Practice Issues January/February 2003
The last “Voices” column was to be my final contribution to Sierra Sacramento Valley Medicine, completing a ten-year labor of love. When I mentioned this to our new editor and managing editor, they asked me to continue reviewing the other county and regional society journals. So I will continue to report on the “Voices Of our colleagues in Medicine,” as gleaned from these journals. My reason for moving on was that during this past year, I started MedicalTuesday, a column e-mailed every other Tuesday to more than a thousand physicians and other interested members of the business and professional community. Tuesday was the night our county and various specialty societies formerly met on a monthly basis. Prevailing wisdom is that members won’t come to monthly society functions. However, that may be a local and regional phenomenon. At a recent meeting in New Orleans, I sat next to a doctor from Alabama. He said his medical society had about 30 members, met monthly (also on Medical Tuesdays), and everyone showed up unless out of town or caring for patients. Doctors will attend society meetings if the agenda is important to them; e.g., fighting managed care or single-payer medicine. If you’re interested in doctors reclaiming the high ground in medicine and wish to receive MedicalTuesday, just send me an email requesting to be placed on the email list.
Direct to Consumer Drug Ads
Last summer, Dr Erica Brownfield, MD, and colleagues of Emory University, Atlanta, taped three major networks for one week to find out how much of the estimated $2.5 billion annual drug company marketing budget is spent on TV advertising. She reported the results at the 25th annual meting of the Society of General Internal Medicine. Her team reviewed every hour of the 84 cassette tapes. They found 907 ads for OTC products with an average length of 22 seconds and 428 ads for prescription drugs with an average length of 44 seconds, reflecting the longer length needed to meet FDA requirements on disclosure. Hence, there were 642 minutes of air time for direct-to-consumer drug ads, exceeding advertisements for beer, clothes, shampoo, deodorant and even the services of trial lawyers. The peak times were between 2–4 and 6–8 p.m. The most advertised drugs are the statins and allergy medications. With the average American watching TV four hours a day, Dr Brownfield contends that physicians must understand and be ready to deal with all the information given to their patients.
Internists and Pharmaceutical Companies
Bimal H Ashar, MD, and colleagues at John Hopkins University School of Medicine studied the relationship between internists and pharmaceutical companies that spend about $6 billion every year on clinical studies conducted by office-based physicians. Of 1,000 Maryland internists who are members of the ACP-ASIM, 835 had office-based practices and were selected to receive mail surveys. After 3 mailings, 444 responses were received. Half were dissatisfied with their income and one-fourth made less than $101,000 per year. Asher said 37 percent of responders had a business relationship with pharmaceutical companies: 27 percent were paid to give lectures and 22 percent participated in clinical trials. Harold C Sox, MD, editor of the Annals of Internal Medicine, while registering surprise, found nothing “inherently unethical” about physicians participating in such trials. However, this should not be confused with pharmaceutical company largesse which frequently violates the AMA guidelines on gifts from industry to physicians.
The Economics of Obesity
Michelle Singletary in her column “The Color of Money” appearing in Southern California Physician, gives us the economics of obesity. On average, about 60 percent of Americans are overweight, including 64 percent for blacks, 43 percent for white women, 65 percent for Hispanics and 62 percent for white men. Approximately 30 percent of Americans are obese; the excess cost of heart disease increases164 percent and diabetes increases 170 percent. . . . In the same issue, Arthur D Silk, MD, points out that fast-food restaurants are catching up with tobacco vendors in the Great American Morbidity Race. Tobacco killed 500,000 Americans last year, obesity-related diseases will kill 300,000. No one is currently analyzing whether group insurance plans, which spread the risks of diseases, can continue to afford to share the increased cost of self-induced excess risks.
More Work for Less Pay
In a recent issue of Sonoma Medicine, Kathryn D Scott, DrPH, and Steve Osborn, MA, managing editor, report on their survey of Uncompensated and Underfunded Care. With a 21 percent response, they found, in a 12-item survey to all 974 practicing physicians of the Sonoma County Medical Association, that uncompensated and underfunded time accounts for nearly one-half (46 percent) of total physician work hours. The value of those hours—mostly spent on direct patient care and patient-related e-mails, phone calls, and paperwork—amounts to at least $40,000 per physician per year. The survey also found that physicians would prefer this be reduced to about 12 percent or 1/8 of their time.
Scope of Practice
A number of the various county medical societies have articles on the enlarging scope of practice of psychologists, podiatrists and optometrists. The podiatrists want to enlarge the area of their surgical practice to include amputation of the foot. There seems to be a pause in their march towards the knee. The optometrists want to do more medical treatments and even minor surgical procedures of the eye. The psychologists want to have prescribing as well as admitting and discharge privileges. I asked a psychologist what he would do if his patient had a cardiac arrest while being treated. He said, “I’d walk fast to the nursing station and have them get an internist.” Maybe the turf battle should be settled once and for all by defining the team players. Psychologists can be valuable team players for psychiatrists in the total evaluation of the psychiatric patient, just as podiatrists can be and frequently are great adjuncts in an orthopedic practice; similarly, optometrists can be and frequently are a great help in an ophthalmologic practice for routine diagnostic evaluation. Wouldn’t patients be best served by these team players working together with MD supervision in each case, thereby improving the standard of care? Shouldn’t we place these three in the physician assistant category? The podiatrists would be an orthopedic PA, the optometrist an ophthalmologic PA, and the psychologist a psychiatric PA. Thereafter, the politicians who love to practice medicine would no longer be involved in the continuing turf battle because we’re all on the same playing field.
The Medical Board – Medicine Chasms – The Drug War March/April 2003
Tell Us Your Story
The Bulletin of the Humboldt-Del Norte Country Medical Society has a column in which physicians report their bad experiences with the Medical Board of California (MBC). Dr. John Schafer, a pediatrician covering for another physician, was called by a five-year-old‘s father to prescribe an antibiotic for an eye infection. Because the child had previously experienced a similar infection, the father asked for cephalexin, the antibiotic previously prescribed by their personal physician. About a year later, Dr. Schafer received a letter from the MBC requesting information concerning this treatment. He responded that he prescribed this antibiotic while covering for the patient’s doctor. The MBC issued a citation for two violations: prescribing a dangerous drug without an exam and failing to maintain proper records. Dr. Schafer was fined $850 and told the citation would appear on the MBC web site for five years without recourse. He then contacted the patient’s father and found that the complaint was made by the ex-wife.
The CMA advised Dr Schafer to appeal the decision. He received a letter from the child’s father describing the excellent care his son received. The father also stated that his former wife, who had been diagnosed with a character disorder, was out to discredit him and anyone with whom he dealt.
This additional information helped Dr. Schafer feel optimistic that the MBC would dismiss the case. However, MBC staff were determined to take action against him. They maintained the statute that allows prescribing without an examination when covering cases did not apply. They offered to remove the complaint if he would take a “useless” course in prescribing — which was held 500 miles away, lasted three days and cost $1800. His attorney warned that an appeal could triple his legal costs because administrative law judges usually uphold the MBC. The CMA and the California Academy of Family Physicians (CAFP) wrote a jointly signed letter to the Executive Director of the MBC urging that the citation be withdrawn based on the statute. Two months later, the citation and fine were withdrawn without explanation. Schafer’s liability insurance covered the $10,000 in attorney fees, after a $1000 deductible.
Stephanie Stapleton writes in Southern California Physician about Complementary and Alternative Medicine (CAM) and the popularity it has engendered in the last 30 years. It is estimated that 43 million Americans have spent as much as $40 billion on CAM. There is a lot of ambiguity in CAM because of the difficulty in defining terms. In general, it has evolved into a catch-all phrase that refers to a range of healing practices — from commonly known therapies, such as acupuncture, meditation and herbal supplements, to more exotic approaches, such as chelation therapy. However, Robert S. Baratz, MD, PhD, an internist in Braintree, MA, and President of the National Council Against Health Care Fraud, a nonprofit organization that promotes reliable health information, contends that CAM tries to combine two distinct concepts. First are the truly complementary or adjunctive therapies used to make people feel better, including massage therapy, physical therapy and even prayer. “These are not news. We’ve been doing these things for years,” Dr. Baratz says. “They do not belong to the CAM movement. But CAM advocates are trying to co-opt them and mix them in with a bunch of other things.” Secondly, he says, “There is no alternative medicine.” “Alternative” suggests there is a viable treatment to use in lieu of standard medical practice. “To get to work,” Dr. Baratz says, “a person may be able to take the subway or the bus, drive a car or ride a bike….But you can’t ride a magic carpet. It will get you nowhere.”
Not everyone embraces this characterization, however. The polarity is so intense that the two sides seem to speak past each other. Stephen E. Straus, MD, director of the National Institutes of Health’s National Center for Complementary and Alternative Medicine, says, “There are avid skeptics who remain convinced that no CAM practices work. At the opposite extreme, some advocates of alternative medicine continue to feel there is no benefit to subjecting CAM to scientific scrutiny because the methodology is inadequate and the investigators are too biased to conclude what has already been long know. There is very little common ground on which these diverse opinions can meet.”
Wallace Sampson, MD, a retired hematologist and oncologist, edits the Scientific Review of Alternative Medicine. He maintains that the debate is not polarized among rational people. But good or bad, proven or unproven, CAM is part of the health care reality. Dr Joseph J Fins concludes, “One of the major issues that needs to be recognized is that patients are utilizing these approaches. In our patients’ interest, we need to foster a dialogue.”
Stop Wasting Money on Failed Programs
In a recent issue of San Francisco Medicine, Robert J Lull, MD, President of the San Francisco Medical Society, makes a plea to not waste money on failed programs. He contends that considerable moneys are wasted on programs that simply do not accomplish their goals; many also create added health care needs. The current San Francisco approach to homelessness is a prime example of such a failed program–a lot of money spent with no measurable decrease in homelessness. However, Lull feels the homeless problem is small potatoes compared to the most pervasive and pernicious of all failed programs — the War on Drugs! This program needs radical change. but that will be difficult because it has become so deeply rooted at all levels of government. Politicians with great leadership, vision and courage are needed to reverse an abject failure to decrease drug abuse in this country that has wasted billions of dollars every year. Lull contends this money could be better used to fund healthcare-oriented solutions to the very real drug problem.
He cites Judge James P. Gray, a former federal prosecutor and Superior Court Judge in Orange County, who describes, in his recent book, the large annual expenditures to create our Prison Industrial Complex which depends on drug-related incarcerations for its size and political power. The Department of Corrections is the fastest growing state agency in California. In the last 15 years, California has built 20 new prisons, each requiring an annual budget of $23 million to operate. The California Correctional Peace Officers Association is the most powerful lobby in Sacramento, slated for pay raises despite the severe state budget crises.
He contends that the War on Drugs has failed just as Prohibition did in the 1920s. Nobel economist Milton Friedman suggests that treating drugs as a medical issue, like we do with alcohol and tobacco, would eliminate the profit and associated evils of the drug trade.
Lull encourages organized medicine to join other citizen groups to bring an end to the War on Drugs and move toward solutions that recognize drug abuse as a medical issue.
Russian Health Care, Rancho Los Amigos, HIPAA, Hispanic Employees and Adolescent Sex May/June 2003
Russian Health Care
The Bulletin of the Humboldt-Del Norte County Medical Society has run a series of articles by J Kim Bauriedel, MD, FACS, reporting on the five weeks he spent in Siberia as part of a Rotary International exchange. In a recent issue he wrote about specific public health issues affecting life span. He says most Russians are heavy consumers of alcoholand he saw, at least in one instance, a surgeon having a shot of vodka between cases. It was not unusual to see physicians at lunch consume several bottles of vodka, whether at a restaurant or in the hospitals. However, he did not notice a lot of people who were incapacitated, sleeping on the streets or in doorways. The water piped to homes is not pure. Bottled water is also contaminated, and only a few brands are trusted. Most Russians boil tap water for cooking and consumption. Dr. Bauriedel feels the lack of safe water contributes to the use of alcohol. He also reports that most Russians over the age of 14 are smokers. However, they were respectful of the nonsmoking American doctors and did not smoke in their presence. When riding in cars, the Russians would stop every 20 to 30 minutes, and get out of the car to have their cigarette before continuing the journey.
Narcotics are also a major problem, particularly in Siberia where drugs are imported from Mongolia and Kazakhstan. The abuse rate is very high; there are few rehabilitation centers, needle exchanges and methadone programs. Life spanin Russian is decreasing. In the late 1980s, life span was 68 years. It is currently 58 years. Bauriedel feels that in addition to the above, infectious diseases, pollution, congenital anomalies, high rates of accidents and trauma contribute to this decline. However, he remains optimistic about Russian medical care, primarily because Russian doctors are communicating via the Internet with the rest of the world, learning about new drugs and technology. They are also traveling outside of Russia for additional training and conferences.
Rancho Los Amigos
When I was evaluating pulmonary fellowships in the 1960s, I visited USC and Chief of Pulmonary Medicine Dr. Oscar Balchum took me on a tour of the famous Rancho Los Amigos Hospital, where iron lungs were prevalent. It is now a national rehabilitation center. It is also on the chopping block and will close on June 30, by a 4 to 1 vote of the Board of Supervisors, absent an emergency infusion of funds by May. It must be hard for politicians to understand when they’re treading on sacred medical ground.
A number of the county medical society journals had articles on the Health Insurance Portability and Accountability Act. The Southern California Physician’s staff writer Dina L Burwell, notes breaches in confidentiality and asks, “Do HIPAA regs assure patient privacy?” According to the California HealthCare Foundation, about 20 percent of U.S. adults believe a health care professional, insurance plan, government agency or employer has improperly disclosed personal medical information. Half believe it resulted in personal embarrassment or harm.
After HIPAA modifications were published on August 14, legislators and patient advocates pounced on the Privacy Rule. After the original Privacy Rule was published in December 2000, HHS received more than 50,000 comments on its workability. A common concern was voiced: “The healthcare industry believed that the ‘consent to use information’ requirement would halt and complicate the provision of health care,” says Ken Gordon, an attorney with the national law firm Jenkens & Gilchrist and leader of its Health Law Practice Group. “Their argument was that a person admitted to a hospital expects his health information to be used by his health care provider in the hospital,” he says. “To add another consent requirement for the use of the information didn’t make any sense and interfered with access to healthcare. So, the administration backed off and said that if covered entities are going to use private healthcare information for treatment, payment or health care operation, they don’t need to get a separate consent form from the patient.” Hence, the rule made consent for routine health care delivery purposes optional. “The Privacy Rule says doctors are allowed to provide certain information to insurers and related entities.” He also states, “Marketing is redefined so patients can be contacted directly about their medicines,” says Deborah Peel, MO, immediate past president of the National Coalition of Mental Health Professionals and Consumers. “These privacy breaches are renamed ‘recommending treatment.’” But the law specifically prohibits covered entities from selling lists of patients and enrollees to third parties or from disclosing protected health information to a third party without the individual’s authorization. “For example, drug stores can’t sell their prescription lists to drug companies for further marketing,” says Serena Simon, an attorney with Miller & Chezalier in Washington, DC.
Patient privacy groups are particularly concerned that privacy violations could have a chilling effect on patients’ frankness with their doctors. “More and more people are becoming afraid to talk openly with their doctors,” Metz says. “According to the California HealthCare Foundation, one in seven Americans has kept personal medical information confidential, such as withholding information from their healthcare provider, providing inaccurate information to a health plan or paying out of pocket for covered care.”
Many patient advocates, nonetheless, remain dissatisfied with HIPAA.
Carol Kleiman, columnist for the Chicago Tribune, writing in Southern California Physician, reminds us that for Hispanic workers, family always comes first. “The 2000 Census found that the nation’s Hispanic population has jumped by 58 percent since 1990, to 35.3 million from 22.4 million,” says Pauline E. Kayes, president of Diversity Works Inc., a consulting and training firm in Champaign, IL. “Currently, Hispanics comprise 11.4 percent of the U.S. work force and will increase to about 22 percent in this decade,” Therefore, it’s important to know what families mean to most Hispanic people. “For Hispanics, our children are the most important things in our lives,” says Mezzetta, who is on the boards of the Indianapolis Chamber of Commerce and Hispanic Chambers of Commerce. The experts encourage employers to be flexible.
In a recent issue of Southern California Physician, Dr. Michael Klein, MD, a retired OB-Gynecologist from Claremont wrote that he “handed out contraceptives, treated STDs and even performed abortions for about 25 years. Condoms have a 3 percent failure rate under the best of conditions, a much higher failure rate in actual practice and probably give almost no protection against condylomata, herpes and other STDs. They are better than nothing, but if tires had a 3 percent failure rate, they would be recalled. A little abstinence, at least until after high school graduation, might be helpful.”
The cost of mandated interpreters, the nation’s largest IPA, loss of collegialtiy in Sonoma County, a possible new hospital in Humboldt and teenage fascination with sex July/August 2003
Mandated Interpreters Close a Physician’s Practice
It is now considered the law of the land for physicians to provide free certified medical interpreters for any non-English speaking patient.
Brian A. Shaw, MD, President of the Fresno-Madera Medical Society, reports that Dr. Kwock, the son of an American-born Chinese immigrant, and his sister have served for 20 years as interpreters for family and community members requiring medical care. He recently was told he had to provide this service, at his sole cost, for all his patients.
The Office of Civil Rights (OCR) states that this has been the law since the Civil Rights Act of 1964. In 2000, President Clinton issued an executive order regarding this new interpretation.
According to the AMA News, “Policy guidance from the U.S. Department of Health and Human Services clarified that physicians who accept federal funds, such as Medicare and Medicaid, must provide language assistance at no cost to any patient with limited English proficiency.” In a letter to Dr. Kwock, the OCR stated that he “discriminated on the basis of race and national origin” when he failed to provide free interpreter services to a single patient, who then filed a complaint with the Fresno Health and Consumer Center. Dr. Kwock readily admitted that he does not employ a medical interpreter in his small private practice. The letter stated the chapter, section and verse of the law and 15 items of issue.
Dr. Kwock immediately complied with all issues and posted signs that all patients have the right to free language assistance. He received a “Resolution Agreement” from the OCR mandating expensive and time-consuming upgrades to accommodate every language spoken on the face of the globe. Dr. Kwock closed his practice. Another expensive vote against government bureaucracy.
A member physician once received a $140 bill for two hours spent interpreting a consult. The physician would eventually receive $95 from Medicare. He, too, is in the process of closing his office.
The additional $45 cost to comply with federal laws, more than what he receives for providing the service, reminds me of the patient who felt the government could certainly increase taxes to provide everyone with medical care, as the single-payer socialized medicine advocates would require.
I asked, “What if that required that the tax rate go to 100 percent?” He stated, “Sure, the wealthy can well afford to pay 100 percent of their income in taxes.” Wondering if he understood what percent “all of his income” meant, I asked him, “What if it takes 200 percent in taxes?” He said, “The wealthy can well afford to pay 200 percent of their income in taxes.”
And so the eventual collapse of our society may rest with the incompetence of our socialized education system being unable to educate people that 100 percent is the total. This gives credence to the single-payer purveyors or socialized medicine advocates who would make our entire health care system as incompetent or third world class as our educational system.
Hills Physician: the Largest IPA of all
The Sacramento Bee and the Sacramento Business Journal recently reported on the largest IPA in our area. Steve McDermott, CEO of Hill Physician, came to Sacramento in 1993 and purchased the ailing Mercy IPA Medical Group. By merging with Bay area members, it has formed the largest IPA group in the country, with 2,000 physicians and 350,000 patients.
Despite cutting costs and terminating 200 physicians in its early days, Hill was able to pay an average of $12,000 to each doctor for cooperating in this effort.
A New Boutique Hospital?
Stephen Kamelgarn, MD, the Editorial “guru” in The Bulletin of Humboldt-Del Norte County Medical Society, writes about the community’s dissatisfaction with the St. Joseph Hospital in Eureka.
This climate has prompted a number of surgeons to begin working on a “specialty surgical hospital.” This hospital would be used for elective procedures. It would not have an emergency department nor would it be involved in care for the medically under-insured.
After presenting both sides of the issues, he summarized his comments. “If the proposed new hospital will hold the St Joe administration’s feet to the fire, and force them to deal with the medical staff in an open, forthright and collegial manner, then I’m all for it. Perhaps, only the threat of the new hospital will do the trick, but I doubt it if past dealings with the administration is any guide.
“If, on the other hand, the new hospital dilutes and fragments an already precarious health care environment, then its construction will be a pyrrhic victory, at best, and we all will have lost.”
Collegiality, Where Are You?
Jerome Morgan, MD, a Santa Rosa urologist and member of the editorial board of Sonoma Physician, asks, “Collegiality, Where Are You?”
In 1971, when Dr. Morgan started his practice in Santa Rosa, Sonoma County Medical Association (SCMA) had about 100 members. They met in a small building across from the old graveyard near the Terrace Market. “We often had medical association dinners, friendships blossomed, and many were nourished and kept.”
Morgan was fortunate enough to consult at Healdsburg General Hospital, the old Petaluma General Hospital, the old Hillcrest Hospital, and Palm Drive Hospital. He came to know many of the doctors in these towns. These smaller medical communities clustered around their own hospital’s CME presentations and social gatherings. Even today, these physicians are fiercely loyal to their local hospitals.
After reminiscing about a number of events, Morgan wonders “Where have they gone?” And continues, “Over the years, SCMA has become less and less of a gathering place for Sonoma County physicians. Our collegiality, as I see it, began to decline in the early 1980s.
“At that time, Health Plan of the Redwoods was supposed to unify the medical community through the Individual Practice Association of the Redwoods. Money, politics, and business stresses eventually led to the breakup of these organizations.
“Redwood Empire Medical Group, Inc (REMGI) was introduced in those times as well. In my view, it split the physician community even more. A deep rift developed between Memorial Hospital physicians and Sutter physicians — a rift that continues to this day. Managed care further divided us as greed and fear took their hold and competition in all ways turned ugly…
“Sonoma Country cannot afford to have Sutter doctors versus Memorial doctors, Santa Rosa doctors versus non-Santa Rosa doctors, specialists versus primary care. The physicians in this area absolutely need to recognize these facts and once again work and play together.”
Melanie Zaharopoulos, an editorial intern working for The Southern California Physician recently discussed teenage fascination with sex. By the time they graduate from high school, approximately 65 percent of teens have had sexual intercourse.
This is not terribly surprising in the United States, where the average citizen boasts more sexual partners per year than in any other nation. But it is risky. One in four sexually active teens contracts an STD each year, and almost 2 percent become pregnant. While the numbers are decreasing, specialists caution they’re still too high.
Originally conceived in 1996 as part of President Clinton’s Welfare Reform Act, abstinence-only education programs were part of an ambitious campaign to curb multigenerational dependence on public assistance. Classes combined moral training with self-esteem-building exercises, all aimed at tapering teen pregnancy rates.
While the $50 million program may have been beneficial to some, it raised a thorny question: Should the federal government legislate morality?
Educators in some states elected to drop the crusade to encourage sexual relations only after marriage from their curricula. But Reps Bill Archer (R-TX) and Thomas Bliley Jr, (R-VA) wrote a letter in 1998 to Peter van Dyck, the Maternal and Child Health Bureau official overseeing the program, “Ignoring marriage is inconsistent with the intent of the legislation, which is to send the unambiguous message that sex outside of marriage is wrong.”
With only their letter and a few steaming editorials published in heavily partisan papers, the program continued unchallenged — hardly a blip on the national radar screen until the 2000 presidential elections, when then-Gov. Bush decided to make it a cornerstone of his campaign. The Bush administration has taken a distinctly different approach to combating teen pregnancy, earmarking more than $27 million in additional funding for abstinence-only education programs.
However, things have gone less smoothly for President Bush: a federal judge in Louisiana ruled that abstinence illegally promotes religion.
Female docs for female patients, growing food portions, an obesity epidemic, horrors of HIPAA September/October 2003
What Do Women Want?
Liz Szabo asks, “What do women want?” in Southern California Physician. When it comes to menopause, mammograms and premenstrual syndrome, many female patients prefer a female physician. In fact, many gynecological practices now market themselves as all-female.
Shawne Bryant, MD, a solo practitioner in Virginia Beach who markets her practice as “healthcare for women by women,” says many of her patients prefer doctors who have experienced the same medical problems.
She states, “It’s like when I think of how I practiced medicine before I had a baby. It’s completely different from how I practice now. Once you’ve had a child get sick, you understand why a mother can be so persistent or insistent.”
In response to why more women physicians are attracted to Ob-Gyn today, she states, “Years ago, some female doctors with children were reluctant to enter a field that often called them away from home to deliver babies at 3 a.m. Today, large group practices allow more flexibility in scheduling.”
Women now make up 70 percent of Ob-Gyn residents, according to the American College of Obstetricians and Gynecologists. The number of women in the field has grown from 7 percent in 1970 to 36 percent today and is expected to reach 50 percent by 2013. An Ob-Gyn specialist tells me that women gynecologists command a higher income than male gynecologists.
Donald Miller, MD, of Norfolk, VA, notes that some expectant mothers bypass physicians — male or female — altogether in favor of nurse midwives. He states, “There are some groups that limit themselves to female doctors only, but that raises the question of ‘who is chauvinistic now?’”
JAMA reports that doctoral student Samara Joy Nielsen and Barry M. Popkin, PhD, a professor of nutrition at the University of North Carolina at Chapel Hill, analyzed data from three national surveys conducted during 1977–1978 and 1989–1996 to determine trends in food portion sizes consumed in the United States, by eating location and food source.
The authors used nationally representative dietary intake data that sampled 63,380 individuals aged 2 years and older. They reviewed the surveyed responses to the average portion size consumed from specific food items (salty snacks, desserts, soft drinks, fruit drinks, french fries, hamburgers, cheeseburgers, pizza and Mexican food) and to the eating location (home, restaurant or fast food).
“Between 1977 and 1996, food portion sizes increased both inside and outside the home for all categories except pizza,” the authors report. “The energy intake and portion size of salty snacks increased by 93 calories, soft drinks by 49 calories, hamburgers by 97 calories, french fries by 68 calories, and Mexican food by 133 calories.
The authors believe their study provides evidence of a trend toward larger portion sizes of food in the United States. An added 100 calories per day of unexpended energy is equivalent to an extra 10 pound of weight gain per year, so it is easy to see the potential impact of large increases in portion sizes. Fast-food establishments served the largest portion sizes, and restaurants served the smallest portions, they note.
“The most surprising result is the large portion size increases for food consumed at home — a shift that indicates marked changes in eating behavior in general,” they add. “These findings suggest that the public requires better education about control of portion size both inside and outside the home.” It isn’t generally appreciated that the average soda now approaches 150 calories. Adding one per day increases one’s weight by 15 pounds per year.
The Obesity Epidemic
Greg Rosa, MD, a Sebastopol physician, writing in Sonoma Medicine states, “We need to develop a combination of clinical tools and community health programs to stem the tide of overweight.”
According to a recent RAND study, three out of every five Americans are either overweight (36 percent) or obese (23 percent). Obesity has replaced smoking as the leading cause of preventable morbidity and mortality in the United States. The problem of tobacco abuse seemed overwhelming and impossible 25 years ago. California has since reduced tobacco consumption by 50 percent, cut lung cancer rates by 14 percent and prevented 33,000 deaths from heart disease.
Physicians are advising only 40 percent of their overweight patients on the health hazards of overweight. To address obesity clinically, Rosa suggests we need to assess patients with a new vital sign: body mass index (BMI). This allows us to develop the clinical strategy: brief negotiation. We can advise our patients about the common behavior associated with overweight: inactivity, excessive television, inadequate fruit and vegetable intake, excessive sodas and processed foods, and missing breakfast.
We should take heart from a recent study of more than 3,000 overweight people who reduced their incidence of diabetes by 58 percent over placebo after implementing an exercise program.
Dr Rosa advises us to be aware of our power as individual clinicians and community members to effect change. We can emulate our success with smoking cessation and begin to reduce the prevalence of obesity.
Office Practice Under the HIPAA
The major portion of the recent issue of the San Mateo County Medical Association Bulletin is “A Tragicomedy in Four Acts, Hip on HIPAA.” Act II is reflective of general opinion.
“ACT II: ’A Day in the Life of an Office Practice Under the Curse of HIPAA Compliance’” by Jonathon F. Feinberg, M.D, a family practitioner in San Mateo.
“My devoted office manager of 16 years was tearing her hair out. ’No way; we can’t do this; we need to have a staff meeting,’ she groaned in frustration. The pizza is ordered; shades drawn; CIA and FBI security clearances obtained to assure the safety of confidential patient information on pain of death. Forms are spread over every desktop and run onto the surrounding floor. There is a tower of bureaucratic mumbo-jumbo and regulations prescribing behavior-all to solve a problem that does not exist.
“Of course we will keep personal medical information confidential: we always have; it comes with the profession. Of course we are sensitive to family dynamics. The issue of discussing diagnosis and treatment with family members can indeed be problematic at times. The point is, situations vary so significantly they cannot be regulated by proscriptions couched in impenetrable legalese as a substitute for careful, personal judgments made in the course of a doctor-patient relationship.
“What are we to do? Can we remain viable as a small business and still be close enough to compliance to survive should we have to endure an inspection?
“The decision is made. We will give patients a one-page form and hope that we understand enough of it to explain the rationale to those who are already confused by a system run amok. Our schedules will be further delayed as we try to accommodate our patients’ need for timely care.
“We cannot possibly translate our form into all of their languages. We cannot build locked shelves for our charts. We can only trust that the janitor is not an undercover spy for some unknown enemy. It is our fervent hope that Big Brother is smiling and will be satisfied until the next regulatory assault.”
Lawyers, Patients, Aging, Native Americans, Mal-Practice and First Heart Surgery November/December 2003
Lawyers Win, Patients Lose
Sherman Joyce, President, American Tort Reform Association, reminds the readership of Southern California Physician that the current de facto regulators of the American health care system are a small army of fabulously wealthy personal-injury lawyers.
Doctors in Nevada, Texas, West Virginia, Pennsylvania, Mississippi and New York are leaving their state because of increases in malpractice insurance. Trauma centers and emergency rooms are shutting down because hospitals can no longer find doctors to fill them.
After a number of anecdotes demonstrating that despite doctors winning 60 percent of lawsuits that go to a jury, jackpot awards continue. Joyce reminds us that less than 20 cents of every dollar in tort costs go to patients, while lawyers often walk away with 40 percent or more. He concludes that any serious discussion about reforming our health care system must first begin with a critical look at reforming our civil justice system.
What is Healthy, Vibrant Aging?
Erica Goode, MD, MPH, at the Institute for Health and Healing in San Francisco, writes in San Francisco Medicinethat “No one can say for sure what healthy aging is. With the average age of death advancing in the US, the focus often shifts to quality of life, especially when illnesses emerge and we feel challenged to reconsider our relationship to our bodies.”
She describes a healthy 109-year-old African-American lady from rural Texas who lived alone in a cabin without running water until the ripe old age of 100, at which time she moved into a Houston nursing home. She was lean, alert, amusing and reasonably active. She had none of the “advantages” in terms of supplements, skin creams, spa retreats, surgery and the myriad other “youth-enhancing behaviors” that many people pursue.
Albert Rosenfield summarized the findings of a 1990 survey of 1,200 centenarian Social Security recipients. “It was clear that, though these individuals worked hard and enjoyed their work, there was a marked lack of high ambition. They had tended to live relatively quiet and independent lives, were generally happy with their jobs, their families, and their religion, and had few regrets. Nearly all expressed a strong will to live and a high appreciation for the simple experiences and pleasures of life.”
More Native Americans in California than in Oklahoma.
In a past issue of Southern California Physician, John Hubner, a reporter for the San Jose Mercury News, reminds us that the Native American population in California has grown by 38 percent — an increase attributed wholly to emigration from Mexico by Hispanic American Indians.
In the past decade, California displaced Oklahoma as home to the most Indians. Nationwide, the American Indian population grew by 26 percent according to the 2000 US Census. Almost half of California’s 330,000 full-blooded Indians identified themselves as Hispanic. They are mostly Mixtec (Los Angeles service industry employees), Zapotec and Triqui (Central Valley field employees).
The 50,000 Mixtec in California make them the largest tribe. Most Hispanic Indians don’t speak English or Spanish, but languages that sound more like Chinese. They are discriminated against on both sides of the border.
Michael E Bird, MSW, MPH, the first Native American president of the American Public Health Association, quotes Nixon’s message to Congress: “The first Americans — the Indians — are the most deprived and most isolated minority group in our nation. On virtually every scale of measurement — employment, income, education, health — the condition of the Indian people ranks at the bottom. This condition is the heritage of centuries of injustice.”
The Indian Health Service notes that the death rates of American Indians and Alaskan Natives are considerably higher than of all other races. In 1998-99, death rates from alcoholism was 627 percent higher; from tuberculosis 533 percent higher, from diabetes 249 percent higher and from accidents 204 percent higher.
Top Reasons You Can be Sued for Malpractice — and Lose
The Alameda-Contra Costa Medical Association (ACCMA) Bulletin presents recommendations developed by the Loss Prevention Department of the Medical Insurance Exchange of California (MIEC). Adverse outcomes can occur despite excellent medical care. That explains why almost 80 percent of claims against MIEC physicians (and more than 60 percent of all claims nationally) ultimately are closed with no payment to the claimant, and why defendants lose only a small percentage of cases taken to trial.
Analysis of closed claims and depositions provides insight on why patients sue after an adverse outcome — even when it is not their doctor’s fault:
· weak or inadequate medical history or documentation;
· inattentive follow-up and undocumented patient education;
· lack of informed consent or informed refusal;
· overlooked lab studies and medication problems;
· doctor–patient and inter-professional communications problems.
For more info check www.miec.com.
The Boston Inquisition
Richard Deaner, MD, editor of the monthly Kern County Medical Society Bulletin, reports of his medical student days in Boston in the 1950s. The newspapers were full of stories about a world- renowned surgeon performing experiments on living dogs.
The antivivisection society marched, held meetings, orated, wrote letters to the editors and thoroughly denounced the performance of surgery on living animals, requesting that the surgeon responds to them at a public forum. There was standing room only as the antivivisectionist dowagers with their lap dogs and their fur coats filled the auditorium. After several hours, there were impassioned calls for revocation of the surgeon’s medical license. The surgeon finally rose to speak.
“Ladies and gentlemen. I appreciate your passionate concern for the well-being of animals. Yes, what you read in the newspapers is true. Over the past several months I have operated on twenty anesthetized dogs. I did experimental heart surgery. I’m sad to report that all the dogs died. The twentieth dog, though, survived thirty-two days before it died. Now, I’d like you to meet my twenty first patient.”
He walked to a side entrance then walked back to the podium, holding the hand of a health-appearing young boy. The papers reported the next day that there wasn’t a dry eye in the hall.