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Am Fam Physician. 1998;58(2):584-588

The Physician's Role in Home Health Care
By Peter A. Boling. Pp. 315. Price, $49.95. Springer Publishing Company, 536 Broadway, New York, NY 10012-3955, 1997.
In the introduction to The Physician's Role in Home Health Care, Peter Boling states that “It is not primarily a book to inform physicians about the details of home care practice.” Instead, his aim is “... to make clear the connections between clinical home care experience, population demographics, and health services research, while examining service provision, efficacy and cost-effectiveness.” The author does his best work, however, when he deviates from this aim and gives details about home care practice.
We learn what to put in (and what to leave out of) a home visit doctor's bag. We learn how many visits an experienced practitioner can expect to be able to make in a day (8 to 10). We get a few glimpses of the homes of debilitated elders and the problems likely to be encountered there. We learn that one full-time home visiting physician could care for a panel of only about 150 home-bound patients, who would probably average 10 visits per year. A practice or teaching program that is considering starting or expanding a home care program would find this book most helpful in a number of ways.
Unfortunately, and through no fault of the author's, some of the information on Medicare reimbursement rates for home visits is already obsolete. The efforts of the American Academy of Home Care Physicians, of which Dr. Boling is the current president, may have had a good deal to do with the improvement in payment that is available for home visits by physicians. The current rates might provide roughly the same income for home visit and office visit activity.
When the author discusses the way home visits may fit into various medical-economic environments and other topics having to do with “systems” issues, the book is less successful. Perhaps this is because less certainty exists in these areas. In any case, I learned more when the author wrote about his particular experiences and the lessons to be learned from them.
The question of efficacy and cost-effectiveness of home visits comes up repeatedly. Dr. Boling would clearly like to state that home visits save resources by reducing nursing home utilization, hospital admissions and emergency department visits. But the supportive data are not there. He reviews the evidence, critiques it and, finally, surrenders to it. “It pains me to read the many studies that have failed to demonstrate these benefits,” he writes in his epilogue. He holds out hope that PACE and social HMOs may yet capture the savings that should be there. In the end, though, he defends home visits for this reason: “Home care should be given because it is the best response to a legitimate need.” He goes on to say that debilitated people need to be cared for somewhere, and many of them are more satisfied with care at home. If it is possible to keep costs down and target services well, it should be possible to get the same outcomes with the same cost but with higher patient satisfaction using comprehensive home care, which must include physician participation. Dr. Boling hopes this improved patient satisfaction will be enough reason to justify home visits. Time will tell.
In summary, much of this book will be useful to a person setting up or expanding a home visit service or an educational program involving home visits. The economic and policy aspects of the book are less effective but are nonetheless of considerable interest.
Western Medicine: An Illustrated History
Edited by Irvine Loudon. Pp. 347. Price, $49.95. Oxford University Press, 198 Madison Ave., New York, NY 10016, 1997.
Western Medicine: An Illustrated History is a title that foretells the contents but not the richness of this fabulous new offering. It is as concise, precise and insightful a tome as this reviewer has ever studied. And, if any summary of the history of western medicine could be called “evidence-based,” this one is. Yet, despite its fresh review of the most modern archaeologic and textual evidence to support or refute historical presumption or fact, the book is a wonderful read—perfect for that bad-weather weekend, for pre-slumber enlightenment or for vacation instruction and enjoyment.
Irvine Loudon, a full-time medical historian and research fellow at the Wellcome Unit for the History of Medicine at the University of Oxford, writes from the perspective of years of experience as a respected general practitioner, and his editing colors the entire volume. Readers will appreciate the “generalist” touch, vision and view—shaped during his general-practice years that render this work a joyful read for most American “in-the-trenches” practitioners. His training and experience as a medical historian also transpose this work into one of immense value and grand intrigue for academics and teachers alike. He has gathered a capable and authoritative group of distinguished medical historians and, with evident editing skill, has woven their masterpieces into an accessible and valuable tapestry of reading as appealing and delightful as it is informative and fascinating.
The extensive but succinct volume covers all periods of western medicine from the Greeks to the present day. Besides being well written, it is beautifully and richly illustrated. Those who enjoy “coffee table” books for their interesting illustrations would appreciate this book on the merits of its historical plates alone, many of which are in vibrant color.
The selected topics are extensive and cover the usual milestones such as the discovery of blood circulation, the evolvement of the smallpox vaccination, the invention of the X-ray and the development of penicillin and recount them against the social, religious and cultural context of each advance. The intertwining of religion and spirituality with the growth, spread and advancement of medicine is a view of the past that needed the preservation and skillful enlightenment this treatise gives.
In addition to providing the usual historical accounts of medicine, this volume assists the reader in discovering medical historical treasures not usually unveiled. For example, patterns of epidemics, the emergence of our profession and nursing as intertwined with religion, the advent of medical education and research, the spread of western medicine, as well as well-written chapters on the historical aspects of childbirth, midwives, hospitals, children's care, mental care, medical politics, unorthodox medicine and our view of patients are included. The icing on this delicious compilation is provided by a fascinating introduction, a very helpful chronology, a useful glossary and an apparently complete index. The name of each chapter and the sub-chapter topic are printed at the top of each left-hand page and the name of the topic of the page is provided at the top of each right-hand page. This technique makes the book easy to mine for the many gems and jewels it contains.
For the family physician with limited reading and study time, this book is one read worth the investment and effort.
The University of Nebraska's 25th Annual Family Practice Review: Skills for the 21st Century
Edited by the University of Nebraska Medical Center/Nebraska's Health Science Center. Price, $650.00. CME Information Services, 2000 Crawford Pl., Suite 100, Mt. Laurel, NJ 08054, 1997.
The University of Nebraska's 25th Annual Family Practice Review course consists of a three-volume set of syllabus materials and a set of six CD-ROM disks. It contains the lectures and syllabus from their 1996 review course. The disks run on both Windows and Macintosh, but users must specify which platform they will use because the first disk comes in either a Windows or a Macintosh version.
The three-volume syllabus is a mixture of formats typically found in any course syllabus. These range from simple outlines to printouts of the presenters' slides to monographs of book chapter length. Almost all are reproduced in a legible fashion for those with the patience to read three volumes, although the portions in outline format are very dry. Paper reproductions of the speakers' slides duplicate are available on the CD-ROM. I think that reproducing 15 pounds of paper when the actual lectures and accompanying slides are available on the CD-ROM is wasteful, but this format may accommodate some individuals' learning style. Some of the most useful parts of the syllabus may be practice protocols and patient education materials that are reproduced for use in practice, such as those included in the urogynecology section.
The electronic portion of the product is easily installed, although it took 28.5 megabytes on my hard drive instead of the 15 stated as the system requirement in the installation instructions. The tutorial clearly explains the program features and how to use them. The CD-ROM disks contain audio and slides from about 80 lectures. The audio accompanying the slides plays well; the producers of these disks have done a good job regenerating the text slides so that they are uniform and readable. The table of contents and search feature make it easy to look for specific topics. Users may not find some topics in which they are interested since this is a review course and is not meant to be comprehensive. Each lecture contains a list of slides. However, this list is of little use because it does not specify what the slide or picture is about. It would only take an extra word or two in this list to enable the user to more efficiently find the information being sought.
The most valuable feature of this product is the reproduction and presentation of the lecturers' images as they were shown during the live review course. The multimedia format makes this possible with much higher image quality than could have been done with videotapes of the lectures. In most cases, this is done well, but a number of lectures are missing images because of “copyright protection.” In these cases, the lecturers have apparently withheld permission for inclusion of some or many of the images. This defeats the purpose of the program. Users could find it annoying to reach a lesson of interest and then find that the image is missing. This was particularly true in the ophthalmology and radiology lectures, which are, of course, very image-intensive. The missing images represent a significant shortcoming of the program.
Image editing is a major challenge in a product like this. While most of the radiologic images are reproduced well, some images are too dark and some have been reproduced upside down. In some cases, it is not clear to which features of the image the lecturer is referring; pointers or annotations should have been added. These problems probably could have been avoided by conducting a thorough critical review of the images before publication.
The course contains lectures on a wide range of topics, but for users interested in preparation for the American Board of Family Practice recertification examination, there is no evidence that the topics covered were specifically geared toward review for the examination.
Overall, this software accomplishes the task of bringing the information presented in the review course to users who were unable to attend. The multi-media format is most useful for bringing visual materials to the user, especially color images that would have been difficult or too expensive to reproduce in printed form.

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