Doing the Right Thing – Return to Solo Practice

Eric Holmberg, MD, a Petaluma family physician , writes the featured article in Sonoma Medicine. He left a salaried position at the Petaluma Health Center and embarked on a solo medical practice. “This move seemed to fly in the face of common sense because the number of private-practice physicians in Petaluma has steadily dwindled over the past decade, with the principal efflux going to Kaiser and most of the remainder to practice opportunities outside of Sonoma County.”

Holmberg states “… in 1992, most young physicians I knew would have been happy to open their own offices or join existing practices to replace their happily retiring older colleagues. Today, however, the ravages of managed care, and the advent of a health system controlled by the insurance industry and neglected by government, have left a barren landscape for new physicians.”

He had for some time thought about returning to a smaller model of care, “… and the shift finally seemed right last year,” he states. “I didn’t intend to practice completely alone; but when partners did not readily materialize, I realized that solo practice was quite doable and perhaps in some ways for the best.” After being on his own for almost a year and enjoying work once again, he’s been able to fix nearly everything he was unhappy about previously.

“With the exception of a few out-of-town trips, I have taken all my own call during this time. Call is much less burdensome than I thought it would be, other than the need to be always available. Patients have both my home and cell phone, and they don’t abuse them. I know the patients who are calling, and I can access their charts and our appointment schedule over the Internet. I never have to quibble with the on-call doctor’s decisions. My patients seem quite happy, and the practice continues to grow steadily without the need for advertising.”

He concludes that to be of real value to patients, the private-practice community needs to offer something unique. “We need to differentiate ourselves from the HMO model by being more accessible, flexible, and caring, and by knowing our patients as well as we possibly can. We have lost the early battles for information retrieval, system organization, and pharmacy management; but as we strive to improve these aspects of our practices, we should also offer the one alternative that patients are most enamored of: the chance to know and be known by your doctor.” To read the featured article, go to www.scma.org/magazine/scp/sp05/holmberg.html.

A Gynecologic Perspective of The Young Female Athlete

Susan J. Spencer, M.D., who practices obstetrics, gynecology and reproductive endocrinology in San Mateo, writes in the San Mateo County Medical Association Bulletin, that exercise is good, but from the gynecologic perspective, there are potential reproductive health concerns for the adolescent engaged in strenuous sports. “Back in 1970, Rose Frisch published in Science the seminal paper on the link between body fat and the initiation of menstruation (menarche). Her key observation was that late-maturing girls gain fat more slowly. Her research established the hypothesis that menarche, as well as maintenance of menstrual function, is related to the percentage and absolute amount of body fat. We now recognize that there is a link between extremely vigorous physical activity in female athletes and menstrual dysfunction. The term ‘exercise-induced amenorrhea’ has been used to describe the suppression of central nervous system pulsatile hormone secretion by the stress of vigorous exercise and concomitant negative energy balance.

“In 1992 The American College of Sports Medicine coined the term ‘Female Athlete Triad.’ This syndrome is defined as disordered eating, osteoporosis, and amenorrhea that occurs in women engaged in regular strenuous exercise or sports activities. For those of you accustomed to acronyms, I do not believe the authors wish to refer to the syndrome as “FAT.”

“In the young female athlete, weight can become a preoccupation. Abnormal eating behaviors may arise in young women, but most vulnerable are those involved in athletic activities that are weight-bearing and favor leanness for performance, such as ballet and gymnastics.

“By the age of 10 years there is a demonstrable difference in concern about eating and weight between girls and boys. One study showed that by fifth grade 31 percent of girls are dieting, and by sixth grade, 62 percent are dieting to lose weight. Thus it appears that attempts to diet in an effort to control weight are common in prepubertal and pubertal girls. All it takes is a glance at Teen Vogue or Britney Spears’ latest video to realize that young girls are bombarded with images that reinforce abnormal eating patterns. Other factors thought to increase a young athlete’s risk for the disordered eating component of this triad include frequent weigh-ins, an overcontrolling parent or coach, and the social isolation of individual sports compared with team sports.”

In summary, Spencer states there are potential health risks for young women in strenuous sports and exercise programs. “Physicians and parents need to be cognizant of the Female Athlete Triad. Supportive care for the adolescent, with collaboration between pediatrician, gynecologist, orthopaedist, and parents, greatly enhances recovery.” To read the entire article, go to www.smcma.org/Bulletin/BulletinIssues/March05issue/A%20GynecologicPerspective.html.

The Trouble With Day Care

David Feddes, in his Mother’s Day message on the importance of motherhood, points out that a Canadian kennel will not place a new puppy in a home with both parents working. He states that equally damaging as a dog being at home with no master, evidence is increasing that a child without either parent at home has a significant chance of behavior problems.

Heide Lang, in the current issue of Psychology Today, discusses the trouble with day care and questions whether scientists are telling parents the whole truth? Stanley Greenspan, a George Washington University child psychiatrist, says the current state of day care could be the greatest social experiment of our time, in which millions of parents are unwitting participants. “In just 25 years, American families have been radically restructured as the number of women in the workforce has nearly doubled. Instead of parents providing early child care, it is outsourced to virtual strangers. An estimated 12 million American infants, toddlers and preschoolers-more than half of the children in this age group-attend day care. The majority of these kids spend close to 40 hours per week in day care; many start when they are only weeks old.

The raging debates around maternal guilt, work/family balance, money and childrearing often drown out scientific insights into the developmental pact of day care. But the latest findings from a huge, long-term government study, are worrisome. They show that kids who spend long hours in day care have behavior problems that persist well into elementary school. About 26 percent of children who spend more than 45 hours per week in day care go on to have serious behavior problems at kindergarten age. In contrast, only 10 percent of kids who spend less than 10 hours per week have equivalent problems.”

“Developmental psychologists are sweeping this information under the rug, hoping studies will churn out better data soon,” argues Jay Belsky, a child development researcher at London’s Birbeck College and a longtime critic of his fellow scientists. He contends that the field of developmental psychology is monopolized by women with a “liberal progressive feminist” bias. “Their concern is to not make mothers feel bad,” he says. To read the entire article, go tohttp://cms.psychologytoday.com/pto/home.php.

Saving MICRA

Sonoma County Medical Association President Heather Furnas, MD, notes that “In the CIA thriller Spygame, Robert Redford’s secretary bemusedly questions his flurry of seemingly paranoid activity. He pauses a moment before asking her, “When did Noah build the ark? Before the rain …… before the rain.”

“Dark clouds are presently gathering over MICRA (the Medical Injury Compensation Reform Act that California enacted in 1975), and CMA is making plans to build an ark. In the current legislative session, Sen. Tim Torlakson (D-Antioch) plans to introduce a bill to raise MICRA’s $250,000 cap for ‘pain and suffering’ to more than $900,000.” (This has since been withdrawn.)

“How lucky are physicians in Sonoma County? Compared to non-MICRA physicians in similar locations around the United States, our malpractice premium costs are almost 80% lower. The average non-MICRA annual premium for all specialties is $90,602; for MICRA, it’s just $19,445.

“What are we up against? A whole lot of money. The No. 1 priority of California trial lawyers is to defeat MICRA. For every dollar California physicians contribute to protect MICRA, trial lawyers contribute $200 to defeat it. Worse yet, while only 20% of California physicians contribute to CMA’s political action committee (CALPAC), 100% of the trial attorneys contribute to their PAC.”

Furnas concludes: “All of us need to pitch in to defend MICRA. If you specify MICRA on your CALPAC donation, 100% of your contribution will go directly to the cause, with none spent on administration. It’s going to take a lot of timber to build this ark, and I think I hear some thunder in the distance.” To read the entire article, go towww.scma.org/magazine/scp/sp05/furnas.html.