The article "Modern Couples Say They're Happy Together" {Sexuality, Oct. 17} reports extremely high ratings of satisfaction for married couples based on a Washington Post-ABC News survey. Polling director Richard Morin correctly points out that "telephone surveys like this might be expected to overstate satisfaction with personal relationships . . ." If two thirds of the sample rated their overall relationships as "excellent" and almost one third rated it as "good," what does that say to all who believe their marital relationship is "satisfactory, but it could be better"? Is there something wrong with them? Do most couples really have a very happy and fulfilling relationship, years after the honeymoon is over?

My personal and professional experience tells me that most couples do not have "excellent" relationships. David Mace, the world's foremost expert in marriage enrichment, says that one of the reasons we are unaware of the conflicts in most, if not all, marriages is the "intermarital taboo" -- an unwritten rule that married couples should never talk to other married couples about what is going on in their interpersonal relationship. Conflict and anger are "givens" in any intimate relationship (even excellent ones), and most of us don't have the skills to deal with them creatively.

Those who want an excellent relationship can have one, if they are willing to put in the necessary time and effort. How? Communicate thoughts and feelings daily; never miss an opportunity to express appreciation; when upset, say "I feel . . ." rather than "you always (or never) . . ."; compromise; make a commitment to ongoing growth and change; attend an enrichment retreat weekend; take a couples' communication course and join a support group. Bill Coffin Association for Couples in Marriage Enrichment Silver Spring

The Waiting Game (Cont'd)

Much of the comment in Victor Cohn's article, "Those L-O-N-G Waits for the Doctor" {The Patient's Advocate, Oct. 27} and in the Letters column the next week assumes that there is no solution to the common experience of long waiting room times. Solutions do, in fact, exist, but carry costs that must be shared by both physicians and patients.

Our excellent pediatrician, Dr. Daniel G. Shapiro of Silver Spring, some time ago adopted a new appointments system designed to minimize waiting times. After becoming concerned about a crowded waiting room and appointments that became progressively later throughout the day, Shapiro studied the situation and found that most of his patients were arriving late for appointments. I suspect that much of this was a result of a circular system in which patients are not seen on time in most physicians' offices, and hence have little incentive to arrive on time themselves.

Shapiro now asks patients to agree to arrive within 10 minutes of their scheduled appointment time or reschedule the appointment. (Exceptions are sometimes made for new patients or extenuating circumstances.) For his part, he commits to making every effort to keep appointments on schedule. Of course, he and his partner, Linda Goldstein, work in sick patients as necessary, and occasionally find that an appointment takes longer than anticipated. Still, my experience over almost six months have been that I have never had to wait to be seen for more than five minutes, and usually no more than one or two other parents and children are in the waiting room -- a real plus in this age group with lots of communicable illnesses.

I know that some patients have occasionally been inconvenienced by this policy, but I think that this is an excellent example of physicians and patients sharing responsibility to solve an important problem. Irene Smith Landsman Washington

Taking Charge

Having spent the greater part of today examining patient records, I was intrigued by Victor Cohn's article, "Who's Handling My Case, Anyway?" {The Patient's Advocate, Oct. 20}. The primary purpose of my record review activities was to ensure documentation of "case management" and interdisciplinary coordination by the home care nurses at the Visiting Nurse Association. Not only is this an essential service provided by us to help patients realize maximum benefits from medical services, but it is required for Medicare and Medicaid payment for home health nursing visits.

Maybe it is time for the medical community as a whole to follow our example and use us as a model to assist patients in attainment of maximum benefits from the medical treatments prescribed. Although case management is a time-consuming activity (for which we do not receive reimbursement), it helps the patient optimize the service of the myriad doctors, therapists, nurses, aides and social workers caring for them during a serious illness. The case manager need not be "in charge" in the sense of being the decisionmaker for the patient. Rather, this person serves as facilitator and interpreter in order to make certain that the patient understands treatments and makes use of services available to him to reach the highest level of recovery as quickly as possible.

The American Nurses Association code of ethics states: "The complexity of the delivery of health care service demands an interdisciplinary approach to delivery of health services as well as strong support from allied health occupations. The nurse should actively seek to promote collaboration needed for ensuring the quality of health services to all persons." Who will accept the challenge to promote this collaboration for those patients who need multiple services but are not under the care of the Visiting Nurse Association? Mary St. Pierre Visiting Nurse Association Huntingtown, Md.

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