From California January 1999
Author D Silk, MD, the editor of the Bulletin of the Orange County Medical Society, suggests that we should stop crowing about the evolution of medicine from a cottage industry to big business as if that transition means progress. He says it doesn’t. Like your grandmother’s pies and hand-tailored suits, some services are better done by individuals working in their own microenvironments than in corporate beehives. Turning out sick patients on a production line . . . is a sociologic experiment that [is] unfortunate for our patients and ourselves . . . despite widespread dissatisfaction . . . Even a flawed system may last for two or three decades before its weaknesses become so prominent that it disintegrates. It took Russian Communism 70 years to fall of its own weight. . . Doctors were not perfect before corporate medicine besmirched the horizon. But when medicine was a cottage industry, a single error in technique or judgment resulting in a malpractice suit . . . became a local headline. Now billion dollar frauds by corporate medicine are almost daily headlines. When the service must be personal and individual, private schools, portrait painting, playwriting, tailor-made suits, home cooking, dressmakers, nurses, and doctors are all examples of the superiority of what some may derisively call a cottage industry.
Larry L Coble, MD, President of the Fresno-Madera Medical Society, writes about the “Big Vise…What can we do about it?” The “vise” he refers to is between those who purchase health care and demand lower prices as opposed to those who receive health care and demand more services. Those who provide it, namely us, are caught in the middle. He feels that we can relieve the pressure of this vise with two primary and potent influences that we control: Professionalism and Quality. To enhance Professionalism we must 1) reestablish the primacy of the patient advocacy role; 2) resolutely defend the patient-physician relationship; 3) reaffirm our strict adherence to our code of ethics; and 4) reaffirm the necessity for holding ourselves accountable to a principled code of conduct. To improve Quality, we must 1) assure the application of scientific principles to quality outcome measurement; 2) assure that sound clinical research is used in development of clinical guidelines; and 3) assume a leadership role in the development, implementation and refinement of quality improvement programs in the facilities where we provide care. He states that we can help ourselves and our profession, and, more importantly, our patients and community by redirecting our energies from fighting the vice to turning the crank to release the pressure.
Elliot C Lepler, MD, in his first column as president of the Santa Clara County Medical Association, admits that joining the medical society in 1981 was a business decision. Patients had occasionally asked him about his membership; not being a member seemed to have negative connotations. As president he pledges to speak to the business community and the service clubs of Silicon Valley so that a wider audience will be able to hear the “Voice of Medicine.”
(North Carolina Medical Journal, March/April 1998 [NC Med J 1998;59:96-7])
The Role of the Medical Profession in a Managed Care Environment
Editor’s note: At the annual meeting of the North Carolina Medical Society in Pinehurst in November 1997, the Bioethics Committee introduced a resolution that would require the Society to take a specific position relative to the practice of medicine in the present era of third-party payment for and influence over medical care. This proposal engendered considerable debate and heated argument–both in the Reference Committee and in the House of Delegates. The final decision of the House was to file the motion, effectively removing it from action.
It is the opinion of the Editor that this statement offers much value for doctors to ponder. It is worth more reflection than a motion ‘to file.’ If the unexamined life is not worth living, the unexamined practice is not worth practicing. The resolution put forth by the Bioethics Committee asks us to look at the distortions introduced into the doctor-patient relationship by the ancient principle that he who pays the piper calls the tune. Doctors often [are forced to] turn for guidance in medical decisions to the insurance companies (or health maintenance organizations) who pay for their services. Patients, insulated from the need to pay directly for services, undervalue the advice that doctors have to offer.
In order to foster further discussion, the Journal showed the slightly edited version of the resolution printed below to a number of physicians to comment. Several declined to respond. We printed responses we did receive in the March/April, 1998 issue. We invite readers to offer their comments in writing or via electronic mail (yohnOO01@mc.duke.edu).
Statement of the Bioethics Committee of the North Carolina Medical Society
Resolved, that the North Carolina Medical Society adopt as policy the following statement on the medical profession’s role in a managed care environment:
I. Origin of the problem. We believe that most of the current problems in medical care delivery originate from the introduction of insurance as a method of payment for medical care services. Because everyone welcomed this “innovation” as the solution to payment concerns, all believed that they would benefit from this change. Therefore, all parties – physicians, patients, and payers – are responsible for this ultimately unwelcome state of affairs. Each member of this “triangular relationship” – physician, patient, and payer – has nurtured this original insurance concept for his or her own benefit, and gradually transmogrified it into paying for medical care with “other people’s money” or “getting something for nothing” with disastrous consequences.
II. Current state of the managed care environment. Presently, because of the desire that insurance pay for all medical needs and other distortions in our economic system, each member of the triangular relationship has lost control over many of the benefits and responsibilities of the simpler “one-on-one” system. Patients frequently lose the choice of hospital, physician, or provider, and procedures they believe are needed. Payers lose control of costs. And physicians, caught in a disingenuous and coercive system and manipulated by gag clauses, capitation, withholds, and “risk-sharing agreements,” lose the most precious possession of their once noble profession: the public trust in them as caregivers, confidants, and advocates.
III. Our professional objectives. It is the obligation of the profession of medicine to preserve the integrity of the institution of “physicianhood” and the role of the physician as caregiver, confidant, and advocate for the individual patient. This, above all other responsibilities, must be the foundation upon which medical societies and individual physicians base their recommendations and policies in areas of medical care reform. Whatever damages, or may damage, this sacred function should be opposed and actively resisted at all levels of medical leadership regardless of the potential for conflict.
IV- What we must do. To preserve the profession and its social mission, it is the recommendation of the Bioethics Committee that the North Carolina Medical Society promote a resurgence of patient control over choice in medical care and reaffirm the trust in the physician-patient relationship by promoting and implementing wherever possible a system wherein patients must exchange something of value for the services (except those required by medical catastrophe) they receive in the medical marketplace. In addition, the Bioethics Committee recommends that this Society actively promote catastrophic medical insurance as the most moral and just method of managing infrequent, high-cost medical expenses.
It is the belief of the Bioethics Committee that the field of medical care reform is too expansive to “solve” with a few suggestions. We also believe, however, that the following fundamental principles will mollify much of the social upheaval resulting from current medical reform efforts:
1) The patient must regain control of the cost and quality of medical care. This can be accomplished by the exchange of something of mutually agreed upon value between patient and physician for care received.
2) The cost of medical care may, on occasion, exceed the resources of the individual patient. This circumstance should be addressed by a system, of catastrophic medical insurance.
3) Physicians are obligated to continue their tradition of providing care to those who cannot afford it.
We believe that these fundamental principles will establish a foundation upon which to rebuild a medical care delivery system that is fair, equitable, and just.
Reprints, available from:
Association of American Physicians and Surgeons. 1601 N. Tucson Blvd Suite 9. Tucson, AZ 85716
Pamphlet No. 1062, August, I998
From San Diego to Santa Rosa February 1999
San Diego Physician editor, Paul K Raffer, MD, gives the demographics for San Diego. Of the 5700 practicing physicians in the county, 2000 members of the medical society. The majority of nonmembers are staff or group practitioners. Of Kaiser’s 650 doctors, 33 are members; Scripps Clinic has 56 of its 400 staff as members; and UCSD has a grand total of 29 of its 1200 doctors as members.
John Greisman, MD, president of the San Diego County Medical Society, found that San Diego doctors had an opinion that was at variance with CMA, AMA, Democrats, and Republicans. He points out that county societies are component societies, not chapters and hence are not required to accept, as policy, statements by the leadership of the CMA or the AMA, which has an “inside the beltway” mentality, driven by staff and abetted by legal counsel. He finds it difficult to determine who really speaks for the members. If members opinions had been sought, perhaps the Cal Advantage debacle could have been mitigated.
Kevin P Glynn, MD, a pulmonologist who completed his term as editor of San Diego Physician, puts our problems in perspective. “We physicians paradoxically cling to antiquated methods of record keeping and rely on ‘clinical experience’ to guide diagnosis and treatment yet espouse new clinical techniques with minimal evidence of effectiveness. Our system of recording and distributing medical information is retarding medical quality. It is archaic and inadequate for the intricacy of contemporary care. No other important segment of contemporary society uses hand written notes (mostly illegible) to communicate information among workers. It is no wonder health policy planners resort to using administrative and financial data to seek information on clinical outcomes . . . [which are] inaccurate. . . . The [AMA-HCFA E & M] fiasco illustrates this. Imagine trying to decide what salary to pay a baseball player by counting his swings during batting practice. . . We need most an efficient electronic medical record to make things come together, and that’s the weak link in the chain. . . The person who creates a coherent system of tracking patients’ data, transmitting information smoothly from office to office, from laboratory to clinic, and from hospital to nursing facility, will make billions of dollars and deserve it. . . Doctors are essential at every step in the process. . . High quality care will follow and health plans and journalists will have to seek other answers for remaining weaknesses in our health care system.”
Richard Marsh, PhD, a forensic Psychologist, reported at the annual meeting of the American Medical Writers Association, that after losing his first legal case 20 years ago over a fender-bender, he became a student of the legal process. He found the process frustrating and screwy. After 20 years of testifying in numerous child custody battles, assessing criminal defendants, and psychological injury, Dr Marsh reached a curious conclusion. “Evidence is viewed with respect to certain criteria, and most would have you believe there are only three: written law, case law, and procedural law.” The salient factors influencing the process, however, is its overarching hypocrisy: “We say that all the evidence will be admitted, that all the witnesses will be heard, that each side will have a fair shake, but we don’t mean it.” The legally naive can find the system’s attitude toward lying especially galling. “Hypocrisy is rampant in the language of perjury. We are taught that perjury is lying under oath. In fact, perjury is defined as a false statement which has probative and compelling impact on the outcome. So if you lie and either they don’t believe you or it’s not very important in determining the outcome, it’s not perjury. . . In certain instances you are expected to lie by omission.” He illustrates this by the disclosure of a jailed suspect who admits to shooting a cop is enough in itself to declare him incompetent.
James K. Gude, MD, Santa Rosa pulmonologist, editorial board member and classic book reviewer for Sonoma County Physician, recently reviewed A. J. Cronin’s 1937 novel, The Citadel, in an editorial. Just as Dr Andrew Manson, the protagonist, moves to London to make more money, various corrupting forces enter his life and he becomes avaricious. As his wealth increases, so does his obsession with power. Manson rises to the top of committees and staff organizations so as to control others. He endorses commercial products for a lucrative return. Dr Gude feels the story is timeless and that we continue to face the same corrupting forces of greed, power, and ignorance. The problems of the good physician lie in sustaining this “good,” given the weaknesses of human nature and our medical system.
From Alternative Medicine to Barbie Dolls March 1999
Robert Jaspan, MD, Riverside County Medical Association Bulletin Editor, discusses alternative medicine. He notes that alternative medicine largely ignores biologic mechanisms and relies on ancient practices which are seen as less toxic, yet more potent. He sees this as a reversion to irrational approaches to medical practice, possibly brought on by the sometimes hurried and impersonal care delivered by conventional physicians. He feels the scientific community should stop giving alternative medicine a free ride. Jaspan feels that alternative treatments should be subjected to scientific testing no less rigorous than that required for the conventional medicine.
Martin Rosten, MD, gives his “Point of View” in the San Diego Physician. As a medical student in the 30’s, he used herbs such as digitalis, thyroid extract, belladonna, etc. These have all been replaced by synthetics where the therapeutic dose can be exactly measured. When a new drug is introduced it costs millions of dollars to ensure efficacy and safety. But label the drug as a food supplement or herb and the public becomes a guinea pig with sometimes disastrous results. He states that it is time we doctors read the results of controlled experiments and enlighten the public that all is not gold that glitters. “Don’t let your patients become guinea pigs.”
Humor therapy: The latest Robin Williams movie is about the life of physician and professional clown Patch Adams. For the last two years, an entire wing of INTEGRIS Health’s Baptist Medical Center in Oklahoma City has been dedicated to a pilot project called the “Medical Institute for Recovery Through Humor” (MIRTH). It is a 21-bed unit designed to measure the healing power humor on patients, their families and their caregivers. “We believe the patients that laughs also lasts,” says Stanley Hupfield, INTEGRIS Health’s president and CEO.
According to a recent press release, Chiropractors are doing well. Chiropractors are seeing a marked increase in the income they receive from HMOs and PPOs, concludes a new survey conducted by the American Chiropractic Association and published in its November journal. Chiropractors in practice for more than 5 years saw their income from HMOs and PPOs nearly double between 1995 and 1997. “These figures demonstrated that managed care organizations are increasingly recognizing the importance of including chiropractic services in their plans,” says ACA President Michael Pedigo.
John Astin, a post-doctoral fellow at the Stanford University Center for Research in Disease Prevention, published in the Archives of Internal Medicine his analyses of 19 surveys which found that 43% of MDs referred at least one patient to an acupuncturist and 40% sent at least one patient to a chiropractor. “We believe our survey is a wake-up call, reminding physicians that they need information so that they can make decisions about the use of complementary medicine based on scientific evidence of efficacy, rather than nonmedical criteria, such as regional economics and cultural norms,” Astin says.
Kenneth C Lane, MD, the President-Elect of the San Bernardino County Medical Society states “The Trial Lawyers Are Coming! The Trial Lawyers are Coming!” Following the decisive victory by the Democrats in the November 3rd General Elections, he expects that political payback will soon follow. After pouring $8.6 million into state-wide races, California trial lawyers will demand a return on their investment. Tolerating 16 years of divided government in Sacramento, trial lawyers have suffered multiple failures to modify MICRA, endured expanded arbitration legislation that has bypassed costly lawsuits, and have confirmed many conservative judicial appointments. Trial lawyers will expect “their” legislature to pass and “their” governor to sign laws that will significantly increase the expense of medical liability. If the entire wish list becomes law, it could add up to $500 million dollars annually to the cost of health care in California.
The Humboldt-Del Norte County Medical Society Bulletin points to the outstanding success of CalPac had in electing 18 of 20 state senate races and 72 of 76 state assembly races and all 44 congressional races. (Are CalPac & Trial lawyers really paying money to the same candidates?)
Los Angeles County Medical Association (LACMA) Physician reports that El Segundo toy manufacturer of Barbie Dolls, Mattel, Inc, has announced a $25 million donation to UCLA Children’s Hospital. UCLA plans to rename the hospital, upon receipt of the donation, to the Mattel Children’s Hospital at UCLA. The donation will augment existing hospital services and construction of a new facility in 2000 and accept patients 4 years later. LACMA says “That’s a lot of Barbie Dolls.”
From Chico to La Jolla via England April 1999
Since that some hospital foundation and HMO groups assign physicians to the inpatient service, where they take over the total management of patients with whom they are unfamiliar, Luis E Cebrian, MD, a GP from Chico has a word of caution. Coming from the National Health Service (NHS) in England, where “hospitalists” are called consultants, he cites one horror story after another in Medical Economics. Dr Cebrian had a patient that presented to the British hospital ER with a stroke. After the patient deteriorated, he phoned the consultant (“hospitalist”) who was annoyed that a primary-care physician and a member of the lower order of the medical world was questioning him and wasting his time. Ultimately persuaded to have a neurologist consult, the patient was transferred to a tertiary hospital where a CT scan showed obstructive hydrocephalus, a surgical correctable disease. However, the two week delay caused severe brain damage with no hope for any quality of life.
In the same issue of Medical Economics, Patricia J Roy, DO, graphically illustrates what happens to office overhead when the doctor/owner of the practice delegates payroll, accounts payable, and office management to administrative people. In eight months, her accountant noted that utilities increased 100%, injectables increased 500% and payroll, 250%. Dr Roy started coming to the office one hour earlier to re-assume these duties. When other doctors questioned Dr Roy’s playing comptroller instead of hiring a $12-an-hour clerk: “Your time is worth $200 an hour,” Dr Roy replied, “Hogwash. Paying the bills myself nets me far more than $200 per hour. It turns me into a well-informed, hands-on manager, enforces fiscal responsibility and, best of all, improves the bottom line. I get to write a bigger check to myself.” She suggests doctors “stir that idea into your morning coffee.”
In another issue of Medical Economics, the senior editor looks at why some physicians are top earners. Surprisingly, three of ten high earners are in solo practice. In solo practice, physician time and energy is not lost to politics and multilayered systems. High earners put in 3% more time, see 7% more patients and charge more per patients. Top earners participate in the most HMOs and PPOs, though they may not derive the bulk of their income from managed care. The surgical specialties still make 50% more than the rest of us. The number of physicians making less than $100, 000 has now increased to over 20%, which is about $30 an hour for the average 65 hour work week.
H Rex Greene, MD, the president of the Los Angeles County Medical Association (LACMA), has made a sharp turn to the left of center. His president’s report, “Human Rights,” advocates that universal healthcare access is socially just. He deplores that we do not recognize healthcare as a human right which may explain the puzzling unwillingness to support universal access. He feels the ethical imperative to serve patients regardless of whether they can pay is inadequate to deliver consistent health care in our communities. He proposes that we reexamine the Constitution, in which there’s ringing language about “equal protection of the laws.” Since the government is willing to be a major purchaser of care for some of its citizens–Medicare, Medicaid, the VA system, CHAMPUS, etc–he submits that it’s depriving the rest of their civil rights. He admits that this line of reasoning is a stretch. . . I would say it’s much more of a gigantic leap across an abyss. As our colleague in Chico above, and my friends in Canada and the National Health Service in England will attest, that equal access doesn’t even mean they will have care. Or as Richard Epstein develops the thesis in his book, Mortal Peril, more people will obtain access through the free market than through any governmental coercive mechanism. Or as Edmund Pellegrino, MD, states in his book, For The Patient’s Good, we will get further in helping the poor through treating this as our moral obligation rather than as a right to health care.
James Lloyd Rice, MD, a La Jolla psychiatrist, deplores that no specialty has been more deprived of managed care funds. In his articles that have appeared in the San Diego Physician and LACMA Physician, he makes excellent points about the trivialization of psychiatric disorders and treatments as well as unfairness in reimbursement, or even having access to psychiatric disorders where the psychopathology can be diagnosed from a distance. … The process he deplores, I believe, began much earlier. In the 1970s, it was quite routine to do consultations not only on the medical, surgical, OB and Gyn wards, but also on the locked psychiatric wards. Almost daily, psychiatrist were in the mainstream, and we discussed our findings with them much the same way as with the surgeons. They took lunch with us in the staff lounge. When administrators sold the psychiatric services for economic reasons, the specialty became isolated. Now we hardly ever see them. If a managed care patient needs a psychiatrist, the patient sees a psychologist or a social worker who recommends pharmacology therapy and writes the prescription for the one or two psychiatrist on the staff to sign or tells us which drug we should prescribe. It’s called divide and conquer–and deprofessionalize. Instead of back to the future, it’s time for physicians to move forward to the past and take charge of our practice.
Sacramento, Santa Rosa, Fresno & Orange Counties May 1999
At the last Editorial Board Meeting we received a report concerning the proposed medical board fee increase. We were told that there is absolutely no question that the Medical Board of California (MBC) needs an increase in fees from physicians. This is because over a 20-year career, a physician beginning practice today in California may have as much as a 50% chance of being investigated by the MBC and almost a 20% chance of being disciplined. (Would the usual 40 year professional life of a physician have twice as many chances of being investigated and disciplined?)
But these conclusions are based on the wrong data. In the course of setting standards, one should eliminate those that are three or at the maximum two standard deviations outside of the norms. This usually is interpreted as the lowest 2 or 3 percent on a bell curve of practitioners. Since American Medical Schools are the world’s best, and even if we doubled the number of physicians that might conceivably be practicing substandard medicine allowing for the influx of foreign graduates, we would be looking at a maximum of 5% of physicians. With the medical board looking at 50% and thinking that 20% of us are substandard, it is disciplining four times as many as is reasonable or justifiable. Thus at least three-fourths of the medical board’s work and expenses are related to disciplining physicians who are well within the norms of practice. It is not a public service, but a tirade of hostility toward physicians that is driving this action. Thus instead of an increase in the fees for the MBC, three-fourths of the current fees should be eliminated which should be more than adequate in order to eliminate only the substandard doctors–not those at the very top of the curve or what would be the high end of the curve in 90% of the countries of the world. Unless leaders of our organizations immediately act to reduce the MBC fees to the appropriate one-fourth necessary to discipline one-fourth as many physicians (or $150,) they will continue to lose members. To our leaders, it may seem that rank and file doesn’t appreciate their superior knowledge, but the dues paying members won’t continue to pay organizations they feel don’t act in their interests.
Richard W Heifetz, MD, an anesthesiologist, has opened an anti-aging clinic in Santa Rosa. According to Sonoma Medicine, which devoted an entire issue on aging, he is a member of a new breed of physicians who belong to the American Academy of Anti-Aging Medicine. This group views aging as a normal process of degenerative diseases which can be slowed. They feel the current focus on the later stages of disease processes, e.g. Alzheimer’s, heart disease, diabetes, and strokes. If we focus on slowing or reversing the onset of “aging,” we could push back the onset of disease, thereby extending life span, and improving the quality of our later years. Dr Heifetz feels we can be as fit and vital at 75 as we were at 45.
Vital Signs, the Fresno-Madera Medical Society’s official publication continues to publish the installments of our editorial board member Dr David Gibson’s three part series we published in November and December 1998 and in January 1999. The importance of Dr Gibson’s analysis of significant healthcare issues is recognized by this small publication. We should have Doctor Gibson present his data to a general meeting of our society and invite all nonmembers. Having 2,600 physicians present would create more excitement than 26 (or was it 27?) at last meeting of 1998.
Samuel A Roth, Orange County Medical Association’s assistant executive director, reports on UCI College of Medicine’s annual “Health Care Forecast Conference” in The Bulletin of the OCMA titled “Things Can’t Get Much Worse Than 1998.” Arnold Milstein, MD, the medical director of the Pacific Business Group on Health (PBGH), pointed out a 3% frequency of errors in hospitals leading to additional injury, illness, or disability. (Could any human undertaking have less than a 3% error rate?) He detailed the very deliberate process undertaken by PBGH to develop appropriate quality survey instruments to complement consumer surveys. Ultimately, PBGH began to drop plans based on quality, added others, and promoted those with the best results. PBGH found that consumers do not necessarily use comparative information. “When patients trust their physicians, they tend to have better outcomes,” he noted. It’s been known since at least the late 1950s that the best clinicians did not necessarily come from the top of the class.
Orange, San Mateo, & Kern Counties June 1999
Sheryl R Skolnick, PhD, managing director at BancBoston Robertson Stephens, who is responsible for analysis and recommendations in the health-care arena, was the final speaker at the UCI Health Care Forecast Conference as reported in the The Bulletin of the OCMA. She concluded that 1998 was a disastrous your for health care. She stated that physician practice management companies (PPMs), the group that was designed to protect physicians from HMOs by concentrating physicians into larger networks, are failing because they do not add any value to health care and were predicated on increasing volume. PPMs accepted more and more risk agreements to increase revenues. In the end they turned on physicians, the very group they were designed to protect. After the FPS Management bankruptcy, and MedPartners decision to abandon the PPM business and its forced bankruptcy, they fell out of favor on Wall Street. Dr Skolnick urges her colleagues to stop viewing HMOs as growth stocks but more like traditional insurance companies. She also feels that while further consolidation will occur, the key to the future health-care model will be “deconsolidation.” Smaller and better companies will emerge because “health care is a consumer service industry.”. . . The MedPartners CEO told me at the first CMA La Quinta leadership conference that they were interested in purchasing Hills Physician. Fortunately, Steve McDermott, CEO of Hills, did not take their money and run. We could have been part of their $2 billion write-off.
Barbara Yates, MD, a psychiatrist for San Mateo County’s Elder Mental Health Outreach team makes house calls on the chronically mentally ill. She shares duties with team members who are psychologists, nurses, social workers, and trainees. They travel to varied home settings, from spacious elegant homes in Hillsborough to trailer units in East Palo Alto. She feels there are great advantages to this type of work for the patient, for the art and practice of medicine, for the doctor, and for health-care systems. And it works out well for her in balancing motherhood with two toddlers and part-time work.
“The trained nurse has become one of the great blessings of humanity, taking a place beside the physician and priest, and not inferior to either in mission.” William Olson, MD, president of the Kern County Medical Society, begins with this quote from William Osler (1849-1919) in his tribute to the nursing profession, “the critical part that other staff play in ‘nursing’ our patients back to good health.” He bemoans the criticism and short tempers that are too frequent during these times of high stress, high patient load, and long hours for our professional colleagues. Those make the nursing profession even more counterproductive and work to further the stress these heroines and heroes labor under daily “in the trenches.” He encourages physicians to pass on the comment of a satisfied or appreciative patient and to ask the opinion of a nurse on how best to care for our patients. He quotes behavioral research which confirms that affirmation and recognition of a job well done are often more cherished than financial rewards. He challenges us never to forget in our dealing with nursing, the mainstay of any good relationship: communication, understanding, praise, and reassurance. He then closes with a quote from Charles Mayo (1865-1939): “The trained nurse has given nursing the human or shall we say, the divine touch, and made the hospital desirable for patients with serious ailments regardless of their home advantages.”
Leo van der Reis, MD, Daly City internist, writes in the San Mateo Co Med Assn Bulletin about leadership in medicine. Dr Reis wonders if the current state and national leaders of medical organizations are competent to deal with the problems the profession faces in this time of turmoil? He points out that our titular heads serve for a brief time with some influence but without the skills needed by a chief executive of a major organization, nor are they elected by a process that exposes them to a majority of their membership. Instead of executive directors being the day-to-day implementors of policy and procedures, we should upgrade the office of president and provide a term of four to six years elected by popular vote of the membership. The president should be allowed every opportunity to govern and to select his or her coworkers and associates. Dr Reis feels such a move would induce many inactive members to become involved in their organization. He feels such a well-trained president would be an excellent substitute for the nonphysician lawyers, nonphysician accountants, and other nonphysician lobbyists who are our representatives to-day.
Los Angeles, Kansas City, Auburn, Bakersfield July/August 1999
The Los Angeles County Medical Association (LACMA) has begun organizing a physicians’ union completely separate from LACMA. Meanwhile, Los Angeles county’s 800 non-resident physicians voted to affiliate with the Union of American Physicians and Dentists (UAPD). The ability to organized physicians got tougher when, in a New Jersey case, the National Labor Relations Board upheld its policy that fee-for-service physicians are not eligible to organize. Maybe LACMA as well as CMA should develop liaisons with the UAPD, since their membership does not seem to overlap and would prevent duplication of effort. Because CMA and the trial lawyers seem to support the same legislative candidates, it may be the UAPD that preserves MICRA for us. When the UAPD, an AFL-CIO affiliate, sent an official letter explaining why MICRA should be upheld, shock waves reverberated throughout the statehouse, where the majority party does not like to antagonize organized labor.
Richard Selzer, MD, winner of a National Magazine Award and a Pushcart Prize, insists that his best writing was done on patient charts. “Only there it was devoid of vanity of the author and the pomp of language.” Speaking at Kansas University Medical Center, he told his story “Whither Thou Goest,” the tale of a young woman who was persuaded to donate the organs of her brain-dead husband. “That way your husband will live on,” the doctor tells her. “He will not really have died.” Three years later instead of feeling comforted, she was baffled; if this is true, could she even call herself a widow? As a surgeon, Selzer is precise about language. “Harvest. Transplantation,” he said “are words of husbandry and the soil.” They are a far cry from the real names of surgeons’ deeds–dismemberment, evisceration. “To reap is synonymous with to harvest. Although they are synonymous, we don’t call the harvester the ‘reaper.'” Selzer began writing at the age of 40, while a surgeon at Yale. He pursued both careers until the age of 57, when he gave up the scalpel for the pen. Selzer creates his craft in longhand with a fountain pen. It has to do with surgery, the feel of implements. “Wield a scalpel, and blood is shed. Wield a pen, and ink is shed.” Selzer is readying his diary of 25 years to be published this fall–in three volumes. (His book, Down from Troy, was reviewed in Sacramento Medicine, November 1993, p 24.)
The Foothill Medical Bulletin, the Hoarse Voice of the Placer Nevada County Medical Society, reprints a Ginseng ad from the early 1900s stating that $25,000 can be made from one-half acre and the plant is easily grown throughout the U.S. and Canada. Roots and seeds for sale. Send 4¢. . . . Editor Ted comments that if the same reasons are valid today, millions can be made since the popularity of Ginseng is much greater, population has increased, and the value of the dollar has been multiplied by one hundred or more. He suggests that if you have a backyard, think about it. . . The editor of this Bulletin has never been listed nor has he signed any of his editorials, but everyone seems to know he’s that famous pulmonologist from Auburn. In this issue he tells us about silicosis and TB, to do a skin test on all patients with silicosis, warning us that the reaction is smaller in silicotics, and to treat all positive tuberculins of 5 mm or greater. Phil Matin, MD, pays tribute for the herculean task that Doctor Theodore Bacharach has done not only in editing, but also researching, writing, typing, setting, and printing the entire Bulletin. . . Hats off to my mentor who taught me bronchoscopy 30 years ago. The last time I saw Ted, he said he was cautiously retiring–he had reduced his work week to 8 days.
The Kern County Medical Society Alliance sponsored a bus trip to the Eberle Winery to Celebrate “The Doctor in Your Life” on Doctor’s Day. The Kern County Medical Society Bulletin warns us that allied health practitioners are preparing legislation to expand their scopes of practice. Optometrists want to increase the number of topical drugs they can prescribe, treat glaucoma, administer injections, and suture areas in and around the eyes. Naturopaths may take advantage of the popularity of alternative medicine to legally establish naturopathy in California. Psychologists are expected to try to pass a bill allowing them to prescribe drugs. Midwives want to eliminate the statutory requirement of physician supervision so they can perform unsupervised at-home deliveries. . . Meanwhile, physicians . . .Oh well, have a good time back on the ranch this summer. See you in the fall.
Denver, San Bernardino & Kern September 1999
Over a span of several years, Roger Bone, MD, a pulmonologist, gave us a running commentary on his fight with Cancer in his “As I lay Dying” articles. Now another world renowned pulmonologist, Thomas Petty, MD, gives us an account of his personal brush with death. I met Professor Petty as a fellow in 1969 when I attended his innovative respiratory care course in Denver. (He was one of the pioneers who established that it was safe for trained respiratory therapists and nurses to do radial artery punctures, a procedure we implemented the following year in this community.) Twenty years later when he gave the respiration seminar in Monterey, he was still the picture of health. Then, in 1992, he had an emergent coronary bypass. In a recent issue of Internal Medicine, he tells of his experience in 1998 with mitral valve surgery; he was developing pulmonary hypertension (PAP 75/35) with reversal of blood flow. He elicited a promise from his pulmonologist not to use paralytic or sedating agents as he was adjusting to the mechanical ventilator postoperatively. “If I get into trouble, I want to know what’s going on. If I’m dying, I want to experience it.” He had taken a powerful antioxidant preoperatively, against doctor’s orders, as a defense against acute lung injury or respiratory distress syndrome (ARDS). Postoperatively, he was extubated, felt nauseated, had emesis, with a blood pressure drop to 50/palp. When he saw the 20 second run of ventricular tachycardia, with the defibrillator being rolled in, he felt like he was in a whirlpool going down a drain feet first. By morning, after circulatory resuscitation, his pressure was restored. He never fully lost consciousness. He also had a 27-pound weight gain. Louise, his respiratory nurse clinical specialist in Denver in 1969, was at his bedside. The following morning he walked. By the fourth day his oxygen saturation was up to 85% off oxygen (normal 97%). Although he had to recover from multi-organ damage, he did not experience ARDS. In a month he was back at work full time; in two months he was on his annual fishing holiday. Petty wonders why his life was spared. “Maybe God was trying to give me a wake-up call. Confronting one’s mortality is not a pleasant experience…. I was lucky enough to be sent back from the brink–and I plan to do something very special in the new time granted me.”
The Bulletin of the San Bernardino Medical Society devoted a recent issue to “Live & Then Give,” encouraging members to become involved in organ and tissue donation. Every 16 minutes a name is added to the 64,500 people on the National Organ Transplant waiting list. Each day, 11 people die while waiting for an organ that didn’t come through. President Victor Ching, MD, suggests that the solution begins with you and me. To be a donor, it is essential to let your wishes be known, preferably to a family member. It is a simple matter — Share Your Life, Share Your Decision. If you haven’t told your family that you are an organ and tissue donor, then you are not.
William Olson, MD, President of the Kern County Medical Society, tells us in his presidential message that some physicians have always believed they practice quality medicine. Few are convinced that the HMO efforts to measure immunization rates, mammograms and Pap smears are equivalent to quality. “We all know [physicians] who may do well on one or several of these statistical measurements, yet can’t diagnose or treat his/her way out of a wet paper bag!” But he warns his society members that only the ostriches among us expect that these measurements will soon disappear. “Quality measurement” is an industry coming of age and will continue during our professional lives. The health of an individual will continue to be the single most important factor and the prime source of satisfaction to us as physicians. Although we may laugh at Dilbert and his view of “organization” and “process,” understanding organization and process is the key to improving quality. Olson feels that lamenting how a health plan is “making my life miserable with inaccurate data” or “beating me with their miserable requirements” is victimhood and an effort to point the finger at someone else. As we resume leadership in medicine, physicians must define quality with data. We must be responsible for legitimate versus illegitimate data. For a taste of the future, log on to “healthcarereportcards.com.”
Orange, Los Angeles & Sonoma Counties October 1999
Arthur Lurvey, MD, reminds the members of the Orange County Medical Society (OCMS) that the waiver of Medicare deductibles and copayments requirement is unlawful and violates the anti-kick-back statutes. Although it may appear that the waiver of the 20% copayments and deductibles helps Medicare beneficiaries, several studies have shown that if patients are required to pay even a small portion of their care, they become better health care consumers who select items or services because they are medically needed rather than simply because they are free. . . . Looks like a good principle for the HMOs to follow. Or are they not interested in patients controlling their costs?
Don McCanne, MD, also of the OCMS, discusses the AMA endorsed Breaux-Thomas Medicare premium reform. He questions whether we really want to inflict this change on our patients. Although cloaked in political language, it is, McCanne feels, a voucher program for the purchase of a health plan in the private sector or traditional Medicare. It is marketed as competition that will provide more health care for less money. He states that unfortunately, the objective data available indicate that the opposite is taking place.
The AMA recommends funding Medicare with private savings. McCanne feels this would bring an end to the concept of social insurance and that we should not accept reform which caters to the healthy and wealthy as it impairs access for the sick and poor.
The AMA also recommends replacing price controls with price competition. McCanne asks, “Where have our leaders been? The market, with unending megamergers, has become anticompetitive.” The AMA supports changing Medicare from an entitlement to a defined contribution program. He feels this can only increase the financial burden on the patient, often impairing access to care. He feels organized medicine has always advocated for the interests of our patients. These trying times should be no different. We must accept cost containment as a permanent reality. The managed care industry has impaired both choice and access, while the ranks of the uninsured grow exponentially. We need to demand that everyone receive high-quality comprehensive care provided by the traditional private and public health care sectors, absent Wall Street. He concludes that physicians need to return to the altruistic role of being the primary advocate of the best medical care possible for our patients, constrained only by availability of resources, not by a corporate mentality that understands only profits, not patients.
Gerard W Frank, MD, the new president of the Los Angeles County Medical Association (LACMA), began medical school at age 33 after having started a career as a physicist. Being the elder statesman of his class presented challenges but as his career advances. His age also allows for a unique perspective. A pulmonologist at White Memorial Hospital, Frank says the time has come for the Association to forge new relationships and partnerships with people and organizations that just a few years ago may have been perceived as outsiders or competitors. “In every aspect of my life, I’ve always learned more from people outside my immediate world than from people inside my world, and I think LACMA has to be the same way. We have to start listening to what other people have to tell us.”
The American College of Physician and the American Society of Internal Medicine have recently announced that 23 leading medical societies have denounced mandatory “hospitalist” programs.
There was an articulate interview of the new Sonoma County Medical Society President Cynthia Bailey, MD, in the Sonoma County Physician. (A number of the county medical societies seem to have new presidents who start in July.) She is another budding scientist-turned-physician who seems to have a grasp on medical issues. As to women in medicine, two-thirds of the women physicians in Sonoma county are members. Bailey advocates curriculum changes in academic medicine to allow more flexibility during women’s reproductive years. She understands MICRA and the implications of losing it, the importance of the continued ban on the corporate practice of medicine so we aren’t controlled by corporations, the maturing of managed care, capitation, the problems in dermatologic referrals, the future of private medicine, increasing patient responsibility, and how patients should be allowed to choose private insurance and apply the HMO premium and only pay the difference. . . . I think we’ll hear from her again.
Sonoma County Physician also devoted an entire issue to teenagers with featured articles on physical abuse; guns and gangs; the psychological profile–where is the depth in being an adult?; teenage sexuality and heartrending stories showing their lack of reality; adolescent nutrition and its impact on growth and pubertal development, diabetes, obesity, dyslipidemia and cancer; and adolescent drug abuse. Managing editor and fellow member of the American Medical Writers Association Steve Osborn, has again put together two very timely, professional, and high quality issues.
San Francisco County November 1999
San Francisco Medicine devoted an entire issue to “Computers & Medicine.” Robert J. Lull, MD, editor, reviews the various applications of computers in the diagnostic and therapeutic arena, including radiology (CT, MRI, SPECT, and PET scans), radiation oncology, nuclear medicine, cardiac catheterization, etc. But Dr Lull feels that the root of physician resistance to computers lies in a concern that computers threaten their intellectual expertise as the prime purveyors of medical knowledge. When Lull was a student and visited a research library, the medical books and journals were in a room that was off limits to everyone except doctors. Now online research is available to all. Not infrequently, physicians experience patients who have done extensive research on specific disease, have copies of all the latest diagnostic and treatment approaches, and are more knowledgeable than their physicians about their specific disease. They frequently ask questions that the physician cannot answer. Lull feels this is just the beginning of a paradigm shift in medicine. Unless we get serious about computers in medicine, he feels physicians will be left in the dust.
Ella G. Faktorovich, MD, discusses Electronic Medical Records (EMR) and gives anecdotal information as to their continuous value. For instance, your patient arrives in the ER as your are enjoying your Sunday afternoon. You receive the page on your Palm Pilot with the ER message that your patient is unconscious. You access your electronic medical records via your Palm Pilot within seconds, bring up the patients records, including all medications that the patient is taking, and forward the information electronically to the emergency room. Immediate information is available to assist in a focused workup for diagnosis and treatment. This same procedure can used while you are traveling.
Electronics in your office is a different scenario. After completing your first patients, you use a touch pen to enter your findings and diagnosis on the computer in the exam room. The computer software processes the information instantaneously, assigns appropriate ICD-9 and CPT codes and within seconds submits the claim electronically to the appropriate insurance provider. You can enter the treatment plan and order lab tests and the request is then instantly forward to the lab. Your prescription automatically prints out for your signature. The letter to the referring physician is automatically generated. . . . Sound simple? Dr Faktorovich then discusses the expense, frustrations, and pitfalls.
Fabio Almeida, MD, discusses overcoming barriers to physician adoption and use of computers. He feels the benefits of the computerized patient record (CPR) (can we be consistent and call this the EMR also?) have been universally recognized. Handwritten charts are often difficult to read, data from different health care sources are difficult to coordinate into a clear picture of the patient’s status, and charts take time to retrieve. Physicians spend 33 per cent of their time writing on charts, producing 50-70 one-page reports daily. Yet 40 percent of the time the diagnosis is not recorded in the patient’s record. Data collection is often repeated when a record is unavailable. The CPR allows the record to be searched for specific information. Physicians hold the key to the data collection problem; yet the CPR (EMR?) has not been embraced by physicians. Physicians are typically ill equipped to perform the tasks of collecting and managing complex clinical and financial data, yet more than 80 percent of the health care dollar is spent when the physician writes patient orders.
Fabio also discusses the speech recognition programs that allow physicians to speak directly into their computers to record the consultation. The technical barriers for parsing “granular medical terms” has recently been improved with the Linguistic User Interface (LUI) which not only works with the speech recognition software and a large and growing medical vocabulary, but also functions very much like a live medical assistant. It retrieves information requested by the user and provides decision support advice, such as adverse drug information or practice guideline recommendations.
Victor A Prieto, MD, orthopedic surgeon, talks about his experience with the Dragon Naturally Speaking voice recognition system that saves him $2500 a month in transcription costs. . . . Vail Reese, MD, describes a number of their medical society members’ Web sites. He feels the most effective Web sites not only provide medical information, but also give a sense of the personality and perspective of the health providers themselves.
I understand that computer problems have precipitated a new line of cybersympathy cards: Sorry to hear your hard disk died; I hope you get over your virus invasion; I can sympathize with forgetting to back up your data; Don’t feel bad that you can’t reach technical support, I haven’t ever reached them and I have had my computer for seven months; Too bad you bought an obsolete PC. (After WSJ)
San Francisco, San Diego & Sonoma Counties December 1999
Robert J Lull, MD, Editor, San Francisco Medicine, in their issue on Women’s Health, outlines the challenges in women’s health since the dark ages and the increased polarization even in our modern era. To reduce the need for abortion clinics and meet the reproductive needs of women, he suggests that the high-dose hormone-based morning after pill as well as RU 486 should be made available to all women for use at home. He feels the solution to the abortion issue is more effective, practical, and safe contraception that avoids pregnancy in the first place.
“This is what’s wrong with medicine,” is the title of an editorial by Paul Raffer, MD, in a recent issue of the San Diego Physician. He was covering a practice in which a 94-year-old Alzheimer patient, bedridden with contractures, was admitted with sepsis. The patient was “no CPR,” was Medicare/MediCal, and so the family would never see or be concerned about a bill. Dr. Raffer was horrified as he counted neurology, nephrology, pulmonology, cardiology, general surgery, and infectious disease consultations the patient had undergone. He feels this abuse borders on assault on a defenseless patient and must stop. He feels our professional standards are lowered by these consultation feeding frenzies which are beneficial only to physicians.
Sonoma County Physician devotes its recent issue to “Love and Sex.” Fellow pulmonologist, James K. Gude, MD, in the leading editorial, refers to Ishimpo, the oldest medical book surviving in Japan, going back to the work of Yasuyori Tamba in the 10th century. Book 28, entitled “Within the Chamber,” consists of 30 chapters about the many aspects of sex. Chapter 1 introduces the topic of sexuality, “Is it not fundamental and far-reaching that Tao consists of one yin and one yang, and its working is found in the perpetuation of life through the interblending of sexual essences?” After giving other historical accounts, Gude feels we need to follow the advice of Su Nu, a plain-speaking woman, to the Yellow Emperor and treat with care the matters of sexual function and dysfunction, homosexuality, and love. The articles that his fellow members wrote are comments and prescriptions about sex and love. Gude feels they offer a new set of answers for the Emperor’s question.
Brien A Seeley, MD, ophthalmologist, chairman of the editorial board, leads off with “What is Love, Medically Speaking.” After an introduction from Shakespeare’s Romeo and Juliet, Seeley asks the questions and gives the answers: “Is love really just a genetically programmed mix of pheromones, neurohumors and autonomic discharges? Can medicine measure, understand and control love? If there is a dry, clinical side to love, it is likely that we can best understand it by studying an extreme example. Therefore, let me be clear that the kind of love referred to in this discussion is that profoundly affecting the strongest of emotions , the romantic love that can make two people content just to stare into each other’s eye. Eventually this voluntary insanity finds nearly everyone. It turns out that we are hardwired for it. . . . The predominance of marriage throughout the world and the fact that more than 90 percent of Americans marry are taken as evidence that monogamy comes naturally to humans. Even in cultures that practice polygamy, individuals generally prefer one partner toall others. Monogamy confers survival advantages distinct from those of sexual attraction. Though not essential to reproductive success, monogamy is thought to have provided a sense of security while reducing feelings of stress or anxiety, leading in turn to shared child rearing and better survival.”
After having a lot of fun discussing romantic love, love behavior, infatuation, sex, other psychiatric aspects, and the psychoneurobiologic process, Dr. Seeley concludes that “we physicians . . . must welcome our patients to unburden their troubled hearts and overcome the emptiness of isolation. Since love is good for you, let’s dispense more of it. There is, after all, enough for everyone.”
Other articles in this issue of Sonoma County Physician on are on sexual dysfunction, sexual discrepancies, and the health hazards of closets. The photography and multicolored cover are of the high caliber we’ve come to expect from Steve Osborn, the managing editor. To end on a more personal note, the humor in several of these articles caused me to reflect on my late uncle who was widowed in his late 60s He became serious about a woman he met at a senior citizens’ ball whom he eventually married. Because she smoked an occasional cigarette after meals, which he detested, he asked her if she ever smoked after sex? “Well, Otto,” she answered, “I’m not sure. I don’t think I’ve ever looked.”