every now and then, an attending physician’s opinion will not be medically correct. It is necessary to secure the medical literature to educate that phy- sician so that he is correct in his medical diagnosis and the causation theories in this case.

You should always look at the damage aspect of the case insofar as it is related to charges against you. Do not hesitate to check the amount of the hospital bills, bills from attending physicians, and any loss of function or disabilities claimed by the patient. For example, if a hospital bill is submit- ted, how is that bill increased over the normal amount for the original disease process? A physi- cian is not responsible for the normal conse- quences of the disease process. He is only responsi- ble for that act of his which prolonged or in- creased the expenses of the patient. If the patient has lost her renal function, not through an act of malpractice, but through a disease process, that is material and should be exploited. Do not assume that all damages or disabilities or permanent im- pairments are a result of malpractice. The act of malpractice must directly or proximately cause the harm or the monetary loss to the patient. In essence, did the act of malpractice alleged against the physician cause the result, damage, or impair- ment of the patient? If it is attributable to the disease process, the physician is not responsible.

Defense is a team effort and as a key member of this team, you should be aware of all the defense efforts.

In summary, you should meet with your at- torney as soon as the action is instituted and prior to your deposition to be sure that he understands

The Journal of the South Carolina Medical Association

A DEFENDANT IN A MALPRACTICE ACTION

your medical position. You should assist your at- torney in securing the medical records of any hospital or attending physician and suggest cer- tain records that may be beneficial to the defense. If you do not know the answer, then secure the records. You do not assume, you do not guess, you must know the facts. Assist your attorney in the medical research and explain to him the results of that research. Your attorney can use the medical research with the other attending physicians to benefit your case and to fortify the opinions of those attending physicians. Make every effort to prevent an attending physician to testify in court and have no opinion which may benefit you in the defense of the case. Most attending physicians would give an opinion as to the standard of care and causation if they think that they are medically accurate in doing so. Accordingly, it is the func- tion of your attorney, with your assistance, to be sure that the attending physician correctly knows the medical standards and the appropriate medi- cal treatment. This will eliminate off-the-cuff opinions or prejudices, which could be very damaging indeed. You must always watch for biases that creep in among cross-specialties. A specialist in infectious disease will immediately think about infection and the appropriate treat- ment to combat those infectious processes. How- ever, a cardiologist will immediately choose to

rule out that the same patient has any inherent heart disease. Each specialty carries its own bias. You must be vigilant that a bias does not become a standard for the non-specialist.

If the Plaintiff’s expert witness is deposed, most defense counsels will offer you the opportunity to be present at the time that deposition is taken. Do not hesitate to afford yourself of this opportunity. It will give you a first hand look at your adversary, and you may be able to assist your attorney in cross-examining the witness. If you have to travel out-of-state to depose the Plaintiff’s expert wit- ness, usually the carrier will pay your expenses in making that trip. Your defense counsel will wel- come your cooperation.

You will find that by working closely with your defense counsel, you will become an aggressor in the defense of the action. Once you have moved from a Defendant to an aggressor, you have picked the high ground and have taken the ini- tiative away from the Plaintiff. You pick when the case is to be tried if possible and be ready. An aggressive defense is a very good offense and you should be successful.

A team consisting of you, your insurance com- pany and your defense attorney are the essential elements of a good defense. Close and continuing support by all members of a defense team are necessary for a winnable case. □

January 1989

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THE ARMY RESERVE OFFERS NEW FINANCIAL INCENTIVES FOR RESIDENTS.

If you are a resident in Anesthesiology or Surgery*, the Army Reserve has a new and exciting opportunity for you. The new Specialized Training Assistance Program will provide you with financial incentives while you’re training in one of these specialties.

Here’s how the program can work for you. If you qualify, you may be selected to participate in the Specialized Training Program. You’ll serve in a local Army Reserve medical unit with flexible schedu- ling so it won’t interfere with your residency

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Call or write your US Army Medical Department Reserve Personnel Counselor:

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COLUMBIA, SC 29201-2430 (803) 765-5696 COLLECT

* General, Orthopaedic, Neuro, Colon/Rectal, Cardio/Thoracic, Pediatric, Peripheral/Vascular, or Plastic Surgery.

ARMY RESERVE MEDICINE. BE ALL YOU CAN BE

THE DEPOSITION— THE DOCTOR, THE LAWYER

WILLIAM F. FAIREY, M.D., LL.B.*

The deposition is the single most significant event which occurs in a malpractice suit. It is the first salvo fired by the plaintiff. The deposition sets the tenor for the entire case, it provides the framework upon which future decisions are made, e.g., the need for additional witnesses, the tactics of the case, and ultimately provides the basis for settlement versus trial. Although the de- position occurs early in the proceedings, it is often a "fait accompli," inasmuch as conclusions and statements are often irretrievable and may not be altered without damage to the credibility of the witness.

It is more important to be thoroughly prepared to give a deposition than to give testimony in an actual trial because the deposition is the "condi- tion precedent” upon which the trial testimony is based; such testimony is substantially and at times exclusively dependent upon the deposition. The comprehensive preparation is vital whether we are the defendant or whether we are a fact or expert witness for the defendant. If we, as physi- cians, want to help resolve the malpractice crisis, we may not be in a position to cast a vote for tort reform, but we can. as a witness to the facts or as an "expert” witness, be maximally prepared to offer medical information in a meaningful, direct and succinct manner to support the defendant s position.

For example, in a recent malpractice death case, the defendants from a smaller South Caro- lina community sought a pre-deposition evalua- tion from specialists, to whom the defendants often refer their patients; however, two separate groups of South Carolina specialists, after only a cursory review, dismissed the facts as incontrover- tible from the plaintiff’s perspective and refused to become involved. One specialist spent more time calculating the damages on behalf of the plaintiff, based on his medical prognosis, than he did in evaluating the case. The defendants ulti- mately obtained an out-of-state specialist who studied the case carefully and testified as the

° P O Box 118, Pawleys Island, SC 29585.

defendants expert. The jury returned a verdict for the defendants after only one hour of delibera- tion! Undoubtedly, had the South Carolina spe- cialists cared enough to give a more incisive evaluation of the case, they would have reached the same conclusion as the out-of-state specialist.

There