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September 1996

Ethics and Micromanaged Care

Author Affiliations

From the Department of Internal Medicine, Dermatology Section, Northeastern Ohio Universities College of Medicine, Rootstown, and the Department of Dermatology, Case Western Reserve University School of Medicine, Cleveland, Ohio.

Arch Dermatol. 1996;132(9):1013-1015. doi:10.1001/archderm.1996.03890330027004

The ethical foundation on which my medical practice is based was recently shaken by an episode involving the intrusion of managed care into my practice. With the patient's informed consent, I prescribed a medication that I knew would not work.

REPORT OF A CASE  A 46-year-old man presented for evaluation of his thickened, dystrophic toenails, which had caused him pain whenever he jogged. Physical examination revealed dry, moccasin-type scaling of his feet and yellowing, subungual hyperkeratosis, dystrophy, and distal onycholysis involving all 10 toenails.A potassium hydroxide preparation was obtained from the subungual debris, which showed septate hyphae, confirming the diagnosis of tinea pedis and onychomycosis. A prescription for oral itraconazole (200 mg twice a day for 1 week) was written, with 1 refill, and the patient was instructed to take the medication for 1 week each month following a pulse therapy protocol. Risks and benefits were discussed.Two hours

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