Lawsuit protection, customer satisfaction coverage, preserving the company’s assets insurance-all could be appropriate names for commercial general liability coverage. The liability exposure is the unknown risk every business faces. Since accidents can and do happen, even the best run business can face bankruptcy every time a customer walks through its door. People walk, children climb, teenagers eat-any activity can result in an accident, and how and where that accident occurs can determine the financial health of a business. Liability insurance is designed to allow the owners of a commercial enterprise to continue concentrating on their business plan, knowing that they have insurance to protect against the unforeseeable.

The CGL can be offered either on an occurrence basis or a claims made basis. It can be written either as a monoline policy or in connection with one or more other lines of insurance to form a commercial package policy. Instead of having to select specific areas of coverage (which may result in gaps in an insurance program), the insured enjoys fairly comprehensive liability coverage. The basic exposures covered by the CGL include:

* Ownership or use of the premises by the insured

* The insured’s operations

* Contractual agreements entered into by the insured

* Products the insured makes, sells or distributes

* Operations the insured has completed

* Personal and advertising injury caused by the insured

* Medical payments coverage on the insured’s premises or jobsite without regard to fault

Section I of the form provides three distinct coverages:

* Coverage A - Bodily Injury and Property Damage

* Coverage B - Personal and Advertising Injury

* Coverage C - Medical Payments

Each coverage is described in section I of the policy with an insuring agreement, exclusions and supplementary payment information.

The following sections apply to all three of the coverages named above:

* Section II describes who is an insured. A number of individuals are covered as insureds but only with respect to the named insured’s business.

* Section III explains the application of the various limits of insurance and how they work together.

* Section IV describes the conditions that are specific to general liability coverage. Many of these conditions explain the responsibilities of the insured after a loss. If the insured violates these conditions, coverage can be voided, so careful attention to this area is warranted.

* Section V covers definitions for certain words and phrases used in the coverage part. These definitions are not the same as the ones found in a dictionary. The important part of every definition section is the coverage that is provided and the coverage that is excluded by a definition.

The CGL coverage form has many endorsements available to tailor the coverage for a particular exposure situation. Some of the endorsements are mandatory for specific classifications while others are optional. The optional endorsements allow the insured to sculpt coverage to fit an individual need. This flexibility allows a standard form to become custom-made coverage.

The CGL has no limitations on the types of risks that can be written on a monoline policy or a commercial package program. Certain types of risks or classifications, however, may not be combinable with other coverage lines and therefore would not qualify for a commercial package policy discount. These include personal liability and farm liability risks. Also, some specific property programs cannot be combined with any other line for a package policy discount. These include highly protected risks (HPR), petroleum properties, petrochemical plants, electric generating stations and natural gas pumping stations.

Underwriting and rating commercial general liability coverages must start with thorough exposure identification. Since coverage follows the named insured operations on and off premises, underwriting efforts must concentrate on defining who is/are the named insured(s) is and what the named insured(s) do/does. All rating and underwriting decisions flow from the answers developed in this exploration effort.

Please note that this is only an overview of this coverage. A thorough discussion of this coverage form may be found in the PF&M Analysis from The Rough Notes Company.

Agency OnLine subscribers, please refer to PF&M Section 270.4-2 - Commercial General Liability Coverage Form Analysis for a more in-depth discussion of this coverage part.

Traditional herbal strategies for treating lung disease are founded on supporting and tonifying the innate protective resources. This is one area where the divide between traditional and modern approaches is particularly great. There are very few modern endorsements of early treatment strategies. Modern medical science, which at first embraced such agents in the earlier part of this century, now sees no role for their use. For example, modern editions of Martindale’s Extra Pharmacopoeia claim that: “There is little evidence to show that expectorants are effective.” Some modern drugs may have expectorant activity, such as bromhexine, but they are usually referred to as ‘mucolytic’. The impact of traditional remedies on the respiratory system is relatively poorly researched. Reliable external measures of change in mucosal functions are elusive; many respiratory diseases are either self-limiting or are among some of the most persistent conditions in the clinic. (1)

However, while the traditional herbal approach is somewhat lacking in scientific support, it is not without a rational basis. This article will examine some important herbal concepts involved in supporting the innate defenses of the lungs during infection. The key concept of expectorants will be discussed in detail, with a focus on the classification of expectorants and the scientific investigations into their effects.

Part of the problem with expectorants probably arises from confusion over their definition. Another aspect of the dismissal of expectorants stems from the difficulties involved with measuring their efficacy.

The four definitions of expectorants given below highlight the difficulties. The dictionary meaning is only concerned with the actual oral production of phlegm or sputum. Since the majority of mucus produced from the lungs is swallowed, this definition is clearly unsatisfactory. Definitions from the pharmacologists Boyd and Lewis are more useful but probably the best definition comes from Brunton, a 19th century pharmacologist.

Oxford Dictionary “Promoting the ejection of phlegm by coughing or spitting.”

Boyd (1954) “An expectorant may be pharmacologically defined as a substance which increases the output of demulcent respiratory tract fluid.”

Lewis (1960) “Expectorants increase the secretions of the respiratory tract and so reduce the viscosity of the mucus which can then act as a demulcent. By virtue of the presence of increased quantities of fluid mucus, expectorants produce a “productive cough” which is less exhausting and less painful to the patient.”

Brunton (1885) “Remedies which facilitate the removal of secretions from the air passages. The secretion may be rendered more easy of removal by an alteration in its character or by increased activity of the expulsive mechanism.”

Why Expectorants?

Many respiratory conditions are characterized by abnormal mucus (catarrh) which can narrow airways. This abnormal mucus may be thick and tenacious and hence very difficult to clear from the airways. If expectorants can render this catarrh more fluid and/or assist in its expulsion, then a clinical benefit should be achieved.

Expectorants can help to relieve debilitating cough. The presence of an irritation in the airways (such as tenacious abnormal mucus) invokes the cough reflex. (The cough reflex is most sensitive in the trachea and larger airways. The sensitivity progressively decreases in the finer airways and in the very fine airways there is no reflex at all. So in alveolitis, there is little stimulation of the cough reflex, whereas for tracheitis the stimulus is strong). By clearing abnormal mucus or by changing its character and making it more demulcent, expectorants can allay cough and are therefore antitussive.

Classification of Expectorants (after Gunn, 1927)

The classification of expectorants by their mode of action is extremely valuable in understanding their appropriate use. In 1927 Gunn proposed four classes of expectorants. (2) A fifth class was suggested by the Russian scientist Gordonoff. (3)

1. Reflex expectorants

These are emetics which cause an increased secretion of respiratory tract fluid when given orally in subemetic doses. Act by reflex from the upper GIT mediated by the vagus nerve eg saponin herbs, Lobelia, Ipecac

2. Central expectorants

Act on the CNS. Possibly Ipecac

3. Parasympaticomimetics

Stimulate the vagus nerve eg Pilocarpus. Also capsaicin (in Capsicum) stimulates bronchial C-fibres

4. Stimulants of secretory cells

Act directly on goblet cells, eg essential oils

5. Secretomotorics (after Gordonoff 1938)

Stimulate mucociliary transport, eg camphor, thyme

From the herbal perspective the two most important classes are the reflex expectorants and the stimulants of secretory cells. The use of the terms stimulating or relaxing expectorants is no longer valuable, as the following quotation illustrates.

The Nevada Nurses Association invites you to celebrate nursing in this regular feature, which looks at the actions and words of nurses who made a difference. This issue addresses the need to protect the word “nurse,” the image of nursing, and the early days of state registration for nursing.

In these days of casual dress and sometimes insufficient identification, the patient has to wonder which of the persons in the health care setting is the professional nurse. Worse yet, the consumer may be even more vulnerable at the doctor’s office, when an efficient young person wearing a scrub suit, with a stethoscope around her neck calls you into the room and says,: “I’m Patsy, the nurse.” An astute consumer, noting this person’s response (or lack of) to some real medical concerns might ask Patsy about her nursing background, and learn that she is “really a medical assistant.”

The need to protect the term “nurse” seems like a new problem. Yet, it is long standing, and we must be continually willing to address it. Here is an example from American Nursing A History: (book review, this issue)

So many Society girls had romantic notions about nursing, after the United States entered what became World War I in 1917, that Clara Noyes, Director of the Red Cross Bureau of Nursing, was flooded with applications. She wrote to her friend Adelaid Nutting in desperation:

Surely we need your prayers. There are moments when I wonder whether we can stem the tide and control the hysterical desire on the part of thousands, literally thousands, to get into nursing or get their hands upon it.

Tell Annie [Goodrich] of Albany that if I were not convinced before, I should be now that the most vital thing in the life of our profession is the protection of the word nurse.

Everyone seems to have gone mad. I talk until I am hoarse,, dictating letters to doctors and [to] women who want to be Red Cross nurses in a few minutes, not knowing the meaning of the word nurse and what a Red Cross nurse is. (p.199).

After the war, Clara Noyes assigned qualified Red Cross nurses to help develop nursing programs in recovering European countries and acquired Red Cross funds to build a nursing school in Bordeaux, “France. During America’s economic depression in America she designed programs for qualified Red Cross nurses to meet people’s health needs.

Noyes was firm about the need for nurses to stay current, to take ongoing coursework, and to be involved in their professional organization. She promoted postgraduate study and often contrasted the active interest of older physicians in continuing education with the indifference of older nurse graduates.

If we are a profession, then surely there is an absolute necessity for advanced study. If we wish to see this profession placed on a strong basis, then we must be strong as a body in the fundamental principles underlying our work. If we attempt to take a position in the front ranks of the progressive movements of the age and, what is more important, stay there, we must as individuals be thoroughly prepared, and this can only be done by courses of study which have been organized on a permanent educational basis. (1905)

It comes as no surprise to any perioperative nurse that the lay public has an incomplete and sometimes erroneous perception of what perioperative nurses know and do. When a question about the adequacy of a perioperative nurse’s actions or competency is brought to the legal system, however, lay judges, juries, attorneys, or administrative law judges must make decisions as if they understood perioperative practice. To make these decisions, they cannot rely on their own knowledge; they must be assisted by documentary and testimonial evidence. More often than not, they require the assistance of an expert nurse witness. This column briefly defines the role of an expert witness, traces the evolution of the need for expert nurse witness testimony, and describes the consultative services a nurse expert can provide.

DEFINITIONS

According to Black’s Law Dictionary, an expert is

a person who, through education or
experience, has developed skill or
knowledge in a particular subject so
that he or she may form an opinion
that will assist the fact finder. (1(p619))

An expert witness is a person

qualified by knowledge, experience,
training, or education to provide a
scientific, technical, or other specialized
opinion about the evidence or a
fact issue. (1(pl633))

An expert witness differs from a material or lay witness in two respects: the expert usually has no first-hand knowledge of what led to the case and unlike material witnesses who are limited in their testimony to providing objective descriptions of what they observed or did, an expert witness is allowed to give his or her professional opinion and draw conclusions.

THE NEED FOR NURSE EXPERTS

Expert nurse witnesses typically are needed whenever the adequacy of another nurse’s actions are in question. Usually, this occurs in disciplinary proceedings against a nurse licensee before an administrative law judge or in malpractice cases where the actions of the nurse are alleged to have contributed to a patient’s injury.

For decades, most courts accepted that physicians had the necessary expertise to explain standards of nursing. More recently, it has been recognized that testimony about what a nurse should have done best comes from another nurse. For example, in 1958, a California court allowed a physician to testify about what nurses should have done saying, “Surely a qualified doctor would know what was standard procedure of nurses to follow” (Goff v Doctor’s Hospital, 166 CalApp2d 314, 319 [1958]). Fourteen years later, a Pennsylvania court recognized that a physician might not be the best expert on nursing standards, but it still allowed physicians’ testimony to be admitted because, “all areas of medical expertise within the knowledge of nurses are also within the knowledge of medical doctors” (Taylor v Spencer Hospital, 292 A2d 449, 452 [Pa Super 1972]). Finally, in 2004, an Illinois court explicitly held that a physician was not qualified to testify as to the standard of care for the nursing profession under the laws of the state of Illinois (Sullivan v Edward Hospital, 806 NE2d 645 [Ill 2004]). Along with this increasing judicial recognition of the unique body of nursing knowledge comes an increased responsibility for nurses to be willing to share their expertise with lay legal decision makers; however, they must do so within the context of the unfamiliar, adversarial legal system.

FINDING A NURSE EXPERT

Identifying a possible perioperative nurse expert is more art than science. Attorneys may conduct online searches for persons who have spoken or written on issues relevant to the case, or they may conduct a search of nursing and health care literature online or in hard copy indices. They may ask attorney colleagues for referrals or contacts. Sometimes, they contact nursing schools or professional nursing associations.

Nurses interested in offering services as consultants or witnesses can place their contact information in classified advertisements in legal journals. Some attorneys may not consult classified advertisements, however, because of concern about the credibility of the nurse expert; some states require that experts earn most of their income from the practice of the profession, not from testifying or consulting in legal cases. (2-4)

NEGOTIATING A CONTRACT

A nurse who is asked to consult or testify must approach the agreement with the retaining attorney as he or she would any other contract. The nurse expert has absolutely no duty to consult and cannot be subpoenaed to testify unless he or she consents to do so. This is a main point that should be negotiated up front. After the nurse agrees to provide a service, the nurse is legally bound by contract to do so; thus, there must be a clear expectation of services, timelines, and remuneration for time and expenses.

* Does the service consist of reviewing medical records and providing an opinion to the retaining attorney?

* Is this opinion to be an oral or written report?

Clinical Quiz questions are based on selected articles in this issue. Answers appear in this issue.

American Family Physician has been approved by the American Academy of Family Physicians as having educational content acceptable for Prescribed credit hours. This issue has been approved for up to 4.5 Prescribed credit hours. Term of approval covers issues published within one year from the beginning distribution date of June 2000. Credit may be claimed for one year from the date of this issue.

The American Academy of Family Physicians is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The AAFP designates this educational activity for a maximum of 4.5 hours in Category 1 credit toward the American Medical Association Physician’s Recognition Award. Each physician should claim only those hours of credit that he or she actually spent in the educational activity.

AAFP Credit

Each copy of AFP contains a Clinical Quiz answer card. AAFP members may use this card to obtain the designated number of Prescribed credit hours for the year in which the card is postmarked.

AMA/PRA Category 1 Credit

AAFP members who satisfy the Academy’s continuing medical education requirements are automatically eligible for the AMA/PRA.

Physicians who are not members of the AAFP are eligible to receive the designated number of credit hours in Category 1 of the AMA/PRA on completion and return of the Clinical Quiz answer card. AFP keeps a record of AMA/PRA Category 1 credit hours for nonmember physicians. This record will be provided on request; however, nonmembers are responsible for reporting their own Category 1 CME credits when applying for the AMA/PRA or other certificates or credentials.

For health care professionals who are not physicians and are AFP subscribers, a record of CME credit is kept by AAFP and will be provided to you on written request. You are responsible for reporting CME hours to your professional organization.

NOTE: The full text of AFP is available online (http://www.aafp.org/afp), including each issue’s Clinical Quiz. The table of contents for each online issue will link you to the Clinical Quiz. Just follow the online directions to take the quiz and, if you’re an AAFP member, you can submit your answers for CME credit.

INSTRUCTIONS

(1) Read each article, answer all questions on the quiz pages and transfer your answers to the Clinical Quiz answer card (bound into your copy of AFP). This will help you avoid errors and permit you to check your answers against the correct answers.

(2) Mail the Clinical Quiz answer card within one year (by June 30, 2001). The bar code on the answer card contains your identification for CME credit hours.

Before beginning the test, please note:

Each Clinical Quiz includes two types of questions: Type A and Type X.

Type A questions have only one correct answer and may have four or five choices. Here is a typical Type A question:

Jul. 27-30: Louisiana AFP 1st annual summer breakaway. Marriott’s Grand Hotel, Point Clear. (17 1/2 hrs: P) Sponsor: Louisiana AFP. Contact Anne Cathey: 225-923-3313.

Arizona

Jul. 15: Clinical reviews: summer sessions 2000. Ritz-Carlton Hotel, Phoenix. (4 1/2 hrs: P) Sponsor: Mayo Clinic Scottsdale. Contact Sarah Dorste: 480-301-4580.

Jul. 18-19: St. Mary’s advanced cardiac life support (ACLS). St. Mary’s Hospital, Russellville. (13 1/2 hrs: P) Sponsor: AHEC Fort Smith. Contact Rhonda Horton: 501-968-2841.

Aug. 19: Clinical reviews: summer sessions 2000. Ritz-Carlton Hotel, Phoenix. (4 1/2 hrs: P) Sponsor: Mayo Clinic Scottsdale. Contact Sarah Dorste: 480-301-4580.

Aug. 24-26: Basic and advanced colposcopy. Sedona. (39 1/2 hrs: P) Sponsor: University of Toronto and Biomedical Communications. Contact Mary Ann Riopelle: 800-477-7702.

Sept. 22-25: Intensive conversational medical Spanish & cultural workshop. University of Arizona, Tucson. (36 hrs: P) Sponsor: Rios Associates. Contact Joanna Rios or Jose Fernandez: 520-907-3318 or 619-218-4875.

Sept. 23-27: PREP: the course. Doubletree Paradise Valley Resort, Scottsdale. (37 3/4 hrs: P) Sponsor: American Academy of Pediatrics. Contact Sandy Goldstein: 847-228-5005.

Arkansas

Jul. 13-15: Intensive workshop in health care ethics. Freeway Medical Tower, Little Rock. (17 1/4 hrs: P) Sponsor: UAMC Division of Medical Humanities. Contact Judy Smith: 501-661-7970.

Aug. 22: Neonatal resuscitation program. Medical Center of South Arkansas, El Dorado. (6 1/2 hrs: P) Sponsor: Area Health Education Center (AHEC) South Arkansas. Contact Carol Cobb/Debra Boyd-Jelks: 870-881-4417.

Oct. 17-18: St. Mary’s advanced cardiac life support (ACLS). St. Mary’s Hospital, Russellville. (13 1/2 hrs: P) Sponsor: AHEC-Fort Smith. Contact Rhonda Horton: 501-968-2841.

California

Jul. 7-9: San Diego Academy of Family Physicians 44th annual postgraduate symposium. Hotel del Coronado, Coronado. (17 1/4 hrs: P) Sponsor: San Diego AFP. Contact Terry Camarata: 619-422-1186.

Jul. 14-17: Intensive conversational medical Spanish & cultural workshop. Glendale Adventist Medical Center, Los Angeles. (36 hrs: P) Sponsor: Rios Associates. Contact Joanna Rios or Jose Fernandez: 520-907-3318 or 619-218-4875.

Aug. 4-7: Intensive conversational medical Spanish & cultural workshop. San Francisco. (36 hrs: P) Sponsor: Rios Associates. Contact Joanna Rios or Jose Fernandez: 520-907-3318 or 619-218-4875.

Aug. 6-9: Essentials in emergency medicine and urgent care. Hotel del Coronado, San Diego. (20 hrs: P) Sponsor: CME Associates. Contact Customer Service: 800-447-4474.

Aug. 6-10: U.S. women’s healthcare congress. Del Coronado Resort, San Diego. (20 3/4 hrs: P) Sponsor: CME, Inc. Contact Melba Hill: 949-250-1008.

Aug. 10-13: Cardiology in primary care. Hyatt Islandia, San Diego. (20 hrs: P) Sponsor: CME Associates. Contact Customer Service: 800-447-4474.

Aug. 11-13: Part B: MDT of the cervical/thoracic spine. La Jolla. (20 1/2 hrs: P) Sponsor: The McKenzie Institute. Contact Stacey Lyon: 315-471-7612.

Aug. 18-19: Controversies in women’s health. Disneyland Hotel, Anaheim. (12 hrs: P) Sponsor: UCLA CME/Iris Center UCLA Women’s Health Center. Contact Catarina Prata: 310-312-0531.

Sept. 7-10: Part A: MDT of the lumbar spine. Glendale. (27 hrs: P) Sponsor: The McKenzie Institute. Contact Stacey Lyon: 315-471-7612.

Sept. 14-18: Internal medicine 2000 fall program. Loews Coronado Bay Resort, San Diego. (20 hrs: P) Sponsor: CMEA, Inc. Contact Customer Service: 800-447-4474.

Sept. 20-23: 17th annual intensive course in geriatric medicine and board review. Fairmont Miramar Hotel, Santa Monica. (31 1/4 hrs: P) Sponsor: UCLA School of Medicine, Geriatrics. Contact Lucio Arruda or Catarina Prata: 310-312-0531.

Oct. 11-14: 22nd year: semiannual wound management workshop. La Jolla Marriott, La Jolla. (14 1/4 hrs: P) Sponsor: University of California, San Diego. Contact Mely Fitzgerald: 619-543-6084.

Oct. 23-26: Primary care update. Hyatt-Embarcadearo Center, San Francisco. (27 hrs: P) Sponsor: Interstate Postgraduate Medical. Contact H. B. Maroney: 608-231-9045.

Oct. 25: Improving end-of-life care for the hospitalized patient. Grand Hyatt Hotel, San Francisco. (7 hrs: P) Sponsor: Department of Medicine, CME, UCSF. Contact Cliff Brock: 413-476-5208.

Oct. 26-28: Management of the hospitalized patient in the managed care era. Grand Hyatt Hotel, San Francisco. (17 1/2 hrs: P) Sponsor: Department of Medicine, CME, UCSF. Contact Cliff Brock: 415-476-5208.

Oct. 27-29: Physician leadership program. Laurel Heights Conference Center, San Francisco. (19 1/2 hrs: P) Sponsor: California AFP. Contact Laura Johnson-Morasch: 415-394-9121.

Nov. 2-5: Advances in infectious disease. Loews Coronado Bay Resort, San Diego. (20 hrs: P) Sponsor: CMEA, Inc. Contact Customer Service: 800-447-4474.

Nov. 3-5: Part B: MDT of the cervical/thoracic spine. Glendale. (20 1/2 hrs: P) Sponsor: The McKenzie Institute. Contact Stacey Lyon: 315-471-7612.

Purpose-Increasing healthcare professionals’ knowledge about organ and tissue donation; the national mandates regarding referral compliance; and the effect on donors, donor families, and transplant recipients is a challenging task. Physicians not routinely involved in organ donation or transplantation are some of the most difficult professionals for organ procurement organizations to access. A course for medical students was developed to initiate the transfer of information, comfort, and familiarity with the organ and tissue donation process.

Methods-Discussions with a local medical school revealed that little organized education on organ and tissue donation existed. An elective course was developed consisting of 2-hour lectures, once a week for 6 weeks. Topics included an overview of tissue and organ donation, history and significance of the current crisis, determination of brain death and its role in organ donation, tissue donation, pretransplant and posttransplant processes, ethical issues, and the donor family and recipient experience.

Results-A thorough course proposal was presented to the medical school’s Chairman of Surgery and Chairman of Transplantation. The proposal was approved for first- and second-year medical students.

Conclusion-Offering medical students a unique and comprehensive course may attract curious students who could become future champions for donation. This type of educational approach may significantly influence future interactions between physicians and organ procurement organizations. If more organ procurement organizations implement this type of program, the medical students’ knowledge of donation will not only affect and benefit the local organ procurement organization’s service area but other procurement organizations throughout the country as well. (Progress in Transplantation. 2005;15:124-128)

There is an overwhelming demand for organs for transplantation. Every day, the waiting list for lifesaving organ transplants grows, and the supply of donated organs remains relatively unchanged.1 In an effort to increase donation and donation awareness in the hospital setting, the 1998 Federal Conditions of Participation from the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) was introduced.2 It was the first major intervention in many years that required collaboration between hospitals and organ procurement organizations (OPOs).2 Since then, OPOs have made aggressive attempts to meet the professional educational demands set forth by the 1998 legislation.

Increasing healthcare professionals’ knowledge about the organ and tissue donation recovery process; the national mandates regarding referral compliance; and the effect on the donors, donor families, and recipients is a necessary and challenging task that may positively affect organ availability for transplantation. Regional OPOs are in a unique position to present all aspects of these processes to a wide range of healthcare professionals. Educating hospital personnel such as physicians, nurses, clergy, and social professionals requires originality, maintenance, and persistence. The hospital development and procurement staff members of OPOs sustain donation education and awareness in the hospital setting with diligence; however, other professional education opportunities remain.

Recent research has shown that nursing schools throughout the United States provide organ donation education in their curricula. One study documents that US nursing education curricula on donation- and transplantation-related content are increasing.3 This donation education describing proper procedures and protocols plays a key role in higher donation consent rates.4 In addition, Frottas and Batten5 demonstrated that nurses’ attitudes regarding donation directly affect their interaction with families. Nurses who believe organ procurement is a professional responsibility have the fewest reservations about facilitating donation.5 In contrast to nursing education, only a small amount of research exists regarding the education of physicians.6-11

Of the various professionals, one of the more difficult groups to access are physicians not ordinarily involved in organ donation and transplantation. The concept of organ and tissue donation during physicians’ education process is limited in the rapidly changing environment of organ donation medicine. The training of physicians directly affects the donation process and their involvement is paramount and should not be overlooked.12 However, achieving a partnership between OPOs and physicians is a complex challenge. In 1992, the United Network for Organ Sharing assembled a consortium of transplant professionals, and developed an organ donation and transplantation curriculum for medical schools.13 Its voluntary implementation was dependent on the medical school and the OPO was not always involved. However, the fact that the curriculum has not been updated since it was originated limits its utility. At the same time, the environment of organ donation and transplantation has experienced numerous changes in practice, policy, and philosophy. To enhance physicians’ knowledge, comfort, and familiarity with the organ and tissue recovery process and procurement organizations, a collaborative course was developed between the regional OPO and local medical school. The goal of this course was to facilitate the transmission of this information at the level of first- and second-year medical students.

Managing a practice in today’s complex health care environment not only requires excellent clinical skills, but also superior business skills. To help practicing physicians better understand the business side of medicine, the American College of Physician Executives has developed a new, completely online, Practice Management course.

Similar to ACPE’s Practice Management Institute offered live at the Spring Institute, this Web-based course allows participants to learn without the expense and hassle of travel. Busy clinicians do not need to leave their practice or their families to gain skills to improve clinical and financial outcomes of their practice.

* How to interpret and use financial tools to measure and improve your practice’s profitability

* Ways to avoid billing and coding mistakes that may be costing you lost income

* Proven methods to improve quality and clinical outcomes

* The business secrets that America’s best practices are using to provide excellent patient care

* Practical, hands-on ways to boost your bottom line through more efficient scheduling, staffing and time-saving technology

Participants will also receive templates and worksheets to put to use right away in their own practices. Physicians, office managers and staff are welcome to participate in the course and take advantage of the expert insights.

We threw out the baby with the bath water when we discarded carbohydrate counting’, said Pat Clarke, Diabetes Specialist Nurse in Nottingham.

Pat described the case of a 21-year-old builder diagnosed with type 1 diabetes in 2000. He was put straight on to insulin but experienced consistently high glucose levels, particularly in the afternoons. A major problem identified was that he never changed his insulin doses to match the number of carbohydrate portions consumed. Being educated on how to do this has since helped him control his diabetes.

Local school districts nationwide are experiencing increases in special education costs. In states that are placing a high priority on education reform, the special education cost increases are rapidly compromising the ability of districts to effectively fund the implementation of these reforms. However, in searching for a way to address rising costs, policymakers often err in their diagnosis of the problem.

Policymakers point to two major causes of the increase in costs. First, they claim schools are funneling too many children into special education to ease the burden on the classroom teacher of addressing behavioral and learning problems. Second, they point to the increased advocacy on the part of parents and physicians.

Based on these assumptions, policymakers tend to recommend that states impose financial disincentives for increases in special education populations. They believe these disincentives will force school districts to apply more rigorously the eligibility requirements, leading to smaller special education enrollment and less special education spending.

Primary Factors

Although these two factors may play a minor role in the increase in special education enrollments, far more significant causes generally have been ignored. In a case study of cost increases in Massachusetts, we determined that the increases were not caused by school district policy and practice. In fact, just the opposite was the case.

School district policy and practice was effective in containing and even reducing the percentage of children who required special education services. We found that cost increases were primarily due to the increased number of children with more significant special needs who require more costly services.

The root causes of these increases were factors beyond the control of schools, such as advances in medical technology, the deinstitutionalization of children with special needs and privatization of services. Also contributing were economic and social factors, such as the rising number of children in poverty and the number of families experiencing social and economic stress.

Because the increase in special education enrollments reflects real increases in the needs of children in the overall population, the solutions recommended by policymakers only exascerbate the problem by making funding to serve these children more difficult to access. This produces a no-win situation for both regular education children and special education children whose interests too often are pitted against each other in funding debates.

These findings emerged from a study of special education cost increases in Massachusetts completed by a task force of the Massachusetts Association of School Superintendents. Although the results of the study draw from data in one state, the national data on special education suggest these factors may be influencing the increased number of special education children nationally.

The Cost Reality

The special education components of the school funding formula for education reform in Massachusetts were built on the assumption that school districts did not effectively contain costs and identified more children than necessary as having special needs. Specific elements of the formula were designed as disincentives to these practices. For example, in all areas other than special education, actual enrollment within a district is used to calculate state aid. Additional allocations are provided for the actual number of students who are from low-income families or who are in bilingual or vocational programs.

In contrast, allocations for special education are based on a preset percentage of children in special education, set at a rate lower than the state average. In addition, the cost allocations for providing services are set at levels well below the actual costs. These disincentives were designed to cause districts to be more rigorous in their use of the eligibility standards and to encourage more cost-effective placement of students.

Our analysis of the data for Massachusetts school districts, not including regional vocational schools, shows that these assumptions are not accurate. In fact, schools have done a good job containing costs. They rigorously have applied eligibility standards and provided regular education and inclusive programming for children as an alternative to special education services. The percentage of children enrolled in special education in Massachusetts reached a high in 1991-92 of 17.4 percent but declined to 16.3 percent in 2000-2001.

In spite of the districts’ best efforts, costs have continued to increase as districts have enrolled a greater number of children with more serious needs. We found that between 1989-90 and 2000-01 per-pupil expenditures in special education escalated from $6,675 to $12,416, while they increased by only one-third as much in regular education from $4,103 to $6,177. This represents an increase of 86 percent in per-pupil special education expenditures in contrast to a 50.5 percent increase in per-pupil regular education expenditures.