The Best Interest of Our Patients January 1997

The California Medical Association held the first of what is hoped to be a yearly Leadership Conference at the La Quinta resort near Palm Springs. Approximately 400 of Hippocrates’s modern-day kin and invited healthcare “leaders” were present.

The keynote speaker was Emily Friedman, writer, lecturer, health policy analyst, and ethicist based in Chicago where she is the health policy and ethics analyst for JAMA. She enjoys coming to California because she loves sports, and Healthcare in California is more like a sport. When a student doctor on the west coast asked where to go to practice, he was told, “Go east, young man, go east.”

She pointed out that in film in times past doctors were portrayed in a negative fashion in only one case out of a hundred. The oldest trust relationship-that between physician and patient-is on the line. Now, the most trusted person in healthcare is the nurse. When she asked a nursing group why this was, a member of the audience replied, “It’s because we always worked for a salary.” She pointed out the difficulty of having doctors work on salary is that less work gets done. As an administrator pointed out to her, “When the doctors work on a fee for service basis, you can’t get them to attend a meeting. When they work on a salary, you can’t get them out of a meeting.”

Physicians have always been very thinly regulated. But when you live outside of the law, you have to be honest. You shouldn’t be making 10 times as much as the person paying you. Congress can’t raise their salaries fast enough during the dark side of the moon to keep up. When someone asked her, shouldn’t society decide on whether they want universal coverage, she disagreed. Society does not decide. Where would they hold the meeting? When Lincoln issued the Emancipation Proclamation, it was not a position held by the majority of the country. It takes a person of vision, honor and charisma to bring about needed change. The challenge is for physicians to represent their patients.

The ethical theme the first day was physician assisted suicide (PAS). Dr H Rex Greene, an oncologist, pointed out the proponents of the PAS movement have an inverse relationship in their activity to their experience with dying patients. We have to handle the problem of pain in the dying. His hospital grades pain as the fifth vital sign.

Stanford Ethicists Ernle W D Young PhD pointed out that a public policy for PAS is problematic. In The Netherlands, it is no longer the release from terminal pain that is the criteria. It is now used for the elimination of the senile and disabled.

Peter Boland, PhD, a prominent writer in the health care field (His book, Redesigning Healthcare Delivery, is over 900 pages and costs $159) pointed out that 35-40% of what we do in health care has very little emotional or clinical benefit to the patient. The patients have voted by taking 40% of health care out of the market into alternative medicine.

Between the Office Visits February 1997

The office visit has been the best deal in medicine–but that was when it lasted 15 minutes. Reduction to 10 minutes was a bit tight. Now Chicago University Professor Richard Epstein states he heard a rumor that managed care office visits in California were down to 5 minutes–about 300 seconds. He suggested perhaps that was not enough time to generate empathy and trust, but should be long enough to look into a pair of ears or to check for a sore throat. Physicians are paid for the time they spend with a patient; their technical training is the expensive input. Epstein holds that their psychological insight can be duplicated by others whose hourly rate is far less.

Professor Epstein goes on to say that technology allows the design of new diagnostic tests that can be applied across the board. The better the test, the less interpretation and evaluation is required. The physician becomes ancillary to the dominant sources of knowledge, and empathetic intuitions are pushed aside by hard data. To have a physician chat with patients for five minutes out of an hour may not seem like much, but over a year it amounts to a month of time.

The distinguished professor continues by saying that allowing physicians to order additional tests increases the need for space, laboratory technicians, record keeping services, and the like. Indeed, to allow physicians to give free care after hours is also expensive, if heat, electricity, insurance, and record keeping are accurately reckoned in the bill.

Under Professor Epstein, the essential services are both transformed and preserved, but the nature of the doctor-patient relationship will be changed, unless and until it can be shown that the traditional doctor-patient relationship controls costs, detects disease, or both. Although the process becomes more impersonal, patients do not leave the system because they value the savings more than they fear the costs. Physicians do not leave the system because the patients will not follow them.

He points out that any change will produce a fair share of losers who will try to recapture some of their gains through politics. Physicians, he states, often lose when HMOs insist on complete control over the physicians who join their staffs. Thus, excluded physicians have secured the passage of “any willing provider law” which requires any plan to agree to work with physicians who are willing to abide by its rules. This makes the health plan work like a common carrier for its physicians. No other business is forced to expand its roster of employees in quite this fashion. Professor Epstein concludes that the state regulations of HMOs has brought with it a host of unintended consequences, mostly bad. It has brought about a level of dependence that places the welfare of the general population in Mortal Peril, which is the title of his book.

Although we may think this philosophy harsh, cold, and unkind, it may be the prevailing opinion of our profession. We best take note, evaluate our profession, and plan damage control. Meanwhile the train continues onward, if not upward.

The non-professional medical entrepreneurs who are now advising us on every front don’t have any idea what could go wrong with their suggested approach. Perhaps they don’t care. Epstein is not sure that traditional doctor-patient relationships even detected disease. So in his understanding, just about anything is better than the traditional practice.

A managed care executive mentioned that primary care physicians should reduce the number of office calls; if currently four a year, try for three; if currently two, try for yearly. But this leaves many problems unattended between visits or delegated to others who may or may not be qualified. Family physicians tell me they work two hours after the office closes, or during their compensatory afternoon off, or spend an extra 8-10 hours on the weekend to complete their charts, make phone calls, fill out forms, complete referrals, and do dictation. Perhaps since he or she is not seeing patients and if the electricity is not used, it won’t disturb Professor Epstein as adding too much to the costs.

Managed Care & Medical Practice March 1997

What goes on between office visits is the second best deal in health care delivery–it’s free. But isn’t it delusional to believe that someone with any significant disease can receive yearly care in two five-minute office visits plus about 45 minutes of uncompensated time from the physicians between office visits? No wonder for-profit HMO Executive’s want to eliminate psychiatry–they don’t want their disease diagnosed.

Mismanaged Care: Wall Street takes the scalpel to For-Profit HMO companies. Investors recently have been trashing the stocks of publicly traded FP-HMO companies. Why? Because Wall Street thinks managed care firms haven’t done enough to control costs.

Bad Medicine: Mergers are to blame for some of the shabby earnings performances. FP-HMOs have been buying each other with a vengeance, and traditional health insurers have been buying FP-HMOs too. Bigger may be better eventually, but the short-term problems have been severe. PacificCare admits that in the commotion accompanying its February acquisition of FHP International, it didn’t do a good job of controlling medical costs. Aetna’s effort to integrate USHealthcare after it purchased the FP-HMO pioneer last year meant letting go thousands of employees and closing dozens of data centers. The result was a big claims backlog. “When the dust settled, we were running at a higher level of costs than we thought we were,” says Aetna CEO Richard Huber. The tumult of the $110 billion-a-year managed-care business has been compounded by computer snafus. Indeed, most of Oxford’s problems stem not from an acquisition or merger but from glitches in a new computer system that led it to overestimate revenue and enrollment and under-estimate costs.

FP-HMOs are still essentially insurance companies and are prone to cyclical ups and downs in their profits. The temporary windfall profits stem from medical costs falling faster than anyone had anticipated… Thank you doctors.

Drug costs are up sharply for seniors on FP-HMOs. More drugs without a generic version are being charged a $25 co-payment. Most seniors don’t see this as a bargain since they are unaware that many of these drugs would cost nearly $100 a month without “senior care.”

Health-care inflation was kept in check in 1997. Although costs have gone up, the shift of Americans to managed care plans increased from 52% to 85% in just four years keeping the overall inflation rate to only 0.2%. It is estimated that fewer of the remaining patients in expensive plans want to shift into cheaper HMO plans. Hence health care costs are expected to rise sharply in the near future.

A CPA told me about giving his daughter a horse. As he was from the city, he went to a stable to see about someone caring for the horse and providing a place to ride. He was quoted a price of $180 a month–plus the stable kept the manure. He shopped further and found a stable that would do it for $120 a month–plus keep the manure. The third stable quoted him a price of $60 a month. After a pause, the father asked, “Who gets the manure?” The stable owner said, “For $60 a month, sir, there ain’t no manure.”

The Medicare formula for long-term hospitals is to pay them in future years based on their costs in one early year. The higher the hospital costs in that one year, the more the hospital can collect in later years. Michael Barr, a respiratory therapist, capitalized on the market by entering an exempt industry, long-term care, and then utilizing congress’ lack of understanding of medical costs. In the base year, Vencor’s costs were high. This allowed them to continue to receive high collections as they cut costs faster and thus make an inordinate amount of profit. Since start-up cost would be prohibitive without this advantage, these rules essentially prevent competition from entering the long-term care market. . . Isn’t anyone upset with enterprising techs making a killing at taxpayers’ expense on government regulations?

The federal government pays HMOs $512 per month per enrollee to care for any Medicare member. The HMOs are required to offer the same benefits that Medicare provides and can add to them. As near as we can tell, they are able to do this for about half that or $250 a month. They then use an additional one-fourth or about $125 a month for pharmacy, dental, and/or vision plans. That still allows the final fourth for profits. Doctors, the brains of a patient’s health care delivery, traditionally received about 20% of the health care dollar. HMOs have reduced this to about $40 per member per month, or less than 10%. Managing life enhancing and death defying decisions has fallen to about the same rate as managing a horse pasture–except you keep the manure as your bonus.

Managed Care & the Patient April 1997

A Fortune 500 company reports that their health plan documents permit them to accept or reject assignments at their discretion. This simple maneuver has saved them millions of dollars. They report, “There is an abundance of evidence correlating fraud and abuse with assignments. . . We see this most commonly in the areas of chiropractic, physical therapy, mental health. . . When we spot what we strongly believe to be billing fraud, one tool available to us is to prospectively disallow assignments to the provider. When we notify a given provider that we will no longer accept assignments, the claim abuse stops on the spot. This particular class of abuse exists because the patient is told that he will not be balance billed and will have the deductible or co-payment waived. In the last 5 or 6 years, since we have used this approach, our plan has saved millions of dollars. Moreover, we have managed to do so with virtually no disruption in patient care. . .” Patient financial responsibility again appears to be the most effective cost-containment tool. But, of course the idea is still so politically incorrect that the company remains anonymous. By extension, all Medicare fraud could be instantly stopped by eliminating Medicare assignment. Why aren’t we interested in saving billions of dollars in alleged fraud and billions more dollars in cost of policing, harassing, and sending doctors into bankruptcy and jail?

The Hastings Center published a report by John Hardwig, “Is There a Duty to Die?” Dr Hardwig, of the Philosophy Department of East Tennessee State University, has previously published, “Dying at the Right Time; Reflections on (Un)Assisted Suicide.” He feels that as medical advances wipe out many of today’s “killer disease,” then one day most of us will survive long enough to become demented or debilitated. These developments, he states, could generate a fairly widespread duty to die. . . I mentioned this to a psychoanalyst, and she responded, “You tell Dr Hardwig that he can go first. . .” A nurse recently told me that they had another patient in their CCICU with a coronary bypass who was so demented that she didn’t recognize her own husband. . . Before non-medical lay people push us into (Un)Assisted suicide (euthanasia) and lawmakers regulate us even more, shouldn’t we as physicians agree that when the brain goes, we should let some of the other organs wear out rather than rejuvenate them?

The International Cellar: Professor Richard Epstein, a law professor at Chicago University, feels that more people will have access to health care in an unregulated medical environment than with all the helpful legislation that is being passed. Why do we support universal access when some very learned minds feel it will actually decrease access? . . . Epstein also presented data indicating that poor people were experiencing a higher rate of increase in income than the wealthy for the first two-thirds of this century until the federal “War on Poverty” came into being, since which time the rich got richer and the poor got poorer. . . Since the federal government added a department of education and has gotten involved in primary and secondary education, the best and the brightest of our high school seniors have now slipped to near the international cellar in math and science. Parents and leaky roofs are being blamed. . . Shouldn’t our profession recognize that government help will place American Healthcare into the International Cellar?

The impact of regulation is more commonly misunderstood. The portability provision of the Kassebaum-Kennedy legislation was predicted to raise insurance rates by only 2 to 3%. According to the Government Accounting Office, the increases by five different carriers ranged between 29 and 125%. Moreover, these were standard rates that applied to generally healthy individuals; carriers might charge higher rates to unhealthy individuals. The premium hikes will only get worse as healthy people flee. . . One of the scenarios that Hardwig referred to in the aforementioned “Duty to Die” was that losing all your savings, your home, and your career at age 55 was worse than a 50 percent chance of six more months of life at age 87. . . Maybe the end result of all medical regulation will be that doctors will want to be euthanized. . . Getting rid of the excess doctors should make a lot of people happy–of course then they would be left to deal with all the lawyers and insurance carriers without a buffer. Maybe they’d want us back.

Universal Access or Restricted Access May 1997

As pressure builds for some form of “universal access” under a government system, even by some branches of organized medicine, some reminders of the effects of such a one-tiered system worldwide are timely.

Canada: 1997 found 11% more patients waiting for treatment than in 1996. Statistics in Canada found that more than 1 million Canadians felt they needed–but did not receive–care in 1994, and 30% of these patients were in moderate or severe pain. Despite the fact that 21 cents of every dollar earned by a Canadian worker in 1995 was spent on health care, they still purchased about $1 billion worth of medical services in the US each year. The unfunded health care liabilities are expected to increase from $1.1 trillion to $3.7 trillion over the next 50 years.

Britain: Tony Blair’s “Waiting List Action Team” is charged with reducing the waiting period for a doctor’s appointment to no more than 18 months for non-life-threatening ailments.

France: 70% of physicians participated in a one-day strike to protest forfeiture of fees collected beyond the designated growth ceiling.

Germany: Drastic budget cuts are expected to result in long waiting times. Some ophthalmologists are traveling to Italy to perform procedures.

Nicaragua: The country’s 3,000 doctors have been on strike against the government for over two months demanding a 1,000% salary increase. The current salaries are about $100 a month.

New Zealand: Dr Richard Feiertag brought articles from the Wellington, New Zealand, Evening Post, after a recent visit. New doctors will soon be barred from starting work in Wellington City to avoid a health budget blowout. A government spokesman said that when more doctors were practicing in an area, more claims are submitted for government subsidies (payments); limiting the number of doctors would in no way limit people’s access to doctors. This just limited doctor expenditure. (Please pause here and re-read governmental logic.) The government was just trying to have a national consistency in the GP/patient ratio which was 7 per 10,000 population nationally and the 8.4 in Wellington was just too high. (The USA has about 30 physicians per 10,000 of which about one-fourth or 7 are listed in primary care by the World Almanac.)

Also Down Under: The New Zealand Herald reported that the government is trying to make sure the neediest patients receive surgery first. A July 1, 1998, date has been firmly set for two years on a point system so that patients could receive surgery within six months if they score enough points. However, 48,000 patients had been dumped from the waiting lists because of limited funds. At the last minute the Minister of Health decided thousands more should get surgery and he was searching for funds. Mr Ruru, the national director of medical and surgical services said the minister’s move was to make the new system politically acceptable. . . Should every hernia, gallbladder, and prostate operation is a political decision?

Seniors are up in arms over the Medicare restriction from obtaining medical care outside of Medicare. Medicare responds they are not limited since their doctor can provide that care, although afterwards the doctor is prevented from seeing any Medicare patient for a period of two years… If Medicare is one-half of a doctor’s practice–which the doctor would lose–and if overhead is 50%, this would reduce take- home pay to zero. The doctor would be working full-time to pay rent, staff and other expenses. A recent Wall Street Journal editorial implied that British and Russian citizens have more rights than American Medicare beneficiaries.

Surprise public health raids of hospitals in New York by nurses and investigators occurred to check on whether medical residents were working without adequate supervision or going without sleep. Surgical residents were most vocal in denouncing the governmental laws and continued to resist them.

Data Deficit: In 1963, Milton Friedman asked John Cowperthwaite, financial secretary to Hong Kong and disciple of Adam Smith, about the paucity of statistics. He replied, “If I let them compute those statistics, they’ll want to use them for planning.”

Back to New Zealand: If the plan produces an extra 48,000 on the waiting list with limited access which makes the statistics look bad, just dump the waiting list and eliminate access to make the statistics look good.

Moral: Universal Access equals Restricted Access in Government Medicine.

Erectile Dysfunction – Health Care Dysfunction June 1997

Within two weeks of its introduction, sildenafil citrate, given the name Viagra by Pfizer, hit 30,000 prescriptions a day threatening to replace world leader Prozac, which held steady at 50,000 a day. Pfizer states Viagra only works if the right stimulus occurs and therefore is safe to take daily. Pfizer might, of course, benefit from this “safety”–selling 30 tablets per patient or $300 of Viagra a month rather than two tablets a week or $80 a month (which is all that can be justified as promoting health.)

Headlines in March: Impotence Pill Worries Insurers. HMOs are struggling to figure out how much they will pay for their customers to have sex. Kaiser-Permanente in Oakland, the nation’s biggest HMO, has tentatively decided to reimburse only half the cost, expected to be $10 per pill.

It is estimated that up to 30 million men have erectile dysfunction. They certainly have come out of the woodwork in the past couple of months. When told their HMO won’t cover it, they seem willing to shell out $10 a pill to get 15 or 30, depending on their budget. Some estimates state that half the men over 40 have a potency problem.

When the news hit that men lived several years longer if they had sex at least once a week, some patients asked if they’d live twice as long if they had it twice a week. But they also wanted performance help.

One patient said he normally had sex with his wife three times a day. He had slowed down to twice a day. He’d like to start coming home for lunch again. He thought 30 pills to take on his way home would solve the problem. . . I wonder if he’ll be back for an evening dose.

Requests for 60 pills a month can usually be managed after the patient finds out it isn’t covered and he’ll have to write a $600 check. I tell them there is no medical reason for more than 3 pills a week or 13 a month–but I’ll write for 15 in case they get nervous and drop one or two.

One lady brought her husband in with a request for a prescription. She watched intently as I did a complete genital and prostatic exam. She even took the prescription from me. I wonder if she had to slip it into his soup?

I explained the side effects of the pill to a patient, including headache, indigestion and a temporary blue tinge in one’s vision, to which he replied, “Well, I’d rather have a red velvet tinge to my vision during these times, but blue will do.”

A woman patient told me that she’s been married to her husband for over 50 years. She felt that the best part of her marriage was the last five years since his “manhood” dried up. She did not want me to prescribe Viagra to stir up any life “down there.”

Of all the complaints about erectile incompetence that have come through my office in recent years, with a negative GU evaluation, only two patients have found the Caverject phallic injection system acceptable. One was married to an RN and one was a DVM assistant who was handy with a needle. Caverject and Muse, the suppository form, had consistent sales but now only 1.5% and 3.8% of the market. Viagra captured 95% of the impotence market during the third week of sales which appeared to be new business. Previously only 5% of impotent men saw their performance as a problem. Hence, this $6 billion in anticipated revenue is new health care cost.

A prostate promotional brochure came across my desk about the same time the Pfizer promotion came. Since sildenafil works in about 2/3 of patients, maybe there still is a place for all the herbs mentioned. Serenoa serrulata decreases the size of the prostate and is a mild aphrodisiac. Panax extract increases testosterone levels and decreases the size of the prostate, providing for a vibrant sex life. The multi-herb product called Prostata, not available in this country, is available through a Canadian source which obtains it from Life Force Laboratories in Italy.

On a financial note, it will be interesting to observe when Kaiser and the For-Profit-HMOs start covering Viagra. Will there really be a 50% co-pay? This is the perfect demonstration that health care costs cannot be controlled without significant patient co-payment responsibility. This change will put every patient in charge of tests, procedures, or treatments, which will again personalize health care.

Medical Science July/August 1997

A 20-year-old college student is the first known person to survive a rare operation in which surgeons completely removed his heart, cut out a malignant tumor, then re-implanted the repaired organ in his body… It’s always been easier to do repairs at a work bench.

Dentistry may be one of the oldest professions as reported in Scientific American. Eric Crubezy of Toulouse University in France and his colleagues recently found a wrought-iron dental implant in a Gallo-Roman necropolis dating to the first or second century AD. Because the implant and socket match perfectly and the iron and bone meshed, they concluded the implant maker used the original tooth as a model and hammered in the replacement… And that was before anesthesia.

Cystic fibrosis trait prevents typhoid fever: Although sickle cell anemia is a killer disease, it has been well known that the single faulty gene produces enough hemoglobin to carry adequate oxygen, but the presence of the faulty hemoglobin somehow inhibits the growth of the parasites that cause malaria, one of West Africa’s top killers. This protection outweighs the fatalities imposed by the anemia, so the faulty gene is preserved in the population. Last month, Nature, reported that Harvard Researcher Gerald Peir similarly found that a single dose of cystic-fibrosis gene protects against Salmonella typhi. It may not be of much comfort for the parents of a CF child to know that their carrier status confers protection against typhoid fever, but it is another neat example, according to The Economist, of how modern life has rendered a genetic adaption from the past irrelevant.

Jerome Groopman, MD, (The Measure of Our Days–New Beginnings to Life’s End) an immuno-oncologist at Harvard, discusses in the New Yorker why the Surgeon General wants to send letters to hundreds of thousands of people informing them that they might be dying of Hepatitis-C even though they are currently feeling healthy. Hepatitis-C has been silently spreading so that it now affects four times more people than HIV in the United States or four million Americans, (175 million worldwide). Three million Americans do not know that they are infected with the virus or that they may be passing it on. Dr Groopman refers to a patient who had, while in college, shared straws to snort cocaine and also engaged in coitus with several men she didn’t know very well. She was found to have Hepatitis-C in evaluating a minimal ALT elevations on a routine chemistry panel. Dr Groopman feels that either of these which occurred over a decade earlier could be the source of her infection. In 1997, the NIH budget for HIV research totalled a billion and a half dollars or about $1600 per infected person in the country. In contrast, the NIH spent twenty-five million on hepatitis-C research the same year or about $6 per infected person.

States vs.. Washington in the fight over organs: UNOS, the United Network for Organ Sharing, is the organization contracted by the federal department of Health and Human Services (HHS) to run the transplant network. UNOS thinks a policy of local organs for local people is the fairest way to allocate them. HHS thinks otherwise, and has given UNOS just four months to come up with a new method to share the 4,000 livers available for the 10,000 Americans who need liver transplants on a national priority basis. UNOS thinks this is impractical. Computer modeling has shown such a scheme would lead to longer waits, with fewer people receiving more transplants since, with the sickest patients, the first operation often fails, thus wasting organs and requiring a second one. This may also decrease the supply since donations are related to local campaigns and neighborly goodwill and this could dry up. While organ donations have increased by one-third over a decade, patients awaiting transplants have trebled. Rationing is never easy.

Fatal Distraction: Over the last 20 years, according to Psychology Today, the rate of suicide among people over 45 has been falling, thanks in part to doctors’ aggressive treatment of depression in adults. But that gain has been almost entirely offset by a rising number of suicides among the young which have tripled in the last 45 years. Of the 30,000 Americans who kill themselves annually, more than 5,000 are between the ages of 15 and 24. Psychiatrist John Mann, MD of Columbia University says, “What we’re seeing is a shift in the demographics of suicide.” Commenting on the effectiveness of antidepressants, Mann says, “We’re doing better at identifying treatments that work. We’re not doing so well at actually delivering them to those who need them.”

Professional Gridlock: Law, Teaching, Medicine September 1997

According to insurance executives, doctors, once among the most dependable workers in America, are leaving their jobs in sharply rising numbers to collect disability benefits, sometimes earning more on disability than by working. Surgeons, known for continuing to practice though suffering from arthritic hands, formerly ranked with lawyers, accountants, and architects in occupations most favored for disability coverage. They now rank below shipping clerks and traveling salesmen. Insurers believe that declining morale is key to the growth of disability claims. Physicians have become frustrated about changes in their profession–working harder for less money under increased stress, having their medical judgement questioned and hearing critics dismiss their complaints as the whining of a spoiled elite. As morale declines, disability insurers are experiencing a drain on their earnings as doctors are incurring disability claims at about twice the rate expected from all other occupations.

In the days when physicians and hospitals were rewarded for doing an unlimited number of tests, Dr Marcia Angell, then executive editor of The New England Journal of Medicine, once said, “If you think you are healthy, you have not had enough tests done yet.”

We send our children to school to learn the traditional 3 R’s . . . which have now been modernized to Reading, Writing, and Math [RWM]. Recently, a majority of teachers in Massachusetts failed a proficiency/certifying test in these basics. How then, can our children learn?

Julie Stroike, Executive Director, Central Texans Against Lawsuit Abuse, reports that personal injury lawyers provide limited work and limited contact with clients, but still reap a windfall while clients are left with little or nothing. For instance, several computer makers were sued for falsely advertising the size of monitor screens. The suit was settled. Each class member received either a $13 rebate toward the purchase of a $250 monitor or the right to a $6 cash rebate in the year 2000. The lawyers had negotiated a $5.8 million legal fee for themselves . . . Meanwhile, the critics of the GM pickup truck lawsuit concerning side-mounted gas tanks questioned the worth of the $1000 coupons awarded to truck owners as compared to the $24 million fee for the attorneys.

The National Education Association and the American Federation of Teachers decided against merging when the reality of departing splinter groups threatened the vice-like grip that the teachers thought they could establish. The teaching profession has been using legal statutes to make what they thought were professional gains: class size, textbook selection, school day and school year length, number of teaching assistants, and credentialing, just to mention a few. With urbanization eliminating the need for a long summer recess, the number of days in class could have easily increased from the traditional 180 days. However, the days that students spend learning has decreased to 175 to allow teachers more time off. Critics claim that teachers who don’t want to join the full-time professions, working 260 days a year, are the biggest obstacles to increasing teaching time for our children.

When the California Supreme Court recently criticized Kaiser Permanente for administering its mandatory arbitration system for members to take claims to court, they asked independent providers to bid to administer its system. The American Arbitration Association [AAA] declined to bid. In fact, the AAA had already begun the initial steps to eliminate all health-care arbitration before the “explosion” of claims with pending patients’ rights legislation. The senior vice president of AAA states that employee and consumer product issues are different from health care. “With a consumer it might be a house or computer at issue. With health care, it’s someone’s life.”

Senator LeRoy Greene has said, very few laws help or protect. Most restrict. We pass a thousand laws in California every year and haven’t learn to subtract. He says we’re headed for legal gridlock.

The Charter Schools are gaining momentum as a mechanism to bypass the network of laws interfering with education. Organized teaching argued against the schools saying that they would be the haven for the white and wealthy. However, the majority of Charter students are blacks and other minorities. The teaching lobby now wants to eliminate this bright light for the poor by closing these schools because of racial imbalance–not enough Caucasians. Apparently, educating children is no longer the primary purpose of the teaching lobby . . . Are patients still the primary concern of the health care lobby? Do we have the courage to eject our leaders that want to define the practice of medicine legally rather than medically? Will we be looking for “Charter Practices” in the not too distant future to bypass the network of laws interfering with the care of patients?

Medical Practice & the Geriatric Patient October 1997

Not to optimally relieve pain is tantamount to moral and legal malpractice according to Dr Edmund Pellegrino in the May 20, 1998, issue of the Journal of the AMA. New York’s Governor George Pataki has signed a bill eliminating much of the red tape doctors encounter as they prescribe painkillers for severely ill patients. Doctors will use a standard single prescription, rather than the current triplicate form, to prescribe controlled substances such as narcotics, barbiturates and amphetamines. The pharmacist will electronically relay that information to the state. To allow doctors to prescribe higher doses of medications and relieve their anxiety, an “addict,” previously defined as anyone who habitually used a narcotic drug, has been redefined as a person who unlawfully uses a controlled substance. And a habitual user is redefined as someone who repeatedly and unlawfully uses a controlled substance.. . . Looks like New York is more sympathetic to doctors and their patients than California.

Surviving old age includes avoiding disease. After morning rounds, my professor of neurology would always take a break with the senior students in the washroom before discussing the day’s cases. He made a point of washing his hands before he emptied his bladder contending that with the type of patients at University Hospital, you never knew what diseases you might pick up. After his bladder was decompressed, and the students had finished washing their hands, he once commented while he was washing his hands a second time, “I don’t know why I’m washing them after I go. That was the cleanest thing I’ve handled all morning.”

HMOs scramble to cut Medicare as they are allegedly losing money on the old folks. Some HMOs are actually pulling out of a number of counties and large geographic areas. HMOs are eliminating pharmacy benefits in some counties and increasing the copayment in others–sometimes to 50%. They continue to treat doctor’s visits as almost valueless–usually only a $5 copay. Some HMOs even brag about no co-pay for office visits. It’s just a free-for-all at the doctors’ trough.

Meanwhile the National Health Service in the UK, celebrating it’s fiftieth anniversary, is toying with the idea of a £10 (~$18) copayment for office visits and a £50 (~$90) copayment for a day in the hospital. It took them 50 years to figure out that “free” medical care is too expensive to afford and that they must make patients aware of the costs at the first interface with healthcare. Will Americans slog through the same fifty years of experiments, or will we take note and implement a significant copayment for each office or hospital visit or stay?

Governor Lamm of Colorado caused outrage when he announced that not only were we doing too much for old folks, but they had a duty to get out of the way for the next generation. Now comes John Hardwig who says that modern medicine and an individualist culture have seduced many to believe that they have a right to health care and a right to live, despite burdening their families and society. His article in the Hastings Center Report describes the circumstances under which we have a duty to die.

Mildred Culp, a syndicated columnist, reports that 2/3 of physicians making less than $50,000 per year are considering career changes. However, only half of the physicians earning more than $125,000 feels the same way. Sheryl Gay Stolberg, in the New York Times, writes that one of our own board members has never earned $100,000. The number of physicians who put $300,000 on the books, of which $200,000 eventually comes in, and who may take home $100,000, seems to be rising. Culp says physicians may opt to become executives with MBAs where the salaries generally start at $100,000.

Dr Charles Krauthammer, a columnist for the Washington Post Writers Group, declares that doctors are drowning. He says people believe that doctors having a hard time means they’re having a hard time making the payment on their yacht or the mountain chalet. “What I’m talking about here, however, is the money to keep a practice–perhaps your doctor’s–from going bankrupt.” He says that lawyers, accountants and consultants of every ilk bill by the hour, not just for office visits, but for phone calls. Doctors are an anomaly, who traditionally have given away phone consultations for free. To keep practices from collapsing, he suggests a nominal telephone consultation fee of, say $1 a minute for a nurse consultation and $2 a minute for a physician. At a 20% copay (20 cents a minute), he figures it’s not much different than making a phone call “to Aunt Sally in Topeka.” Krauthammer suggests we call it the Physicians Rescue Act of 1998.

Children November 1997

Programming Minds: The magazine Civilization reports the uncivilized results of subliminal messages on your TV screen and what can now be done about them. These 2-3/32 second scenes are oftentimes responsible for violence. For instance, in Tokyo, the photograph of cult leader Shoko Asahara that flashed across the screen during a national cartoon broadcast was the alleged cause for the Tokyo subway gas attacks of 1995.

Then in December 1997, more than 700 Japanese children, watching an episode of Pocket Monsters simultaneously convulsed with seizures, writing in pain. Frightened parents rushed their children to the hospital. A ratlike “pocket monster” with strobe-like explosions of lightning shooting out of its eyes was to blame.

In April, after program producers agreed to avoid such hazardous flashes and reduce scenes to no more than three per second, Pocket Monsters returned to Japanese TV, this time with slightly slower but just as deadly lightning-bolt explosions. Enter, Mediachef, a device that scans video information frame by frame, measures the time lapse between scene changes, and flags any abrupt one- or two-frame “scenes” as possible subliminals. The rat, his show and a Nintendo video game based on his adventures are scheduled to arrive in the US shortly. The Mediachef can be acquired from Hitachi.

Children with Guns: While passing by the video arcade in a Century Theater, I observed a very determined lad equipped with a gun manipulating an arcade machine. As “people” walked on a street on the screen, he shot off their heads, blood spurting all around. When he noticed me, he turned the gun toward me, but alas, the weapon only shot electronic bullets. Had the gun been real, I doubt I’d be writing this column. Furthermore, I wonder if this young boy may eventually shoot real bullets. One of our candidates for governor suggests outlawing such arcade games. But we already have enough laws and have problems enforcing them. It seems the owner or the lessee of the arcade or the game manufacturer is contributing to the delinquency of a minor and perhaps inciting criminal behavior.

Infant & Fetal Rights: Princeton University has hired Peter Singer to the Professorship of Bioethics at the University Center for Human Values at Princeton effective July 1999. Known in the United States for his defense of animal rights, in Europe advocates of the disabled object to his idea that children with birth defects have less moral value than most animals and therefore can be euthanized. Singer asserts that “killing a defective infant is not morally equivalent to killing a person. Sometimes it is not wrong at all.” He argues that if a parent may consider aborting the child in the womb, they should be equally prepared to consider euthanasia if birth reveals unexpected imperfections in the child. Princeton justifies his appointment “for his quality as a scholar, not to endorse his point-of-view.” Are the boards of Senior Deans and University Trustees really so naive as to think that an Assistant Professor will be promoted to Associate Professorship and make tenure without endorsing the Chief’s (Singer’s) point of view?

Headless Children for Organs: Also at Princeton, a Biology Professor, Lee Silver, has developed headless mice. His research team discovered the gene that produces the head and deleted that gene in a thousand embryos. Four mice survived until birth. He feels this is the first step in producing humans without a forebrain, which he would not consider persons. Hence Silver feels it would be legal to keep them alive as sources of transplantable organs . . . A few technical problems, but remember, Dr Robin Cook was able to overcome them in COMA.

Mice vs. microbes: White mice and guinea pigs are no longer laboratory fixtures. Molecular biology, built on the rock of DNA and its double helix, was largely realized out of the study of a single-celled microbe–the human symbiont in the colon: Escherichia coli. Five decades of research of single-celled life caused the joke that soon biology PhD’s wouldn’t remember how to raise a white mouse.

Youth vs. golden years: University of Pennsylvania researchers followed 71 adults aged 64-94 to see how they responded to life’s disappointments. Expecting to find that pessimistic individuals would be more prone to depression, as is true in young people, they were surprised to find the reverse–elderly pessimists appeared to experience less depression. Being optimistic may not be realistic later in life.

Research Triangle December 1997

Having recently been selected to introduce a new emphysema drug into Northern California (the other practice centers are in the Bay Area, Los Angeles, and San Diego), I attended an investigator’s meeting as well as a practice meeting in the Research Triangle area in North Carolina. Although I have communicated with several firms from Research Triangle Park, I never knew why they had chosen that name.

The Research Triangle has three universities at its apices: Duke University in Durham, North Carolina University in Chapel Hill, and North Carolina State University in Raleigh. Eight other colleges are scattered throughout the Triangle. The Triangle was established in 1959 on 6,900 acres of North Carolina pinelands to create an economic focus and provide jobs for university graduates who had been leaving the state for jobs elsewhere. Today, more than a hundred research organizations employ nearly 40,000 people in various pharmaceutical, biotechnology, telecom, and healthcare firms.

In 1924, James Buchanan Duke created Duke University when he donated a large share of his father’s tobacco fortune to a small Methodist college founded in 1859. This institution was renamed for the family, and although built by tobacco, it is tobacco free. Tobacco money, ironically, allows Duke to research into how cigarette chemicals insidiously damage developing brains. Duke’s Primate Center has the largest colony of endangered primates and Duke boasts 30,000 mice in its Transgenic Mouse Facility. The cost of regulations was epitomized when one professor imported 38 frogs for research which turned out to be on the Endangered Species List. This unwitting violation cost the school $50,000 per frog. These costs eventually were passed on to the students in the form of increases in tuition.

I looked for the cemetery Zig Ziglar described as being on a rolling hill near a freeway over which a huge billboard announces: “Marlboro Country.” I now understand the tobacco attorneys had the promotional ad moved to another site.

The practice seminar (“When Bad Things Happen to Good Doctors”) was depressing as we heard doctor after doctor describe the atrocities they had experienced. One allergist was prosecuted for overcharging $1.00 on his allergy shots. He asked HCFA how he was to know that the medicare intermediary was paying him a dollar too much on that particular RBRVS when Medicare paid him the allowable charge irrespective of the billing charge on all the other items? He was told that it was ultimately his responsibility and therefore, he was guilty of Medicare Fraud. Fighting this charge–unsuccessfully–cost him more than $50,000. Another doctor lost his license without a hearing or notification as to why. A sting operation was set up where a long-time patient called the doctor and asked for help. The doctor went to the patient, and while he was giving emergency care, police officers sprung from a closet and arrested and jailed him. A judge gave the doctor a 28-year prison term for practicing without a license. This, thankfully, was reversed on appeal. What one judge ruled was so egregious as to warrant 28 years in prison, another judge felt it was just an ambush without merit. Is it an accolade for an US Attorney to number the doctors he’s made into felons? One is batting a perfect record: 20 felons in twenty tries.

Two Washington, D.C. Bureaucrats who attended this meeting mentioned that the AMA was so far to the left of center that it was no longer representative of the practicing physician. “As far as we’re concerned,” one stated, “the AMA is just a trade organization, like the American Grapegrowers Association.” It was pointed out that when the AMA participated in developing the National Physician Data Bank, this was the second national data bank in the country–the first one was the FBI. It took another four years for the third national data bank to be developed. It was for sex offenders. How did doctors find a home in this illustrious company? Two members of the AMA House of Delegates were making a pitch for joining and remaining in the AMA. After two days of horror stories from doctors and attorneys, many stating that the AMA can no longer be reformed, one AMA delegate addressed the assembly and admitted sadly, “I have to agree.”

Well, it has been a rough season for Hippocrates’ modern Kin. For those of us on the inside of organized medicine, we have enormous challenges ahead. Thanks for your constant feedback and keeping me posted of medical practice in the trenches. Best wishes for a great year for medicine in 1999 with less government prosecution–and persecution–of doctors.