The issues, cases, decisions and situations discussed by Severin
indicate that, fortunately in one area and unfortunately in another,
the more things change, the more they stay the same. Furthermore,
his article raises an important medicolegal policy issue.
With regard to what stays the same, I note that what I learned
as a medical student in the late 1960s, and what I then taught
my interns when I was a resident and my residents when I was an
associate professor of family practice, still is the mainstay
of effective clinical medicine: A thorough and thoughtful history
and physical examination performed by the attending physician
remains fundamental to the timely and proper diagnosis and treatment
of patients. An accurate family history, which has been taught
to medical students from time immemorial, is still the bedrock
of diagnosis of not only the complaining symptoms but also potential
hereditary, familial, and genetic conditions.
Short-Sighted View of Insurers
That which also, unfortunately, remains the same is the apparent
short-sighted view of the insurance companies. Rather than authorizing
and reimbursing indicated prophylactic surgery, it appears that
the companies plan to test in every state the question of whether
family cancer syndromes and similar conditions constitute "disease"
states that are compensable under the various health contracts.
I find it frustrating that the insurance companies remain outside
the health care "loop" and prefer to expend their funds
on litigation rather than indicated prophylactic care of patients.
Moreover, if the indicated surgeries are not completed now, it
is clear that the insurance companies will later be paying for
much more expensive (and preventable) radical surgeries, chemotherapy,
and numerous hospitalizations. Thus, given the large number of
family cancer syndromes that have been recently described, the
insurers' view is not only medically short-sighted but also not
in their own long-term financial interests.
An Important Policy Issue
Finally, the policy matter that affects patients, their families,
physicians, and attorneys (for both plaintiffs and insurance carriers)
is the following: What responsibility does a physician owe to
the family of a patient in whom he or she has diagnosed a familial
cancer or other familial condition? It is hoped that the organized
medical and legal professions, along with the other members of
the health-care industry, such as the insurance carriers, HMOs,
and PPOs, will cooperate in formulating proper mechanisms for
primary-care physicians to inform nonpatient relatives of their
potential for developing genetic-based illness in a speedy, economical,
and, hopefully, nonlitigious manner.