Letters To The Editor

To the Editor: I certainly enjoyed Dr. Byron J. Hoogwerf’s excellent summary article regarding intensive therapy of type 2 diabetes. I was concerned, however, about the sentence in his last paragraph stating that “any strategy that lowers glucose and is not associated with a risk of hypoglycemia and does not cause excessive weight gain should be considered appropriate in patients with type 2 diabetes.” This statement begs the question: What is excessive weight gain?

In view of the known adverse effects of obesity on hypertension, lipid disorders, and insulin resistance, how can any weight gain be beneficial? Is there any evidence that lowering glucose has any benefit when it is associated with weight gain?

To the Editor: I certainly enjoyed Dr. Byron J. Hoogwerf’s excellent summary article regarding intensive therapy of type 2 diabetes. I was concerned, however, about the sentence in his last paragraph stating that “any strategy that lowers glucose and is not associated with a risk of hypoglycemia and does not cause excessive weight gain should be considered appropriate in patients with type 2 diabetes.” This statement begs the question: What is excessive weight gain?

In view of the known adverse effects of obesity on hypertension, lipid disorders, and insulin resistance, how can any weight gain be beneficial? Is there any evidence that lowering glucose has any benefit when it is associated with weight gain?

To the Editor: I certainly enjoyed Dr. Byron J. Hoogwerf’s excellent summary article regarding intensive therapy of type 2 diabetes. I was concerned, however, about the sentence in his last paragraph stating that “any strategy that lowers glucose and is not associated with a risk of hypoglycemia and does not cause excessive weight gain should be considered appropriate in patients with type 2 diabetes.” This statement begs the question: What is excessive weight gain?

In view of the known adverse effects of obesity on hypertension, lipid disorders, and insulin resistance, how can any weight gain be beneficial? Is there any evidence that lowering glucose has any benefit when it is associated with weight gain?

In Reply: Dr. Najman’s concern about reasons for the slight mortality increase in the intensively treated group in ACCORD¹ resonates with all of the ACCORD investigators and clinicians. However, several features of the ACCORD trial should provide reassurance about his concerns.

At the time of protocol development, it was recognized that the complexity of the protocol was such that some issues, including medication combinations, might generate safety concerns.² The ACCORD trial—like all appropriately designed large clinical trials—has a data safety and monitoring board. The ACCORD data safety and monitoring board is composed of people with extensive experience in the conduct and analysis of clinical trials. Among its roles are ongoing evaluation of the conduct of the trial (to ensure adherence to the protocol), determination of whether the trial has achieved efficacy outcomes (based on predetermined stopping rules), and judgments as to whether there are any safety concerns. The board may request any analyses it deems necessary for the safe conduct of the trial. The board meets regularly and reports regularly to the National Heart, Lung, and Blood Institute (NHLBI) project office.

The ACCORD data safety and monitoring board has been very attentive to issues that may have been of concern during the course of the trial. Most notably, when the report by Drs. Nissen and Wolski about rosiglitazone (Avandia) was published,³ the board requested interim analyses of the ACCORD data for their review. It reported that rosiglitazone use in the ACCORD trial was not associated with a risk of increased cardiovascular events or death. The fact that they recommended to the NHLBI that the intensive glucose arm be closed early also attests to their care in ensuring the integrity of the ACCORD trial and the safety of each study participant.

Although the details of the board’s discussions are not made available to investigators (or to the public), I am quite certain that the concern about the combination of PPAR alpha and gamma agonists is on their radar screen. And in the absence of safety concerns from the ACCORD data safety and monitoring board, it would be inappropriate to report any analyses to address the question raised by Dr. Najman prior to the closure of the lipid arm in ACCORD.

Dr. Drake raises a question for which there is no easy answer. We do not know how much weight gain actually contributes to coronary heart disease risk and mortality in a group of patients whose risk factors are otherwise well treated. Weight gain is clearly associated with increasing blood pressure, more adverse lipid profiles, and probably increased nontraditional risk markers, including high-sensitivity C-reactive protein and plasminogen activator inhibitor-1. The former risk factors can be treated with additional medication, and the effects of the latter are uncertain. Thus the writer raises an excellent question, but one that does not readily lend itself to a clearly quantifiable answer for “how much weight gain is too much?”

In Reply: Dr. Najman’s concern about reasons for the slight mortality increase in the intensively treated group in ACCORD¹ resonates with all of the ACCORD investigators and clinicians. However, several features of the ACCORD trial should provide reassurance about his concerns.

At the time of protocol development, it was recognized that the complexity of the protocol was such that some issues, including medication combinations, might generate safety concerns.² The ACCORD trial—like all appropriately designed large clinical trials—has a data safety and monitoring board. The ACCORD data safety and monitoring board is composed of people with extensive experience in the conduct and analysis of clinical trials. Among its roles are ongoing evaluation of the conduct of the trial (to ensure adherence to the protocol), determination of whether the trial has achieved efficacy outcomes (based on predetermined stopping rules), and judgments as to whether there are any safety concerns. The board may request any analyses it deems necessary for the safe conduct of the trial. The board meets regularly and reports regularly to the National Heart, Lung, and Blood Institute (NHLBI) project office.

The ACCORD data safety and monitoring board has been very attentive to issues that may have been of concern during the course of the trial. Most notably, when the report by Drs. Nissen and Wolski about rosiglitazone (Avandia) was published,³ the board requested interim analyses of the ACCORD data for their review. It reported that rosiglitazone use in the ACCORD trial was not associated with a risk of increased cardiovascular events or death. The fact that they recommended to the NHLBI that the intensive glucose arm be closed early also attests to their care in ensuring the integrity of the ACCORD trial and the safety of each study participant.

Although the details of the board’s discussions are not made available to investigators (or to the public), I am quite certain that the concern about the combination of PPAR alpha and gamma agonists is on their radar screen. And in the absence of safety concerns from the ACCORD data safety and monitoring board, it would be inappropriate to report any analyses to address the question raised by Dr. Najman prior to the closure of the lipid arm in ACCORD.

Dr. Drake raises a question for which there is no easy answer. We do not know how much weight gain actually contributes to coronary heart disease risk and mortality in a group of patients whose risk factors are otherwise well treated. Weight gain is clearly associated with increasing blood pressure, more adverse lipid profiles, and probably increased nontraditional risk markers, including high-sensitivity C-reactive protein and plasminogen activator inhibitor-1. The former risk factors can be treated with additional medication, and the effects of the latter are uncertain. Thus the writer raises an excellent question, but one that does not readily lend itself to a clearly quantifiable answer for “how much weight gain is too much?”

In Reply: Dr. Najman’s concern about reasons for the slight mortality increase in the intensively treated group in ACCORD¹ resonates with all of the ACCORD investigators and clinicians. However, several features of the ACCORD trial should provide reassurance about his concerns.

At the time of protocol development, it was recognized that the complexity of the protocol was such that some issues, including medication combinations, might generate safety concerns.² The ACCORD trial—like all appropriately designed large clinical trials—has a data safety and monitoring board. The ACCORD data safety and monitoring board is composed of people with extensive experience in the conduct and analysis of clinical trials. Among its roles are ongoing evaluation of the conduct of the trial (to ensure adherence to the protocol), determination of whether the trial has achieved efficacy outcomes (based on predetermined stopping rules), and judgments as to whether there are any safety concerns. The board may request any analyses it deems necessary for the safe conduct of the trial. The board meets regularly and reports regularly to the National Heart, Lung, and Blood Institute (NHLBI) project office.

The ACCORD data safety and monitoring board has been very attentive to issues that may have been of concern during the course of the trial. Most notably, when the report by Drs. Nissen and Wolski about rosiglitazone (Avandia) was published,³ the board requested interim analyses of the ACCORD data for their review. It reported that rosiglitazone use in the ACCORD trial was not associated with a risk of increased cardiovascular events or death. The fact that they recommended to the NHLBI that the intensive glucose arm be closed early also attests to their care in ensuring the integrity of the ACCORD trial and the safety of each study participant.

Although the details of the board’s discussions are not made available to investigators (or to the public), I am quite certain that the concern about the combination of PPAR alpha and gamma agonists is on their radar screen. And in the absence of safety concerns from the ACCORD data safety and monitoring board, it would be inappropriate to report any analyses to address the question raised by Dr. Najman prior to the closure of the lipid arm in ACCORD.

Dr. Drake raises a question for which there is no easy answer. We do not know how much weight gain actually contributes to coronary heart disease risk and mortality in a group of patients whose risk factors are otherwise well treated. Weight gain is clearly associated with increasing blood pressure, more adverse lipid profiles, and probably increased nontraditional risk markers, including high-sensitivity C-reactive protein and plasminogen activator inhibitor-1. The former risk factors can be treated with additional medication, and the effects of the latter are uncertain. Thus the writer raises an excellent question, but one that does not readily lend itself to a clearly quantifiable answer for “how much weight gain is too much?”

To the Editor: Levine and colleagues have done an excellent review of congenital long QT syndrome.¹ I would like to emphasize that there are significant differences in risk between children and adults with long QT syndrome. According to a recent registry study,^2,3 the following are salient differences.

In children²:

• A prolonged corrected QT interval (QTc) (ie, > 500 ms) seems to predict risk of sudden cardiac death in boys.
• Syncope predicts aborted cardiac arrest or sudden cardiac death in both boys and girls, with recent syncope carrying a higher risk than a remote history of syncope.
• Although 63% of the sample in the registry consisted of girls, who also had longer baseline QTc intervals than boys, only 1% of girls had events, compared with 5% of boys.
• Family history of sudden cardiac death does not predict risk of cardiac events during childhood regardless of genotype.

In adults³:

• Event rates were similar regardless of QTc interval in men, whereas women with longer QTc intervals had more events than those without significantly prolonged QTc intervals.
• Recent syncope carries a tenfold increased hazard ratio for serious adverse events.
• A prolonged QTc interval predicts a substantial risk of aborted cardiac arrest or sudden cardiac death in people older than 40 years.
• The combination of a family history of sudden cardiac death and the LQT3 (long QT syndrome type 3) mutation carries a significant mortality rate.

To the Editor: Levine and colleagues have done an excellent review of congenital long QT syndrome.¹ I would like to emphasize that there are significant differences in risk between children and adults with long QT syndrome. According to a recent registry study,^2,3 the following are salient differences.

In children²:

• A prolonged corrected QT interval (QTc) (ie, > 500 ms) seems to predict risk of sudden cardiac death in boys.
• Syncope predicts aborted cardiac arrest or sudden cardiac death in both boys and girls, with recent syncope carrying a higher risk than a remote history of syncope.
• Although 63% of the sample in the registry consisted of girls, who also had longer baseline QTc intervals than boys, only 1% of girls had events, compared with 5% of boys.
• Family history of sudden cardiac death does not predict risk of cardiac events during childhood regardless of genotype.

In adults³:

• Event rates were similar regardless of QTc interval in men, whereas women with longer QTc intervals had more events than those without significantly prolonged QTc intervals.
• Recent syncope carries a tenfold increased hazard ratio for serious adverse events.
• A prolonged QTc interval predicts a substantial risk of aborted cardiac arrest or sudden cardiac death in people older than 40 years.
• The combination of a family history of sudden cardiac death and the LQT3 (long QT syndrome type 3) mutation carries a significant mortality rate.

To the Editor: Levine and colleagues have done an excellent review of congenital long QT syndrome.¹ I would like to emphasize that there are significant differences in risk between children and adults with long QT syndrome. According to a recent registry study,^2,3 the following are salient differences.

In children²:

• A prolonged corrected QT interval (QTc) (ie, > 500 ms) seems to predict risk of sudden cardiac death in boys.
• Syncope predicts aborted cardiac arrest or sudden cardiac death in both boys and girls, with recent syncope carrying a higher risk than a remote history of syncope.
• Although 63% of the sample in the registry consisted of girls, who also had longer baseline QTc intervals than boys, only 1% of girls had events, compared with 5% of boys.
• Family history of sudden cardiac death does not predict risk of cardiac events during childhood regardless of genotype.

In adults³:

• Event rates were similar regardless of QTc interval in men, whereas women with longer QTc intervals had more events than those without significantly prolonged QTc intervals.
• Recent syncope carries a tenfold increased hazard ratio for serious adverse events.
• A prolonged QTc interval predicts a substantial risk of aborted cardiac arrest or sudden cardiac death in people older than 40 years.
• The combination of a family history of sudden cardiac death and the LQT3 (long QT syndrome type 3) mutation carries a significant mortality rate.

In Reply: In contrasting the findings of two recent papers on long QT syndrome in children and in adults age 40 years or older, Dr. Ramaraj makes an excellent point—ie, that risk stratification strategies need to be age-dependent.^1,2 We agree with him and thank him for calling the readers’ attention to the issue. Apropos of his letter, we wish to highlight additional data recently published from the long QT syndrome registry summarizing the age-dependent relationships for risk of aborted cardiac arrest or death in long QT syndrome between ages 1 and 75.^3–5 Notably, beta-blocker therapy reduced risk at all ages, although the effect was of borderline significance in the older age groups.

Specifically, we would also like to stress the work of Sauer et al⁴ that deals specifically with patients ages 18 to 40. Their study demonstrated the ability to use sex, genotype, QTc, and history of cardiac events as risk stratification tools in long QT syndrome patients. Specifically, Sauer et al found that:

• Patients with LQT2 are at greater risk of arrhythmic events than patients with LQT1 or LQT3.
• QTc remained a significant predictor of events in this cohort.
• Aborted cardiac arrest or sudden death was related to QTc ≥ 500 ms, female sex, and having experienced a syncopal event after the age of 18.
• 
  Beta-blocker therapy resulted in a 60% reduction in risk; most of that risk reduction was in the LQT1 and LQT2 genotypes.

Table 1 highlights the major risk factors for life-threatening events (as opposed to syncope alone) in patients across the spectrum of age.

In Reply: In contrasting the findings of two recent papers on long QT syndrome in children and in adults age 40 years or older, Dr. Ramaraj makes an excellent point—ie, that risk stratification strategies need to be age-dependent.^1,2 We agree with him and thank him for calling the readers’ attention to the issue. Apropos of his letter, we wish to highlight additional data recently published from the long QT syndrome registry summarizing the age-dependent relationships for risk of aborted cardiac arrest or death in long QT syndrome between ages 1 and 75.^3–5 Notably, beta-blocker therapy reduced risk at all ages, although the effect was of borderline significance in the older age groups.

Specifically, we would also like to stress the work of Sauer et al⁴ that deals specifically with patients ages 18 to 40. Their study demonstrated the ability to use sex, genotype, QTc, and history of cardiac events as risk stratification tools in long QT syndrome patients. Specifically, Sauer et al found that:

• Patients with LQT2 are at greater risk of arrhythmic events than patients with LQT1 or LQT3.
• QTc remained a significant predictor of events in this cohort.
• Aborted cardiac arrest or sudden death was related to QTc ≥ 500 ms, female sex, and having experienced a syncopal event after the age of 18.
• 
  Beta-blocker therapy resulted in a 60% reduction in risk; most of that risk reduction was in the LQT1 and LQT2 genotypes.

Table 1 highlights the major risk factors for life-threatening events (as opposed to syncope alone) in patients across the spectrum of age.

In Reply: In contrasting the findings of two recent papers on long QT syndrome in children and in adults age 40 years or older, Dr. Ramaraj makes an excellent point—ie, that risk stratification strategies need to be age-dependent.^1,2 We agree with him and thank him for calling the readers’ attention to the issue. Apropos of his letter, we wish to highlight additional data recently published from the long QT syndrome registry summarizing the age-dependent relationships for risk of aborted cardiac arrest or death in long QT syndrome between ages 1 and 75.^3–5 Notably, beta-blocker therapy reduced risk at all ages, although the effect was of borderline significance in the older age groups.

Specifically, we would also like to stress the work of Sauer et al⁴ that deals specifically with patients ages 18 to 40. Their study demonstrated the ability to use sex, genotype, QTc, and history of cardiac events as risk stratification tools in long QT syndrome patients. Specifically, Sauer et al found that:

• Patients with LQT2 are at greater risk of arrhythmic events than patients with LQT1 or LQT3.
• QTc remained a significant predictor of events in this cohort.
• Aborted cardiac arrest or sudden death was related to QTc ≥ 500 ms, female sex, and having experienced a syncopal event after the age of 18.
• 
  Beta-blocker therapy resulted in a 60% reduction in risk; most of that risk reduction was in the LQT1 and LQT2 genotypes.

Table 1 highlights the major risk factors for life-threatening events (as opposed to syncope alone) in patients across the spectrum of age.

Things are what they are

To the Editor: I finished residency in 1996. I’m not sure this qualifies me to respond to Dr. Lansdale’s article, but I will anyway. In 12 years, I have witnessed what he describes, even though I work in a not-for-profit military hospital (medical center). Yet I am uncertain that things are worse than they were then, even though it seems like the house staff spend thrice the time typing on a keyboard in the team room than they do at the bedside. Things are what they are. Patients are living longer—I have seen this with my own eyes. Some of them are seeing children graduate, get married, and have babies and spending final holidays with other loved ones. I often feel a sense of helplessness at exactly the sort of obstacles to true excellence Dr. Lansdale points out. However, in the spirit of evidence-based medicine, it remains to be established that spending less time touching the patient doesn’t reduce nosocomial infections. We were putting Swan-Ganz catheters in 12 years ago, and I am pretty sure in retrospect we were hurting patients—we don’t do that much any more. When I struggle with these difficulties and I try to figure out how to emulate my mentors from what seems like a better time, I remember what my mom told me when I was a second-grader: “Just do your best, and no one will fault you.” While I understand burnout, I think a more productive approach would be to redouble efforts at preserving humanistic traditions, valuable clinical skills, and a sense of what we were, rather than to retreat.

Things are what they are

To the Editor: I finished residency in 1996. I’m not sure this qualifies me to respond to Dr. Lansdale’s article, but I will anyway. In 12 years, I have witnessed what he describes, even though I work in a not-for-profit military hospital (medical center). Yet I am uncertain that things are worse than they were then, even though it seems like the house staff spend thrice the time typing on a keyboard in the team room than they do at the bedside. Things are what they are. Patients are living longer—I have seen this with my own eyes. Some of them are seeing children graduate, get married, and have babies and spending final holidays with other loved ones. I often feel a sense of helplessness at exactly the sort of obstacles to true excellence Dr. Lansdale points out. However, in the spirit of evidence-based medicine, it remains to be established that spending less time touching the patient doesn’t reduce nosocomial infections. We were putting Swan-Ganz catheters in 12 years ago, and I am pretty sure in retrospect we were hurting patients—we don’t do that much any more. When I struggle with these difficulties and I try to figure out how to emulate my mentors from what seems like a better time, I remember what my mom told me when I was a second-grader: “Just do your best, and no one will fault you.” While I understand burnout, I think a more productive approach would be to redouble efforts at preserving humanistic traditions, valuable clinical skills, and a sense of what we were, rather than to retreat.

Things are what they are

To the Editor: I finished residency in 1996. I’m not sure this qualifies me to respond to Dr. Lansdale’s article, but I will anyway. In 12 years, I have witnessed what he describes, even though I work in a not-for-profit military hospital (medical center). Yet I am uncertain that things are worse than they were then, even though it seems like the house staff spend thrice the time typing on a keyboard in the team room than they do at the bedside. Things are what they are. Patients are living longer—I have seen this with my own eyes. Some of them are seeing children graduate, get married, and have babies and spending final holidays with other loved ones. I often feel a sense of helplessness at exactly the sort of obstacles to true excellence Dr. Lansdale points out. However, in the spirit of evidence-based medicine, it remains to be established that spending less time touching the patient doesn’t reduce nosocomial infections. We were putting Swan-Ganz catheters in 12 years ago, and I am pretty sure in retrospect we were hurting patients—we don’t do that much any more. When I struggle with these difficulties and I try to figure out how to emulate my mentors from what seems like a better time, I remember what my mom told me when I was a second-grader: “Just do your best, and no one will fault you.” While I understand burnout, I think a more productive approach would be to redouble efforts at preserving humanistic traditions, valuable clinical skills, and a sense of what we were, rather than to retreat.

The current system is nuts

To the Editor: To add to what Dr. Lansdale said, advances in outpatient management and what one can do in “day surgery” have reshaped medicine. Medicine is now more of an outpatient enterprise. Hospitals have contracted to take care of only the sickest. Many things have been lost, including much of the fabric and texture of medicine. There are few of us left who are trained to do primary care, or willing to do it…

…For any provider, it is uneconomic to round on one or two patients. Hospitalists, who are often last year’s residents, try to manage sicker and more complex medical patients, whom they don’t know well. Emergency rooms are overflowing with primary care patients who go there in frustration and for urgent care, since there are not enough primary care physicians. The most expensive place is being used for basic care, and these patients are now seen by less adequately trained mid-level personnel, with reimbursements hugely in excess of what office visits generate…

…Most of us really do know how to practice economically, use resources appropriately, and manage our patients effectively. We are simply not being allowed to do so, or not paid for it when we do. In one word, the current system is nuts.

Before it is too late, and it may already be so, we need to restructure the system. That means rebuilding it around an outpatient model where doctors are paid and really rewarded for performance, and not for how many patients they see in a day…

The current system is nuts

To the Editor: To add to what Dr. Lansdale said, advances in outpatient management and what one can do in “day surgery” have reshaped medicine. Medicine is now more of an outpatient enterprise. Hospitals have contracted to take care of only the sickest. Many things have been lost, including much of the fabric and texture of medicine. There are few of us left who are trained to do primary care, or willing to do it…

…For any provider, it is uneconomic to round on one or two patients. Hospitalists, who are often last year’s residents, try to manage sicker and more complex medical patients, whom they don’t know well. Emergency rooms are overflowing with primary care patients who go there in frustration and for urgent care, since there are not enough primary care physicians. The most expensive place is being used for basic care, and these patients are now seen by less adequately trained mid-level personnel, with reimbursements hugely in excess of what office visits generate…

…Most of us really do know how to practice economically, use resources appropriately, and manage our patients effectively. We are simply not being allowed to do so, or not paid for it when we do. In one word, the current system is nuts.

Before it is too late, and it may already be so, we need to restructure the system. That means rebuilding it around an outpatient model where doctors are paid and really rewarded for performance, and not for how many patients they see in a day…

The current system is nuts

To the Editor: To add to what Dr. Lansdale said, advances in outpatient management and what one can do in “day surgery” have reshaped medicine. Medicine is now more of an outpatient enterprise. Hospitals have contracted to take care of only the sickest. Many things have been lost, including much of the fabric and texture of medicine. There are few of us left who are trained to do primary care, or willing to do it…

…For any provider, it is uneconomic to round on one or two patients. Hospitalists, who are often last year’s residents, try to manage sicker and more complex medical patients, whom they don’t know well. Emergency rooms are overflowing with primary care patients who go there in frustration and for urgent care, since there are not enough primary care physicians. The most expensive place is being used for basic care, and these patients are now seen by less adequately trained mid-level personnel, with reimbursements hugely in excess of what office visits generate…

…Most of us really do know how to practice economically, use resources appropriately, and manage our patients effectively. We are simply not being allowed to do so, or not paid for it when we do. In one word, the current system is nuts.

Before it is too late, and it may already be so, we need to restructure the system. That means rebuilding it around an outpatient model where doctors are paid and really rewarded for performance, and not for how many patients they see in a day…

The good old days weren't that good

To the Editor: Dr. Lansdale's stroll down memory lane reminiscing about the “good old days” brought back lots of memories (I graduated from medical school 10 years before Dr. Lansdale) but is of absolutely no help with today's medical challenges…

…Most of the physicians working in the trenches today did not set our current health care policies, and most of us will not change them either. That will only come from those we elect to go to Washington. I can vote responsibly, but I would not be very good in Washington. Until things change, it is my responsibility to learn the rules of engagement and care for my patients the best I can within the system we have. Like the waiter in the restaurant, I didn't set the table, I'm just trying to clean up the mess. Today's medical students and residents don't want to or will not work the hours we did 20 or 30 years ago, and I don't blame them. Maybe they will have a lower divorce rate, live longer, and practice medicine longer than our current retiring physicians…

…Dr. Lansdale worries about infection in the hospital, where handwashing between patients is abysmal. I can't do anything about my peers' handwashing habits, but I can wash my own hands. Don't like retrospective review for quality measures? We all know what is best for CHF and AMI patients, but studies show that less than 50% of our patients get the care we know is best. Physicians have always done a better job when somebody is watching. More oversight is coming. Get used to it…

…I am a hospital guy. As long as patients, medical students, and residents need me, I'll be a hospital guy.

The good old days weren't that good

To the Editor: Dr. Lansdale's stroll down memory lane reminiscing about the “good old days” brought back lots of memories (I graduated from medical school 10 years before Dr. Lansdale) but is of absolutely no help with today's medical challenges…

…Most of the physicians working in the trenches today did not set our current health care policies, and most of us will not change them either. That will only come from those we elect to go to Washington. I can vote responsibly, but I would not be very good in Washington. Until things change, it is my responsibility to learn the rules of engagement and care for my patients the best I can within the system we have. Like the waiter in the restaurant, I didn't set the table, I'm just trying to clean up the mess. Today's medical students and residents don't want to or will not work the hours we did 20 or 30 years ago, and I don't blame them. Maybe they will have a lower divorce rate, live longer, and practice medicine longer than our current retiring physicians…

…Dr. Lansdale worries about infection in the hospital, where handwashing between patients is abysmal. I can't do anything about my peers' handwashing habits, but I can wash my own hands. Don't like retrospective review for quality measures? We all know what is best for CHF and AMI patients, but studies show that less than 50% of our patients get the care we know is best. Physicians have always done a better job when somebody is watching. More oversight is coming. Get used to it…

…I am a hospital guy. As long as patients, medical students, and residents need me, I'll be a hospital guy.

The good old days weren't that good

To the Editor: Dr. Lansdale's stroll down memory lane reminiscing about the “good old days” brought back lots of memories (I graduated from medical school 10 years before Dr. Lansdale) but is of absolutely no help with today's medical challenges…

…Most of the physicians working in the trenches today did not set our current health care policies, and most of us will not change them either. That will only come from those we elect to go to Washington. I can vote responsibly, but I would not be very good in Washington. Until things change, it is my responsibility to learn the rules of engagement and care for my patients the best I can within the system we have. Like the waiter in the restaurant, I didn't set the table, I'm just trying to clean up the mess. Today's medical students and residents don't want to or will not work the hours we did 20 or 30 years ago, and I don't blame them. Maybe they will have a lower divorce rate, live longer, and practice medicine longer than our current retiring physicians…

…Dr. Lansdale worries about infection in the hospital, where handwashing between patients is abysmal. I can't do anything about my peers' handwashing habits, but I can wash my own hands. Don't like retrospective review for quality measures? We all know what is best for CHF and AMI patients, but studies show that less than 50% of our patients get the care we know is best. Physicians have always done a better job when somebody is watching. More oversight is coming. Get used to it…

…I am a hospital guy. As long as patients, medical students, and residents need me, I'll be a hospital guy.

We're chart doctors now

To the Editor: Dr. Lansdale appears to have jumped from the frying pan into the fire. In clinical medicine he will quickly find out that the quality of patient care has become nearly irrelevant. The quality of the medical record (chart) is all that matters to insurance companies, bean counters, and government agencies. I have been a primary care internist in private practice for 29 years. Instead of taking care of patients, I now spend most of my time taking care of charts. I'm a chart doctor.

We're chart doctors now

To the Editor: Dr. Lansdale appears to have jumped from the frying pan into the fire. In clinical medicine he will quickly find out that the quality of patient care has become nearly irrelevant. The quality of the medical record (chart) is all that matters to insurance companies, bean counters, and government agencies. I have been a primary care internist in private practice for 29 years. Instead of taking care of patients, I now spend most of my time taking care of charts. I'm a chart doctor.

We're chart doctors now

To the Editor: Dr. Lansdale appears to have jumped from the frying pan into the fire. In clinical medicine he will quickly find out that the quality of patient care has become nearly irrelevant. The quality of the medical record (chart) is all that matters to insurance companies, bean counters, and government agencies. I have been a primary care internist in private practice for 29 years. Instead of taking care of patients, I now spend most of my time taking care of charts. I'm a chart doctor.

Let's not retreat

To the Editor: It would be rare to find a physician who has witnessed the changes in the last several decades of medicine who does not share many of the sentiments and observations of Dr. Lansdale. The key to a solution lies in examining a very telling phrase of Dr. Lansdale: “retreating to the privacy of clinical medicine.”

We are living in an era of unprecedented opportunity for physicians to lead us to new levels of care by combining molecular and population levels of understanding of disease and health that will greatly dwarf the many public health victories of the mid-20th century. We need the deep and careful clinical descriptions of individual patients to inform genetic and molecular understanding. But we also need every practicing physician linked to wider improvement of both rare and common diseases through research registries and through practice-level and population strategies. We need various specialties to link efforts around patients rather than to retreat into their own intellectual and economic silos. We need to reclaim leadership stature by putting ourselves in service of solving the heath care crisis rather than retreating to the privacy of clinical medicine…

…The problem is that as the focus of medical care and medical education naturally and inevitably widened beyond the hospital, we have not developed the infrastructures to support this broadened approach. One of the fundamental ingredients to begin building this infrastructure is the community orientation of physicians. Let us not lament the great community spirit of the training hospital environment of old. Instead, let us translate it to the larger medical community beyond the confines of the hospital.

Let's not retreat

To the Editor: It would be rare to find a physician who has witnessed the changes in the last several decades of medicine who does not share many of the sentiments and observations of Dr. Lansdale. The key to a solution lies in examining a very telling phrase of Dr. Lansdale: “retreating to the privacy of clinical medicine.”

We are living in an era of unprecedented opportunity for physicians to lead us to new levels of care by combining molecular and population levels of understanding of disease and health that will greatly dwarf the many public health victories of the mid-20th century. We need the deep and careful clinical descriptions of individual patients to inform genetic and molecular understanding. But we also need every practicing physician linked to wider improvement of both rare and common diseases through research registries and through practice-level and population strategies. We need various specialties to link efforts around patients rather than to retreat into their own intellectual and economic silos. We need to reclaim leadership stature by putting ourselves in service of solving the heath care crisis rather than retreating to the privacy of clinical medicine…

…The problem is that as the focus of medical care and medical education naturally and inevitably widened beyond the hospital, we have not developed the infrastructures to support this broadened approach. One of the fundamental ingredients to begin building this infrastructure is the community orientation of physicians. Let us not lament the great community spirit of the training hospital environment of old. Instead, let us translate it to the larger medical community beyond the confines of the hospital.

Let's not retreat

To the Editor: It would be rare to find a physician who has witnessed the changes in the last several decades of medicine who does not share many of the sentiments and observations of Dr. Lansdale. The key to a solution lies in examining a very telling phrase of Dr. Lansdale: “retreating to the privacy of clinical medicine.”

We are living in an era of unprecedented opportunity for physicians to lead us to new levels of care by combining molecular and population levels of understanding of disease and health that will greatly dwarf the many public health victories of the mid-20th century. We need the deep and careful clinical descriptions of individual patients to inform genetic and molecular understanding. But we also need every practicing physician linked to wider improvement of both rare and common diseases through research registries and through practice-level and population strategies. We need various specialties to link efforts around patients rather than to retreat into their own intellectual and economic silos. We need to reclaim leadership stature by putting ourselves in service of solving the heath care crisis rather than retreating to the privacy of clinical medicine…

…The problem is that as the focus of medical care and medical education naturally and inevitably widened beyond the hospital, we have not developed the infrastructures to support this broadened approach. One of the fundamental ingredients to begin building this infrastructure is the community orientation of physicians. Let us not lament the great community spirit of the training hospital environment of old. Instead, let us translate it to the larger medical community beyond the confines of the hospital.

The perfect is the enemy of the good

To the Editor: My initial impression is sadness—sad that a dedicated physician should feel this way about his career. I’m not an internist, but rather a cardiac and transplant pathologist and member of the editorial board of the Cleveland Clinic Journal of Medicine and recently retired from Cleveland Clinic. Two days ago, at a social event, a grandmother approached me and told me with pride that her son was doing well in pre-med and was interested in oncology. She asked for my thoughts. I told her that I had had a great career, that I thought medicine was terrific, always stimulating and exciting, as well as demanding, and that I was well compensated. I still feel that way. I sympathize with Dr. Lansdale but wish he had taken to heart the message from Future Shock, ie, that the current rate of change is far faster than it has ever been, and that the rate of change is constantly accelerating…

…I’d like to end with another thought: the perfect is the enemy of the good. I found medicine to be a great career, and I’m afraid that too many physicians are dissatisfied because it isn’t perfect.

The perfect is the enemy of the good

To the Editor: My initial impression is sadness—sad that a dedicated physician should feel this way about his career. I’m not an internist, but rather a cardiac and transplant pathologist and member of the editorial board of the Cleveland Clinic Journal of Medicine and recently retired from Cleveland Clinic. Two days ago, at a social event, a grandmother approached me and told me with pride that her son was doing well in pre-med and was interested in oncology. She asked for my thoughts. I told her that I had had a great career, that I thought medicine was terrific, always stimulating and exciting, as well as demanding, and that I was well compensated. I still feel that way. I sympathize with Dr. Lansdale but wish he had taken to heart the message from Future Shock, ie, that the current rate of change is far faster than it has ever been, and that the rate of change is constantly accelerating…

…I’d like to end with another thought: the perfect is the enemy of the good. I found medicine to be a great career, and I’m afraid that too many physicians are dissatisfied because it isn’t perfect.

The perfect is the enemy of the good

To the Editor: My initial impression is sadness—sad that a dedicated physician should feel this way about his career. I’m not an internist, but rather a cardiac and transplant pathologist and member of the editorial board of the Cleveland Clinic Journal of Medicine and recently retired from Cleveland Clinic. Two days ago, at a social event, a grandmother approached me and told me with pride that her son was doing well in pre-med and was interested in oncology. She asked for my thoughts. I told her that I had had a great career, that I thought medicine was terrific, always stimulating and exciting, as well as demanding, and that I was well compensated. I still feel that way. I sympathize with Dr. Lansdale but wish he had taken to heart the message from Future Shock, ie, that the current rate of change is far faster than it has ever been, and that the rate of change is constantly accelerating…

…I’d like to end with another thought: the perfect is the enemy of the good. I found medicine to be a great career, and I’m afraid that too many physicians are dissatisfied because it isn’t perfect.