Calories Don’t Count January/February 1999

Sixty-nine-year-old-Ruby came in for her annual pulmonary evaluation. Among other complaints, she was putting on weight. Her exam confirmed a 20-pound weight gain since her last evaluation. Ruby stated that the extra pounds were NOT from the food she was eating. “In fact,” she said, “I have to eat 5 or 6 times a day because otherwise I wouldn’t get enough.”

A 43 year old Pickwickian male with hypersomnolence and alveolar hypoventilation secondary to the 325 pound weight was being evaluated. I began a serious discussion on reducing his caloric intake, even if only 500 calories a day which would equal one pound per week. After a few minutes, I noted that his hand opposite from me was going back and forth with a 64-ounce plastic container with a cap and a straw–one of those 2,000-calorie fast food milk shakes. I asked him how many of these milk shakes he drank per day. He said, “About six. Aren’t we supposed to drink a lot of fluids?” This man drank 12,000 calories a day on his way to the table before he even counted the calories in his food.

When I was a resident in medicine at Wayne County General Hospital, we had a diabetic patient whose widely fluctuant blood sugars defied all attempts at dietary and insulin management. One day, while on staff rounds, the RN informed us that she had found several cartons of candy bars in this patient’s bedside table. When we confronted the patient, she readily admitted that every day she consumed two cartons of candy bars–that’s 24 candy bars in 24 hours. She then added, “Doesn’t everybody?” She didn’t start counting calories until after two cartons of candy.

A 5′ 2″, medium-framed, 43-year-old female patient weighing 285 pounds couldn’t understand why she was gaining weight. She assured me that she was only eating one bowl of peaches per day. I looked her in the eye and told her she had to reduce that to half a bowl and proceeded with my medical interview.

A woman with asthma refused to be weighed. My PFT tech said we needed a weight statistic to plug into the computer so it would read out the normals for the pulmonary function test. Still she refused–though she admitted to at least 350 pounds which we accepted since weight is a secondary factor in interpretation only. She said she had not eaten in days. But we noted that she required a 32 ounce soft drink from the coffee shop with at least 500 calories in it to get through the several breaths and 25 minutes required to obtain a complete PFT. Twenty calories per minute does add up.

And then it happened. A stout, forty-year-old woman who carried her 220 pounds well, tried to establish medical care in my office after six unsuccessful ventures with other physicians. Among other complaints she wanted some of her calories removed surgically. After an hour in my lab and an hour and a half with me–and still an incomplete history–I felt so sorry for her that I quickly completed four short appointments that followed her and continued with this desperate woman for another hour. At 5:30 I felt that I could perhaps accommodate her in her search for a sympathetic physician and help her in her medical confusion. Then I said, we’ve been here for 3-1/2 hours and I had to bring this medical evaluation to a close. She responded, “We have not yet even begun to scratched the surface of my medical problems.” She had no significant medical illnesses that I uncovered during those hours. I then closed the medical file, looked her in the eye and told her that there was no way that I or my office and staff would be able to meet her medical needs, and that I was sorry that I would be number seven in her quest, but she would have to call her HMO in the morning and get herself reassigned to another physician. However, I was unprepared to spend another eight hours in responding to her HMO, the Managed Care Organization, the Medical Society, and her numerous letters concerning the care she had received in my office. She stopped payment on the $10 co-payment check because the 3-1/2 hours had no value to her. My office manager put the check through again six months and one day later. It covered about 75¢ an hour of my $75 an hour office overhead. Despite this unfortunate incident, I believe we all must periodically try to help the desperate in order to maintain our perspective on the foibles of patient care.

At the Public Trough – I got what I wanted, did you? March 1999

During Career Day in High School, another student and I went to our local family physician to see what medicine was all about. He showed us his office, discussed a few patients, and showed us his books. He charged $1 for an office call. When I went to medical school, he told my parents there would never be another charge for taking care of them for the rest of their lives. He called it professional courtesy to a colleague’s family.

During my preceptorship with a family physician in a rural town of Kansas, when a patient couldn’t pay, the doctor didn’t enter a charge. He was generous in not recording a charge for many patients who obviously were poor or by canceling a charge on a patient who alleged financial difficulty. There was one or two such patients every day. Office calls were $2. This doctor said he made plenty of money to live in a nice house and buy a Pontiac when most of the town drove Chevies. He even got his wife a credit card. It made her happy and that made him feel good.

When I came to Sacramento in the 1960s, a neurosurgeon said he never charged the poor or retired for craniotomies or back surgery. He made enough money from the workers who paid cash or with a Blue Cross/Blue Shield card.

When Medicare and MediCal came into being in 1966, the need for this charity was lessened. Many felt these services helped to provide care for the less fortunate. The cost of providing care, however, greatly increased with the inflation that Medicare and MediCal caused. But if the reimbursement was only half of the fee, it covered the half that paid the expenses. Thus, the doctor could donate his time unencumbered by the cost of the practice.

Some physicians didn’t accept government re-imbursement, feeling it was unethical. Dr Sanford Marcus, President of the Union of the American Physicians and Dentists (UAPD), stated in an address to the Sacramento Society of Internal Medicine (SSIM) that when some of his patients brought in those little MediCal stickers that he was supposed to apply to an insurance form to get paid, he told them to keep those pasties and he would continue to take care of them for the rest of their lives or as long as he was in practice. Marcus also felt it was un-professional to place those little pasties into little boxes on an insurance form. As I recall, he hadn’t pasted anything like that since the second grade in school, and he knew someone under the capital dome was having a big belly laugh at what they had gotten doctors to do.

Recently there was a discussion in the staff room about our leadership asking the legislature for fee increases for MediCal patients. Most were at a loss as to how this could be otherwise. This is unfortunate. As a profession, should we be at the “public trough?”

As MediCal reimbursement slipped from 50% to 40% of the fee structure, many physicians were unable to take on new MediCal patients but kept the ones they had. When reimbursement slipped to 30%, even fewer were accepting new MediCal patients. At this point, some of our leaders felt we should go to the legislature to “help” the poor. However, that gives the public an image that we are at the “public trough” asking for money. Even the MediCal patients don’t understand why we should be asking for more money. Private HMO patients already feel that their $10 co-payment is the full cost of an office visit and is more than it should be.

The best service we can provide, is to let the market handle the problem. As more MediCal patients can’t get care, they automatically call their senators and assembly person. These office holders, always anxious to please the electorate, will figure out that the MediCal reimbursement rate is the bottleneck. They will loosen the bottle neck in a few days, if not hours, by an emergency increase in re-imbursement, so MediCal patients will be seeing their doctors and not calling the officials.

Isn’t it better that the patients requesting services are at the public trough, rather than the professionals? The legislature, the public, and our patients will no longer see us as the people with their hand out for taxpayer money. And when we go to the market, or the theater, or a restaurant, we won’t have to defend our medical associations as being more than a trade organization or lobbying group.

The Relative Value of Our Services April 1999

In the 1970s, there were presentations to the Sacramento Society of Internal Medicine (SSIM) indicating that we as internists and medical specialists were not being fairly rewarded for our cognitive skills. Some of the more “enlightened” members spent a great deal of time and effort in order to come up with a Resourced Based RVS to recognize this discrepancy. But in order to get paid for it we had to come up with a way to document our thinking processes. Thus the simple RVS gave way to the more detailed RB-RVS which in turn was further codified by complicated Clinical and Procedure Terminology (CPT) codes. These had to be further defined by Evaluation and Management Guidelines which have been evolving to document the time spent.

Since it has now been 25 years since the 1974 RVS codes were published, it is appropriate to make an objective appraisal. Did we do the right thing? I think not.

Medical writers tell me that they may spend many hours, sometimes days, to record a simple dialog so that the words will accurately describe what is actually taking place. How can we record a nebulous, changing symptom story from a patient in 10, or 20, or even 30 minutes of dialog that will pass legal scrutiny? Especially when the legal requirement is also a nebulously changing document. In a two-page pulmonary section of the CPT codes, 20% of the codes are new, or revised, or the text is new or revised. I understand there are 600 code changes now in transition. How can we as physicians, keep up with the advances in medicine, and learn hundreds of new rules that have nothing to do with taking care of patients? If we miss, we can face being prosecuted as felons.

The 1974 RVS codes haven’t died and after 25 years are still being used. Last week I received a fee schedule from an insurance company giving the conversion factor for the 1974 RVS codes. The last edition of the workers compensation fee schedule that I have still uses the 1974 RVS codes. The RVS codes had simple one line descriptions of the evaluations we did, e.g. Brief (xxx40), Limited (xxx50), or Extended (xxx70) office or hospital examination. (xxx60 was effectively eliminated by a reimbursement value that was less than the xxx40). These were used by family physicians, internists, and subspecialists respectively. The “Relative Value” in this particular schedule was listed as 3.5, 5.2, and 8.7 units which, on a $12 conversion factor used at that time, translated into $40 for the family physician who scheduled 6 patients an hour, $60 for the internist who scheduled 4 patients an hour, and $80 for the subspecialist who may have scheduled 3 patients an hour. Thus our specialty, training, and mode of practice would quite well define the type of service we rendered. There was no need for Medicare to hire 400 ex-FBI officers with guns (the Medicare conference in this area made a point that their investigators were armed) to invade our offices and check our records as to how much we documented when arriving at a diagnosis. In fact, as far as Medicare and the FBI agents are concerned, the diagnosis is totally irrelevant. They are only interested in the documentation of the time spent and the billing code. The practice of medicine and service to patients is totally irrelevant.

The lawyers that our professional organizations hire to put this subterfuge together, of course, can only think in terms of time spent. However, medicine is at the opposite extreme. We are result-oriented. We are interested in saving lives, improving health, and giving realistic prognostications, not in taking hours to utilize time to no end. In fact, the best doctors take the least amount of time to do the best work. My cardiologist is worth far more than Blue Shield pays him for examining my heart and doing an exercise ECHO. But after what seems like only 15 or 20 minutes, he assures me that my cardiac function is perfectly normal and I have no myocardium at risk. He tells me to see him again in four years, that my chances of having an infarct during that time is less than 2%. But that information and prognostication is worth more than money can buy, certainly more than a 90070 code (or a xxx14, xxx15), or $80 that a twenty minute code suggests for that amount of time. And it can’t be bought for any price in 95% of the world. It can’t even be bought in countries with universal coverage because they don’t come close to universal access. Canada now has a watch dog organization to document how many people have to wait more than 48 hours in an emergency room before being seen. Organizations that naively believe that lawmakers can provide universal access will continue to lose members. HCFA’s guidelines state that my cardiologist requires decision making of only “moderate” complexity, whereas a decision to terminate treatment is of “high” complexity. This was further exemplified when Linda W Wilson, MD, in Culver City, CA, was told by Occidental Life Insurance that since she is a specialist, complex medical decision-making is not warranted because it is easy for a specialist to make complex medical decisions by virtue of the fact that they are specialists.

In staff room discussions, more physicians have told me that this splitting of hairs in order to get a few dollars more for time spent with one patient (CPT code xxx15) and sacrificing a few dollars for less time spent with another patient (CPT code xxx13) ends up costing more non-professional time, which is money, than if our office visits were simply averaged for the usual time spent. Hence, for an internist, if all our office visits were an RVS 90050 (rather than a CPT xxx12, or xxx13, or xxx14, or xxx15,) and our hospital visits were an RVS 90250, (rather than a CPT xxx21, xxx22, xxx23, xxx24, xxx25 etc) we would be better off, the time would be averaged, and the entire issue of Medicare fraud for not having the time to document in detail what we did, and the need for 400 Ex-FBI investigators to police us, would all disappear. We could no longer be the scapegoats for Medicare’s fiscal problems.

The fraud in Medicare may be huge but it’s seldom from physicians. Yesterday there was a report that a health facility paid $4 million in Medicare fines for billing Medicare for lottery tickets, vacations, condos, and other nonmedical items. Physician fraud doesn’t come close to such egregious items. In physician fraud, except when physicians become non-practicing businessmen and thus no longer clinicians, the physician still sees the patient and provides the service, but someone takes issue with a variance in their understanding of our service. A conscientious physician could spend hours trying to satisfy the legalese that the AMA & HCFA have put together, and still go to jail despite his or her competence. Since physicians comprise less than 20% of the health care dollar, eliminating all physician reimbursements entirely would not solve the Medicare short fall and eventual bankruptcy.

The RB-RVS, CPT codes, and E & M guidelines were grievous errors which are now the undoing of the practice of medicine which in turn is unraveling our professional organizations. Our profession must come to terms with it soon. It looks like now is the time to dump the whole RB-RVS, HCFA, AMA mess which has made potential criminals of all of us. I know it will be hard for the AMA to be more loyal to the dues paying members who provide $69 million of income rather than the business interests, such as the publishing of the changing CPT code book, which bring in $120 million. The AMA’s publisher felt the AMA was too demanding in royalties for the CPT code book. So the AMA and the publisher have sued each other. It may have back fired. The Circuit Court of Appeals ruled that the AMA could not own a copyright of a code book that was required by law. If the code book is required, it has to made available on the same cost or free basis that any other code or statute. The AMA appealed and the Supreme Court had agreed to rule during this year’s session. Millions of business revenues may be declared illegal. We are a dues-paying professional organization and if we don’t provide service to our dues paying professionals, then when the business dealings disappear, there will be no AMA.

The old 1974 RVS could be simplified even further and serve us better. We’ve heard about going “back to the future.” This may be a case of where we should “move forward to the past.” If organized medicine doesn’t proceed along these lines soon, it will cease to exist. Then we will have to start over. So why don’t we just get the job done now and tell our leaders and administrators what we expect to happen and how soon? How about a Y2K-RVS revision and living within our dues paying revenue. The old KISS plan.

World Wide Reports May 1999

My London Correspondent: GPs in England use computers to automate their medical records; the system, however, is extremely fragmented. There are 18 different OSs (operating systems). Moves were made to privatize and allow local budgets in the British National Health Service, but when New Labour was elected, they stripped the doctors of their funding. The new Practice Care Groups (PCGs) which emerged are artificially forcing GPs into groups that are controlled by either the NHS or locally– whichever ends up being more powerful. . . . Do American physicians and their patients really understand Government medicine as being controlled by power rather than science, clinical acumen, and what’s best for the patient?

My staff recently attended an OSHA meeting since the Feds are transferring this function to the state. The rules are essentially the same for the mandated state employees as it was for the federal employees. This seems to be the current trend– to make the federal government seem smaller. However Big Government is even bigger than we think. The federal government has nearly 3 million employees as civil servants, the uniformed personnel, and postal workers. However, it has nearly 14 million hidden contract-created workers, state & local mandate-encumbered employees, and grant-created employees. Although our president says the era of big government is over, it seems that it is only getting bigger.

A watchdog group in Canada is monitoring Canadian medicine. They are keeping a log of how many people have to wait more than 48 hours in a Canadian Hospital Emergency Room before being seen. Is this still the preferred system that many who believe in Government Medicine want to implement in this country? They obviously are not interested in patient welfare but in power.

The building of prison beds continues to exceed hospital beds. The US, which just a few years ago led the free world with 350 prisoners per 100,000 population, is now at 645 prisoners per 100,000, and is fast catching up with Russia at 690 per 100K. With crime rates continuing to fall, it must be the doctors’ coding errors and other non-criminal acts that are expanding the ranks of criminals, felons, and inmates.

A local Canadian physician who states he escaped Canadian medicine tells me he got a phone call from a former patient asking for his advice. The patient had cancer of the liver and was given less than six months to live. He was advised to go on the liver transplant waiting list where the waiting time exceeds six months. It does solve two problems–kills two birds with one stone. The patient dies and you save the cost of the transplant with a single decision. Some call it government efficiency.

There is now a noncardiovascular reason to limit your patients to only two drinks a day. When the body processes ethanol, it produces acetaldehyde, the chemical that produces the hangover. When the body system is overloaded with alcohol, we do not have enough of the enzyme alcohol dehydrogenase to detoxify the acetaldehyde. This can damage a nucleotide leading to mutated DNA that according to other studies, as reported by Biochemistry, is linked to cancers of the esophagus, larynx and liver.

Rising medical costs are a worldwide problem, but nowhere are they higher than in the United States. Roger Doyle reports in Scientific American that the major reason for high US costs is over-investment in technology and personnel. America leads the world in expensive diagnostic and therapeutic procedures such as organ transplants, coronary artery bypass surgery and magnetic resonance imaging. Orange County, he states, has more MRI machines than all of Canada. According to political scientist Lawrence R. Jacobs of the University of Minnesota, universal access is the strategy other countries use to impose fiscal controls. In other words, one must have universal access to control access so that social planners and government can control our health. There would not be 48-hour waits in the ERs of Canada without universal access. There would not be 18-month surgical waiting lists without universal access. And when the United States gets universal access, there will be no escaping from other countries’ controlled universal limited access to our unlimited access. So beware of organizations that propose universal access. They are not acting in either our patients or our own professional interest. Without any value, they will continue to lose members.

The New American Thoracic Society June 1999

The American Thoracic Society composed of 13,000 pulmonologists and physicians with related interests, met in San Diego for their annual scientific meeting. For the last 7 years, this has become an international conference with 16,000 attending this year, including 6,000 from the international community. All fifty states were represented as well as nearly 50 foreign countries including Washington, DC. I use this opportunity to discuss practice issues with as many colleagues from overseas as possible. It’s the best opportunity that I have to obtain a perspective on health care around the world as seen “from the trenches.” However, even pulmonologists from the same country sometimes vary widely in their perspectives of the prevailing practice. Perhaps this is more like medicine as seen from “fox holes.”

The high point pervading the meeting was the impending divorce of the ATS from the American Lung Association. In 1905 the medical arm of the TB Association was known as the American Sanitorium Association. In 1939 it became the American Trudeau Society and in 1960 the ATS as the TB & Health Association became the American Lung Association. The physician organization was completely owned by the Lung Association, and the relationship has been somewhat stormy for decades. I was on the Board of Directors of the TB & Health Association of Sacramento Emigrant Trails in the 1970s for six years and it was during my term as president that we changed the name to the Sacramento Lung Association. It was later changed to the American Lung Association of Sacramento. I thought this made about as much sense as changing CMA to the AMA in California or changing SEDMS to AMA in Sacramento.

Doctor Julius Comroe, the Director of the UCSF Cardiovascular Research Institute, and author of the definitive textbook, THE LUNG, told me about 1980 that he’d love to sue the ALA if only someone would cure his back pain. Unfortunately, it was progressively fatal. Comroe, however, epitomized the feeling of much of academia against the ALA which has been a topic at the last several conferences. This year we became separately incorporated and the split will be final on January 1, 2000. We will be paying the ALA a half million dollars a year for the next 15 years for the rights to our name, the ATS, our international conference, our two world class journals, and our dues and membership list. These items had an averaged appraised value of around $15 million. If one considered this “community property,” the “alimony” was reasonable. This past year the divorce became more amicable and more like a legal separation. We will probably continue to share resources, but on a more equitable basis. One of the ALA staffers who is now an ATS employee, told me they tried to get the local lung associations to forward up to 25% of the donated dollar to lung research to get on par with the American Cancer Society and the American Heart Association, but had to settle for 10%.

The conference was of the usual high caliber type with 18-24 concurrent sessions going from 7 am sunrise to the 7-9 pm evening sessions. Most of the senior members were content to follow the 8:15 am to 6:30 pm schedule. The fellows in training and the practitioners from some of the developing countries were so thirsty for knowledge that it was always interesting to see them run ahead on the escalators trying to rush from a lecture in one hall to a lecture in another hall rather than sit out a three-hour symposium. Asthma continues to increase, and roach dust may be more important in the homes of the urban poor than dust mites. Tuberculosis continues to increase bringing us back to our roots. Research on lung reduction surgery is moving forward, but slowly. It seems some patients are concerned that they will receive the placebo.

The between session discussions with practitioners from around the world that took place in the halls, on escalators, elevators, walking the street between centers, and while having lunch was quite rewarding. The United Kingdom had their usual 900 pulmonologists. Belgium had 100 which they said was one-third of the country’s pulmonologists. Taiwan had 30. Japan had many hundreds. While waiting for one luncheon conference, I found myself at a table with pulmonologists from Canada, Scotland, Columbia, Japan, and Belgium. Medical practice seems to be government operated or socialized in essentially all countries. Private practice is allowed in most of these countries with financial restrictions rather than medical restrictions with criminal repercussions as in our country’s socialized medicine for the elderly known as Medicare. These financial restrictions effectively discourage private practice. For example, in the National Health Service of UK, the physician income peaks at £57,000 (about $90,000). If they make more than 10% or £5,700 gross from private practice, they will lose 1/11 or £5,282 of their income. However, private patients are unwilling to pay for their care while being seen with the masses in the clinic. Therefore, the doctor has to have a small privately staffed office. The cost of this is usually greater than the amount he/she makes from the private fees minus the forfeiture of governmental subsidies and thus a great disincentive. If they make £57,000 from private practice, then 10/11 will be lost and £5282 will be their entire government “subsidy.” But with a 50% overhead, they will only net one-half of their private income, which, to come out ahead, would have to be twice their governmental income. But that is a pittance in comparison with the United States where you will lose 100% of the income from your Medicare patients for a two-year period for treating even one as a private pay patient. Although there may be instances, I was unable to find any country where the government makes every patient a federal case as in the USA.

In no country could I find that pulmonologists would even consider a simple charitable goal of hanging out their shingle and providing service to sick people and just take their chances. Everyone had to have a primary anchor, an appointment in a hospital, a medical center, a medical school, or a research center.

One professor asked a European pulmonologist if the waiting times in his country were really up to the two years as we had been led to believe? He agreed they were and that, of course, was a political problem. The political system had to put enough drag in obtaining health-care so that many, maybe up to a half of the patients that wanted to see a doctor, were unable to do so in a timely manner or even during the course of the illness in question. But if and when a patient gained access to the system, they felt they received good care–maybe not CTs or MRIs, but what the patient really needed.

Is the AMA, the CMA, and the SEDMS listening? In some countries, universal access really means reduced access, sometimes only 50% access to an inferior system which is far less than a free market system provides. Do we really want to snuff out the last bastion of freedom in health-care which provides the highest quality of care the world has ever seen? Are we on the government’s side of power, politics, and perverse incentives or on our patient’s side of their health-care needs? Can we get our priorities in order before it’s too late?

Summertime Fun July/August 1999

An 88-year-old woman came in for a complete examination. Afterwards she said she was concerned about her late husband possibly having had Herpes and asked if I could recommend someone to check her out “down there.” She was becoming quite daffy over a 77-year-old man who lived in her complex and wanted to know she was free of disease if romance progressed. Our nurse practitioner found her clean and gave her some advice concerning lubrication. The patient then asked the RN-NP (since her intended had diabetes) could she give her some advice in case he could not perform? The RN-NP recommended that she apply a small amount of her nitroglycerine ointment on his organ to help it get ready. She cautioned my patient to be very careful not to apply too much or he might develop a headache.

Which of the following Watergate thugs were lawyers? a) Richard Nixon, b) John Mitchell, c) Spiro Agnew, d) Gordon Liddy, e) John Dean, f) Charles Colson, g) Robert Mardian, h) Herbert Kalmbach, i) John Ehrlichman, j) Donald Segretti?

Answer: a, b, c, d, e, f, g, h, i, & j. –Jess Brallier: LAWYERS And Other Reptiles

The law is the only profession that records its mistakes carefully, exactly as they occurred, and yet does not identify them as mistakes.” –Eliot Dunlap Smith

I was told about a patient who took an albuterol and Vanceril inhaler and aimed both to the front of her face, then stuck her nose and mouth into the cloud, took a deep breath and held it. I understand she was from San Francisco where they are use to dealing with “air you can see.”

A 40-year-old woman asked for an air purifier. When she was reminded that she was still smoking cigarettes, she said, “That’s true. But by cleaning up the air around me, surely the cigarettes wouldn’t harm me as much. I know MediCal pays for it.”

Bureaucrat to doctor: Don’t you feel bad taking money from sick people?

Doctor: Not really. . . I just keep them alive so you can get their taxes.

Bureaucrat to himself: I guess doctors are more important to me than I have given them credit. (After Parker)

Remember: For every doctor in prison, there is an attorney out there who represented him.

Doctors should never talk to patients about anything but medicine. When doctors talk politics, economics or sports, they reveal themselves to be ordinary mortals–you know, idiots like the rest of us. –Andy Rooney

LAWYER: Trying to explain to his doctor client how the “Law of the Deep Pockets” might affect the litigation, “By way of the converse, A Bum is Judgment Proof.”

DOCTOR: So by treating this BUM, I get sued. But if he had struck me and paralyzed me, that would just be too bad?

LAWYER: So you’re beginning to see how we attorneys win no matter who loses.

Will Rogers said, “I never met a man I didn’t like.”

Attorney: “I never met a man in a neck brace I didn’t like.” (After Parker)

An email from my Auburn connection. He says it’s a true story, although rather dated. An old country doctor went out to the boondocks to deliver a baby. It was so far out that there was no electricity. When the doctor arrived, the lady said her husband was out in the fields and no one was home except for her 5-year-old child. The doctor instructed the child to hold a lantern high while he helped the woman deliver the baby. The child did so, the mother pushed and after a little while, the doctor lifted the newborn baby by the feet and spanked him on the bottom to get him to take his first breath. “Hit him again,” the child said. “He shouldn’t have crawled up there in the first place.”

“I would like to see the time come when the massive hemorrhage of some of our best talents into the law will cease. . . Our country is already sufficiently litigation-prone and legalistic. The over-supply of lawyers not only helps create its own demand but can get in the way of solving problems. Jess Brallier: LAWYERS and Other Reptiles II

Attorney to client who had just fired him: “You can’t act as your own attorney. This kind of trickery and duplicity is best left to professionals.” WSJ

Attorney Jill Demmel reporting in our local newspaper about the unending assault on her profession, “I think it was maybe five or six years ago that we ranked right above used-car salesmen in respect and it’s gone downhill from there…” Well don’t worry Jill. Our administrative and professional leadership feels that your efforts and more laws are the answer to medicine’s problems. So we’ll be right down there with you shortly.

Conference Brochure: We follow the educational principle that to learn anything important, you must be able to swim, ski, or sail afterwards.

To register for the conference: call 1-888-CME-EASY

Topic in a Dermatology Meeting: The Diagnosis of Rashes that Resolved Last Week

Topic in a Primary Care Conference: The Management of Acute and Chronic Death

Topic in an Endocrine & Metabolism Seminar: Managing Carbohydrate Emergencies

9:45 to 10 am: Break – 10 Kilometer Run

Topic in Obstetrics: Intrauterine Circumcision

Topic in Infectious Disease: Foot-in-Mouth Disease

Topic in an Internal Medicine Conference: Management of Congestive Chart Failure

Topic in a Medical Legal Seminar: Anaphylactic Reactions to Lawyers

Topic in a Pathology Seminar: The Prognostic Value of Hypothermia in Dead Patients

Topic in a GI Conference: “Self-Colonoscopy”–How Reliable Are the Results?

Pharmacology Seminar: Comparison of Placebos in Treatment of Type I Hypochondria

PacificNet Conference: How to see 80 patients a day and not miss lunch

Medical Economics: Join an HMO to solve your high tax problems

Sports Medicine: HMOs: Transitional job to make the jump from medicine to wrestling

Laboratory Medicine: How to manage patients without ordering any lab work

Proctology: A Blind Study of Herbal Tea in the Treatment of Chronic Hemorrhoids

Weight reduction clinic: Forget essential amino acids-get the essential carbohydrates

Topic at Bankruptcy Lawyers Conference: Chapter 11 Health Plans

Estate Planning Conference: It’s never too late to go to law school

MBA Seminar for Doctors: The Cut-Rate Health Plan–Kevorkian Plus

Did you hear of the new managed care plan, Equivocare–the Suboptimum Choice?

Have a great summer of fun. Hope you were able to get your cat to fetch. See you in the fall when the ax meets the emery wheel.

A Couple of Ways to Improve Practices September 1999

Summer is over and I hope we’ve all had some respite from our usual routines as we get down to the business of what we do best–practice medicine and surgery. Our best offense is to do it well. Otherwise we may be replaced by a Physician Assistant or a computer.

While reading ECGs the other day, I saw a colleague’s comment on an adjacent ECG: “I agree [with the ECG computer].” I was so amazed I asked the ECG tech if she’d seen such a comment before. She said it was common practice. Then she looked in her basket and found 20 of 25 ECGs interpreted that very day in which the doctor’s only comment was “I agree [with the computer].” Remember when the hospitals elected not to reimburse us for interpreting ECGs because Medicare had only one reimbursement figure for the combined technical and professional components? They maintained that doctors provided no additional value. It was a Medicare mechanism to get cardiologists and internists to donate further services to a losing government operation. Although we won the battle temporarily, we know there are other hostile carriers sleuthing around to see if doctors really add any value to patient care. I would guess that if they found any area of practice where a computer could do 80% as well as a real live doctor, they would remove that item from the reimbursement list. Do we provide real value to patient care? I think we do. In the instance of ECG interpretation, the computer cannot compare the present tracing with the previous one, which is very important cardiac data. We must compare each ECG to the previous ECG and, if there isn’t one, record a disclaimer. We must take an extra moment to record the value we add to patient care.

A new federal law went into effect on July 1, 1999 that was supposed to reduce phone bills. Actually it increased the charges by 70%. . . . I think Adam Smith predicted the result of government intervention over a century ago.

A related issue for improving our practices is telephone refills of prescriptions. For at least 30 years practice management workshops have advised against practicing medicine by phone, especially prescription treatment. This allegedly gives one the greatest exposure to liability. In a stable solo practice, this never was a problem. Patients were given prescriptions with enough refills to last until the next scheduled evaluation. If a three-month appointment was recommended, all prescriptions were given with three monthly refills, which in effect allows the patient to change the appointment up to a month later. On a stable patient with yearly appointments, the prescription would be for 12 refills which in effect still gives the patient an extra month’s supply, thus eliminating the need for a pharmacy call or fax in case the appointment is delayed a few weeks.

Along come changes in practice patterns: Patients now switch doctors with less concern than changing hairdressers or barbers. Because new patients are not trained in appropriate liability-reducing care, the rash of phone calls and faxes from pharmacists can paralyze an office for hours. Attempts to retrain patients are resisted by such comments as, “Dr. Previous always called them in and never complained,” or “Dr. Prior even had a phone line for prescription refills.” To staff the latter on a full time basis must have cost $30,000 per year at current certified medical assistant rates of $15 an hour. Even taking up to half or quarter time of an office assistant, the cost would still be $7500 to $15,000 per year. A good suggestion would be for the medical community to implement the concept of giving enough medications to last until the next appointment plus one month. That would save the nearly 3,000 doctors in this community (if they are anything like Dr. Prior) about $21 million a year.

The federal government has released guidelines warning academic institutions not to rely too heavily on Scholastic Testing. . . . Actually I think that fits. They are also worried about too much medical excellence, as can be seen in their moves to reduce the reimbursement codes to board certified specialists–explaining that they require less time to make complicated diagnoses. Anyone try to do six consults an hour?

Healthy Doctor-Patient Relationships October 1999

When I was a summer extern in a Kansas City hospital some years ago, the hospital employed Danish interns. As an idealistic third year medical student, I was struck by their comparison of American medicine with the practice of medicine in Denmark. American doctors, they said, try too hard to please their patients. In their country physicians work for the government; the patients come to their designated doctor, who works from 8:30 to 5. Physicians make decisions without any deference to patients’ feelings; there is no need to entice the patients to come back since they have no other choice.

This freedom to choose, a hallmark of a free society, has been important in our country. However, it is eroding even among professionals. There is diminishing hope then, for patient freedom of choice, and they will be locked into a regimentation that is normally associated with a totalitarian or socialistic society.

An estimated 2/3 to 3/4 of physicians believes in limited government and personal liberty and that humans behave for the betterment of their status, not because of any innate altruism. This becomes noblest under a system of economic and political freedom where we have to provide a wanted service before we can benefit from our endeavors. Any disruption of this process, e.g., by government intrusion, creates more problems than solutions; this holds true, by extension, to the ills we face in medicine.

Adam Smith in his Inquiry into the Wealth of Nations drew an analogy between London and Paris in the eighteenth century. Was Paris with four volumes of laws safer than London which had only a few pages? Most people believe more laws make us toe the mark. However, Professor Smith pointed out that murders and robberies were committed in Paris daily. Meanwhile, London, a larger city with only a few laws, had only three or four robberies or murders per year. Increased laws only worsened society and increased lawlessness and crime.

In discussions with colleagues over the past decade in the staff rooms of our community’s hospitals, I would guess that a large majority agree with the premise that more laws are not the answers to our problems. Yet, many who agree in private will not admit the same if the staff lounge is filled with physicians. Also, many give examples in which they feel the government is the answer to malpractice, gas price inflation, the cost of health care, HMOs, and other problems.

Andrew I. Cohen of the University of Oklahoma defines a “free society” by three key features: 1) private property (which includes our medical license) is protected as inviolable; 2) the government’s role, at most, is to prevent and punish the violation of individual rights; and 3) all human relationships (such as the doctor–patient relationship) are voluntary. To the extent that a society is free, it will provide the best opportunities to nurture and sustain deep friendships or relationships.

Considering what is necessary for a deep relationship, two persons must share some form of good will. This sincere good nurtures a sense of trust and healthy interdependence. If, however, you find yourself in an institutional environment or an alliance that allows no choice, this involuntary relationship will restrict the development of any healthy relationship, including a healthy doctor-patient relationship. A free society will always try to minimize the extent to which human relationships are involuntary.

The practice of medicine has, in a significant way, become an involuntary relationship. The doctor-patient relationship is frequently forced. For twenty years, patients sought my medical advice or opinion and gladly waited for it. If I gave that medical advice at 6:45 pm when the appointment was at 4:45 pm, they thanked me for staying late to see them and some even asked if they could pay me extra for my working late. Now we have administrators who tell doctors that a 15-30 minute wait for patients is unreasonable. The record of that professional opinion was held inviolable by the doctor in trust for the patient. Seldom was that relationship terminated.

Now patients frequently come because they are directed by their insurance carrier into an involuntary relationship, making the doctor–patient relationship suspect. Patients don’t completely trust what the physician records if they believe what is recorded may prevent the care they want.

Occasionally doctors sell their practices for $25 a chart. An administrator who bought the charts, now his organization’s property, may not readily release a patient’s chart to a new doctor. Thereby, the most confidential of all records has been auctioned off to the highest bidder, who considers a patient who has to wait for 30 minutes for an appointment as merely two or three units of lost revenue.

Patients who leave one hospital HMO because the appointment terminates at exactly 15 minutes sometimes find that the doctor in the next HMO presses a time clock when he walks in and a beep goes off after 9 minutes alerting the doctor that he has 60 seconds to bring the medical evaluation to a close and start his/her next appointment. Doctor, medical group, administration, insurance carrier, and patient are all now adversaries in a forced relationship.

Doctors see no hope in solving this problem voluntarily. The profession that in the past looked to the law and lawyers as the ultimate losing game, now is actually looking to lawyers and laws to solve their problems. If we considered ourselves as the protector of our patient’s health, we would never have sold a chart at any price. If we controlled the patient’s medical file we could never be asked to compromise care or to be held hostage. We would continue to have a trusting, healthy interdependent relationship. And none of this has any relationship to laws or lawyers. It’s us, a profession based on principles, simply being professional.

Are We Going in the Wrong Direction? November 1999

On a recent trip to London to visit our daughter and see the organization she cofounded (www.firsttuesday.com) go international, we were met at the airport by a driver who proceeded to drive on the “wrong” side of the street. It caused me to reflect on a recent story about an elderly lady who was increasingly concerned over her husband’s progressive forgetfulness and his getting lost. In turn, she became anxious about his ability to drive to his weekly golf game and was compelled to buy him a cellular phone, programmed to call home when the send button was pressed. One day, after sending him on his way to golf and extracting a promise to “be careful,” she was doing her housework and noted a news bulletin on the TV that some idiot was driving in the wrong direction on the freeway. As the camera closed in, the car became disturbingly familiar. She immediately called her husband on the cellular phone to ask if he was on the freeway going in the wrong direction? He told his wife, “Don’t worry, honey. There must be hundreds of cars going in the wrong direction.”

Our society president makes a plea for our involvement in the legislative process. She remarks about the half days she’s spent waiting for a bill to come up, only to find that it is rescheduled for the following day. Would any medical group, whether Kaiser Permanente, Sutter Medical Group, or MedClinic, allow a physician to stay in waiting for two half days in one week? We also get weekly multipage e-mails from AMA and CMA asking for our involvement in the legislative process. One recent combination listed two pages of addresses for letters to be written by us to influence legislation. I would estimate that it would take up to 10 hours a week to follow through on many of the weekly requests. This is about a $1000 weekly donation of time?

Our president also points out that our legislators frequently write laws that direct us to provide medical care in a particular way that may not be appropriate for our patients. She states that legislators need our guidance because few have any background in medicine. If the lawmakers insist on practicing medicine, should they not have to complete medical school and internship and obtain a license to do so? Jane Orient, MD, president of the Association of American Physicians and Surgeons, has also talked about the fact that many of our lawmakers practice medicine without a license. Perhaps it would more cost-effective to champion a lawsuit by a patient who has been injured by legislative medicine and place that lawmaker behind bars. It would reduce the need for legislative advocacy, make our professional dues fully professional and tax deductible again, and it would free up more time for us to practice medicine.

I recently had a patient who stated that she had PVD. (She called it Pulmonary Vascular Disease.) She had symptoms of leg aches and slight swelling. Her computer printouts indicated that if PVD wasn’t diagnosed immediately, it could lead to gangrene and amputation. She had warm feet with bounding pulses but could not be reassured. In the Wall Street Journal the next day, Ann Carrns reported about a new class of patients that have a powerful new tool for worrying as they search the 15,000 health-related Web sites, convinced that their symptoms are the result of a serious if not fatal disease. Sites discussing neurological or autoimmune diseases with difficult to pinpoint symptoms have the highest incidence of this new disease called “cyberchondria.” Meanwhile Alyssa Robinson, who operates the “Wonderful World of Diseases” Web page, states, “People love diseases. There’s sort-of a gore to it that people find fascinating.”

UAPD physician Deane Hillsman, MD, states that the AMA stance “We’ll never strike” is “sanctimonious foolishness.” He also points out that the Union of American Physicians and Dentists has made many mistakes during their decades of learning and predicts the AMA will repeat many of the same mistakes. Our president-elect says “not so.” He states that doctors could, for example, refuse to sign the face sheet on medical charts. To what end? That would only get the doctor’s and his colleagues’ staff privileges suspended. After 45 days they could face the Medical Board of California and possibly get their medical license suspended as well. To speed up our learning curve, we should recall that Sanford Marcus, MD, the president of the UAPD for decades, told the Sacramento Internal Medicine Society in the 1970s, that the most effective strike for physicians, after writing the appropriate medical care orders so patient care would never be jeopardized, would be to put their pens in their pockets and not write discharge orders. One of our past presidents also mentioned a similar measure that happened during his house staff training which brought the administration to their knees as beds were filled and emergencies stacked up in the corridors waiting admission. Yes, our PE is suggesting a rather ruthless strike against hospitals that insurance carriers, against whom the “strike” is intended, would disregard and, would only hurt physicians. We should leave union activities to the Unions.

Our editorial vice-chairman, commenting on the torching of the synagogues, referred to Abe Foxman, the principal speaker of a program at the community center, a child-victim of the holocaust and national director for the Anti-Defamation League, who tearfully wondered whether the Holocaust and World War II might have been averted if Austria and Germany had responded to the attacks on Jews as Sacramento was now doing.

Dennis Prager, co-author of “Why the Jews? The Reason for Anti-Semitism,” comments on the anti-Semitic attack on the Jewish community center in Granada Hills, California. He feels the reactions of many Jews to this terrible event were extraordinarily dramatic. The ADL had a large advertisement in the press. The next day he was stopped by guards at his own synagogue not far from Granada Hills. He states the Granada Hills attack conjured up memories of the European Holocaust–memories that gnaw at every Jew, whether atheist or Orthodox, left or right. He agrees with the ADL that America must combat anti-Semites. But he cautions America’s Jews to be careful not to panic, not to let memories of slaughtered Jewish children cloud the reality that America remains the most tolerant, open and Judaism-loving country they have ever lived in. He feels we have a uniquely tolerant form of religious expression that has been the conduit of American democracy and which has created a uniquely secular government and religion-based society. He states, “Jews have never been merely tolerated in America. Despite our small numbers, we have been full partners in the historic endeavor to build this country. . . [only] if America’s Jews recognize that their security depends on that Judeo-Christian soul–will Granada Hills [and Sacramento] remain an aberration. In Europe, the seeds of modern Jew-hatred were laid by centuries of Christian anti-Semitism. In America, the seeds of anti-Semitism are laid by a rejection of Christianity. In this way, too, America is different.”

Physician, Heal Thyself December 1999

As we close out another year in our professional lives, and the last month of this millennium, we reflect on where we’ve been and envision where we’re heading. Many disgruntled physicians ask, “Are we moving forward in the cause of helping our patients, or are they worse off?” One doctor wrote me a five page letter on how to revamp health care—if I didn’t think his suggestions would work, he had a dozen more. I also hear from unhappy patients. Few of them understand the complexities involved. It may be helpful to go outside our organization to take a look within. And this is what happened at a recent conference.

A quite resort on a lake in Coeur d’Alene, Idaho, with forested mountains all around, with chefs designing an entire dinner around the Idaho potato, was the background for the recent seminar, “Physician, Heal Thyself—Reclaiming the Medical Profession.” Sponsored by the Association of American Physician and Surgeons, it highlighted the experiences of physicians in this country during the final year of the twentieth century. Their experiences are very unsettling.

Each year at this conference a number of physicians recount their interface with Medicare. Opting out of Medicare continues to be a major story—one which chronicles the progress of physicians in restoring private medical practice. Dermatologists, internists, family physicians, and others are now seeing patients and, during the visit, are receiving a fee for services rendered. These physicians related how, when the day is over, the professional services are all paid for and there are no books, billing records, or accounts receivable to worry about. These physicians return home to their families at a decent hour satisfied that the services for which they were paid were also appreciated. Although their gross income may have dropped 50%, their net income has dropped very little. Billing costs, collection costs, patient mailings, E & M guideline costs, coding costs, record costs, and the personnel required to do such things, have nearly been eliminated with the medical record reduced to only what is essential for patient care. And many felt that the costs of compliance with the AMA guidelines have now exceeded the medical costs of caring for patients.

Living simply is a complex problem. How are physicians simplifying their lives? “SimpleCare” is the answer for some. Their Web site (www.simplecare.com) lists physicians who are part of this simplified system. Any physician can join for $35 a year (about 10¢ per day) and then signs a simple pledge, “SimpleCare patients who pay in full at the time of service will get my best price.” In these practices, charts are flagged with an orange sticker, the patient states whether he wants 10, 20, or 30 minutes with the doctor, and after that amount of time, pays his bill and no further billing records need be processed. State authorities reviewed this plan and found that it did not conflict with any laws. Although these doctors still see Medicare and Medicaid patients, the cash portion of their practice is growing faster than the insured portion is declining.

A former FBI agent, who now is an HCFA cop, stated that his job was to make sure that all physicians in the United States taking care of Medicare patients would be prosecuted, hopefully jailed, and if that failed, to be fined at least $200,000. When pushed, he stated that all physicians are crooks, guilty of overcharging Medicare, and deserved to be imprisoned.

Physicians are being treated like gangsters, drug runners, and violent criminals.The speaker stated that never has a profession or a business been as ill treated. No other profession, whether law, clergy, or teaching, has been treated like the medical profession because doctors don’t have the leadership to do anything about it. In fact one AMA delegate stated that our leaders are in bed with the government and thus are party to the assault on us.

What the public doesn’t understand is that doctors are spending as much time on office calls and consults as they ever have. Many doctors, I know, have not increased their charges in nearly a decade, except for minor adjustments. For example, a doctor may have charged $50 for an office or convalescent hospital call for many years. With the old RVS, a code was assigned for this service. Now we have to get used to the new RBRVS system, which many physicians still do not understand. Why should they? They may still be charging the same $50 for the same amount of work in an inflationary economy. Charging but by not coding the services according to the RERVS, many physicians are now criminals without any medical practice component to the crime. We found that Sacramento is not the only place with physicians spending time in jail. And in the process, they have lost their most valuable piece of property known as a “medical license.”

Can we, physicians, still heal ourselves? Remember in colonial America, less than 10% of the population believed that they could regain freedom. But after they won the war, the other 90%, as well as succeeding generations, were grateful. My email and faxes, as well as my interface with colleagues in the staff rooms, at meetings, and on the avenues, suggest that the majority of us still feel we can regain the freedom to practice patient-based relational medicine. We have to network to get our strategy in focus. It is the electronic age; we cannot process any more paper. Send an email if you want to join the network and explore the possibilities. Our patients and their children will be grateful for your efforts. Otherwise, after we have spent our life surmounting our professional challenges, we may find that we have climbed the wrong mountain.