As a form of risk management, healthcare financial managers need to know more about the elements of risk and the ways that risk is managed. (a)

In malpractice cases involving physicians, a healthcare organization’s credentialing process becomes an important element of the discovery process. Lawyers for both plaintiff patients and defendant physicians have a vested interest in tying healthcare organizations to the physician’s negligence. Lawyers for plaintiff patients view healthcare organizations as “deep pockets” in possible recoveries of damages, while lawyers for defendant physicians may want to redirect culpability from the physicians to healthcare organizations. Some defendant physicians settle early and later testify against the healthcare organization. Healthcare organizations, on the other hand, often prefer not to testify against the physicians to avoid any inference that the organization was negligent and to show support for their medical staff.

Lessons in Negligence

To prove negligence, the plaintiff’s lawyers must prove the following:
* A legal duty existed between the plaintiff and the defendant.

* The defendant breached that duty.

* The plaintiff received an injury.

* A causal relationship existed between the defendant’s breach of duty and the plaintiff’s injury.

Healthcare organizations can be held negligent in a variety of ways. Under the legal doctrine of respondent superior, organizations can be held liable for the negligent acts of employees if the employees were acting within the framework of their job descriptions and/or practice acts and were working on assigned shifts. Under the legal doctrine of ostensible agency, organizations can be held liable for the negligent acts of apparent or ostensible agents, such as physicians and others who have a working relationship with but are not employed by the healthcare organization. Under the legal doctrine of corporate negligence, organizations can be held liable for their own negligence.

The key issue in establishing an agency relation ship is defining the extent to which the patient perceived the physician to be under the organization’s control. The following questions are often used to establish the organization-to-physician relationship from the patient’s perspective:

* Did the patient rely on the healthcare organization for selection of the physician, such as emergency department physicians, pathologists, radiologists?

* Did the organization make any representations, such as advertisements or announcements, Io the patient regarding the physician’s status?

* Did the physician’s actions indicate organizational control to the patient (e.g., wearing the organization’s lab coat or scrubs, using the organization’s prescription pad, maintaining an office in the organization’s building)?

Under corporate negligence, which often results in the largest recoveries for plaintiff patients, organizations can be held liable for their own negligence by breaching a duty owed to patients. In proving corporate negligence based on a breach of the credentialing duty, plaintiff patients must prove the following:

* Their physician was negligent, and the negligence resulted in injury.

* The organization credentialed the physician and therefore owed the patient a duty to exercise reasonable care in the selection and supervision of the physician.

* The organization failed to exercise reasonable care because it knew or should have known that the physician was incompetent or unfit.

* The organization’s negligence in selection and supervision was a proximate cause of the injuries suffered by the patient (i.e., had the organization not credentialed the physician, the physician would not have been available to injure the patient).

Case law in corporate negligence is well established, with the organization’s duty to select competent physicians established in Johnson v. Misericordia Community Hospital, 294 N.W. 2d 501 (1980), and the organization’s duty to supervise physicians established in Darling v. Charleston Community Memorial Hospital, 383 U.S. 946 (1966).

The Johnson ca se, while binding only in Wisconsin, provided the following valuable credentialing criteria:

* Require completion of the medical staff application, and verify the accuracy of the applicant’s statements.

* Solicit information from the applicant’s peers, including those not referenced in the application, who are knowledgeable about the applicant’s education, training, experience, health, competence, and ethical character.

* Determine whether the applicant is currently licensed to practice in the state and whether the license has been or is currently being challenged.

* Ask whether the applicant has been involved in any adverse malpractice action or has experienced a loss of medical staff membership or privileges at any other provider organizations.

In addition, the credentialing process should verify information from secondary sources, such as AMA Physician Masterfile, Federation of State Medical Board’s Physician Disciplinary Data Bank, U.S. Drug Enforcement Administration lists of violations, and the HCQIA Data Bank. The HCQIA Data Bank, established by the Health Care Quality Improvement Act (HCQIA) of 1986, requires the reporting of the following:

* Malpractice payments made on behalf of a physician or licensed healthcare practitioner

* Licensure actions taken by state licensing boards against physicians

* Adverse professional review actions taken by healthcare organizations against physicians

* Professional review actions taken by a professional society that adversely affect the physician’s membership in the society

Defenses to Corporate Negligence

When plaintiff patients bring corporate negligence lawsuits against healthcare organizations, the organizations can pursue a variety of defenses, both procedural and substantive. If plaintiff patients have waited too long to file the claim, healthcare organizations can invoke the statute of limitations. Statutes of limitations are state procedural rules that dictate time limits on the filing of lawsuits. Historically, depending on the state, plaintiff patients had to file a lawsuit within one to seven years of discovering the injury. More recently, in response to tort reform, many states have reduced the time to file to one to three years after discovering the injury.

Another procedural defense healthcare organizations can use is to support the physician’s defense, in effect rationalizing that if the physician was not negligent in treating the patient, the issue of whether the healthcare organization was negligent in the credentialing process becomes moot. Healthcare organizations should use this defense cautiously because the physician could, during the lengthy discovery process, admit negligence and settle with the plaintiff patient. When this happens, the plaintiff patient has a clear avenue to the “deep pockets” of the healthcare organization.

Hospitals also can use the HCQIA as a procedural defense. The IICQIA attempts to shield physicians engaged in the peer-review process from lawsuits against physicians the process is reviewing. The act provides protection from both federal and state lawsuits. Some argue that the act’s protection of the peer review process extends to hospitals. However, most argue that the act’s intent is to protect reviewing physicians, trot to protect the physician or the healthcare organization from lawsuits by patients.

Finally, healthcare organizations can use immunity provided by state statutes as a procedural defense. While attempting to balance the patient’s right to recovery with the public’s need to protect meaningful peer review, many states have enacted statutes that govern the release of peer–review proceedings. State laws vary widely on this subject, from prohibiting both the discovery of peer reviews and their use at trial to allowing the release of peer reviews in certain circumstances.

Details of former-Olympian Robert Howard’s suicide–and his slain wife–are still puzzling Little Rock, AR, police.

Howard, who made the Olympic finals in the triple jump twice at the 1996 Atlanta Games and again in Sydney in 2000, was a third-year medical student. He recently had been spotted late at night in blood-covered scrubs on the seventh-floor at the University of Arkansas for Medical Sciences. A few minutes later university police were notified that someone was trying to get into rooms on the 10th floor of a dormitory next to the hospital, school spokesman Leslie Taylor said.

Once in the dormitory, officers followed a blood trail to the room where they found Howard barricaded. By the time police were able to get in, the window was broken and Howard had jumped to his death.

When police went to tell his wife, Dr. Robin Mitchell, that her husband had committed suicide, they found her body stabbed nearly 50 times.

Officers also found a two-page, handwritten note from the 28-year-old Howard that police said was neatly written in the beginning but, by the end, was illegible.

“It was just a note from him saying he was sorry for the mistakes he made in his life and some things about his family,” Sgt. Terry Hastings said. “There’s not a mention in there that he killed her.” Yet, investigators are calling the deaths a murder-suicide.

“This may be a case that we never know,” Hastings said. “Probably, the two people who can tell us are dead.”

Mitchell, 31, was chief neurosurgery resident at the medical school’s teaching hospital and herself a track star in her hometown of Newburgh, NY.

Howard was a star athlete from Shea High School in Pawtucket, RI, and was a 10-time NCAA champion at the University of Arkansas, earning titles in the indoor and outdoor long jump and triple jump. He went on to finish seventh and eighth respectively in his Olympic appearances.

AFTER surgery, Peggy Piontkowski spent four years being a stay-at-home mom with a disability. One day, her daughter came home complaining about the stiff and scratchy scrub suits she had to wear in nursing school.

“She asked me to make her a scrub suit, and at that moment, I had the whole company vision,” said Piontkowski, president and founder of Sassy Scrubs, a company based in North Syracuse, N.Y. that designs scrub suits for real-life doctors and nurses, as well as for actors like George Clooney on the TV show “ER.”

Piontkowski relied on technical help from a little-known government program to get her company’s online sales effort off the ground. The Manufacturing Extension Partnership, a division of the National Institute of Standards and Technology (NIST) in Gaithersburg, Md., has a $104.2 million budget this year to help business owners around the United States.

“Women don’t usually start out with an idea to make something like automotive parts,” said Kevin Carr, director of the MEP. “They just end up in manufacturing because their product got so popular they were forced to mass produce it.”

MEP’s federally funded centers provide technical assistance and consulting services to all sorts of small manufacturers. It appears to be money well spent. A survey of 4,551 MEP client companies reported an increase in total revenues of $294 million and savings of $20 million in inventory based on the services provided by NIST MEP.

While many people think only big corporations make things, small companies supplying arts and equipment accounted for 55 percent of the value-added content of finished products, according to government research.

Learning more about manufacturing and online sales has helped Sassy Scrubs compete with much bigger companies. Piontkowski went to the Central New York Technology Development Organization in Syracuse, an NIST affiliate, when she decided to sell products on the Internet.

“They helped us register the name Cyberscrubs,” said Piontkowski. “Now, I rely on them to create more marketing and development strategies.”

Scrutinizing systems

Sassy Scrubs recently introduced scrub jackets made from fleece and printed corduroy. Each scrub suit piece sells for between $25 and $50 said Piontkowski, whose 10-year-old company now posts annual revenues of $1 million.

“I didn’t invent the scrub suit, I just made it better by taking out all the things that would drive me crazy about wearing a uniform,” said Piontkowski.

MEP’s Carr said the program helps business owners adopt the best manufacturing business practices to minimize costs. It also promotes new and better methods to mass-produce products.

“Business owners usually call a center when they have a problem with quality or overall output,” said Can. “We go in and look for the bottlenecks in their process and see where things could be streamlined.”

There is no fee for the initial assessment, but if the company decides to go further with the recommendations, they do pay a consulting fee based on the specific project.

“We don’t just target a specific machine that could be improved, we look at the total picture, the whole process, and the entire enterprise as it exists in a supply chain,” Carr explained.

According to Carr, most MEP clients need help figuring out what to buy to improve their manufacturing process.

“Clients come to us saying, ‘I need to buy something that does this, but I don’t know which one to get or where to buy it,’” said Carr.

Thanks to help from the MEP, more than 50 percent of Sassy Scrubs’ sales now come from the Web site. Piontkowski still works at home. She has 18 other employees working from their own homes, making 300 to 400 suit pieces a week at a rate of $6 an hour.

“It’s very rewarding for me to see so many people able to work from home because I would’ve liked to do that after I had my surgery,” said Piontkowski. “I want to keep it a cottage industry, although I can foresee, the day when we will have to build a plant.”

Going to the dogs

Many businesswomen become manufacturers based on a home-based hobby. Melissa Trombley took a recipe she had for all-natural dog biscuits and launched a small manufacturing business last year.

“For 18 years, I’d been making these biscuits for our dogs in my kitchen,” said Trombley, president of The Barking Bakers Inc., based in Syracuse, N.Y. “Then, I realized that there’s probably a market for this, so I rented some space in a commercial, bakery and started churning out 1,300 biscuits a day.”

Trombley went to an NIST affiliate, the Technology Development Organization in Syracuse, N.Y., when she needed more production capability.

“I didn’t want to buy the equipment to produce a huge amount of biscuits,” said Trombley. “So they helped me find a good alternative in outsourcing.”

Trombley now relies on workers managed by the Association of Retarded Citizens to help her bake biscuits in their commercial kitchen.

“They learn skills that they can take out into the community to become productive citizens,” said Trombley. “I get help with the baking.”

Trombley sells her biscuits in grocery stores in five states; a box of 15 biscuits costs $5.99. She eventually plans to have her own production facility. The TDO continues to provide her free research assistance with her next idea — producing a biscuit cart (like a hot dog stand) to sell dog biscuits in parks.

“I’m trying to license the cart and the biscuits to county parks as a service they can provide to their community,” said Trombley. “If I could sell it to Central Park, I’d be making millions.”

Jane Applegate is the author of “201 Great Ideas for Your Small Business,” and is founder of ApplegateWay.com, a multimedia Web site for busy entrepreneurs.

QUESTION: In response to the recent joint Commission on Accreditation of Healthcare Organizations (JCAHO) sentinel event alert regarding surgical fires, our facility manager claims that we need fire blankets, not fire extinguishers, in the ORs. Should fire blankets be used in the OR instead of fire extinguishers?

ANSWER: Fire blankets are not recommended for use in the OR. Fire blankets usually are made of wool that is impregnated with a fire-retardant chemical. They are meant to be wrapped around the burning person to smother the fire. According to ECRI, fire blankets should not be placed in an OR or used for patient fires. Following are the many reasons for this strong statement.

* The fire could be sustained by oxygen delivered to the patient, preventing the blanket from being effective.

* A blanket traps the fire next to and under the patient, causing further injury.

* Placing a fire blanket on a patient may displace instruments and cause further injury.

* Fire blankets will burn if used in oxygen-enriched atmospheres.

* Blankets are less effective at extinguishing fires on a patient than other methods, such as the use of a carbon dioxide fire extinguisher.

* Their use on a patient can lead to additional complications, such as wound contamination or even spreading the fire.

* If the blanket is placed in the OR, staff members may assume that it is suitable to use to extinguish a surgical fire, placing the patient at further risk. (1,2)

The JCAHO sentinel event alert on preventing surgical fires does not suggest that fire blankets be used in the OR or that they should replace fire extinguishers. The joint Commission does recommend that health care organizations do the following things to prevent surgical fires.

* Inform all surgical personnel about the importance of controlling heat sources by adhering to laser and electro-surgical safety practices, managing fuels by allowing sufficient time for patient prep, and establishing guidelines for minimizing oxygen concentration under drapes.

* Develop, implement, and test procedures to ensure appropriate response by all surgical team members to fires in the OR.

* Report any instances of surgical fires to JCAHO, ECRI, the US Food and Drug Administration, and appropriate state agencies as a method of raising awareness and preventing the occurrence of fires in the future. (3)

Fire extinguishers should be located in or near the OR to deal with fires that engulf or have migrated off the patient. Staff members should know when, how, and why to use fire extinguishers to put out a fire. Water-based, carbon dioxide C[O.sub.2], and dry-powder fire extinguishers commonly are used in the OR. According to ECRI, a 5-Ib C[O.sub.2] extinguisher should be mounted just inside the entry of each OR. (1) Local authorities have jurisdiction over specific requirements for health care facility portable fire extinguishers. Requirements for each type of fire extinguisher vary from state to state. Each state authority for fire regulations is governed either by the fire marshal or the state department of health. Some states may have local or regional regulations as well. Facilities should contact the local fire district for specific regulations for their area. (4)

QUESTION: Our infection control officer has asked OR staff members to evaluate alcohol-based surgical hand scrub products to replace the iodophor impregnated scrub brushes that we have used for years. Are these new brushless, alcohol-based scrub products acceptable?

ANSWER: Surgical hand scrubs have been known to play a vital part in preventing surgical site infections for many years, beginning with the pioneering work of Ignaz Philipp Simmelweiss, MD, and Joseph Lister, MD, in the 1860s. Antiseptic products and techniques used to perform the surgical hand scrub have evolved and improved, reflecting the continuing advancement of medical and nursing science.

In recent years, manufacturers have begun to introduce new hand scrub products that are challenging traditional lengthy scrub routines that use water, brushes, and, most commonly, either iodophor or chlorhexidine gluconate preparations. In the 2002 “Guidelines for hand hygiene in health care settings,” the CDC suggested that health care providers also consider the use of alcohol-based surgical hand scrub products when selecting hand hygiene agents, citing studies demonstrating that hand scrub formulations containing 50% to 90% alcohol combined with chlorhexidine gluconate are more effective than chlorhexidine gluconate, iodophor, and plain soap alone. (5) The publication of this CDC guideline produced a flurry of interest in the new brushless, alcohol-based surgical hand scrub products.

Many infection control and perioperative professionals are interested in trying these new products. Adapting traditional practices to new technology and innovation should be encouraged but approached with informed caution. Selection of surgical hand scrub products should not be taken lightly, and changes in products and technique should be made only after careful consideration and evaluation.

Surgical hand scrub products should be evaluated first for their ability to substantially reduce microorganisms on intact skin. The product should have broad-spectrum activity, be effective immediately, and have persistent activity. (6) A cumulative effect, measured after multiple applications during five days, also is desirable. An important additional consideration is the effect on the user’s skin over time. The product should not be irritating or damage skin after frequent and long-term use.

Alcohol-based brushless scrub products generally combine an antimicrobial agent, such as chlorhexidine gluconate with 60% to 70% alcohol, and added moisturizing emollients. They may or may not require the use of water. Hands should be pre-washed and nails cleaned with a nail pick under running water to remove gross debris and superficial microorganisms before applying the alcohol-based scrub product. Water will dilute the product and reduce its effectiveness; therefore, hands and arms should be dried thoroughly before the alcohol-based scrub is applied. The product contains alcohol and is flammable, so it must be allowed to dry before an individual dons gown and gloves. The entire process requires approximately three to five minutes.

The benefits of selecting a brushless, alcohol-based surgical hand product may include

* fast and easy application,

* limited or decreased damage to the user’s skin,

* improved compliance with hand antisepsis protocols,

* simplified application technique, and

* reduced material waste (ie, water, brushes, packaging).

Disadvantages may include

* user training needed;

* failure of the user to properly wash his or her hands before applying the product; and

* potential fire hazard (eg, failure of the user to allow the alcohol to evaporate before he or she dons sterile gloves and gown, improper storage).

Improper use and application technique as a result of user unfamiliarity with manufacturer instructions can be a problem. Physicians and other personnel who are new to the facility or who practice in multiple facilities may not be familiar with the important differences between the traditional scrub routine using a brush and antiseptic solution and the brushless technique using an alcohol-based scrub product. New users may not understand that hands still must be washed and nails cleaned before the alcohol-based product is applied, even though the product itself may be waterless. They may not understand the importance of allowing the product to dry completely before donning gown and gloves. Although the brushless technique is easy to learn, old habits often are difficult to break. Introducing a brushless surgical scrub product requires additional staff member preparation and education.

Alcohol is flammable, and alcohol-based scrub products must be used and stored carefully to minimize fire hazard. Although alcohol-based products have been used in health care settings for general hand hygiene without incident for some time, the American Journal of Infection Control recently reported an incidence of flash fire associated with the use of an alcohol-based hand antiseptic agent[..sup.7] Flash fires associated with use of alcohol-based hand hygiene products can have potentially severe consequences for health care workers and their patients. Health care workers should ensure complete drying or evaporation of the product before they engage in other activities. Other risk reduction strategies include maintaining ambient humidity within recommended limit (8) and avoiding use of 100% polyester gowns and drapes. If polyester gowns and drapes are used, they should have an antistatic carbon fiber or an antistatic finish.

Question: As a teaching institution, our hospital has a large number of students rotating through the OR. These students often request a copy of the next day’s surgery schedule so they can prepare for their learning experiences. I remember reading about a situation In which a medical student took a copy of a surgery schedule to the cafeteria and inadvertently left it there. A patient’s family member found the schedule listing the patient’s name end surgical procedure and immediately reported the incident. In light of this, should we remain firm in not allowing students to have a copy of the schedule?

Answer: You are correct to be concerned about protecting patient privacy. Although it is important to provide learning experiences for students, surgery schedules contain confidential patient information that must be carefully protected. The surgery schedule should be shared only with authorized individuals after all patient identifiers have been removed. As it may be possible to identify patients without having their actual names, schedules that contain any information that could be used to identify specific patients should not be distributed randomly or given to individuals who do not understand the importance of securing the information. In addition, schedules should not be placed in areas where unauthorized individuals can view the information (eg, unattended volunteer desks, nonstaff member areas, admitting desks).

Protecting patient confidentiality remains a basic ethical responsibility of perioperative nurses. AORN’s “Standards of perioperative professional performance” state that perioperative nurses are patient advocates and as such have a responsibility to maintain and protect patient confidentiality.(1) As health care facilities continue to develop privacy policies and procedures to comply with the Health Insurance Portability and Accountability Act, more attention is being focused on protecting confidential medical information.(2) Security of surgical schedules should be included in policy discussions, and a common-sense strategy should be developed to protect patient confidentiality while providing health care workers and students the information needed to care for patients safely and efficiently.

Question: There is a big debate at our hospital about whether student nurses observing in the OR for one day should wear scrubs or jumpsuits. Some believe the students should wear scrubs because they come close to the sterile field, and some believe that because students are not involved in the procedure, jumpsuits will suffice.

Answer: From a practice standpoint, either type of attire is acceptable; however, why give potential future perioperative nurses such a poor welcome? Singling them out with jumpsuits is no way to create a positive reception. Why not make their first experience in the OR pleasant and welcoming? Give students the accurate OR experience of donning surgical attire and make them feel as comfortable as possible. Be nice and give them scrubs.

Question: Some people ore starting to wear homemade cloth masks in the OR. The same masks are worn all day. Is this acceptable? What argument can be made against this practice?

Answer: Homemade cloth masks are unacceptable. Although early masks were made of muslin or linen, they only redirected exhaled air away from the surgical wound. Cloth surgical masks were replaced in the early 1960s with synthetic materials that also provide bacterial filtration.(3)

Wearing masks is recommended for two reasons. First, they contain and filter microorganism droplets that are expelled from the mouth and nasopharynx during talking, sneezing, and coughing. Second, they protect the wearer from exposure to infectious materials and other respiratory hazards, such as electrosurgical and laser smoke.(4) Fluid-resistant surgical masks are considered personal protective equipment (PPE), and the Occupational Safety and Health Administration requires health care workers exposed to blood and other body fluids to wear them. To be considered appropriate, PPE must

not permit blood or other potentially infectious materials to pass through
to or reach the employee's work clothes, street clothes, undergarments,
skin, eyes, mouth, or other mucous membranes under normal conditions of use
and for the duration of time which the protective equipment will be
used.(5)

Surgical masks should filter at least 0.3 [Mu] of bacteria for regular use and 0.1 [Mu] for laser use, or they should provide 90% to 95% bacterial filtration efficiency.(6) Masks must be changed between uses and whenever they become moist. Masks should not be reused throughout the day or saved by hanging them around the neck or tucking them into a pocket for future use.(7) The filter portion of the mask harbors bacteria collected from the nasopharyngeal airway, and care must be taken when removing the mask to avoid contamination of the hands.

It is extremely unlikely that an individual would have an adequate supply of freshly laundered–not home laundered–reusable masks to be able to change as frequently as recommended. Although there may be reusable materials that could meet fluid resistance and filtration criteria, it is extremely unlikely that a suitable reusable cloth material could be found, tested by an individual according to US Food and Drug Administration (FDA) guidelines, and manufactured on a home sewing machine according to industry specifications. Surgical masks are an FDA class II medical device that require special controls and are subject to premarket notification procedures (ie, 510k guidelines).(8)

Homemade cloth masks are inadequate to protect patients and OR personnel from exposure to infectious agents and other hazardous materials. Only masks approved by the FDA for use in the surgical setting should be used.

Question: How should a surgical mask be worn? I have started working at a new facility and have noticed that several staff members do not conform the top of the mask across the nose and cheeks, nor do they lower the mask completely under the chin. Many tie the bottom of the mask so loose that you can see their chin, mouth, and nose when looking at their profile. In 28 years as an OR nurse and 15 years as a manager, I have never seen this problem before. Is this a “sacred cow”?

Answer: This is not a “sacred cow.” The masks at your facility are not being worn appropriately. Masks should be worn according to the manufacturer’s written directions, based on the mask design. When not worn appropriately, masks will not perform as designed. Masks with strings should be tied tightly to prevent the strings from coming loose during the procedure. The upper strings are tied at the back of the head, and the lower strings are tied at the neck. The strings should not be crossed as this will cause a gap around the cheeks. The metallic strip at the nose should be contoured to fit the bridge of the nose.(9)

NOTES

(1.) “Standards of perioperative professional performance,” in Standards, Recommended Practices, and Guidelines (Denver: AORN, 2001) 145.

(2.) C Peterson, “Stained surgical linen; gowning at the back table; cloth hats; removing medication stoppers; patient privacy,” (Clinical Issues) AORN Journal 73 (June 2001) 1169-1171.

(3.) J Prust, “Surgical mask selection and application: Evaluation of performance criteria,” Infection Control Rounds 18 (February 1995) 4.

(4.) Ibid.

(5.) “OSHA Preambles, Bloodborne Pathogens (29 CFR 1910.1030) Section IX. Summary and explanation of the standard,” Occupational Safety and Health Administration, http://www.osha-slc.gov/Preamble /Blood_data/BLOOD9.html (accessed 16 May 2001).

(6.) Infection Control Devices Branch, Guidance on the Content and Format of Premarket Notification [510(k)] Submissions for Surgical Mask (Washington, DC: US Department of Health and Human Services, Public Health Service, Food and Drug Administration, Center for Devices and Radiological Health, Jan 16, 1998).

(7.) “Recommended practices for surgical attire,” in Standards, Recommended Practices, and Guidelines (Denver: AORN, 2001) 176.

(8.) Federal Register (2000) (codified at 21 CFR [sections] 878.4040).

(9.) N H Fortunato, Berry & Kohn’s Operating Room Techniques, ninth ed (St Louis: Mosby, 2000) 240-241.

RAMONA CONNER RN, MSN PERIOPERATIVE NURSING SPECIALIST AORN CENTER FOR NURSING PRACTICE

This is the first in a three-part series on the work, financial strategies and budgetary constraints facing St. Francis Medical Center in Lynwood, Calif., a hospital that turns no one away. Like other Catholic hospitals around the country that adopt this outreach-to-all approach, St. Francis has to balance budget and belief in the midst of traumas that come down to caring for sick and dying people one person at a time.

Part One: The ER–violence in the city. Personal tragedies–and $3,500 a day in the intensive care unit for penniless survivors. “Angels” in the mortuary.

Part Two, Feb 20.” No boundaries creating jobs and futures to heal the community while healing the sick: the hospital that intends to open its own inner-city university.

Part Three: Twenty hours in the ER: a pile of paperwork two-and-a-half feet high, plus bills that no one can pay. Hard cash and fundraising at a medical center that does not intend to go away.

Code Yellow. Trauma victim. A shooting. Ceiling speakers echo the alert throughout the Emergency and Trauma Services Department. As the ambulance wails toward St. Francis Medical Center emergency department bay, this is not television ER, with green or blue scrubs-garbed medical staff running and shouting, alive on an adrenalin rush

Those assigned to Trauma Room One here move quietly yet quickly along the corridors to take up position. The operating table is covered with sheets. Hope is high but experience breeds practicality–the edge of a body bag can be seen under the top sheet.

The en route emergency medical technicians–EMTs in the ambulance have already reported the victim’s cardiac arrest and resuscitation.

The alerted team is arriving: trauma surgeon, and ER doctor, anesthesiologist, surgery RNs, ER RNs, the X-ray tech with his mobile unit, respiratory therapist, people from admissions and social services. And the chaplain. Some take up positions around the bed, others remain by the curtains or in the corridor.

The exterior doors swing open. The gurney is on its way in. In the lead, IV drip held high, a Los Angeles County Fire Department EMT, two others alongside. They head straight into Trauma Room One, the lead EMT clearly reporting the situation. The gurney-to-table transition is smooth. The victim–Latino judging from his light brown skin visible in the break between the gurney sheet and the top of his shorts–is a dark-haired young man, early 20s. His faced is masked by oxygen equipment.

Around the table, skilled hands move rapidly. Electrodes for monitors, IV hook-ups, painkillers. The surgeon has the chest open, his hand is inside seeking to massage the heart. Readings freefall into another cardiac arrest. The resuscitation team “whoomps” the chest. The surgeon’s hand is back inside the chest in an attempt to locate the severed blood vessels. His finger goes into a hole in the heart. A bullet had come through from the back.

“I’m calling it,” said the surgeon. The young man was dead.

He died as John Doe. The chaplain did not know a name to use as she commended the young man’s soul to God.

Southern California’s most prestigious hospital is probably Cedars-Sinai in Beverly Hills. Think of St. Francis Medical Center as “Cedars-Sinai for the Poor.” There are private rooms in an ultramodern complex, the latest technology. The medical center has its own career college. Twice-a-year health fairs attract thousands, and a mobile health unit is out in the neighborhoods five days a week.

The hospital’s income from the care it provides falls millions of dollars short of the costs. St. Francis turns no one away in an area where the per capita income is $9,000 a year (compared to $23,000 for Los Angeles, $30,000 for the United States).

The city of Lynwood has gone from being white in the 1940s and ’50s, to African-American in the 1960s and ’70s, to all Hispanic in the 1980s and ’90s. Population is mostly Catholic and mainly–85 percent–extremely poor.

Overcrowding has reached astonishing proportions with two-and-three bedroom houses now occupied by 12 or more, sometimes many more, people. People live in garages and in their cars.

Despite its sun-drenched, pastel bungalow appearance, this is tough territory.

St. Francis Medical Center is in the toughest of hardboiled urban territories. Nearby neighborhoods served by the hospital are staked out by no fewer than 240 active gangs in Lynwood, Compton, Downey and abutting Los Angeles.

Little wonder that the hospital initiated an anti-gang program–or that the trauma department’s flow by mid-evening is periodically punctuated by a siren wail signaling another assault, another drive-by shooting, another beating, another knifing. Between times the emergency room also serves the heart attacks and respiratory failures, car crash victims, people injured in household accidents, folks who have fallen off ladders in their backyards picking avocados, or another homeless person collapsed on the sidewalk. Some victims of random violence survive, but not necessarily into a full life. A walk through the Intensive Care Unit makes that clear. A gas station attendant, 19 years old. The customer refused to pay and held the attendant by the collar while he fractured his skull with a baseball bat. The attendant will never walk again.

What, in that situation, does a chaplain say? To the family? To the young man?

“Mostly I don’t say anything,” said Friars of the Sick Poor Br. Richard Hirbe. “Being silent, that’s more than saying something. Present to the pain, testifying to God’s love. That’s all they want. We don’t have an answer. If you don’t have an answer, don’t make one up. Just be present. You have to cry with them.”

One day it was a victim who had something to say.

Cesar Galant, in his late 20s, had been shot. Paralyzed from the nipple-line down. His brother was killed. When Hirbe leaned over Cesar’s bed to tell him he was paralyzed, the young man said, “Teach me to fly, Brother. Teach me to fly.”

Those words were a defining moment for both Hirbe and Galant. Hirbe was so moved he founded the Friars and Sisters of the Sick Poor (NCR, Oct. 10, 2003).

Galant was so strong and determined that after he had regained strength and gone through rehab, he was hired as the medical center’s posttraumatic stress disorder counselor–part of the spiritual care team.

Five days a week he wheels into the rooms of patients suffering some type of trauma, listens and talks. And gives off encouragement by being who he is, not what he is, a person in a wheelchair. Not long ago he stopped by the friars’ house in Long Beach. He told Hirbe, “I’ve been to places that my legs could not have taken me.”

It’s true. He has brought his children and extended family back into the church; and made a series of pilgrimages to Mexico and elsewhere. In Rome Oct. 15, with Hirbe, Galant was blessed by Pope John Paul II, to whom Hirbe presented a copy of the statutes of the Friars and Sisters of the Sick Poor.

When Galant pulls up at the bedside of a young man newly paralyzed, said Hirbe, that young man already knows his legs are going to go. “The big concern–their hormones are raging at that age–will I be able to father children? And when they see Cesar and some of the things he does,” said Hirbe, “other questions surface, and it puts them on a spiritual path.”

Day in, day out, the hospital’s clientele is dealing with “grief, hopelessness, trauma, death, a tremendous amount of abuse, a tremendous amount,” said Hirbe. “So it’s about being a ray of hope, giving them some inspiration, pushing them to a window. This is not about health care, that’s not why the hospital is here. We’re continuing the mission that was started 2,000 years ago, to give people a sense of dignity.”

A day’s tally in the 36-unit ICU department includes a gunshot wound to the face; overdose; stab wound; gunshot wound to the left leg; rip in the stomach that won’t, can’t heal; and a woman in a coma, Jane Doe, on full life support until the ethical team meets to discuss her status. Unknown, broke–treated like a human being, a lady, a person of dignity. At a cost of $3,500 a day for days on end.

The cost of three days in ICU is more than the average Lynwood resident sees in a year.

Money no one’s got, and someone has to find.

Downstairs in the morgue, there’s more evidence of the Catholic way of death and life. A white household freezer hold fetuses and amputated limbs. There’s a contract with a local mortuary that will dispose of them properly, in a way that satisfies Catholic religious sensibilities.

From one freezer Hirbe removes a small white zippered case not much larger than one that could hold a laptop. He places it on a table and unzippers it. Inside there’s a little boy in blue, fully clothed and ready to go home. But frozen, awaiting burial instead. He died postpartum.

He was baptized “Angel.”

WHAT: Manufacturer of personalized doctors’ scrubs for children

WHO: Jacquelyn Aven of MiniScrubs Inc.

WHERE: Naperville, Illinois

WHEN: Started in 2002

SEEING A SICK CHILD ON TV INSPIRED Jacquelyn Aven to start her business. The little one, who’d spent a lot of time in the hospital, had on child-size scrubs. According to Aven, 38, the medical uniform seemed to make the child feel better, like he was a part of the team.

Aven knew countless kids–both in the hospital and out–would love to wear doctors’ scrubs of their very own in the same material and colors worn by real doctors. A mom herself, Aven was expecting her second child while starting up this part-time venture. However, she soon discovered that it would be no simple task to find a manufacturer willing to make the child-and infant-size scrubs with a high-quality material.

“I thought this was going to be the easiest thing,” Aven recalls. “It’s a great idea, and there are already adult scrubs on the market.” Learning by trial and error, Aven found a manufacturer who could make the scrubs to the specifications she needed–big enough to fit over a child’s head, with extra room in the diaper area. They’re also available with personalized embroidery to help little Molly feel like the future Dr. Molly Smith.

Aven started selling wholesale to hospital gift shops and got a good response; but her best outlet has been her Web site (www.miniscrubs. com), where she can get feedback directly from customers, “You can tell their excitement,” says Aven. >From moms who got the scrubs as baby shower gifts to children battling illnesses, Aven hears how her creation has brightened people’s lives.

Aven, who donated some of the profits from her sales of about 500 scrubs last year to organizations including the American Cancer Society and the Muscular Dystrophy Association, now plans to target doctors and dentists who want to outfit their children like morn and dad–and even has an eye on the veterinary market as well. Sounds like MiniScrubs is in very good health.

Ready for Takeoff

WHAT: A portable DVD-player rental service for airline passengers

WHO: Barney Freedman, Michael Freedman and Dave Kight of InMotion Pictures

WHERE: Jacksonville, Florida

WHEN: Started in 1998

MICHAEL FREEDMAN SPENT MUCH OF his time in airports and airplanes in the late ’90s, observing how bored people were in transit. Sure, there was in-flight entertainment–but it certainly didn’t interest everyone on board. It would be better, he thought, if passengers could choose their own movies and watch them on their own timetables.

At the time, DVD technology was still competing with the DivX format for consumer loyalty, but the trio of entrepreneurs put their money behind the DVD concept and designed their rental service offering. There are a few different rental options: Customers can rent the unit with a lilt DVD movie for the duration of the flight and then turn it in to a drop-off box at the destination airport. They can also keep the unit for the entire trip and return it ‘after the flight home. Or they can take a prepaid mailing envelope and mail the unit back from their destination.

The hard part was getting airport execs to warm to the concept. Freedman and his partners pitched all the airports they could and finally got Minneapolis-St. Paul International Airport and Portland International Airport to allow them to build storefronts in their concourses in 1999. Though Michael, 34, and partners Barney Freedman, 29, and Dave Kight, 38, lacked experience in the airport and film worlds, Kight had a retail background, which was helpful.

The business grew rapidly during the first two years, though the events of 9/11 slowed business dramatically. The company still hasn’t returned to its pre-9/11 rate of expansion, but its revenue growth is holding steady. Michael notes that today’s long security lines and even longer airport waits have made the InMotion product more useful than ever: People are actually watching movies at the gates well before takeoff. With 25 locations in 21 airports nationwide and sales well into the eight figures, these entrepreneurs are in for a very long ride.

All Dolled Up

WHAT: A manufacturer of authentic Russian nesting dolls with the likenesses of sports and entertainment figures, as well as traditional Russian nesting dolls

WHO: Alexander Krilov and Julia Butler of Newcrafters Nesting Dolls Co.

WHERE: Encino, California

WHEN: Started in 2000

ALEXANDER KRILOV WAS A MEDICAL doctor by trade, but when he emigrated from Ukraine 15 years ago, his thoughts turned to entrepreneurship. After running a variety of businesses, ranging from athletic shoes to international distribution for online florists, Krilov landed on the idea for sports-themed Russian nesting dolls while working as a business manager for Los Angeles Lakers star Stanislav “Slava” Medvedenko.

Krilov, 40, and his wife, Julia Butler, 45, noticed sports fans would buy anything featuring their favorite player’s likeness, so the pair decided to create a traditional-looking Russian nesting doll with the modern twist of a superstar’s face. Obtaining licenses from the NBA took perseverance, but in the end, Krilov and Butler were able to make dolls with the renderings of Kobe Bryant, Rick Fox and Shaquille O’Neal.

Manufacturing the dolls in high-quality plastic with almost portrait-quality artwork, Krilov and Butler have since secured licenses from the NHL and Major League Baseball, in addition to Elvis Presley and I Love Lucy properties. With these unique collectible alternatives to bobblehead dolls now being sold nationwide in arena stores, specialty stores and online, sales should hit $1 million in 2004.

ON A SHOESTRING

WHAT: A company that prints advertising on parking-garage tickets and other types of tickets in the transportation industry

WHO: Christopher Gilliam of AdverTickets

WHERE: Dallas

WHEN: Started in 1998

HOW MUCH: $5,000

With an eye for untapped marketing vehicles, Christopher Gilliam saw prime advertising space on the empty backs of parking-garage and valet tickets. People had to take the tickets, he reasoned, and keep them in their cars or hold onto them for the valet. Gilliam, 41, worked for an advertising company at the time and pitched the idea as an addition to the company’s offerings. When the agency didn’t want to take the chance, Gilliam decided to make a go of it on his own.

With a little less than $5,000 to start, he hit the ground running. He trekked to local parking garages and advertisers to gauge their interest in the concept. The interest was there, but learning the ins and outs of printing was a challenge for Gilliam, as was finding a printer he could trust. In fact, a mishap with a substandard printer cost him a substantial portion of his startup cash.

Despite his loss, Gilliam, a marketer at heart, spoke to anyone and everyone about his business. With luck on his side, he eventually met a property owner in Dallas who leased him an office for a very low rate–with no big deposit upfront. Located over a restaurant, the place had interesting (read: funky) food smells wafting in at 11 a.m. each day, but the space helped Gilliam grow the business fast and rebound from the printer glitch.

To further spread the word, Gilliam crashed the National Parking Association’s Parking, Transportation and Services Convention & Exposition trade show–”I didn’t have money to get a guest pass; [I was] sneaking around the monitors”–and started meeting people and showing them the product. His stealthy maneuver worked. Today, AdverTickets has clients like Delta Air Lines, DreamWorks; Jiffy Lube, Lexus and Sony, and can be found in parking garages all over North America and in Mexico and Puerto Rico. Sales are expected to exceed $10 million in 2004.

An experienced chief medical officer shares pearls of wisdom on ways to maintain the delicate balance between the medical staff and the administration.

**********

“No margin, no mission,” “physician satisfaction,” “patient satisfaction,” “high quality at low costs” are frequent topics of discussion occurring in the administrative “C suites” of today’s for-profit and not-for-profit hospitals.

As the challenges facing health care grow in scope and complexity, the role of the physician executive has evolved beyond the traditional duties of a medical director. Today’s vice presidents of medical affairs and chief medical officers are often positioned as major decision makers for hospital budgeting, operations and strategic planning.

Like a double-edged sword, the expanded responsibilities are coupled to higher expectations of performance as negotiator, facilitator, change agent and disciplinarian. Expecting Camelot, many new physician executives find ruling the hospital medical kingdom a daunting task for even the most politically astute.

Tom Dolan, president of the American College of Healthcare Executives, once described the physician executive “as a minister of state without portfolio.” Your physician colleagues believe you have gone to the dark side and your administrative associates consider you an enigma.

As a previous hospital chief of staff and current CMO of a two-hospital system composed of nearly 600 medical staff, I am often faced with decisions that must be made in times of crisis. I consult the works of Aristotle, Sun Tzu, and Machiavelli and then debate which one offers the appropriate advice.

The job life expectancy of a CMO is five years or less: therefore the physician executive today is often hired with expectations of immediate results with a short–if any–honeymoon period.

I find the adage “experience comes from doing many things and wisdom comes from doing many things badly” applicable to the physician executive. Here are some pearls of wisdom–or secrets–offered not from the perspective of a perfect CMO, but from one who has learned his lessons in harm’s way.

Tell no lies

Your personality may get the door open, but only your integrity can keep it open. Each day the busy physician executive has 10 to 20 conversations with members of the medical staff, very few of which are discussions of the weather. A staff member is often inquiring about the hospital’s strategic plans, the status of a future partner’s privileges or the purchase of the latest medicated, coated cardiac stent.

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Telling the truth is always the best practice, even if the message is not the most pleasant. The CMO is frequently the messenger of bad news in the form of new policies concerning medical records or surgical equipment that will not be purchased. Physicians are bright people and will see through your lies. Remember the old cliche “say what you mean and do what you say.” It will serve you well.

Relativity matters

When most of us think of the subject of relativity, we think of Albert Einstein’s famous theory about time. You probably do not realize that relativity is also important to your success as CMO.

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The time references used by hospital administrators differ from the time references of physicians. A physician will make numerous decisions each day regarding treatments and patient care, many of which really are a matter of life and death. The medical staff member cannot begin to fathom why it takes six weeks and four committees to approve a new foley catheter.

Occasionally, the physician executive may reduce the endless red tape of hospital policy; he/she must always acknowledge the physician’s frustration with the system. Return all physician phone calls on the day received and make it a habit to follow up on the progress of a project with your medical staff member either in writing, by phone or in person Remember, time is relative.

Be principled, but not inflexible

If this is your first physician executive position, you may believe many issues are black and white; after all, managing a hospital is not brain surgery. Unfortunately, after a short period of time, the wise CMO will discover multiple shades of gray. Compromise and negotiation are part of the job. Knowing which hills to charge and die on and those to carefully climb will distinguish the average physician executive from the exceptional one. Remember, do not let perfect stand in the way of possible.

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Go to the problem

Japanese business executives do not tolerate their young associates who try to describe problems they have not seen firsthand. If the surgeon tells you the OR is a disorganized mess, put some scrubs on and make your own assessment. It will more often than not be an enlightening experience. Remember, a picture is worth a thousand words.

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Never forget why you are there

Even if you are one of the 18 percent of physician executives with management degrees, the letters behind your name that got you the job were MD or DO. You were not hired because of your business skills: the woods are full of hotshot MBAs.

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You were employed to be the conduit between the medical staff and hospital administration because the most expensive piece of equipment in the hospital is the physician’s fountain pen. A few strokes of the physician’s pen can be the difference between black and red ink at the bottom of an income statement. Often you are the only one on the senior hospital administrative team that has gotten out of a warm bed at 2 a.m on a cold winter’s night to treat a scared, frightened patient in the emergency room.

Despite the fact that some of your medical staff feels like you are sleeping with the enemy, never forget you earned your place in the “club” and that position does not go away just because you go through the doors of administration.

Leadership delivers ROI

You will never be able to accomplish your goals and objectives without developing your own leadership skills, as well as the leadership skills of those around you. Provide your key medical staff leaders the opportunity to attend off-site leadership development meetings and also provide on-site speakers and books. Leadership can be your “true North” when faced with the difficult decisions encountered frequently in the role of CMO. Leadership isn’t everything; it’s the only thing.

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Be a life-long learner

When you were sitting before the medical admissions committee, you undoubtedly were asked. “Why do you want to be a doctor?” I suspect you did not respond “because I want to be a chief medical officer.”

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The skills that made you a great clinician are not enough to make you a successful physician executive. In fact, some may even impede your development.

As a clinician, you make rapid autocratic decisions each day about the care of your patients. The physician executive also makes autocratic decisions, but more frequently the process is collaborative, requiring leadership to reach consensus. Ask your CEO and board to provide the gift of an external coach/mentor to provide frank and sometimes painful advice regarding your weaknesses and blind spots.

Advanced management degrees like MBA, MMM, MHA, and MPH are required by many large hospitals because of the expanded operational roles physician executives play. Even if not required, I strongly recommend them because the degree differentiates you from others who may be experimenting with the role of physician executive because they are unhappy with clinical medicine.

Remember, you can only go as far as your current level of knowledge.

Always ask for help

Most physicians went into medicine to fulfill a need to help others. You will be surprised how often your medical staff will help if you will only ask. It does not mean they will necessarily like the idea, but it may buy you some time to win them over.

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When a physician does help, a follow-up handwritten note of thanks goes a long way to increasing future positive behavior. Remember, the four most powerful words of the CMO: “I need your help.”

Don’t go to a gun fight with a knife

Sun Tzu in The Art of War teaches us to avoid a battle and bloodshed through diplomacy whenever possible. Unfortunately, conflict is inevitable in certain circumstances and the physician executive must be prepared for and committed to war.

WHAT can a medical supply company do to boost sales in a flat industry?

At Scrubs Unlimited in Westwood Village, owner Phillip Gabriel generates nearly a third of his annual revenue in October selling everything from surgical scrubs and stethoscopes to lab coats and nurse’s uniforms for Halloween costumes.

During October, Gabriel said he gets between 200 and 300 customers a day while the rest of the year he averages 30 or 40.

“October is my Christmas,” he said. “Call me in December and I’ll cry on your shoulder, but this time of year is great for me.”

He started marketing his garb as costumes two years ago with a banner across his store proclaiming, “Everything you need to be a doctor or a nurse without the debt.”

Medical costumes have become so popular with UCLA students that fraternities and sororities now hold doctor and nurse parties. This year, Gabriel added “dirty doctor” and “naughty nurse” costumes, which have been a hit with more than just the college crowd.

“A lot of mild mannered soccer morns are getting into these outfits,” he said. “The nurse’s dress is pretty tight and form fitting, but it all depends how naughty they really want to make it.”

And it doesn’t matter if anything is left over after Halloween, because Gabriel can sell it during the rest of the year. “Except for nurse’s hats,” he said. “Nobody ever buys those things during the year.”

The real doctors and nurses that make up his clientele the rest of the year are apparently amused by the trend, even its more risque variations.

“In a way, it’s kind of flattering,” Gabriel said.

Summary points

Several websites provide information for geneticists on genetic disease, genetic services, and professional training

Two UK sites act as gateways to information on specific diseases and support groups, suitable for patients and their carers

Public health professionals and policymakers are well served by sites maintained by the Department of Health and the NHS

Good web based information on genetics for general practitioners and non-geneticist clinicians is lacking

Ethical, legal, and social issues in genetics are covered in sites maintained by national and international regulatory bodies in bioethics

Health professionals, patients, and the general public need authoritative, up to date information on genetics to enable them to understand and apply advances in this discipline. The immediacy and accessibility of the world wide web make it the perfect vehicle for this information. Identifying high quality, resources tailored to the requirements of particular users among the vast number of sites is not easy. We have compiled a list of useful web resources from the perspective of users based in the United Kingdom.

Methods

We selected sites on the basis of those used most often by our colleagues in different specialist areas of genetics. This article represents a consensus of their views. Sites are grouped by their major user communities; there is overlap, but the contents of the site give a good indication of those with wider relevance. We have also included both national and international online resources for bioethics.

Sites for genetics professionals

OMIM–Online Mendelian Inheritance in Man (www.ncbi.nlm.nih.gov/Omim/) is the “Bible” for all geneticists. The site contains constantly updated information on over 12 000 genetic diseases, their symptoms, inheritance patterns, and associated genetic loci (where known). It is easy to search and is now linked to the National Center for Biotechnology Information’s “Entrez” system, so that it can be queried in the same way as other resources such as PubMed and GenBank.

The British Society for Human Genetics (www.bshg. org.uk) is a federation of professional associations representing genetics professionals. Its site includes information about training and accreditation in genetics, regional genetic centres, and the society’s policy statements. It also hosts the minutes of the joint committee on medical genetics, the profession’s main advisory body to the government and other organisations.

The Clinical Molecular Genetics Society (www. leeds.ac.uk/cmgs) provides a useful compendium of practical information. The site includes a searchable list of DNA tests offered by NHS based laboratories (and a link to the European directory of DNA laboratories), best practice guidelines for DNA tests for several different genetic diseases, and information on jobs and accreditation.

The European Society of Human Genetics (www.eshg. org) is an international professional association. Its well organised and frequently updated site includes information about courses and conferences, a page of links, and the policy documents formulated by the society’s professional and public policy committee.

The human gene mutation database (archive. uwcm.ac.uk/uwcm/mg/hgmd0.html) is a comprehensive international database of genetic lesions that cause disease. It is regularly updated and may be searched by disease, gene name, or identifiers used by OMIM.

The familial cancer database (facd.uicc.org/) offers free software for downloading, which is designed to aid in the differential diagnosis of familial cancer. Registration is required.

Sites for other doctors and other primary care professionals

We could find no single site with comprehensive coverage of genetics topics of interest to professionals in primary care. A promising development is the planned addition of a “virtual genetics group” to the Royal College of General Practitioners clinical and special projects network. Its web page should be operational later this year (www.rcgp.org.uk/rcgp/ clinspec/index.asp).

The South West Thames Regional Genetics Service (www.genetics-swt.org/main.htm) operates from St George’s Hospital Medical School in London. The site contains information on local services. The “GP forum” pages contain brief notes about topics such as taking a family history, inheritance patterns for single gene disorders, and familial cancers.

Two sites based in the United States offer courses on genetics for doctors that can be downloaded. Although they are tailored for American users, they are a useful resource for organisers of training courses for general practitioners and for doctors with a special interest in genetics.

Genetics and your practice (mchneighborhood. ichp.edu/wagenetics/906317226.html) is produced by the Washington State Department of Health. The course was last updated in August 2000.

Clinical genetics: a self-study guide for health care providers (med.usd.edu/som/genetics/curriculum/ Handspic.html) is produced by the University of South Dakota Medical School. The course is not dated.

Sites for patients, families, and carers

Those affected by genetic diseases need information about their disease and its inheritance, advice on management, and how to find both knowledgeable clinicians and other affected families for support. For many affected families in the United Kingdom there are good local resources, but those with extremely rare diseases may need a larger resource such as the American based Genetic Alliance website (www. geneticalliance.org).

The Genetic Interest Group (www.gig.org.uk/) represents over 120 different support groups for families affected by genetic diseases. Its site contains basic information about inherited diseases and a list of member groups, many of which have their own websites (of these, the Tuberous Sclerosis Association (www.tuberous-sclerosis.org) has recently set up an online chat room for siblings of children with any genetic disorder (www.sibspace.org/)). The Genetic Interest Group is also active in policy development, and its papers can be downloaded as pdf files.

Contact a family (www.cafamily.org.uk/) provides support and advice to families caring for children with severe disabilities, many of which are genetic in origin. The site contains a searchable directory of conditions. Basic clinical information on each condition is provided by a named medical specialist, and this is dated. The site also includes contact details for support organisations and information about their activities.

The Cancer Research Campaign (www.crc.org.uk) provides a good summary of familial cancer (www.crc.org.uk/cancer/Aboutcan_fam1.html/). This page outlines the types of family history that indicate a high risk of breast, ovarian, or bowel cancer and explains genetic testing in families at high risk.

Sites for public health professionals and policymakers

The Department of Health has a genetics page (www.doh.gov.uk/genetics.htm) that links to all the major genetics advisory groups (Human Genetics Commission, Genetics and Insurance Committee, Gene Therapy Advisory Committee) and to the online text of policy and consultation documents.

The Human Genetics Commission (www.hgc.gov.uk/) is the major advisory body on genetics to the government. Its views and recommendations are not yet represented on the site in a systematic, subject based way, but those with sufficient interest can glean a great deal from the published minutes of its plenary and subcommittee meetings. Information about the commission’s public meetings and consultations are also posted on the site.

The Public Health Genetics Unit (www.medinfo. cam.ac.uk/phgu/) provides regularly updated information on the regulatory framework and policy development for genetics and the policy implications of ethical, legal, and social issues in genetics. A set of “disease profiles” outlines the genetic basis of nine diseases of importance to public health. The monthly newsletter highlights news, events, and papers of interest in the literature.

The Office of Genetics and Disease Prevention, US Centers for Disease Control and Prevention (www.cdc.gov/ genetics/) is the pioneer in the field of public health genetics. Its site features papers and policy documents on public health aspects of genetics, links to the human genome epidemiology net, and a listing of news stories, new papers, and events that is updated weekly.

HumGen (www.humgen.umontreal.ca/en/) was developed at the Centre de Recherche en Droit Public at the University of Montreal. Its three modules offer a searchable international database of policy documents in genetics, a monthly news update, and a searchable listing of organisations involved in developing genetics policy.