When I went into practice in 1970, I made home visits to tracheotomy patients too sick to come in to the office. I remember one patient who had been hospitalized in the ICU at the cost of tens of thousands of dollars. I then visited her every three weeks for tracheal changes, about 17 visits a year, which kept her out of the hospital for years. As I recall, Medicare and Medicaid didnít even pay me that $15 a visit, or less than $300 a year, that saved them over 100 times that amount for just one hospitalization.
With cost containment, home visits are in vogue again. However, hospitals are conducting them this time. I still make home visits to my respiratory failure patients on life support, changing the trach every three weeks, and Medicare does pay me about $85. However, they pay the hospital over $115 for a nurse visit. Dr Davis wrote a letter to Medicare and asked why. Medicare wrote back saying the hospital has to pay the nurses salary, the car expenses, and other overhead. Dr Davis wrote back that he had the same expenses, so why couldnít he get paid the same as the hospital nurse? Medicare never wrote back.
Doctors just donít talk administrative language very well. Administrators from the HMO talk to the administrators of the hospital and each feathers the otherís nest.
How do the hospitals drum up this business? When I discharge a patient, the hospital discharge planner asks for a Home Health order so the hospital can make home visits. To avoid retaliatory action, most doctors write the order. However, patients frequently tell me there is nothing useful that they can see that the home health care nurse does. Even when they tell the nurse not to come out, the nurse will make one or two more visits.
Hospital Administrator/HMO COO/Medical Director
The medical director of a hospital sleep laboratory told me of this incident that reflects the physician position in the health care team.
The HMO operations office had an appointment with the hospital administrator to work out the agreement for doing polysomnograms for Obstructive Sleep Apnea and the reimbursement plan. The hospital administrator was new at his job and invited the medical director of the sleep lab to the meeting. The HMO administrator seemed upset with his presence. The meeting was rather short and the doctor left.
Later the hospital administrator told the medical director that the HMO felt they should have been able to work out the details of payment and supervision between administrators without the intrusion of a physician.
The feeling seems to be that medical directors are only a legal requirement, not one with any important medical or supervisory responsibilities. They are present in name and title like the equipment but should not interfere with any medical operational activity.
Physicians must remember that patients hold us accountable for anything that occurs in the hospital. We had best make our presence felt.
Politics and Spirits
A politician was asked if he was for or against alcohol? His answer indicated that it all depends on what you are talking about.
If you're talking about the spirits that cause cirrhosis, encephalopathy, gastritis, peptic ulcers and a myriad of other diseases, as well as drunkenness, family fights, child and spousal abuse, divorce, accidents and death, I'm against it. However, if you're talking about the fruit of the vine that helps people to relax, be congenial with each other and digest their foods better and that provides tax money to build our roads and schools, then I'm for it.
Medicine is just that sort of thing. There is nothing that is ever purely good or bad but rather some mixture in between. When in doubt, whether in food or drink, always be moderate. We have seen so many medical problems related to alcohol that we would never encourage anyone to drink who hasn't. Neither would we encourage anyone to drink who has had a problem with drinking in the past, where moderation would never work. Alcohol-related diseases have been estimated to cause 100,000 deaths each year in the United States.
What is a moderate drinker? Research suggests that people who have a drink or two a day live longer and have better health than those who don't drink or who drink four or more drinks a day. So if you do drink, the limits are quite clear. Don't drink more than one or two drinks a day.
A drink can be defined as 1.5 oz of 40 percent spirits; 5 oz of 12 percent wine; or 12 oz of 5 percent beer. As you can readily see, each of these equals 0.6 oz of alcohol. So there is very little difference in what you drink, only in the quantity that you drink.
So, Salud and be responsible and careful.
Your Personal Physician
Everyone should have a personal physician. Don't get sick without one for the life you save could be your own. When you find one that you trust and are comfortable with, don't let go. When you see another doctor or specialist, don't let him do anything unless you first go back and discuss his recommendations with your own doctor. Don't ever change insurance plans that require you to change doctors.
Let me tell you about Mr Bacon who was 78 years old and healthy. He never had any operations and only one significant medical problem his entire life.
Mr Bacon developed some bloating and discomfort in his abdomen. On the advice of a friend, he went to a surgeon. The surgeon found that Mr Baconís gallbladder wasn't working. Since there were no gallstones, he suspected a cancer and recommended major surgery to remove not only the gallbladder but also the adjacent bowel, stomach, liver and pancreas.
The surgeon was surprised that he couldn't find any cancer during the operation and proceeded with the skillful task of removing the nonfunctional gallbladder and adjacent structures and putting things back together. Unfortunately, this hookup didn't heal. In fact, he had to operate three more times to redo some of the connections. After six months, the patient was finally able to go to a convalescent hospital.
His wife came in and cried about this horror story. She felt badly about not returning to the primary doctor to discuss her husbandís options before the operation. She said he really wasn't doing that badly and the pain didn't bother him all that much. In fact, Mr Bacon was "putzing" around in his garage playing his favorite tapes and CDs the day before the surgery. He will never do that again.
The point not to be missed is that the personal doctor would probably have put things in perspective and advised a period of watchful waiting. Many patients would prefer to have a year of enjoyable life over several years in a convalescent hospital. And in these times of saving medical costs, it would have saved Medicare about $800,000.
Choosing your Personal Physician
Last week we told you about how having your own physician is critical to your health and life. But sometimes it is very hard to find a competent, caring physician. It is best to acquire a physician during your healthy years, before a crisis develops.
If you have a job and are raising a family and are in your 30s or 40s, it would be a good idea to obtain a medical checkup. It won't cost much more than your 30,000-mile car checkup. Get a copy of your county medical societyís physician directory. Look for the internists and general physicians. Choose one in your area and call your hospital to ask if she/he's on the staff. Call her/his office to find out about the cost and length of the initial comprehensive exam and to make the appointment. At the conclusion of the visit be sure to ask the reason for any recommendations and when to schedule your next evaluation. If, at your age, the recommendation is every three years, then return in three years for another checkup.
If a medical problem occurs, you should always see your doctor first. Even if it's a bad knee, a bad shoulder or a backache, and you just know you need a neurosurgeon, go to your personal physician first to get an experienced overview. Let me tell you about Mr Cole who did things on his own.
Mr Cole had a bad back and saw a neurosurgeon who operated on a herniated disk. His backache persisted and he found yet another neurosurgeon to operate on his back again. He did this five times before he became paralyzed from his waist down. And he's only 40. He takes pain pills 6 & 8 times a day for his back pain that is worse than the one he complained so loudly about before he had the operations. Back operations only help the pain that goes down into the leg, not the back pain itself. If he had just gone to his personal physician before any of the operations, he may be experiencing some chronic pain but not the severe pain he now suffers. He probably would still be able to walk, and wouldn't have to urinate through a rubber hose coming out of his bladder passing through his abdomen.
And in this age of crackdown in medical costs, he not only would have saved the five major hospitalizations, but probably most of the 40 hospitalizations he's had since, which has made his life very unpleasant.
Getting a Doctor That Will Work with You
The cost of health care in this country has orbited out of control. Doctors have not only been blamed for their own costs, but also for expensive tests and prescriptions they write. Let me give you an example of why this may NOT be true.
Mr Allen, a patient with bad emphysema, came in stating that his wife was disabled and had to quit working. She would therefore lose her health insurance, an HMO that paid for their prescriptions. He was left with Medicare that pays all the important things except prescriptions.
He went to the pharmacy and found out that his medication bill would cost about $600 a month. Since he only made a little more than that from Social Security, he asked if I could get his medication costs lower.
We went through all his required medications, streamlined them a bit, and wrote generic equivalents for the others that would do essentially an equally good job. He reported to me later that he was pleased that his medication cost had been reduced to nearly $200 a month.
This points out frequently overlook things. The doctor and patient, when they are jointly in charge of the patientís health care, are unbeatable in reducing health care costs, even better than HMOs or government regulations. Patients are not aware of the true medical costs until it hits them over the head and overwhelms them. A small $5 or $10 co-pay doesnít really tell us what the entire costs are. Letís get informed before we acquiesce to the government that will have to tax us to death. They canít even control the costs of Medicare. Can you imagine what will happen when they take over the rest of health care?
To remain in charge you will need a doctor that is willing to spend the time with you to accomplish what you need. We will tell you in a future installment how to do that.
Doctor Let Me Die
More and more patients are making the request that when things are hopeless, "Doctor, please let me die without all those tubes and machines keeping my heart and lungs going." When I ask them who should determine the course of action when things are hopeless, they frequently ask me to use my judgement. Many patients know that members of their family will have difficulty in being rational when the end is near.
Yet many physicians are reluctant to order anything less than life-sustaining extremes. Perhaps they fear retribution from the surviving family if they "donít do everything possible, even though hopeless."
Recently I was covering for another physician for a weekend. Of his three patients, one had cancer that had spread throughout his body; one had a stroke and could not swallow and could only be fed through a tube; one had a stroke and was so senile that she didn't know who or where she was or what year it was and didn't recognize any of her family. Before my colleague left town, he told me that each patient was a "full code" -- that means if their heart stopped, the doctors and nurses would marshal their full force to restore life by compression of the chest (which may break ribs in the elderly) and place the surviving patient on life support with breathing machines.
Why is there such vigor in salvaging a deteriorating heart in the hopeless patient at great emotional, professional and economic costs? When a desperately ill patientís heart stops, shouldnít that be regarded as the next stage of illness and a blessing -- to both patient and family?
Though your physician is committed to saving your life, there may come a time when the situation becomes hopeless. Then it is reasonable to say, "Doctor, let me die in comfort." You must then also communicate that to your family. The best idea is to put your wishes in writing. Many medical societies have forms available called "Durable Power of Attorney for Health Care." You can use this form to instruct your physician and family about the level of care you wish to receive under various medical circumstances.
When Doctors are the Problem
Parade Magazine has a cover story, "Why some doctors may be hazardous to your health." It stated that when Dr Ted Lewers, a kidney specialist in Easton, Maryland, was asked how many of the nationís 650,000 doctors could be categorized as incompetent, unscrupulous or impaired, he estimated "Very few__5_10%." That would suggest that up to 65,000 physicians could pose a significant risk to you. Unfortunately, thatís not a "a few."
In an attempt to identify bad doctors, physicians have set up a "peer review system." This means that doctors in a given field review the work of doctors in the same field by inspecting patientsí medical charts. Peer review determined that many doctors were giving inferior care. Many lost their hospital privileges and were reported to the medical board and to a computerized information service. Everyone thought the system was working and that the bad doctors were being removed.
But then some researchers decided to check on these so-called "bad docs" to evaluate what they did wrong. So when they gave these same charts to specialists in another community who werenít in competition with the doctors being reviewed, an amazing 70 percent of the so-called "bad docs" were performing satisfactorily.
The researchers then decided to review the records of the original doctors who had reviewed these so-called "bad doctors." They found that many of the reviewing doctors were making worse errors than the alleged "bad doctors." Some had even caused fatal injuries and were being protected by hospitals that were receiving "business,"--patient referrals--from these doctors.
At this time there is no good way to determine if your doctor is incompetent. But it behooves all of us to be cautious when medical recommendations are made that seem unusual. If in doubt, just say, "give me a few days to think this over" and then discuss if with family and friends. A little time will frequently clarify many things.
Twelve Reasons to Change Doctors
Marti Ann Schwartz, in her book titled LISTEN TO ME, DOCTOR, has a chapter on "Finding a New and Better Doctor." Her lead sentence is, "If you don't have a good relationship with your doctor, change doctors." The doctor/patient relationship is so personal that it should be pleasant, caring and trustworthy. She gives 12 reasons to change your physician: poor quality of care, poor relationship, lack of interest in you, rude behavior, bad attitude, doesn't take time for you, unwilling to discuss your diagnosis fully, ignores your concerns, lose trust, objects to second opinions, retires or leaves practice.
It usually is best to make a change when your medical status is stable. So while waiting for your next routine examination, begin the process. If you wait until something serious like a heart attack or stroke happens, you will have to take whoever is on call at the emergency room.
One way to select a doctor is to call your local county medical society and ask if you can obtain a directory of the physicians in your area. Some medical societies let you go to their office and will help you personally to choose by providing some background. Most of them have directories with photos that are available for a small fee. You can tell a good deal from a picture. So take a good look at the face. After all, you will be looking him or her in the eye a lot. Take down the names of the ones who interest you.
Another good resource is to ask your friends and coworkers for their recommendations. Then select one for your next checkup. It's never too early to established a good patient/doctor relationship.
When you make your appointment, be sure to check all the office policies to see if they are acceptable to you. Be sure to follow all the office rules and regulations and don't impose yourself outside of office hours unless it's an emergency. When questions about your health arise, write them down. When you have several that can't wait, then it's time to make an appointment to discuss them with your doctor. Don't discuss medical problems over the phone. The only person who could get hurt in such a "curb stone" medical opinion is you, the patient. It is always best that whenever you discuss your medical problems, that you face your doctor with your medical record in his hands. Otherwise it's too risky. Don't take risks with your own life.
Disclaimer: These messages were written in the years as noted and may be somewhat dated at this time. Please consult your physician or other health care provider.