Prevalence of gestational diabetes and risk of complications before and after initiation of a general systematic two-step screening strategy in Germany (2012-2014)

AIMS

Information on the prevalence of gestational diabetes mellitus is scarce on national and international level. On July 1st, 2013, a general two-step screening was implemented in Germany harmonizing gestational diabetes diagnoses. We aim to provide prevalence estimates for gestational diabetes and pregnancy-related complications for the large region of North Rhine for the 12 months before and after introduction of the general screening.

METHODS

Routine care data covering all outpatient diagnoses of more than 150,000 pregnancies per 12-month period in women aged 15-55 years was used to determine cases of gestational diabetes. Gestational diabetes diagnosis and pregnancy-related complications were assessed according to the International Statistical Classification of Diseases and Related Health Problems (ICD-10). Relative Risks for pregnancy-related complications were calculated in pregnancies with and without gestational diabetes.

RESULTS

Before the screening, diagnosis of gestational diabetes was made in 6.02% of pregnancies and in 6.81% after this date (other types of diabetes mellitus: 1.67% and 1.76% respectively). The prevalence of GDM increased with age and was highest at age 36-40 years (8.45%). The relative increase in prevalence after introduction of the screening was highest in the age group≤25 years (24.9%). The frequency of pregnancy-related complications such as hypertension, pre-eclampsia, cesarean section was increased in pregnancies with gestational diabetes in comparison to those without independent of observation period.

CONCLUSIONS

We found a high prevalence of gestational diabetes, which has relatively increased by 13.12% after the introduction of the general screening.

Mobile phone base stations and adverse health effects: phase 2 of a cross-sectional study with measured radio frequency electromagnetic fields

OBJECTIVE

The aim of the cross-sectional study was to test the hypothesis that exposure to continuous low-level radio frequency electromagnetic fields (RF-EMFs) emitted from mobile phone base stations was related to various health disturbances.

METHODS

For the investigation people living mainly in urban regions were selected from a nationwide study in 2006. In total, 3526 persons responded to a questionnaire (response rate 85%). For the exposure assessment a dosimeter measuring different RF-EMF frequencies was used. Participants answered a postal questionnaire on how mobile phone base stations affected their health and they gave information on sleep disturbances, headaches, health complaints and mental and physical health using standardised health questionnaires. Information on stress was also collected. Multiple linear regression models were used with health outcomes as dependent variables (n = 1326).

RESULTS

For the five health scores used, no differences in their medians were observed for exposed versus non-exposed participants. People who attributed adverse health effects to mobile phone base stations reported significantly more sleep disturbances and health complaints, but they did not report more headaches or less mental and physical health. Individuals concerned about mobile phone base stations did not have different well-being scores compared with those who were not concerned.

CONCLUSIONS

In this large population-based study, measured RF-EMFs emitted from mobile phone base stations were not associated with adverse health effects.

Mobile phone base stations and adverse health effects: phase 1 of a population-based, cross-sectional study in Germany

OBJECTIVE

The aim of this first phase of a cross-sectional study from Germany was to investigate whether proximity of residence to mobile phone base stations as well as risk perception is associated with health complaints.

METHODS

The researchers conducted a population-based, multi-phase, cross-sectional study within the context of a large panel survey regularly carried out by a private research institute in Germany. In the initial phase, reported on in this paper, 30,047 persons from a total of 51,444 who took part in the nationwide survey also answered questions on how mobile phone base stations affected their health. A list of 38 health complaints was used. A multiple linear regression model was used to identify predictors of health complaints including proximity of residence to mobile phone base stations and risk perception.

RESULTS

Of the 30,047 participants (response rate 58.6%), 18.7% of participants were concerned about adverse health effects of mobile phone base stations, while an additional 10.3% attributed their personal adverse health effects to the exposure from them. Participants who were concerned about or attributed adverse health effects to mobile phone base stations and those living in the vicinity of a mobile phone base station (500 m) reported slightly more health complaints than others.

CONCLUSIONS

A substantial proportion of the German population is concerned about adverse health effects caused by exposure from mobile phone base stations. The observed slightly higher prevalence of health complaints near base stations can not however be fully explained by attributions or concerns.

[The new private health insurance subscribers]

The new German legislation concerning the modernisation of statutory health insurance allows statutory health insurers to cooperate with their private health counterparts to offer supplementary health insurance. This study investigates the demand for such policies and how much someone is prepared to pay for them. Furthermore, the study tries to characterise the subscribers of supplementary health insurance. This analysis is based on data from the TNS Healthcare Access Panel on 896 statutory health insured persons aged 20 to 79 years. Statutory health insured persons show a great interest in supplementary health insurance policies. 67.3 % are prepared to subscribe to one or more policies and pay monthly 29.37 on average. Subscribers to supplementary health insurance policies also support a model of statutory health insurance which gives them an opportunity to choose between a basic level of cover and the extended benefits of a supplementary health insurance policy. In addition, they are high earners and rarely see a physician. They are very content with their statutory health insurers; however, their opinion about the German health system differs because part of the subscribers are very content and others are dissatisfied. Moreover, the study shows that persons who see a physician often and who assess their state of health poorly would significantly buy fewer supplementary health insurance policies. It is not certain why this group come to such a decision. However, if supplementary insurance policies help to determine the levels of access granted to see a physician then this study demonstrates that persons with a high demand for medical care and poor persons are excluded.

Leistungen und Kosten der Hochschulambulanzen in Forschung, Lehre und Versorgung

BACKGROUND

Outpatient clinics of university hospitals (Hochschulambulanzen) play a significant role in the German health care system. Universities have in contrast to other hospitals the right to implement an outpatient clinic, but the health care services they can render are restricted to clinical research and teaching activities. The university outpatient clinic study evaluates the intensity of medical care, teaching, research activities, and the related costs. METHOD AND DATABASE: 6 university hospitals with 51 outpatient departments in Germany were included. The prospective documentation of consultations was restricted to 800 visits per department. A total of 26,312 consultations with approximately 40,000 diagnoses and 150,000 services were documented. Furthermore, data concerning costs, teaching activities and research facilities were documented.

RESULTS

Clinical treatment without any correlation to research or teaching activities amounted to about 81 % of the working time in the outpatient department (research 11 %; teaching 8 %). The primary task of the university outpatient clinics takes up less than 20 % of the working time. The physicians documented that the disease of every fourth visit was in accordance with their main field of research. 6.9 % of the visits were asked to take part in clinical trials, of these 1.25 % were included for the first time, 3.7 % were already included. 6.5 % of the visits were addressed to participate in specific teaching activities. The average total costs per case added up to 149 Euro. No outpatient clinic could cover the total per case costs with the lump sum payments. On the average 31 % of these costs were covered by lump sum payments (without cases concerning research and teaching).

CONCLUSION

Treatment in outpatient departments of university clinics is far beyond research and teaching activities required by law. However, the ability of outpatient departments of universities to provide excellent outpatient services should have a more dominant role in the health care system. Therefore access to care should be deregulated for the patients and reimbursement schemes should be adjusted to adjust for the present losses.

[The Bavarian Health Survey--goals and selected results]

The Bavarian Health Survey (1998/99) is a new element in the Bavarian health reporting system. It was conducted in close connection with the German Health Survey as a combination of a questionnaire and health examination survey with participation of the Bavarian local health offices. Based on a random sample of more than 1,800 persons aged 18 to 79 years, life-prevalence data on diseases of the metabolic system, selected laboratory results and obesity are reported.

[The Menopause Rating Scale (MRS II): methodological standardization in the German population]

The Menopause-Rating-Scale (MRS I) was used in clinical practice since 1992. The physician had to document the severity of 10 important estrogen-related climacteric symptoms. Practical experience and a critical methodological evaluation justified a revision: The MRS I should be converted into a self-administrative rating scale, the wording somewhat optimized, the layout adjusted and one item added. The standardization of the new scale (MRS II) was performed in a representative sample of the German population aged 45-60 years. Three dimensions were extracted from the menopausal symptoms using multivariate statistical techniques: somato-vegetative, psychological, and urogenital complexes of symptoms. A simple evaluation scheme was developed for the MRS II by summing up scoring points. Reference values for the frequency of 4 levels of intensity of complaints in the population were defined and provided for purposes of comparison. The MRS II meets a high methodological standard as an instrument standardized in the population. Moreover, it is convenient to apply this instrument in daily practice in order to quantitate variation of menopausal complaints.

The Menopause Rating Scale (MRS): reliability of scores of menopausal complaints

OBJECTIVE

To analyze the reliability of scores of the recently developed self-administrative Menopause Rating Scale (MRS) in a follow-up investigation of a cohort after approximately one and a half years, and to look for possible reasons for variation.

METHOD

A follow-up investigation of a random sample of an initially representative survey of German women (aged 40-60), which dated back to early 1996, was performed in late 1997. A subsample of 306 women participated. The MRS scale, a self-administrative standardized questionnaire, was applied with additional, mainly health-related, questions.

RESULTS

The MRS results at baseline and follow-up were significantly correlated (r = 0.60). The majority of women remained in the category 'no or mild menopausal symptoms'. The kappa statistics showed significant agreement of the various subscales (total, somatic, psychological and urogenital scales) between the two measurements. Neither age nor social factors contributed to a change of score according to a multiple regression analysis. Some, but not all, health-related variables showed a slight association with change of score, such as satisfaction with health in general and, specifically, the presence of hypertension, cardiac and gastrointestinal diseases. No overall relation to hormone replacement therapy (HRT) was found during this observation period.

CONCLUSIONS

The majority of women demonstrated sufficient reliability of MRS scores. Changes in the score after one and a half years were little influenced by the variables tested, except some health conditions such as cardiac disease. It should be stressed that the MRS has the benefit of being a self-administrative tool for the assessment of climacteric complaints with convenient applicability, and representative reference data have been collected in a German population.

The Menopause Rating Scale (MRS): comparison with Kupperman index and quality-of-life scale SF-36

OBJECTIVE

To evaluate further the Menopause Rating Scale (MRS) for scoring menopausal symptoms by comparison with other instruments relevant for women in their menopausal transition: the Kupperman index and the quality-of-life scale SF-36.

METHOD

A population sample of 306 women, who had been randomly selected from an initially representative survey of German women (aged 40-60), completed three questionnaires in 1997: the Menopause Rating Scale (MRS), the Kupperman index and the short form-36 (SF-36).

RESULTS

A comparison of the MRS with the Kupperman index produced a high correlation of raw scores (r = 0.91). The highest association of scores (80%) was found in the highest quartile of the MRS. The terms 'mild', 'moderate' and 'severe', relating to the degree of severity of menopausal symptoms, reflect different contents and spread in each scale, i.e. are not directly comparable. There is a strikingly good association between the subscales of the SF-36 and the MRS. The MRS correlates best with those dimensions of the SF-36 that are highly relevant for women in the menopausal transition. For this reason, the MRS can be utilized as an age- and condition-specific quality-of-life instrument.

CONCLUSIONS

The Menopause Rating Scale is a valuable modern tool for the assessment of menopausal complaints. It combines in practice excellent applicability and good reliability, and there are normal values for the population available. The MRS could serve as an adequate diagnostic instrument for menopausal quality of life.

[Process and results of field work concerning the Federal Health Survey]

"I + G Gesundheitsforschung" was responsible for data acquisition and data processing of the survey, which included the production of the survey documents and the conceptualization and production of the operation manual. Furthermore, the institute's task was sample design and sample drawing. This article reports on the continuity and the results of the field work and includes experiences and realizations resulting from the field work. These might be helpful for similar surveys in the future and contribute to the improvement of the procedures.

Predictors of early retirement and rehabilitation for use in a screening to detect workers in need of rehabilitation

In the German pension insurance sector a screening is being suggested to ensure the participation in rehabilitation measures of workers at risk of health-related early retirement. Screening presupposes empirical indicators of rehabilitation needs. A study is presented that determined predictors of early retirement and rehabilitation from longitudinal data for use in a screening for the selection of workers likely to be in need of rehabilitation. We gathered longitudinal data by conducting a second survey with a cohort for which the first survey had delivered clinical findings, lab. values, medical diagnoses and self reports regarding morbidity, medication, health-related behavior, family- and occupational-related strains, and sociodemographic information (first survey T0: 1975/76, n = 3.968; second survey T1: 1992/93, n = 28.463). The survey of T1 also comprised inquiries of the pension insurance institutions concerning the retirement and rehabilitation status for pension-insured study subjects (n = 1.794). Based on these subjects, using multi- and bivariate regression analysis, we determined those T0 variables which were significantly related to the events of early retirement (98 cases/357 controls), rehabilitation (127 cases/200 controls) and early retirement or rehabilitation (185 cases/270 controls) in the period T0-T1. The significant T0 variables were subsequently used for the definition of a selection index which measured rehabilitation need by a simple sum score (number of significant T0 variables present). We tested the discriminative power of this index for a subsample of the cohort (cases who retired early or underwent rehabilitation and controls). The index classified 68% of the cases correctly. The sensitivity reached 57% and the specificity 76%. In connection with this result, the long prognostic time interval (up to 17 years) has to be considered. In the case of screening the preselection of workers via the index would occur at the same time as the medical assessment of the actual need for rehabilitation. An earlier study showed that this would raise sensitivity and specificity of an index based on predictors of early retirement substantially.

["Index for rehabilitation eligibility" for screening social insurance workers]

The principle "priority of rehabilitation over early retirement" might be realised by a screening by which employees in need of rehabilitation are detected in time and rehabilitation measures are purposively started. With the "Index of Rehabilitation Need" we continued our efforts to develop an applicable screening tool on an epidemiological basis. To this end (1) longitudinal data were established by repeating an epidemiological survey of a population sample in the Nordenham/Brake region (T0 = 1975/76, T1 = 1992/93); (2) T0-variables were identified which correlated significantly with the events of early retirement and/or rehabilitation in the period of T0 to T1 (98 cases of early retirement/357 controls; 127 cases of rehabilitation/200 controls; 185 cases of early retirement of rehabilitation/270 controls) using bivariate and multivariate regression analysis; (3) significant T0-variables were used to construct a questionnaire index (based on self assessment of symptoms/complaints, consumption of medicaments, smoking, and work load--16 items), a medical examination index (based on clinical/laboratory findings and medical diagnoses--10 items), and an overall index (sum of both indices--26 items); (4) the index values were calculated for cases of early retirement of rehabilitation and controls of the cohort (185/270), for each index significant differences between cases and controls tested, and the screening characteristics of the overall index analysed; (5) possible reasons for incorrect classifications were examined using a subsample of cases and controls (n = 96/78), for which additional data on medical and work history, stressful life events, and attitudes towards rehabilitation had been collected. All indices showed significant differences between cases of early retirement or rehabilitation and controls. These differences proved to be stronger with the questionnaire and overall indices (p < .0000 each) than with the medical examination index (p < .0006). The overall index did not detect 18% of the cases in need of rehabilitation (false negatives). The proportion of the false positives was 14%; sensitivity and specificity amounted to 57% and 76%. The analysis of the subsample revealed only two possible and plausible reasons for incorrect classifications: the time span between the first survey and the year of early retirement as well as injuries. The index detected cases of early retirement or rehabilitation more easily where the time span between T0 and the year of early retirement was shorter. The index cannot detect cases of early retirement and rehabilitation caused by injuries between T0 and T1, since it is based on chronic disorders and stresses to be the reason for both events. With respect to the sensitivity and specificity of the index the relatively long prediction period needs to be taken into consideration--between T0 and the time of the events there could have been a period of up to 17 years. However, the objective of a screening is not to predict the long-term outcome but to preselect persons who are likely to need rehabilitation and should be invited to a socio-medical examination in order to clarify their rehabilitation need and to start appropriate rehabilitation measures. The chance to detect true positive candidates and to exclude false negative candidates is essentially higher when the measurement of the predictors and the examination are carried out at the same time as has been shown in a former study. With regard to further proceedings we suggest to apply the index in a screening and to investigate the cost effectiveness and other aspects of the screening in a demonstration project.

[Health status of spa visitors]

German compulsory health insurance grants outpatient and inpatient prevention and rehabilitation treatments at spa facilities to avoid early retirement and long term care. A survey including participants between the age of 55 and 75 (n = 721) was conducted to determine the extent to which the current granting of spa treatment complies with regulations ("Begutachtungsanleitung Kuren"). The analysis was based on the data provided in the treatment application form by the general practitioners and on the answers of participants to a questionnaire on health-related quality of life (IRES). It compared a) cases granted outpatient/inpatient treatment at spa facilities, b) cases granted prevention/rehabilitation treatments at spa facilities and c) participants in spa treatments and controls from the IRES standard sample. For musculoskeletal diseases and diseases of the connective tissue, outpatient treatment was more often granted than inpatient treatment. There were no differences in the diagnoses of participants in prevention and rehabilitation treatments. Patients complaining about severe impairments/disabilities were granted inpatient rather than outpatient treatment. There were only minor differences between cases granted prevention and rehabilitation treatments respectively. The participants in spa treatment felt more impaired/disabled than controls of the standard sample. Overall, the selection of participants in spa treatment and the referal to outpatient and inpatient and inpatient treatments for the most part follows a needs-based pattern; however, improved differentiation is required between outpatient and inpatient prevention and rehabilitation treatments.

Assessment methods for rehabilitation

Diagnostics and evaluation in medical rehabilitation should be based on methods that are as objective as possible. In this context quantitative methods are an important precondition. We conducted for the German Pensions Insurance Institutions (which are in charge of the medical and vocational rehabilitation of workers and employees) a survey on assessment methods for rehabilitation which included an evaluation of American literature, with the aim to indicate procedures that can be considered for adaptation in Germany and to define further research requirements. The survey identified: (1) standardized procedures and instrumented tests for the assessment of musculoskeletal, cardiopulmonary and neurophysiological function; (2) personality, intelligence, achievement, neuropsychological and alcoholism screening tests for the assessment of mental or cognitive function; (3) rating scales and self-administered questionnaires for the assessment of Activities of Daily Living and Instrumental Activities of Daily Living (ADL/IADL Scales); (4) generic profiles and indexes as well as disease-specific measures for the assessment of health-related quality of life and health status; and (5) rating scales for vocational assessment. German equivalents or German versions exist only for a part of the procedures identified. Translation and testing of Anglo-Saxon procedures should have priority over the development of new German methods. The following procedures will be taken into account: (a) instrumented tests for physical function, (b) IADL Scales, (c) generic indexes of health-related quality of life, (d) specific quality of life and health status measures for disorders of the circulatory system, metabolic system, digestive organs, respiratory tract and for cancer, and (e) vocational rating scales.

Screening process to discover insured persons in need of rehabilitation

In order to prevent early retirements in Germany, medical rehabilitation measures are implemented among workmen and salaried employees whose fitness for work is jeopardized or diminished. Only around half of those retiring early take advantage of these measures in the last 5 years prior to retirement. To increase the numbers making use of rehabilitation measures, we developed a screening process whereby the pension insurance institutions responsible for the measures are able to identify insured persons in need of rehabilitation and urge them to take part. The screening process comprises two stages: written questioning to determine the probable risk cases by means of predictors of early retirement, and medical clarification of these cases by means of a standardized rehabilitation assessment. The screening process and devices were tested in an experimental trial involving 600 people aged between 45 and 54 insured with a pension insurance institution responsible for workers in the Stuttgart area. Main results were: (1) The screening process was accepted by the insured. Around 70% of the insured took part in the screening. (2) The questionnaire is suitable for pre-selection of the probable risk cases that require medical clarification. Given complete answers, 83% of the cases were correctly classified in comparison with the judgement of the pension insurer's physicians. (3) The screening was effective, i.e. it increased the participation of insured persons in need of rehabilitation in rehabilitation measures. Compared with a control random sample, in the experimental trial, 70% more rehabilitation measures were applied for and approved.

[Screening for determination of workers in need of rehabilitation]

Blue collar workers whose fitness is at risk may receive in-patient rehabilitation therapy in the Federal Republic of Germany, provided they apply for it to their annuity insurance company. Only 50% of the workers who retire early (before the age of 60) and are in need of medical rehabilitation make such an application within the five-year period before retirement. It is against this background that we are developing and testing a screening procedure which includes all insured workers and recommends a rehabilitation therapy to those at risk. The screening procedure involves two steps: a questionnaire which is then followed by a medical examination. In an experiment with 600 workers who are insured with the LVA Württemberg (the relevant insurer) we tested: whether the screening is accepted by the insured and their family doctors, to what extent the insurer's appointed doctors ratify the family doctor's report and give approval for rehabilitation therapy, whether the questionnaire is suitable for the preselection of insured at risk, and whether the screening detects insured at risk who do not apply for rehabilitation therapy. Participation at the screening was 68% and speaks well for the acceptance of the procedure. The family doctors recommended rehabilitation therapy in 43% of all cases whereas the insurer's appointed doctors recommended such a therapy only in 25%. This discrepancy arose in 2/3 of the cases due to the fact that the insurer's appointed doctors refused renewed rehabilitation therapy during the mandatory three-year waiting period or considered out-patient rehabilitative treatment sufficient.(ABSTRACT TRUNCATED AT 250 WORDS)

[Predictors of early retirement and focused assignment to medical rehabilitation]

Previous work and results from the project "Identification of a high-risk profile for early retirement" were presented. The project is being supported by the LVA-Württemberg (pension insurance for blue collar workers). In this project, a two-step screening process to determine prospective early retirees and provide specific assignment for medical rehabilitation is being developed and tested, with the goal of adhering better to the basic principle of "rehabilitation before retirement". The foundations for the solution proposed in the two-step screening are predictors of early retirement, with which prospective retirees can be detected early on. On the basis of a cohort study on environmental effects and frequency of illness during the period 1974-85, we have identified predictors for early retirement and premature death. Early retirees complained of health problems even years before retirement. In particular, they complained of shortness of breath and respiratory tract ailments, general impairment of physical performance, and ailments of the skeletal and motor apparatus. Data for persons who died prematurely after 1974 were largely consistent with those for early retirees. Most prominent in this case were complaints indicating coronary risk or angina pectoris, chronic bronchitis, and peripheral circulation problems. We evaluated the significantly increased health problems in the risk groups from the 1974 inquiries as indicators or predictors for early retirement. We utilized them for a questionnaire which was designed to determine the predictive risk profile for early retirement, and may be therefore suitable as a screening instrument for identifying prospective early retirees among currently employed insured persons (screening stage 1).

[Condition and satisfaction of patients after gynecologic surgery]

The effects of gynaecological operations on the well-being and satisfaction of patients can be viewed as important supplements to quality assurance which is mainly based on clinical parameters and medical ratings. In the present study 215 patients undergoing gynaecological operations assessed different components of their subjective health status at times of admission to the hospital, at discharge and six weeks after discharge. Additionally, the patients gave satisfaction ratings at discharge. The study resulted in demonstrating considerable improvements of complaints and well-being that continued into the postdischarge period. The improvements were most pronounced in the cases of patients with vaginal hysterectomy. Satisfaction with the hospital department was high, especially with regard to the care given by the physicians and the nurses. After mastectomy, women expressed problems with their self-image and with their partners. Considerations to take the results of the study into account for quality assurance are discussed.

Cost containment in a statutory health insurance scheme by substitution of outpatient for inpatient care? The case of the Bavarian Contract

Among manifold attempts at containing the rapid growth of health care expenditure, one which attracted considerable attention was the 1979 agreement between Bavarian sick-funds and the office-based physicians of Bavaria that, in some ways, reshaped the remuneration scheme for ambulatory medical treatment. This so-called 'Bavarian Contract' tried to approach cost containment by initiating transsectoral substitution processes in favour of outpatient medical care and to the disfavour of, above all, the hospital sector of the health care system. This paper deals with the question whether in Bavaria (between 1979 and 1983/84) the structure of services and prescriptions was modified in a way that indicates the occurrence of substitution processes as intended by the 'Bavarian Contract'; also, whether there is any evidence of cost containment effects brought about the intensifying the ambulatory services of office-based physicians. The study results provide some weak hints at substitution processes in favour of ambulatory services; but there is no evidence that expanding ambulatory medical services may help to contain the growth of health care expenditure.

[Study on pre-operative information on the medical aspects and prospects of a suggested operation, to be given by the gynaecologist to his woman patients]

Legislation prescribes the doctor's obligation to inform the patient of his situation and prospects before performing an operation. This obligation is of a mandatory character, the only exception being that the patient's life and health should not be seriously jeopardized by such information. The present study was based on questioning 100 woman patients, and it is evident therefrom that such an obligation places too much of a burden on the patient who is unable to cope with the information the doctor is compelled to give. In fact, our results show that frequently patients wish not only to be informed in a factual manner but also expect and desire an optimistic approach to be mediated by the doctor. Hence it appears important to pass on relevant information to the patient in a manner adapted to his personality traits and character. The article demonstrates a model for pre-operative information of this kind to be given to gynaecological patients, and it is shown how justified it is if the doctor demands a wider scope for using his own discretion and judgment in his talks with patients in respect of the information to be given to the patients. Information given by a doctor mainly with the object in mind to legally protect himself against any possible legal consequences, cannot be reconciled with the predominantly altruistic goals of the medical profession.