Outlaw eating, supply-side economics, medical writing and health care rights January/February 2004
Mert’s Musing: Outlaw Eating?
Merwyn G Scholten, Executive Director of the Fresno-Madera Medical Society, and author of the monthly column Mert’s Musing, is amused and amazed at the ridiculous way people use the court system trying to make society “better,” or healthier, or safer or whatever. Recently he discussed the lawsuit outlawing the sale of Oreo cookies in California. The attorney’s legal argument claimed the filling contains a high amount of trans-fatty acids that engender obesity in children. Filing a lawsuit to prevent the sale of a food product that has been around for years on the basis that its ingredients might make children obese is reaching the extreme. How could the attorney prove that any client he represented is obese because he/she ate Oreo cookies? Is that all this person consumed? And how many cookies per day for how many years? What other factors contributed to the obesity? Are there hereditary ties or evidence that the child never exercised but rather sat immobile in front of a television munching Oreos? Mert wasn’t certain if the lawyer only sought personal attention in the event that the suit became class action or if he was legitimately concerned about the health of a young client. Thankfully, the attorney withdrew the suit after a few days – he maybe came to his senses, caught too much public flak or realized the case was likely to be summarily thrown out of court. If Nabisco Foods was ordered to not sell its cookies in California, how would the measure stand up in a higher court? How would it be enforced? Would we see a black market with interstate smugglers? Would we need to finance new border patrols to confiscate the illegal booty? But Mert’s most important question, “Would preventing the sale of a brand of cookies make any dent in weight reduction for California’s obese?” As John Stossel would say, “Give me a break!” To which Mert muses, “We got one when the suit was withdrawn.”
Patrick D Daley, MD, President of the Kern Country Medical Society Bulletin, speaks of Supply-Side Economics. Many proposals in the last few years have addressed the health care crisis, managed care, increased deductibles, EPAs, PPOs, POS and cafeteria plans. All were meant to stop, or at least slow down, the rising costs of health care in this country. In short, they’re failing. All of these policies address only the supply side of the equation and ignore the demand.
A problem on the demand side is the American public’s insatiable appetite to consume health care. You have a new MRI test? I want it. You have a new PET scanner? I want it. I don’t want to pay the actual cost of the test, but I do want it done. Our sense of entitlement is high, our sense of attendant responsibility is low.
We’ve certainly come a long way in combating illness and premature death. Fighting the spread of infectious diseases through immunizations, hand washing and antiseptics, sewer systems, water purification processes and ICUs have made a difference in our lives. But what have we actually done? Do we really believe there’s a limited amount of disease in the world, and working hard and doing enough CABGs and cataract removals will , will cure them all? I don’t think so. In largely eliminating starvation in this country, we’ve substituted obesity. In lengthening life span, we’re faced with dementia and Alzheimer’s. In lessening poverty, we now deal with anxiety and depression. Where will this end? I don’t see an end in our country. And, if the demand for health care is not controlled, all the supply-side efforts will surely fail, with ever more persons uninsured.
Supply and demand are related only if the supplier (physician, hospital, provider) gets paid directly by those that make the demand (patients). This way, the patient can never demand more than s/he is willing to pay the physician, hospital and provider. A portion of that liability is insurable, but the total should never be covered because that would disconnect the basis of the law of economics.
A Second Look Back at Medical Writing
A Guest Editorial, by Thomas Gegeny, MS, ELS, in the Journal of the American Medical Writers Association (JAMWA), takes a look at physicians’ writing ability. He references What Medical Schools Can Do to Improve Medical Writing, by Dean F. Smiley, MD, Editor, Journal of Medical Education. Dr Smiley, in turn, references a 1957 reprint from A Group of Papers on Medical Writing, in collaboration with the American Medical Writers Association, Parke, Davis and Company Publishers, which discusses: The average medical student today does not have the ability to express himself clearly and concisely in writing.
Dr. Lewis J. Moorman, President of the American Medical Writers Association, recently sent a questionnaire addressing this problem to the deans of our country’s medical schools. He has kindly permitted the guest editor to study the returns, and Mr. Gegeny feels they definitely confirm the above statement.
He listed three possible causes of the inability of medical students to express themselves well in writing. “The first, though perhaps not the most important reason, is insufficient basic training in English composition in the liberal arts college. The second reason, and in my opinion the most important one, is the lack of practice in composition and the essay type of writing in medical college. The third reason is the greatly increased preoccupation of the medical student with text-book reading to the exclusion of reading of the current literature both general and medical. As lectures have given way to laboratory exercises, clinics, and bedside teaching, students have been driven by force to their textbooks for standard coverage. How else can they get ready for their State Board or National Board examinations? A few textbook writers like Osler, in medicine, Sir James Mackenzie in radiology and Edward Keyes in urology have written with unity, coherence and emphasis and, above all, conciseness in mind. Too many have, however, given up all ideas of readability, accepted their role as a producer of completeness of coverage. Continued preoccupation with the writings of such authors would naturally tend to develop in the student a style of writing which is ponderous, verbose, detailed, full of technical phrases, and little designed to attract or hold the reader…. In my opinion, it is extremely important that medical men be able to communicate and perpetuate their thoughts in writing. I feel, therefore, that improving medical writing is a real responsibility of our medical schools which somehow must be met.”
This serious deficiency is, however, not restricted to medical students. For many years, I taught courses in personal and community hygiene to undergraduate students at a large university. Having read hundreds of their examination papers, I would be inclined to say that the inability to express oneself in writing was even more marked in the engineering, agriculture and chemistry students than those students in the arts or preparing for medicine, veterinary medicine or law. I make this statement not to excuse or condone the deficiency in medical students, but to make sure that we visualize the problem in its full scope. The hard fact is that the vast majority of college-trained men and women today fail to gain proficiency in writing their mother language while they are getting their general educational or professional education.
Health Care as a Human Right
John D Longwell, MD, President of the Santa Clara County Medical Society, discusses human rights. In 1948, the United Nation’s Declaration of Human Rights included health care as a human right. Well, that certainly sounds good, but for many philosophers would be an impossibility. A “right” cannot be tangible, and since health care involves goods and services, it’s certainly tangible, though provided by someone else. For example, if two or more people were on a desert island, they could still claim the “unalienable” rights of life, liberty and the pursuit of happiness in our Declaration of Independence. But who would provide health care, if it were a right? What if one of them happened to be a physician? Does it become his/her duty to provide care because another person has a right to it? Or is it his/her duty because as a physician, s/he feels a moral obligation to provide it?
In most developed countries, our “expectations” have translated into “entitlements;” access to health care is mediated through some form of insurance. But health insurance is unlike any other insurance (although 60 percent of health care costs are paid for by taxes). When you buy home insurance, for example, you expect coverage for major accidents, fires, leaks, structural defects, etc., but not for replacing the roof, painting the house, adding a room, and certainly not for cleaning the carpets, washing windows or changing light bulbs. Similarly, we buy car insurance to cover major accidents, usually collisions and unforeseen events. We do not expect it to pay for gasoline, 50,000-mile check-ups, oil changes or a new set of tires. Somehow, though, we have the notion that health insurance should cover more than unpredictable major events; it should cover expected maintenance, minor sniffles and scrapes, and cosmetic enhancements. We want our insurance to pay first dollar, or maybe $100 deductible with a $5 co-payment. We want that insurance to be paid for by our employers, and we want immediate access to physicians of our choice.
Voices of Yesteryear March/April 2004
Although our society is a century and 35 years old, we do not have good records prior to our journal predecessor, The Bulletin, which started in September 1950. During 1997, we wrote a column titled, “Yesteryear,” in which we included vignettes from The Bulletin. Since in 1997 we were unable to reach even 50 years into our past for an historical perspective, we chose items from 45 and 25 years ago. For this historical issue, we’ll take a look at the first publication of our journal predecessor, The Bulletin, to see what was important to our society members, some of whom are still members.
PRESIDENT’S MESSAGE: We Dare To Do by Andrew M. Henderson, Jr., M.D. (Vol 1 – No 1, September, 1950)
AGITATION for various types of medical legislation inimical to the health of the nation prompted the American Medical Association to embark on a large scale educational campaign. The campaign has gone far to thwart the propaganda issued by various pressure, groups and individuals whose objective is to inaugurate a system of compulsory, health insurance. But it is not enough. County medical societies must do their part to prove to the people of the United States that American medicine free of political interference, has done, is doing and will continue to do the best medical job in the world.
The proximity of the state legislature makes it particularly important for our society to have a strong public relations program. This year such a program is being instituted. Through the cooperation of our members we intend assuring everyone in this county of expert medical care, twenty-four hours a day, regardless of ability to pay. Actually this is nothing new. It’s not a dream of the future. It’s here now. The medical profession has always cared for the sick, rich and poor. The indigent have been cared for through part pay clinics and the county hospitals and doctors have always attempted to scale their fees to fit the budgets of their full-paying patients. What is new is the fact we are offering the guarantee to the public as society, instead of as individual physicians.
EDITORIAL MESSAGE: Our Voice by Charles E. Grayson, M.D. (September, 1950 – No 1)
The Sacramento Society for Medical Improvement takes considerable pride in initiating its own publication, THE BULLETIN. The Bulletin is the first regular or periodical publication of our society. Our society has, in the past, sponsored various scientific articles published by individual members. The Bulletin, however, is intended for diverse and general interest. A brief survey of this issue well demonstrates the scope of coverage. There is notice of regular society meetings, staff meetings, clinical conferences, meetings of interest to special groups and special meetings or sessions of interest to everyone. Contemporary activities of our society and of members of our society will also receive attention. Space is allocated for expression of individual opinions and for the presentation of professional problems. Written contributions are requested.
The Bulletin is not intended for a publication for its own sake. It is neither intended nor desired as a medium by which the society or its members degrade or prostitute the medical profession. It is not intended as a publication of newsy chit-chat to be discarded.
The Bulletin is our voice, individually and collectively. It is for our interest is a medium for the dissemination of knowledge and for the expression of our opinions. Its value depends on the efforts of each individual member of the Sacramento Society For Medical Improvement-not on the efforts of a few. Let’s take it and keep it the worthwhile project which the quality of the medical profession in the Sacramento area deserves.
This is a part of our program for better medicine, better service and better relations. Suggestions and constructive criticisms are welcome.
MANAGING EDITOR: Our Public Relations Program — Blueprint for Building by Jane Algeo Watson
Many MEMBERS of the medical profession seem to know better what they do not want than what they want. Perhaps this is the professions greatest weakness in public relations.
Medical men have definitely and irrevocably stated they want no part of regimented medicine — now or ever. The public isn’t so sure. Warning has been repeatedly sounded from all quarters that if the profession is to successfully combat socialized medicine it must come forward with an alternative and unanimously and vigorously support such an alternate. The profession can not just say “no” and oppose; it must settle its views on what it does want and convert those views from vociferous assorted negatives to tangible positives.
Your society has taken a big step forward on the positive side. It has awakened to the imperative necessity of earning good relations with the public and has embarked on an extensive public relations program with that objective in mind.
Members of the medical profession can be and are justly proud of the fine traditions, the accomplishments and the aims of the American system of the private practice of medicine. That is system based on free enterprise, individual initiative and service to the public. It is worth preserving. But if it is to be preserved the public must be made fully aware of the merits of the system and its superiority over all others-extant or proposed. And the public-right here in Sacramento, as elsewhere-must be enlightened to the inherent dangers not only to the medical profession but to itself, in the various proposed schemes directed toward the regimentation or compulsion of medicine.
A WAY OF LIFE
This then, is a report on the general objectives, the philosophy and the basic policy of our public relations program. This is the blueprint and some of the bricks for the foundation to be used in building our program. This is the positive alternate we will offer to combat the selfish, the socialistic and others who would change the private practice of medicine for political gain. This is your program; it is intended and can be achieved only by an alert, active, honest and united society.
Public relations isn’t magic, it’s no panacea; it’s applied action and hard work. It’s not a special committee; it’s our whole society working together. It’s not our duty alone of an employed publicist; it’s the day to day conduct activities of each and every member of this society — a gauge by which the entire conduct of affairs will be measured. Public relations is not just something to achieve; it’s something to follow. It’s not a project, or even a series of projects; its way of life — a way that has to be lived every day, by everybody. But it’s the only way to earn and keep good relations your public. Someone has called it: enlightened selfishness.”
BOOK NOTICE: Memories, Men & Medicine by J. Roy Jones, M. D.
For our history from 1868, Your Public Narration, refers to the above book from which we can wield from the instructive potentialities discernable in and between the lines of “Memories, Men and Medicine.” We are on record for 100 years of tangible accomplishment. Our substantial 500 page volume amply covers a wide sphere of facts.
It is an estimable history providing us potent testimony through recitations of the acts, words and personalities of countless members of the Sacramento Society For Medical Improvement, current to 1940. Our predecessors indelibly wove a fabric of high reputation for us to sustain. The book describes early California’s medical tribulations, proceeds to our society formation in 1868, and traces our growth from struggling infancy. Now, with our reasonable maturity as an organization it behooves us to indulge in pride and gratification. Our saga is a published reality, factually and gently written by our untiring, studious colleague, J. Roy Jones. It is an instrument with which to whet strong bonds in effectual public relations.
BOOK REVIEW: The Ethical Basis of Medical Practice reviewed by Edmund E. Simpson, M.D., Secretary-Treasurer.
Sperry, Willard L.: The Ethical Basis of Medical Practice, New York, Paul B. Hoeber, 1950. pp. 185. $2.50. This fine little book, by the Dean of the Harvard Divinity School, had as its beginning a lecture at the Massachusetts General Hospital following a request by Dr. James H. Means to address the staff, and subsequently another lecture to the faculty and students of the Medical School of the University of Michigan. These lectures were expanded into the present book.
There are no lists of “thou shalt” and thou shalt not,” as in the Code of Ethics published by the A.M.A. The book points out that when presented with a concrete situation there is usually no simple choice between black and white but the more difficult problem of choosing between various shades of gray. Many of our problems arise because of a conflict of loyalties and not a clash between good and evil.
There is a short but significant chapter on Democratic vs. Totalitarian Medicine. Another discusses Telling the Truth to the Patient. Sperry does not agree with Richard Cabot, who felt the patient must always be told the truth, the whole truth, and nothing but the truth. The author states there is no single categorical rule about truth-telling, and that whether a factor is to tell the truth to the patient depends primarily upon his knowledge of the patient and his observation of the patient’s own frame of mind.
There are chapters on The Prolongation of Life, and on Euthanasia Pro and Con, all well done. Several other chapters are equally well written.
This book does not tell us what to do. It makes us think what we are doing. The foreword is by Dr Means. The reviewer heartily recommends this book.
This space is reserved for you-a place where you can blow off steam-talk back, to the editor. Both bouquets and brickbats are welcome. We’ll print ALMOST anything to which you’ll sign your name. We’re starting off the column with a thought-provoking letter from a dentist in Oxford, England.
Seeing in the papers today that the American Medical Association is making fight against socialized medicine, and as I spoke to a meeting of doctors in Sacramento last year, I felt that I must write to you and your colleagues.
I wish that it were possible for me to come to America again to speak, not to doctors, but to the ordinary man and woman, to warn them of the dangers of accepting socialized medicine.
Do the people realize that nothing is free in this world, and that they will find that when government control of medicine or dentistry is in force the cost government administration goes up to enormous proportions.
Ask them if they would like to pay a tax of about half a dollar, on every 20 cigarettes they buy,. or a third of every car they bought, a purchase tax on their clothes, and in fact nearly all the necessities of life. That is the price the British working man is paying for his free medicine. The doctors are now terribly overworked, caused by a huge number of patients who attend with petty complaints and take up the time of the doctor who should be seeing patients who are really ill.
We have two of the largest hospitals in the old city. Since government control there are more clerks and administrative staff than all the doctors and nurses combined. The doctor or surgeon has lost his freedom, his contacts with his patients and is just a little cog in the big wheel.
We are rapidly losing our best men, who are leaving for Australia, etc., because they will not suffer the indignities imposed on them. As regards dentistry, my own profession, we are no longer a body of men who took pride in their work, but a group of civil servants, working to a state schedule and dominated by inspectors of the state.
So do I appeal to you and your colleagues, fight hard against the evils of socialized-medicine, get to the people and tell them the truth.
George W . Clarke, D.D.S.
ANTIDOTE FOR SOCIALISM:
Medicine is not alone in its efforts to resist socialization. Attempts at government control threaten other professions and industries. As these efforts at government regimentation become apparent, more and more groups are becoming outspoken in their condemnation of anything leading to socialization. Not only are they resisting control of their own professions or industries but are joining medicine in its fight against socialization. Over 10,000 organizations are now on record as opposed to compulsory health insurance. Unquestionably some of this resistance has been activated by the realization socialized medicine would be only the opening wedge of the “welfare state” and that no compromise can be made with this philosophy.
Robert Gordon Menzies, the present Prime Minister of Australia, has said: You can’t beat socialism by trying to be better and wiser socialists. You’ve got to fight socialism-not try to out- promise it.”
The Bulletin: Official Publication of the Sacramento Society for Medical Improvement
(The Sacramento County Medical Society)
Andrew M. Henderson, Jr., M.D., President; Herbert W. Jenkins, M.D., Vice President;
Edmund E. Simpson, M.D., Secretary, Treasurer; Jane Algeo Watson., Executive Secretary
BOARD OF DIRECTORS
Charles E. Grayson, M.D. Ralph C. Teall, M.D. Adolph T. Ogaard, M.D. Paul H. Guttman, M.D. John W . Rovane, M.D. Maurice A. Hopkins, M.D. Milton V. Sarkisian, M.D. Dan O. Kilroy, M.D. John G. Walsh, M.D.
This review of the first issue of the first journal of our medical society gives us a view of what was dear to our predecessors. Many in our society feel that we have lost our moral compass. This brief review of yesteryear could facilitate a return to it.
In 1954, Richard Johnson was appointed Editor, a post he continued for 40 years. We were then appointed to a four-year term beginning with volume 45 through volume 48. In 1970, with volume 21, the name was changed from The Bulletin to Sacramento Medicine, a name that has worldwide recognition — something we may have lost with our current name.
The Bay Area’s Super Messenger Model, obesity in adults and kids, inadequate care at the end of life. May/June 2004
Bay Area Preferred Physicians Starts Up!
The Alameda-Contra Costa Medical Association is pleased to announce its sponsorship of a Super Messenger Model Organization, the Bay Area Preferred Physicians Medical Group (BAPP). BAPP was created by seven Bay Area Medical Associations (ACCMA, San Francisco, San Mateo, Santa Clara, Napa, Solano and Sonoma) to assist physicians, as a group, to communicate fees and contract issues with third-party payers, without violating anti-trust laws. The Bay Area medical associations decided to form BAPP as a unique organization that would provide physician coverage for the entire Bay Area, a feature that benefits patients, health insurance companies, PPOs and physicians. The physician’s entire financial obligation is an annual membership fee of $850 and a one-time credentialing fee of $250 (reduced to $150 before April 1, 2004).. Read about BAPP at www.accma.org/webpages/bapp.asp.
Hospitalists Are a Great Idea But . . .
S Clarke Smith, MD, of the Orange County Medical Association, tells about his frustration with the seeming abandonment of physician-to-physician communication, such as between consultants and primary physicians but especially with hospitalists. He gives the background of the hospitalist movement, the use of highly trained intensivists to coordinate care during a hospitalization. From the viewpoint of everyone concerned, it is a great idea except for the patient and his/her physician. He feels it is not acceptable to practice in isolation and that those physicians treating inpatients need to keep everyone in the loop by frequent communication, including sending copies of all labs and x-rays to the primary care physician.
The Obesity Epidemic
Tony Iton, MD, JD, MPH and Brooke Kuhn, MS, remind us in the ACCMA Bulletin, “Preventing Overweight & Obesity,” that to enhance physician success rate in the battle against the growing obesity epidemic, we should routinely screen normal weight, overweight and obese patients for fruit and vegetable intake and physical activity during the complete physical. Further, we should advise pregnant women and new mothers to breast feed infants during the first year. A “brief negotiation” with overweight and obese patients can be the impetus that patients need to lose weight. It is never too early to promote healthier lifestyles and food choices. Roughly a third of overweight preschool children and half of overweight elementary school children carry the weight throughout adulthood.
Preventing Childhood Obesity
In the same issue, Dick Deutsche, MD, in “Preventing Childhood Obesity: A Grassroots Approach,” contends that increasing awareness of childhood obesity is not enough. He recommends this approach as a necessary complement to the public approach and highlights Dr Dexter Louie’s pilot project at the San Joaquin Moraga Middle School aimed at “junk food” consumption. Working through the leadership class, the students provided vegetarian lunch options, replaced one soda machine with a Milk Chug machine, increased the price of junk foods and decreased the price of nutritional foods, increased student awareness through the school newspaper, and created a “Health Awareness Week” for peer-to-peer health education. He challenges his colleagues to help implement the program that requires (1) physicians willing to bring the obesity issue to the attention of local school administrators and students; (2) a faculty sponsor to assist students with day-to-day operations of the program; and (3) informed students who choose to initiate a program to offer their peers healthier food options at school.
Henry Chang, MD, Tells Us How to Lose Weight Forever
Along the same lines, our member, Henry K Chang, MD, has recently written a book WEIGHT LOST FOREVER _ The æ Second Guide to Permanent Weight Loss. His very simple three-part formula is to weigh every day to catch any weight gain, diet your way to lose the excess weight (although he recommends fat reduction with a simple chart) and exercise to keep the weight off. If there isn’t enough space in this issue to print the book review, it can be found atwww.healthcarecom.net/bkrev_WeightLostForever.htm. It’s a very readable book for our patients, with numerous personal testimonies to which they can relate. Order your copy at www.longbowpublishing.com, www.amazon.com orwww.barnesandnoble.com. It can also be obtained at Borders, Barnes and Noble and Tower Book Stores.
Experience on End of Life Suffering
Brian A Seeley, MD, discusses “The End of Life Suffering” in Sonoma Medicine. He describes how his generation was shielded from death and states that he never saw a dead person until gross anatomy classes in Medical School. At the Hospice and the EPEC (Education For Physicians on End-of-life Care) program in Santa Rosa in October 2003, he learned that experts have demystified death and dying and have formu1ated better ways to relieve suffering.
Hospice agencies have focused on how to ensure that the experience of dying is gracefully accepted, rather than seeing it as a horrible agony. He suggests we periodically check the website of the Sonoma County Academic Foundation for Excellence in Medicine, www.scafem.org, for their next course. It fulfills the 12 hours of CME in pain and palliative care, required by December 31, 2006.
Dr Seeley recites that in the 1970s, Elizabeth Kübler-Ross published On Death and Dying, approaching the topic with love and kindness and bravely opening the door to its mysteriousness. The book became a helpful part of the curriculum for doctors and nurses at UCSF. It presented five recognizable emotional stages through which nearly all dying patients must sequentially pass: denial, anger, bargaining, depression and, finally, acceptance.
We should also add that when Elizabeth Kübler-Ross had her stroke at age 71 and was in need of end-of-life emotional support, her sad comment to the press regarding the effect she had on those who were caring for her was, “It’s almost as if I had not lived.”
Medical Liability Rates Are Down in Fresno
Merwyn G Scholten, Executive Director of the Fresno-Madera Medical Society, announces in his “Mert’s Musing” column in Vital Signs, their monthly publication, that despite the overall increases in Medical Liability insurance premiums across the state and the country, they along with Monterey, Santa Clara, Santa Cruz and San Mateo counties had a rate reduction. Other NORCAL insured areas had increases.
Our ebbing idealism, unattended children, obesity and baby feeding, and mepillsed wrdos July/August 2004
Are Youthful Medical Idealism and Adult Realities at Odds?
Philip R. Alper, MD, clinical professor of medicine at UCSF, writing in the San Mateo Country Medical Association Bulletin, draws an important parallel between the idealism of young physicians and the realities they experience during their training and early careers.
Weren’t we all idealistic at one time? And if that’s the way we were, what happened to us? Why, for example, did one study show women OB-GYN residents have measurably more compassion than their male colleagues at the outset of their residencies, but no difference by the time they completed training? Is this the effect of wider responsibilities or wearing down and becoming cynical?
Dr Alper feels physicians have become strident. We gripe. We complain bitterly. We reach new highs of self-righteousness when commenting on insurers, government, the drug industry, and even patients. If you think this is overblown, Alper advises us to listen carefully the next time we are in the surgical lounge or the doctors’ lunchroom.
There’s a lot we’ve overlooked, such as the grossly inflated retail charges of the hospitals, laboratories, pharmacies, and their impact on the uninsured. The distorted economics of managed care let some patients get too much for their money, while we sock it to others pretending not to know what’s happening. The plight of the poor, the uninsured, and the underinsured is something we’d prefer not to think about.
Some people believe doctors are uncaring or just in it for the money. They have lots of anecdotes to support their point of view. Haven’t we seen or even participated in instances of debatable testing or surgery? But we also observe tough-minded physicians take care of lepers, teach medical students and contribute unpaid time in other ways. Those that volunteer at the Samaritan House aren’t always the ones you’d expect to see there. Alper is convinced that what brought us into medicine is more likely to be partially submerged than to have entirely disappeared. That hard crust may conceal “the rest of the story.”
These observations were provoked by Dr. Alper’s attendance at the World Health Care Congress in Washington, D.C. in January. There were 45-minute addresses by Bill Frist, Hillary Clinton, and other luminaries. CEOs, CFOs, and CIOs of dozens of health care corporations mingled and broke into small groups for presentations and discussion.
In addition to the political and economic types, the medical directors of many health plans were also invited, something that he was told was highly unusual in such high-level gatherings. Clinical guidelines, best practices, error prevention, pay for performance, and value for the dollars expended dominated the discussion designed to facilitate the reshaping of medicine.
By the third day, Alper observed that the perspective of the practicing physician was considered superfluous. Physicians had been studied and were “known.” To health policy “players,” doctors appear to resemble a herd of cattle, to be maneuvered, manipulated, and molded. The same powerful corporations that have their own crack Human Resources departments approach physicians as if we are inhuman resources. Bizarre as it sounds, the very people who dehumanize us desire humanity from us.
Alper concludes that doctors aren’t saints. We can’t legitimately blame all our shortcomings on others. But we are not ready to walk away from our patients despite the increasing stresses of practice. It helps that the spark that brought us into medicine continues to warm us from within.
Go to http://www.smcma.org/ and click on Bulletin to read the entire article.
Never Leave Children Unattended in a Car: Not Even for a Minute
Marilyn Gunnell became aware of the “Not Even for a Minute” project developed by the state of New Jersey. She brought the project to two organizations of which she is a member: her Rotary Club, and the Los Angeles County Medical Alliance. Debbi Ricks, president of the Alliance of the Santa Clara County Medical Association writing the cover story for The Bulletin, has enlisted the Alliance Board to underwrite this project. You can order brochures and posters in several languages. The email addresses are given at http://www.notevenforaminute.org/. She invites physicians and others to participate in this effort to prevent child tragedy.
Are Physicians Part of the Problem in the Epidemic of Childhood and Adult Obesity?
Emily Lambert Dalton, MD, writing in The Bulletin of the Humboldt-Del Norte County Medical Society, observes how the feeding advice given to parents of newborns five or six decades ago is so much different than now. In that era new mothers were told to feed their babies on a strict schedule such as every four hours and never feed early. The schedule was based on the clock, not the infant’s cry, demeanor or anything else. It was strict and inflexible.
Nowadays we scoff at that old-fashioned approach, thinking (based upon what evidence?) that “on demand” feeding is highly superior. She thinks this may have come about because of the notion that this pattern more closely resembled the feeding pattern of a breast-fed infant.
Dalton opines that breast feeding, even if proffered liberally, is limited by physical and logistical factors. Breast milk needs time to replenish once a breast is drained. A child nursing on an empty breast doesn’t get much. Breasts get sore and mothers need to stop nursing to do other things.
Bottles can dispense an unlimited amount of formula at any time. Babies have a need to suck and if their bottle dispenses calories, they will take them in. To assume a newborn will regulate the caloric intake if offered an unlimited supply is ludicrous. Most adults don’t know when to stop eating; how can we expect an infant to know?
Most infants are bottle-fed at some point during the first year. Without a schedule, the parent can never be exactly sure when the infant is hungry. They soon begin to offer bottles at the first sign of infant discomfort or fussiness. A strict feeding schedule makes the answer clear: if it is feeding time, the infant is hungry. If it isn’t, the problem is gas, boredom, discomfort, or something else.
An infant who becomes accustomed to getting fed every time it experiences any discomfort learns that the proper response to pain, boredom, irritation, or any discomfort is to suck on a bottle and take in calories — usually more than needed. The number of adipose cells increase. By the end of the first year, both the parents and the infant have undergone powerful conditioning that encourages both to turn to food frequently and for the wrong reasons. Dr Dalton recommends that we all break out the first edition of Dr Spock’s Baby Care for his wisdom and sound feeding advice.
The Human Mind
Robb Smith, MD, the new editor of the Fresno-Madera Medical Society’s Vital Signs (he was jettisoned into this position because he was late for the Editorial Committee meeting) has the above title and the following “filler” after his editorial for the month.
Aoccdmig to a rscheearch at Cmabrigde Uinervtisy, it deosn’t mttaer in waht oredr the ltteers in a wrod are, the olny iprmoetnt tihng is taht the frist and lsat lteer be at the rghit pclae. The rset can be a total mses and you can sitll raed it wouthit probelm. Tihs is bcuseae the hmuamn mnid deos not raed ervy lteter by istlef, but the wrod as a wlohe.
Talking with with terminal patients, Nurse-to-Patient ratio concerns, and dealing with our legislature. September/October 2004
Talking with the Dying
San Francisco Medicine has two articles on talking to terminal patients. Fran Moreland Johns, author of the forthcoming book, But I Don’t Know What to Say, explains “Conversations 101: How to Talk with Patients Who are Facing Death.” She outlines the questions and fears surrounding terminal disease in three areas.
Assessment: “What do you want to know about your illness?” gives the patient a chance to ask, or not ask, specific questions about how much longer he might live, what treatment options to consider and what would be involved.Dialogue: “Let’s look at all this” addresses the personality – a fearless stoic, a fragile worrier, a cynic? Both questions provide unique responses. Conduct the conversation thoughtfully and unhurriedly. Most patients will give their physicians clues. Assurance: Dying patients simply want to know their physicians will be around to do what they can. Few want false hopes or empty promises. The more certain patients are that they won’t be abandoned and will be kept comfortable, the better their final days and months will be. She gives several examples.
Jack Kenny declined when told that removing his tongue, voice box and a portion of his jaw would extend his life the longest.. Instead, he went to Seattle for external beam radiation and then to Southern California for brachytherapy. Although he recalls that his surgeons told him exactly how bad it would be, “I guess I didn’t quite believe them.” He praised his physician for his straightforwardness. The lesson of Kenny’s experience is simple but profound: Getting to know the patient is key to successful doctor-patient communication.
A woman was more devastated by the way her physician delivered the news of her terminal disease, than by the knowledge of the disease itself. Word games are seldom necessary, but physicians are wise to consider them. References to pain, distress, comfort and control are easier to handle than, “You’re dying.” One 48-year-old woman said, “Nobody wants to hear, ‘There’s nothing more we can do.’ What I want to hear is ‘I’ll do everything I can.’” That covers the primary issue and requires no lies.
Oncologist Brian Lewis, MD, tells of a personal friend and exceptionally strong woman who was his terminally ill patient but had never spoken of her impending death. He sat at her bedside feeling as though these were the longest few minutes of his life. Then she began to talk about her apprehensions and to raise questions that clearly had been on her mind for some time.
Jack Kenny wanted straight talk. Dr Lewis’s friend needed the encouragement of his time. Every death is unique. Physicians whose words bring peace give a very special gift. To read the entire article go tohttp://www.sfms.org/sfm/sfm304e.htm.
Christine Okon, a hospice volunteer, expresses the importance of helping a dying patient create a personal legacy. She writes that leaving a legacy is bestowing a gift of continuity to those who survive us. The legacy of one’s self is deeply personal and precious.
A personal legacy could be as simple as a letter, an audio or video recording or a photo album. A chronological approach is probably the most familiar way to tell one’s story. When asked about themselves, people generally start with where and when they were born and move on from there. A timeline illustrates the path of a person’s life, a path then continues to the next generation. Another approach might be to discuss an area of personal significance in an individual’s life. This is called a “domain.” Important areas might be family, career, travels, religion, hobbies, pets, humor, friends and philosophy. Domains traverse decades, but are not defined by chronology. A third approach is perhaps the most profound: making a statement to loved ones. The dying person can share lifelong dreams, loving wishes, sound advice and mend emotional rifts.
Helping patients create a legacy involves listening actively and encouraging them to leave behind their essence, that which is most meaningful to them. To learn more about end-of-life issues such as hospice, palliative care, pain, grief, death with dignity, go to www.growthhouse.org. To read this entire article go to http://www.sfms.org/sfm/sfm304g.htm.
The Nurse-to-Patient Ratio Law Raises Safety Concerns
The president of the Alameda-Contra Costa Medical Association, Vin Sawhney, MD, comments in the ACCMA Bulletin about the law passed to prevent overworking nurses may indeed worsen safety. Under the regulation, compliance with the nurse-to-patient ratio is required at all times in accordance with the minimum ratios established for each hospital department by the California Department of Health Services (DHS). Although the law seeks to improve quality of care, the ACCMA has learned that strict adherence to the new requirements is actually jeopardizing patient care.
Under the Nurse Practice Act, a nurse is entitled to refuse responsibility for a patient if unable to ensure quality of care for the patient. Some interpret this as a violation of the nurse-to-patient ratio and are thus refusing to admit patients if the ratio is not met. Significant delays are occurring in assessing and treating patients in hospital emergency departments due to strict application of this new law. One emergency department reports that the number of patients leaving the emergency department without being seen has doubled. Patients are also sent to the lobby to await triage while emergency physicians and treatment beds remain idle.
It is certainly understandable that nurses should not assume responsibility for more patients than is medically appropriate, but delaying assessment and treatment of patients in emergency departments where patient census is constantly changing may be dangerous. The ACCMA will continue to assess this matter to ensure that any shortcomings in the practical application of the nurse-to-patient ratio law are addressed so that the quality of health care delivery in emergency departments is maintained. To read the entire article, go to http://www.accma.org/ and enter Sawhney.
As an alternative, we need to focus on the fact that as physicians, we have learned that when politicians, who know little about health care, tell physicians how to practice, health care will worsen and patients will get less care. The same can be said for nurses. The wise would say that the law should be repealed, not amended, revised or modified, which will only further burden our nursing colleagues and endanger our patients’ lives. It looks like the need for a part-time legislature, similar to 47 other states, is extremely important.
Politics as Unusual
The vice president of CMA’s Government Relations Department, in an article in Southern California Physician, explains why physician involvement in the political process is critical. He feels that the California Medical Association is organized medicine’s eyes and ears in Sacramento. Quite simply, our job is to pass legislation beneficial to physicians, kill legislation harmful to physicians, and maintain a practice environment that is economically healthful and free from intrusions on clinical decision making.
Since a large number of the physicians in my primary hospital are not members of CMA, I’ve been presenting the above four theses to them. The majority feel that CMA should be our eyes and ears, but that all four tenets are worse today than two decades ago. Many feel the very nature of physician advocacy is causing this and also hurting the physician image in the public eye. A full-time legislature leaves our Senate and Assembly with far too much time to become busy bodies destroying not only the practice of medicine but also other elements in our society. Organized medicine should advocate for a legislature that meets for three months at the beginning of each year and return for a one-month session every October. This would eliminate at least two-thirds of the harmful laws that interfere with our practice, with nursing practice and with health care.
Perceptions on Lobbying
Merwyn G Scholten, Executive Director for the Fresno-Madera Medical Society, has an important observation in Mert’s Musing, his column in Vital Signs, their official publication. He discusses one of his lunchtime experiences on perceptions of lobbying. The opinion at the table on who spent the most on lobbying was “the medical doctors, that’s who! And the NRA is right behind them.” Mert mused as to what made these people think that physicians and their organizations are far more powerful than the facts reveal.
Mert then did some research and found that the Association of Trial Lawyers of America was the top PAC contributor on the federal level giving $2.7 million to candidates, 85 percent to Democrats and 14 percent to Republicans. The second was the labor union, American Federation of State/County/ Municipal Employees, whose PAC contributed $2.6 million, 96 percent to Democrats and 4 percent to Republicans. AMA came in third with $2.6 million, 30 percent to Democrats and 69 percent to Republicans. Five of the top ten spenders were labor unions giving nearly $11.4 million, 95 percent going to Democrats. This, along with the Trial Lawyers contribution equals nearly $14 million. The NRA was fourteenth giving $1.7 million. The combined teacher unions, NEA and AFT, contributed some $3.8 million, virtually all to Democrats. You may reach Mert at www.fmms.org.
Although the perceptions at the table were in error, it appears that reality is far worse.
Stem Cell Research, 911 Tax, Gynecology Exams and Voicelessness November/December 2004
CMA Backs Stem-Cell Research
The California Medical Association has endorsed the California Stem Cell Research and Cures Initiative that will earmark $3 billion for embryonic stem cell research to develop cures for Alzheimer’s and other debilitating diseases. That one sentence in Southern California Physician continues the confusion of equating embryonic stems cells that have never cured any diseases with adult stem cells that have shown promise in curing a large variety of diseases.
Bob Davis and Antonio Regalado, staff reporters of the Wall Street Journal, report that Bob Davis and Antonio Regalado, staff reporters of the Wall Street Journal, report that three years ago, President Bush used his first televised presidential address to put the emotional issue of embryonic stem-cell research behind him. He unveiled a compromise: The federal government would, for the first time, provide funds for the research, but wouldn’t pay for work that required new embryos to be destroyed. Scientists and patient advocates who wanted the funding spigot fully opened grumbled but accepted the decision — as did abortion foes who wanted the work banned.
With that compromise, President Bush alienated both camps: Orthodox Jews, Evangelical Christians, Catholics and Muslims for extending the research from stem cells to embryonic stem cells; and scientists, including Nobel Laureates, and large hopeful patient groups for preventing unlimited embryonic stem cell research. Yet, Bush is the first President to authorize any tax funding of embryonic stem-cell research that had previously advanced only with private funding..
Opponents of stem-cell research say it’s unethical to destroy embryos and that using stem cells found in the bone marrow of adults could accomplish the same goals. President Bush has also praised the potential of adult stem cells. Stem-cell scientists say adult cells aren’t as abundant and malleable as embryonic cells. Other scientists say embryonic stem cells have yet to cure any disease, have limited potential to do so and carry a high risk of teratomas.
It is important that the CMA, composed of physicians from the same spectrum of society noted above, not take sides on such divisive issues. It destroys the collegiality left in organized medicine. Who then will be the Voice of Medicine?
Resuscitating ERs with a 911 Tax Increase
Dina Burwell reports in Southern California Physician that the Coalition to Preserve Emergency Care (CPEC) has a solution to the crises in the emergency rooms – a 911 tax initiative. The California Healthcare Association announced in April that it was dropping out of the 911 initiative because of a downward spiral in voter support. CHA thinks we should come up with something more publicly acceptable to fund the safety net. CMA should have dropped out also.
There are already seven taxes and four surcharges and fees on my telephone bill. There are hundreds of worthwhile causes and this is certainly one of them. But how many taxes are reasonable? When will it all end? The answer: Not until we have a constitutional tax limitation amendment.
Because we have limits on our primary taxes, a more worthwhile CMA policy might include a tax-limiting initiative. Instead of a myriad of taxes, surcharges and fees, it seems we need a federal constitutional amendment limiting each branch of government to two taxes. The American Taxpayers’ Union has several proposals. Another could be to limit the feds to a 15 percent income tax and a 10 percent excise tax on interstate commerce and imports, limit the states to a 5 percent income tax and a 5 percent sales tax, and limit the counties to a 1 percent property tax and a 1 percent sales tax. The addition of these taxes is still more than the 25 percent cost for government that public polls indicate Americans feel they should not have to exceed.
These limitations would bring order out of chaos and credibility to government. They would also increase the enthusiasm for joining the CMA and county medical societies. They could even restore our membership from the current 40 percent of all physicians to its former 80 percent, when we advocated private practice solutions instead of government-based solutions.
Making Practice Choices
When I was serving my two military years at the Mather Hospital, the base commander felt active duty personnel were waiting too long to be seen. So the hospital commander shortened the time for military dependents’ medical appointments. The wives and daughters who required pelvic examinations had previously been given 30-minute appointments; these were reduced to 15 minutes. He said that having the women draped for the pelvic exam prior to seeing the doctor would conserve time. I asked if he thought it was somewhat vulgar to introduce himself to a new female patient from between her thighs as he’s preparing to insert the vaginal speculum? He did not.
Ricki Pollycove, MD, a gynecologist writing in San Francisco Medicine, reviews her decision to leave insurance-dependent private practice and make the leap to fee-for-service medical practice in 1997. She had observed the development of managed health care deep in the medical soil of the Bay Area in the mid-1980s.
Physicians signed onerous managed care contracts that guaranteed them access to large numbers of patients, hoping to compensate for the loss in reimbursement for services. Participating providers (doctors) struggled to undercut competitors, keeping their market share of subscribers (patients).
The sacred physician/patient relationship for gynecologists became encumbered by “primary care provider (PCP) gatekeeper” rules. Frustration for consumers (patients) and providers (doctors) rose to levels of dissatisfaction never before witnessed.
Dr Pollycove had been deeply satisfied with her role as an academically grounded and psycho-socially sensitive gynecologist providing comprehensive integrative care for all aspects of her patients’ physical and mental well-being for 16 years. By 1977 she was at an impasse. “My attentive personalized style of practice, offered in the manner in which I would want my mother, friends and self to receive care, was no longer financially sustainable due to declining reimbursement rates.” She no longer could make a living with a minimum 20-minute patient appointment.
Rather than being seen as an elitist or snidely referred to as a “boutique doctor,” she honored her nature and practice-pace comfort zone and resigned from the encumbrances of the PPO-HMO insurance world. She now sees 15 percent of her patients at little or no charge.
To read the entire article as she explains how “life is good” and “patients are wonderful” and review other articles in the annual Women’s Issue, go to www.sfms.org/sfm/index.htm.
Voices for the Voiceless
The recent Mercy San Juan Medical Grand Rounds gave a whole new perspective on adult illnesses. Vincent J Felitti, MD, reported his studies of the Kaiser Permanente Medical Care Program in San Diego on the Relationship of Adverse Childhood Experiences to Adult Illnesses. Most physicians have little comprehension of how childhood experiences translate into adult illnesses.
The Adverse Childhood Experiences Study (at www.acestudy.org) is an outgrowth of observations made in the mid-1980s of an obesity program that had a high dropout rate. The first of many unexpected discoveries was that the majority of dropouts actually were successfully losing weight. Accidentally, and to our surprise, we learned from detailed life interviews of 186 such individuals that childhood sexual abuse was remarkably common and, if present, always preceded the onset of their obesity. Some had brought up their history of abuse only to have the information rejected by a physician as being in the distant past and hence not relevant to current problems.
The counterintuitive aspect was that, for many people, obesity was not their problem; it was their protective solution to problems that previously had never been acknowledged. An early insight was the remark of a woman who was raped at age 23 and gained 105 pounds in the subsequent year: “Overweight is overlooked and that’s the way I need to be.”
The contrast was striking between this statement and her desire to lose weight. Many were driving with one foot on the brakes and one on the gas, wanting to lose weight but fearful of the change in social and sexual expectations that would be brought about by major weight loss.
The 26,000 consecutive adults coming through the Department were asked if they would be interested in helping understand how childhood events might affect adult health status. Seventy-one percent agreed. These volunteers were asked how many ACE events they were exposed to.
Adverse Childhood Experiences (ACEs) are defined as growing up (prior to age 18) in a household with:
· recurrent physical abuse;
· recurrent emotional abuse;
· sexual abuse;
· an alcohol or drug abuser;
· an incarcerated household member;
· someone who is chronically depressed, suicidal, institutionalized or mentally ill;
· mother being treated violently;
· one or no biological parents;
· emotional or physical neglect.
An individual exposed to none of these categories had an ACE score of 0; an individual exposed to any four had an score of 4, etc. The two most important findings are that these adverse childhood experiences:
· are vastly more common than recognized or acknowledged; and
· have a powerful relation to adult health a half-century later.
One in four were exposed to two categories of adverse experiences; one in 16 were exposed to four categories. Given an exposure to one category, there is an 80 percent likelihood of exposure to another category.
A person with an ACE score of 4 is 260 percent more likely to have COPD than a person with an ACE score of 0. A person with an ACE score of 4 has a 240 percent increase in developing hepatitis; a person with an ACE score of 4 has a 250 percent increase in contracting sexually transmitted diseases; a male child with an ACE score of 6 has a 4,600 percent increase in the likelihood of later becoming an IV drug user.
The same correlation occurred with emotional disorders. An individual with an ACE score of 4 or more was 460 percent more likely to be suffering from depression, 1,220 percent more likely to attempt suicide. The totals went to 3,000-5,100 percent with higher ACE scores.
The Kaiser study found that 22 percent of their members were sexually abused as children. How does that affect a person later in life? How does it show up in the doctor’s office? What does it mean that sexual abuse is never spoke of?
Dr. Felitti asked what is this hypertensive, diabetic old woman’s diagnosis? He conceptualized the problem this way:
Childhood sexual abuse
Coronary artery disease
Dr Felitti concluded: This is not a comfortable diagnostic formulation because it points out that our attention is typically focused on tertiary consequences, far downstream. It reveals that the primary issues are well protected by social convention and taboo. We physicians have limited ourselves to the small part of the problem, where we are comfortable as mere prescribers of medication. Which diagnostic choice shall we make? Who shall make it? And, if not now, when? For more details, go to www.acestudy.org/docs/GoldintoLead.pdf.