From California to New York December 1998

John Greisman, MD, president of the San Diego Medical Society, uses the quiet summer months at society headquarters to write his mother, apologizing that his hospital is not listed in the US News honor roll of hospitals in the United States. He assures her that the 30 hospitals in San Diego do liver transplants, AIDS research, separate Siamese twins, develop new anti-cancer pharmaceuticals, advance the human genome project, fix bones, hearts, lungs, gall bladders and prostates and it was only a careless omission that San Diego wasn’t in the top ten honor roll. After assuring his mother that he’s not working in a second rate hospital, he chides US News: “Sorry, you’re dead wrong.”

The San Francisco Medical Society has had their own symphony orchestra for more than 30 years. In 1946, SF Medical Society members returning from World War II set up the SFMS Symphony which met every Monday night at either the medical society auditorium or area hospitals. The SFMS symphony gave two public concerts each year performing each program twice. Contributions of the members funded the symphony, and the proceeds from the concerts were donated to charitable causes such as the Blood Bank and The Hearing and Speech Center. As interest declined in the 1970s, the Monday sessions took a summer recess. They were never resumed. Ten years later, the son of a physician, a graduate student in biophysics at UCSF, asked to join the symphony and finding none, organized one that he led until 1995. Today the Medical Society symphony is no more but the UCSF orchestra is carrying on beautifully.

Robert Jaspan, MD, Editor of the Riverside County Medical Association Bulletin, reviews a New England Journal of Medicine article by Robert Kottner that defines two forms of managed care: socially-oriented (e.g. Kaiser) and market-oriented (For Profit HMOs). The first form, or the staff model, realizes efficiencies in three ways. (1) It emphasizes prevention and patient education and building a long-term member-plan relationship. (2) Physicians are salaried so that clinical decisions are neutral with respect to income. (3) These plans carefully monitor what physicians do, to educate them about “best practice” protocols.

Market-oriented For-Profit HMOs, developed since the 1970s, have the following additional features: physicians assuming financial risk through capitation; pre-selecting members, targeting industries with young, healthy employees, and in the Medicare market using health-fitness programs to deselect the chronically ill.

The important question is, has the competitive pressure to cut costs caused the socially-oriented staff model group of HMOs to embrace practices once abhorred just to stay in business?

This is a point for us to remember–always identify which type of HMO we are discussing.

San Francisco Medicine devotes 12 columns (four pages) to the news from 12 SF hospitals. Thus twelve physician editors give an overview of what’s happening in the SF medical community. A nice idea to keep members informed of happenings about town. devotes 12 columns (four pages) to the news from 12 SF hospitals. Thus twelve physician editors give an overview of what’s happening in the SF medical community. A nice idea to keep members informed of happenings about town.

Richard H Guth, MD, AMA delegate from Riverside, comments on the AMA Annual Meetings. Each year the solution to the problem of organized medicine becomes more obvious to him. He feels we need an AMA that truly represents all of America’s physicians even if membership dues must be dropped so low that the AMA has limited staff and limited budgets for all its activities.

Atul Gawande, MD, in a Medical Dispatch column of the September 21, 1998, issue of The New Yorker , writes an article titled “The Pain Perplex.” When a patient has chronic pain without physical explanation–and such patients are common–physicians tend to be dismissive. Psychologist Ronald Melzack and Physiologist Patrick Wall propose that the Cartesian model of pain be replaced with the gate-controlled theory of pain. They argue that before pain signals reach the brain, they must pass through a gating mechanism in the spinal cord that could ratchet the signals up or down or even stop pain impulse from going to the brain. However, the most startling suggestion of Melzack and Wall was that emotions and other “output” from the brain also controlled the gate. This helped explain how mood, gender, and beliefs influence pain. Studies have shown that social conditions play a dominant role in many chronic-pain syndromes. This does not mean that people are faking their distress, but that a more compassionate approach toward chronic pain includes investigating its social coordinates, not just its physical ones. The solution to chronic pain may lie more in what goes on around us than in what is going on inside us.