The Devil’s Details
Dr. Stephen Kamelgarn revisits the “Devil’s Glossary” in the January issue of The Bulletin of the Humboldt-Del Norte Medical Society. Here are some items at the start of the alphabet.

This was a guide originally published by the CMA back in 1993 (during the Clinton Health Care Reform debacle) as an aid for medical journalists covering health care in California. Version 1.0 of the Devil’s Glossary was published way back in 1994. I felt that it was time to revisit the issue.

The guide was published using the usual bureaucratic jargon, so (in the finest tradition of Ambrose Bierce) I have liberally provided a translation.

Accreditation: A process by which a number of licensed bureaucrats (medical and non-medical) pass judgement on the adequacy of one’s hospital institution. This gives them a feeling of self-importance, and makes the accredited institution feel loved and wanted. See JCAHO

Advance Directives: …preferences about life-sustaining procedures. Unfortunately, these are almost never available when the patient is comatose in an emergency department, thereby making their existence moot.

All-payer system: A health care pricing or reimbursement system in which all payers, including insurers and government programs, must participate and pay an equal percentage of nothing for physician, hospital and other provider services. In the old days this was referred to as Price Gouging, but we live in enlightened times now…

Ambulatory care: Care delivered only to people who can walk and pay at the same time.

American Medical Association (AMA): A national association of fossilized old men still living out in the medical practice climate of the 1950’s and 60’s…. They claim to be the voice of organized medicine, but since fewer than 20% of practicing physicians belong, they are living in a fantasy world. Today, there are high powered psychotropic medications to dissolve their delusions of relevance…

Bio-medical research: One of many ways to tap into government coffers to pursue one’s pet projects. This is usually affiliated with major universities where the president or department chair needs new living room furniture.

Budget predictability: The fantasy that one can plan in advance for expenditures over a stated time period. In health care, the relationship between predictability and actual expenditures is tangential, at best, thereby leading to both a credibility gap and health care oversight by CPA’s, bookkeepers, and other bean counters whose knowledge of medicine is gleaned from past issues of Reader’s Digest and The National Enquirer.

Capitation: A method of payment for health services that is the darling of Kaiser-Permanente, insurance companies and other HMO health policy wonks. A provider is paid a fixed, less than subsistence fee for each person served over a period of time without regard to how much care that person actually requires…

Cherry picking: Yet another clever ploy by insurance companies…. Here, they only accept healthy people for coverage. They then have the option to cancel that person’s policy as soon as he/she gets sick, and really needs the insurance…

To read more of the Devil’s Glossary, go to: www.sonic.net/~medsoc/images/bulletins/2010-01%20JANUARY%20BULLETIN_excerpts.pdf.

An Anesthesiology Convention is…
Stephen Jackson, MD, editor of the CSA Bulletin of the California Society of Anesthesiologists writes on “A Carnival for Anesthesiologists” in the winter 2010 issue.

Because of illness, he could not attend the ASA convention in New Orleans. But he recalled an earlier ASA contention in the Big Easy:

…two decades ago when the Loma Prieta earthquake exploded toward the end of the ASA meeting. I recall distinctly how I became aware of the quake: I had been demanding that the bartender change the channel on the big screen TV over the bar to show the San Francisco Giants-Oakland Athletics World Series game rather than the incessant panoramic view of smoke rising in a city and a crumbled freeway bridge. Neither he nor I could immediately explain why all the channels had the same aerial view…

…the magnificent ASA Annual Meeting truly is…a huge gathering of anesthesiologists from around the world. And, when held in New Orleans, the ASA Annual Meeting (and any other large meeting held there) has been dubbed, appropriately, a “carnival!” Indeed, the anthropologist Lawrence Cohen considers conferences and conventions such as ours to comprise not entirely or even mostly scholarly goings-on, but rather carnivals — “colossal events where academic proceedings are overshadowed by professional politics, ritual enactments of disciplinary boundaries…tourism and trade…the care and feeding of professional kinship, and the sheer enormity of discourse.”

Indeed, the popular physician writer, Atul Gawande, in his book, Complications, is of the same mind and comments “that [for] such national meetings…some [surgeons in his case] had come just to be seen, others to make their name, still others for the spectacle of it all…. Yet…one still had the sense that the draw was deeper than mere carnival.”

Read the entire article by Dr. Jackson at www.csahq.org/pdf/bulletin/ednotes_59_1.pdf

Screening for Breast Cancer?
In the November/December issue of the Bulletin of the San Mateo County Medical Association, Dr. Philip R. Alper had this response to a colleague’s views on breast cancer screening:

Dr. Borofsky’s arguments for not tampering with the breast cancer screening guidelines are impeccable…but they are not the last word on the subject. There are two undisclosed, underlying assumptions made by supporters of the existing guidelines: 1) all services that offer value to individual patients should be provided and 2) there is no trade-off between money and clinical utility in determining overall societal value. Perhaps a third underlying assumption is that the money supply is infinite…

The luxury of such thinking has done much to fuel the epidemic of specialism (if I dare be so impolite) that now characterizes American medicine. To do well by unrestrainedly doing good must be highly appealing; the AMA lists 112 Specialty Societies under its rubric of the Federation of Medicine. Only a handful of these concern themselves with primary care.

It has essentially been left to primary care to concern itself with integrating competing needs and costs in ways that “right way” and “wrong way” specialty thinking finds alien. Surely it is easier to define one’s horizon by the limits of one’s own specialty obligations and declare everything else “not my area of expertise.” But that leaves both competition for funding and professional freedom in the arenas of politics and public relations.

How does this meandering speculation relate to breast cancer guidelines? When the news of the new guidelines came out, I was struck by the complaint that the U.S. Preventive Services Task Force wasn’t composed of experts who presumably know the most about the subject but rather of generalists who — dare we say? — can’t be trusted to provide the last word. Such was the flavor of the comments made by the American Cancer Society and by representatives of the various specialty organizations concerned with breast cancer…

Read the article and more on the issue at www.smcma.org/bulletin/issues/BULLETINNovDec09.pdf.