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VOLUME 22, NUMBER 9
FEBRUARY 28,1975
DURHAM, NORTH CAROLINA
Protocols: A Check-List for Health Care
I i* a
JUST A SIMPLE SORE THROAT?—Maybe so. Maybe not. Oeterminmg when they
are and when they're not, and setting out the proper course of action to take, is the
purpose behind a “patient care protocol” on sore throat developed by Dr. Kitty
Shinfioni (left) of the Department of Community Health Sciences. The sore throat
patient being examined in the University Health Services clinic in the Pickens
Building is Vinnetta Golphin, a Duke freshman. Nurse Practitioner Cathy Severns
conducts the examination. (Photo by Jim Wallace)
Two Researchers Receive
Grants for Cancer Studies
The National Cancer Institute has
announced grants to two medical
center scientists who are conducting
clinical and basic science research on
malignant tumors.
The awards will total almost $240,000
over the next three years.
Dr. Nelson L. Levy, assistant
professor of immunology, will receive
$182,440 to support his studies of the
body’s immune response to tumor
growth, and Dr. F. Stanley Porter,
professor of pediatrics, has been
awarded $56,531 to finance his
participation in the activities of the
Southwestern Oncology Group.
Levy prefaced an explanation of his
work by saying that when a tumor
t>egins to grow in a cancer victim* the
victim’s immune system recognizes that
unnatural growth is occurring. Some of
the host’s responses to the tumor are
protective of the host, and others are
strangely protective of the tumor itself.
The researcher said he is currently
attempting to discover what part of the
tumor cell stimulates a particular
response and how the response comes
about.
Working with melanomas, tumors of
pigmented cells often found on the
skin, and sarcomas, tumors arising out
of connective tissue. Levy is particularly
interested in “a type of immune
response known as blocking
antibody."
An antibody should normally be one
of the body’s allies in combating
disease and preventing the formation of
tumors, the Duke scientist explained,
but for some reason the ‘ human
blocking antibody" does just the
opposite. It inhibits the natural defenses
and thereby "encourages tumor
growth.”
Porter said the Southwestern
Oncology Group is one of a number of
similar cancer research associations
around the United States. Its members,
all physicians involved in clinical
research, treat their cancer patients
"under a common protocol ” (using
similar methods) agreed upon by the
group.
The physicians have joined together,
he said, so that data concerning the
illnesses and the results of the
treatment can be collected in a central
location and analyzed more rapidly.
“We’re involved in those aspects of
cancer which have to do with various
malignant diseases in children,” Porter
explained, "such as leukemias and
certain solid tumors. "
The term "patient care protocol” isn’t
exactly a household expression, and it
probably never will be.
But it just could have something to do
with the quality of health care you
receive in the years to come.
At least that’s the tjelief of a group
here, and the Henry J. Kaiser Family
Foundation has become interested
enough in it to award Duke a two-year.
$50,000 grant to develop the idea
further.
A protocol is a system of doing
something, and a patient care protocol
is a system of decision-making steps in
the diagnosis and treatment of an
illness. When followed, precisely. Duke
physicians believe it can greatly reduce
the chance for error, it may mean a cost
saving to the patient, it can t>e a training
aid to medical students and others and
it can be a means of monitoring the
quality of care patients are receiving.
The work is being conducted in the
University Health Services clinic under
the direction of the Department of
Community Health Sciences. The
person working the closest in
developing the protocols is a
Swiss-born physician who also has a
master’s degree in public health. Dr.
Kitty Shimcni.
So far Dr. Shimoni has written
protocols for sore throat and urinary
tract infections in women. Others
planned for development include
vaginitis upper respiratory infection,
lower back pain and hypertension (high
blood pressure). As many as 10 may be
developed under the grant.
If protocols were developed for the 10
most common complaints brought to
the Health Services clinic (which treats
Duke students, faculty, staff and some
off-campus patients). Dr. Shimoni said,
"We believe they would cover more
than 80 per cent of the visits to the
clinic.”
Among the reasons for having written
procedures to be followed step-by-step
are these:
* They provide standardized pathways
Seven Faculty Promotions,
Appointments Announced
Two appointments and five
promotions at the medical center have
been announced by University Provost
Frederic N. Cleaveland.
They are:
* Dr. David G. Warren appointed
professor of health administration.
* Dr. Robert F. Wilfong appointed
assistant professor of neurosurgery.
* Dr. Joseph C. Farmer Jr. promoted
to associate professor of
otolaryngology.
* Dr. Dorothy E. Naumann promoted
to assistant professor of community
health sciences and administrative
director of the Student Health Service.
* Dr. John W. Reed promoted to
associate proiassor of ophthalmology.
* Dr. M. Bruce Shields promoted to
assistant professor of ophthalmology.
* Dr. Walter G. Wolfe promoted to
associate professor of surgery.
A Chicago native, Warren received his
A.B. degree from Miami University in
Oxford. Ohio, and his J.D. degree from
the Duke School of Law in 1964. He has
held faculty appointments at the
University of North Carolina’s Institute
of Government and School of Public
Health.
A 1967 Duke University School of
Medicine graduate. Wilfong is a native
of Madison, Wis. He has been a
research fellow in neurology at Duke
since 1971.
Farmer is a Fayetteville native. He
received his M.D. degree from Duke in
1962 and was named an assistant
professor in the division of
(Continued on page 4)
for handling patient problems with the
objective being a high standard of
health care.
* They are a means of teaching
medical students how to approach and
care for minor illnesses in an organized,
efficient and economical manner.
"Most students have little contact
with such illnesses in a teaching
hospital setting, ” Or. Shimoni said,
“and certainly an inadequate exposure
in which they can devise and perfect a
personal approach to each presenting
complaint.”
* They provide a means of training
health-care professionals such as
physician's assistants and nurse
practitioners.
Physicians and medical students
“should be taught to delegate to others
those simple tasks which do not require
their skills, ” Dr, Shimoni said.
“The wisdom and necessity of
delegating tasks which do not require
the physician's skill to those with lesser
training has been underscored, not only
by the shortage of physicians but also
by the positive demonstration of the
high quality of the services rendered by
nurse practitioners, physician’s
assistants and others,” she said.
All the physicians and other health
care professionals at the Duke Health
Services clinic are following the
protocols.
Dr Harvey Estes, chairman of the
Department of Community Health
Sciences, said the protocol might be
compared with the check list an airline
pilot uses in preparing for takeoff.
If a pilot flips a switch on his control
panel and a light comes on. or doesn’t
come on. this may mean he can
advance to the next item on his check
list or it may mean a malfunction he
needs to check out first.
In the same fashion, Estes explained,
if a doctor finds a high fever and
swollen glands accompanying a sore
throat, this is the signal of a
“malfunction" that needs to be
investigated further before going on
down the check list.
Sore throat was selected as the
subject of the first protocol because it is
a common symptom of upper
respiratory infection and because
streptococcal throat infections
(commonly called “‘strep throat”) can
have very serious complications if not
detected and treated early.
Rheumatic fever, for example, which
can result in heart damage, is almost
always preceded by a streptococcal
respiratory infection.
The sore throat protocol also
contains guidelines for the
management of non-strep sore throat
and infectious mononucleosis, a
debilitating illness accompanied by
swollen glands and abnormal blood
counts that most often strikes
adolescents and young adults.
The sore throat protocol is a 38-page
booklet which is summarized in the
form of a two-page flowchart at the end
giving each step that should be
(Continued on page 4)