Insurance leeches, the way doctors think, and the weaponry of numbers January/February 2008

Medicine’s Parasite

In the The Bulletin of the Humboldt-Del Norte County Medical Society, October 2007, Dr. Emily Dalton discusses “Leeches in Medicine.”

“According to Stedman’s medical dictionary, a parasite is an organism that lives on or in another and draws its nourishment there from. Leeches suck nutrients from the host – not enough to cause death – yet they have no beneficial effects for the host…. Insurance companies are the parasite of our times, and like the leeches, it is time for insurance companies to get out of healthcare.

“Twenty percent of the money spent on health care premiums gets pocketed by the insurance companies. They collect the money and they dole out medical care (also known as the “medical loss ratio”) in capricious and self-serving ways. Insurance companies create barriers to care by denying payment to doctors and by denying medical care to patients…

“The insurance model does not apply well to medical care. Insurance works best for catastrophic problems that are unlikely to actually happen. For situations such as home-destroying disasters or automobile crashes, the insurance model works well. Most people do not have damaging house fires or severe auto accidents on a regular basis. People get covered for losses that could be financially ruinous, insurance companies make their profits, and it all works out fairly well. Healthcare is different! Healthcare is something that everyone needs on a regular basis. Preventative care, treatment for minor illnesses, and treatment for catastrophic illnesses are basic human necessities.* Serious illnesses will occur for each one of us at some time in our lives. We deserve better than to be at the mercy of a cold-hearted insurance company when that time rolls around.

“The insurance model is a poor way to structure the delivery of efficient and sensible healthcare. The time has come for medicine to become leaner and more efficient, which can only be accomplished by eliminating the parasitic growths that insurance companies have become, and replacing them with a single payer system.”

Go to www.humboldt1.com/~medsoc/images/bulletins/OCTOBER%202007%20BULLETIN_for%20web.pdf for the original article.

*[If Dr. Dalton had continued the analogy so nicely made with houses and autos, the article would have ended on a positive, instructive and optimistic note: “Serious illnesses will occur for each of us at some time in our lives. But only serious illnesses are insurable. Treatment for preventative care, minor illnesses and routine health care should be paid out of pocket, like car maintenance and home repairs. Then health insurance would be appropriate and affordable just like car and home insurance.” – D.M.]

Art and Science of Medicine

Dr. John Toton reviews the book, “How Doctors Think,” by Jerome Groopman, MD, in Sonoma Medicine, the Magazine of the Sonoma County Medical Association.

“In How Doctors Think, the much-published Dr. Jerome Groopman uses multiple case histories (all of them initially misdiagnosed or mistreated) to highlight the perceived inability of doctors to think and communicate effectively with their patients – an issue of great importance in these times of medical stress and change. Groopman is a reluctant apologist for this issue, and he argues for corrections that he feels are needed. The case histories he presents are a sad journal, particularly since – from his perspective – all were preventable. Groopman also chronicles his own experiences with ‘aggressive back surgery’ and a long effort to diagnose scaphoid-lunate ligament injury as the source of his own chronic wrist pain.

“After much patient suffering or risky delays, the cases Groopman describes are almost always resolved by ‘open communication,’ including listening, open-ended questioning, systematic thinking, patient activation and engagement in the process, and exclusion of good patient-bad patient prejudices…

“Groopman accepts that we are in a time of rapid change in how we practice the art and science of medicine. The ‘older’ generation, he explains, acquired their skills primarily by the Socratic method of sharing knowledge, questioning and responding, learning from our experience and that of our mentors, and on-the-job honing of these skills. We trust our experience; we learn from our errors. We search for the ONE diagnosis that seems to fit the data and explain the symptoms (Ockham’s Razor). We always look for patterns and similarities so we can shortcut to the diagnosis. From there, it’s just a short leap to developing ‘confirmation bias,’ often based on recent experiences, leading in turn to ‘diagnostic momentum.’ As a result, we sometimes give short shrift to atypical symptoms, especially with alcoholic, diabetic, or other stereotypical patients.

“The ‘younger’ generation is in transition, but with much the same burden. They are taught to depend on algorithms, ‘diagnostic certainty,’ evidence-based diagnosis and treatment, computerized records and formulas, all available in one nice BOX (PalmPilot or Blackberry). They may be worshiping the science and ignoring the art of medicine…” For the complete review, go to www.scma.org/magazine/scp/Fall07/toton.html.

The Numbers Game

Thomas H. Lee, MD, writes on “Dangerous Numbers: Misconstrued Data Hazardous To Health Care” in Vital Signs, official publication of the Fresno-Madera Medical Society and Kern County Medical Society

“$2 trillion. Forty-four million uninsured. Sixteen percent of gross domestic product. Respectively, that’s how much the U.S. spends on health care each year, how many people are uninsured and the portion of the GDP that health care consumes. To those of us who follow health care, these numbers are more than just familiar – they are macroeconomic symbols of our woeful health care system. As health care reform continues to burn near the top of political issues in the U.S. presidential race, these numbers increasingly are being used as weapons. Weapons against insurers, pharmaceutical companies and providers.

“These numbers can be somewhat misleading. For example, just a few weeks ago, the New York Times published a controversial article – ‘Sending Back the Doctor’s Bill’ by Alex Berenson – about how many health care economists believe that both political parties were missing the real source of cost savings: physician incomes. The article argued that physician incomes were more than double those of their European counterparts and that health spending could be reduced significantly if doctors were paid less and were salaried rather than being paid per procedure.

“Not surprisingly, the article drew plenty of criticism, including some from noted economist Uwe Reinhardt. Reinhardt counter argued that physician take-home incomes represent only 10 percent of health care spending and that even a 20 percent reduction in incomes would reduce national health care expenditures only by two percent.

“Regardless of how you think physicians should be compensated, health care reform inevitably will be determined by the politics and economics of change…. Numbers increasingly will be wielded as fact, argument and weapons of ideology…” The entire article is on page 8 of www.fmms.org/pdf/Oct07_VS_FINAL.pdf.

The growth industry of diagnostic codes, and when consultants go too far March/April 2008

#@&%! that 5-Digit Number

“And Now-A Minute with Andy Rooney (With Apologies to 60 Minutes)” by Stephen Kamelgarn, MD, discusses the ICD-9 codes, in the December issue of The Bulletin of the Humboldt-Del Norte Country Medical Society:

Dontcha just hate little five digit numbers. I know I do. Little numbers that comprise the ICD-9 – this three pound paperback book I’m holding in my hand. (Camera pans into Andy fanning the pages of a huge tome) A five digit code that supposedly encompasses the full gamut of medical diagnoses that may ever have entered the mind of humankind. Isn’t that a bit of hubris, thinking we can classify all diseases with a five digit code? But people keep trying.

Here’s an example: 711.4 Arthropathy associated with other bacterial diseases.

The fifth digit is Code for the underlying disease, as: diseases classifiable to 010-040, 090-099, except as in 711.1, 711.3, and 713.5 leprosy (030.0-030.9) tuberculosis (015.0-015.9) Excludes: gonococcal arthritis (098.50) meningococcal arthritis (036.82)

It’s nice to know that we can separate out tuberculous arthritis from gonococcal arthritis. It also makes no sense at all: is leprosy 030.0? or is it 030.9? or is it somewhere in the middle? What happened to the 711.4 code, which was the original number I looked up?

When the folks keeping track of the numbers were mostly medical people (and actually understood this stuff) those five digits were (and still remain) an important way of tracking diseases and disease trends. But somewhere along the line the bean counters and the insurance ‘droids and the government bureaucrats hijacked those five digits for their own nefarious purposes. Now those same five numbers have taken on a life of their own and have become a tyranny. Nothing moves anymore without that five digit code accompanying it; and they’d better be the right code, or you can forget it…

“I’m sorry doctor, the patient’s insurance plan doesn’t pay for the code ‘V77.91; Screening for Lipoid Disorders.’ I’m afraid the patient will have to pay out of pocket.” This, despite the fact that the American Colleges of Everybody say that all adults should be screened for this problem at age 40, or whatever.

“I’m sorry doctor, you’ve only put down 493, the first three numbers. We need the fourth and fifth.” Do they really need to differentiate “extrinsic” asthma from “intrinsic” asthma to pay for a nebulizer? Not only that, but the online reference I’ve been using icd9.chrisendres.com doesn’t even carry 493 out to five places. “I’m sorry doctor, Incontinence, ICD 788.30, doesn’t qualify your patient for adult diapers. We need a code for why the patient is incontinent.” Does it matter? The patient has a problem with his/her bladder, and just needs the damn diapers, for goodness sake!…

When did we allow this to happen to us? As medical costs rose, the insurance industry, out of a sense of their perceived necessity, intruded more and more into our autonomy and our ability to advocate for what is right (as opposed to what is cost effective). We found our time slowly being chipped away, as slowly, relentlessly more and more forms and insurances started demanding that we supply the appropriate code, and now we can’t put a halt to it as more and more of our office time gets taken up by having to look up and provide the appropriate damn code.

It’s become a growth industry unto itself. Just Google ICD-9 and see how many hits one gets: dozens of web sites devoted to telling us the appropriate code for whatever ails us. Our mailboxes (both email and snail-mail) are flooded with junk mail, advertising “coding” conferences, so that we may make the best use of these abstruse codes to obtain, or heaven forbid, increase reimbursement. This must be a financial boon to the companies putting on these dog and pony shows….

I guess that it is nice to know that I’ve found some part of the economy that’s profitable and growing. When I get out of medicine I can always get a job as a coding consultant.

The entire article is atwww.humboldt1.com/~medsoc/images/bulletins/DECEMBER%202007%20BULLETIN_for%20web.pdf.

They Want What?

Lytton W. Smith, MD, editor of the Orange County Medical Association’s Bulletin, urged “Dare to Say No!” in the December 2007 issue.

A presentation on peer review and medical staff issues became a discussion on insurance contracting.

While at the California Medical Association House of Delegates, members of the Solo and Small Group Practice Forum (SSGPF) invited me to attend a presentation by Howard Lang, MD, dealing with peer review and medical staff issues. The evening evolved into a self-confessional discussion about insurance contracting.

At the House of Delegates, the SSGPF represents physicians practicing alone or in a small group of four or fewer. The CMA has more than 8,000 members fitting that category. Other practice forums include the Medium Group Practice Forum (5 to 150 doctors), the Large Group Practice Forum (150 to 1,000) and the Very Large Group Practice Forum (1,000 plus).

After a short presentation about a messenger model developed in Los Angeles County, various members spoke about dropping contracts. The sharing of personal experiences with contract termination has become chic. The solo practitioner sitting beside me made the observation that he felt like an Alcoholics Anonymous meeting erupted. “My name is H—–, and I terminated my contracts!” In response, know-ing sighs from attendees filled the room. Those still afflicted with insurance contracts listened in admiration…

Now shift to the floor of the House of Delegates. We learned that legislation had been passed to study the peer review process in Cali-fornia, and that the Medical Board of California had contracted with Lumetra to perform the as-sessment. Further, we learned that medical staff offices across the state had received letters from Lumetra demanding confidential peer review information.

What? They want what?!? Calls from medical staff offices to chiefs of staff and medical staff attorneys ensued. What information could, should or would be released? Was this information about peer review protected by SB* 1157? Most hospitals collect reams of data about peer review. Physicians participating in review of other physicians assumed SB 1157 protected them from discovery. Hospital administration feared that exposure of cases with severe criticism of patient management could lead to increased legal liability. Who pays for the collection, copying and mailing of confidential patient and peer review data? Faced with another unfunded mandate from the state, what would medical staffs do? Could they dare to say no?

The House of Delegates passed a resolution requiring that the CMA legal department immediately look into the legality of the Lumetra demands…. It’s not that we physicians are a bunch of naysayers. We gladly say yes to proven innovations, evidence-based medicine and new surgical techniques. Yet over the past 20 years, demands by insurers, legislators, regulators and even specialty boards have increased physician angst – and in that environment we must dare to say no.

The article is at www.socalphys.com/article/articles/625/1/OCMA-Viewpoints—Dare-to-Say-No/Page1.html.

Re-scripting medicine, successful Electronic Health Records, a plea for the hearing impaired May/June 2008

I am happy being a doctor, I am well compensated, I am…

Kate McCaffrey, DO, discusses “Re-scripting Our Profession” in the President’s Message column of The Bulletin of the Humboldt-Del Norte County Medical Society, March 2008:

I have been re-scripting my self-talk lately. It helps being around optimistic medical students who aren’t jaded by the storms of practice and the insurance sharks.

Instead of saying, it’s hard practicing medicine I say to myself, I am happy being a doctor, my patients and colleagues respect me and I am being compensated well for my efforts and expertise. I have committed to re-scripting my thoughts for one month. As a scientist, I like to test my hypotheses. I’ll let you know how the re-scripting goes and what changes, if anything!

On the larger scale, I think our profession needs to re-script itself. The public still has the highest regards for doctors. When we complain, we erode this reputation. If any of you has had the unfortunate experience of being injured or ill, you know how important the opinion of your physician can be…

As the Touro University medical students arrive in Humboldt and Del Norte this June, I will think about how I am portraying our profession with my words. Yes, it is broken, but am I living in the problem or in denial or am I living in the solution? Am I calling and emailing my representatives?

Am I involved locally? I will become aware of my version of the torch I am passing on to the next generation. How can I involve them in the local and state political process early in their careers? What hope and reassurance can I give them that they still entered one of the most important and revered professions in the world?…

The entire column can be read atwww.humboldt1.com/~medsoc/images/bulletins/MARCH%202008%20BULLETIN_for%20web.pdf.

Electronic Health Records

“Nine Strategies for Successful EHR Adoption” by John C. Whitham and Steve Davis, DO, appears in the January 2008 issue of Vital Signs, published by the Fresno-Madera Medical Society and Kern County Medical Society:

If you are going to implement an EHR system, following are 9 guidelines to managing the art of successful system adoption:

1. It is imperative to minimize the impact to a physician practice’s cash flow… Regardless of how well the system works or how spectacular the other components are, if income to the practice stalls, the physician’s perception is that the whole implementation is a disaster. Practices will always assume it is the implementer’s fault, no matter the circumstances…
2. Include an evaluation of the practice’s billing, business, and clinical processes and practices in your preimplementation evaluation. Each practice has its own unique processes and business and clinical practices, and the practices need to understand that a new system will not allow them to always do things the way they have always been done…
3. Make sure that the practice’s lead physicians are “leading” staff and other physicians to effectively manage change and that their motives are understood. Each practice needs to have good leadership to get the rank-and-file to follow and be enthusiastic…
4. The practice management system is a tool for billing, not a system that “does” the billing…
5. If an office is unreliable and difficult in the training and implementation process, then they will be unreliable and difficult in using the new system…
6. Find the reliable and enthusiastic individuals within the practice to be the super-users for the practice…
7. Allow adequate opportunities for “practice” between training and go live…
8. Develop a post-implementation follow-up process for both the practice management system and the electronic health record…
9. Understand that the electronic health record implementation is difficult…

John C. Whitham is a partner who chairs the Clinical Integration Practice in the JHD Group. Dr. Steven Davis is medical director of Physician Associates Clinical Integration Services (PACIS), and a Board Member of Physician Associates, an 800-member IPA based in Pasadena, California.

Details of the nine strategies appear at www.fmms.org/pdf/Jan08_VS_FINAL.pdf.

Can You Hear Me Now?

Basil Meyerowitz, MD, who is hearing impaired, writes “A Plea to the Hearing Intact: Advice to the Auditory Challenged,” in the San Mateo County Medical Association Bulletin of March 2008:

…Those that don’t have this disability often don’t recognize our plight and do not try to alleviate the problem…and some treat the hard of hearing as if they are intentionally plotting to not hear (although, in some circumstances, it may be an advantage not to hear some things, but this is rare indeed).

We sufferers are able to recognize that hearing aids do help, but they are not a panacea, particularly in areas that have poor acoustics or are occupied by large crowds. And sometimes, hearing aids work a little too well! For example, wind noise is greatly enhanced, and raindrops falling on an unfurled umbrella sound very loud indeed.

A hearing aid’s basic principal is to maximize sound waves as they reach the ear. However, hearing aids accentuate ALL sound waves (even extraneous ones), which frequently overwhelm the voices of those one wishes to hear. It is possible to adjust one’s hearing aids to try to pick up selected sounds, but this is difficult to engineer: For example, when sitting in a restaurant, background noise is impossible to filter out.

At public meetings or lectures, if the sound system is good – although most often it is not – it is relatively easy to follow the speaker. However, some lecturers and lay speakers are not always familiar with the proper use of microphones.

Moreover, even in normal discourse, too many people are careless with their speech. A good many speak softly or indistinctly; some speak very quickly without enunciating their words. At mealtime, speech is often garbled by food in the mouth of the speaker…

Tips for the Hearing Impaired…

When conversing in person or by telephone, it’s a good idea to immediately announce that one is hard of hearing and to request the speaker to please speak louder and a little slower.

Conversations on cell phones, even in the best of circumstances, are often awkward. Instead, request using a landline phone.

A speakerphone permits the listener use of both ears at the same time…

There are innumerable web sites that offer advice to the hearing impaired…or for those that want or need to have a sensible dialogue with somebody that is hard of hearing. One that I found… [is ] The Hearing Exchange (www.hearingexchange.com)…

Perhaps my plea should be directed to unite those of us with hearing problems (and it appears there is no shortage of fellow sufferers) instead of those that do not. We need to have our disability taken more seriously.

The complete article is at www.smcma.org/Bulletin/BulletinIssues/March08issue/BULLETIN-0803_Meyerowitz.pdf.

Vague health care instructions, saluting old soldiers (and MDs), advertising vs. marketing July/August 2008

Not Doing Everthing
“Do Everything (…that makes sense!)” is a piece by Ken Meece and Scott Sattler, MD.

Among the common but unhelpful phrases people use when talking about their preferences for intensity of healthcare interventions are “No heroics” and “Do everything.” “Heroics” is obviously vague, and we naturally go on to name the specifics. “Everything” doesn’t seem so vague, and can seem clear enough to be taken at face value.

It’s very hard for people to specify preferences about life-prolonging measures, not only in a crisis or stressful moment but also (for different reasons) pre-need, ahead of time as in completing one’s Advance Directives. So it’s natural to use quick, global phrases to try to circumvent difficult details. Unfortunately, the actions encompassed by the phrase “Do everything” often have unintended negative consequences, sometimes unanticipated and severe…

Interestingly, there is a way of hearing and dealing with a “Do everything” request that can lead to helpful, detailed communication and reasoned choices, rather than to truncated communication and frustration. This approach was shared with me years ago by Dr. Albert Jonsen, a medical ethics pioneer and current Emeritus Professor of Ethics in Medicine at the University of Washington. He suggested that whenever we hear “Do everything,” we always add ‘in our mind’s ear’ the phrase “…that makes sense”. Presuming that people are never asking us to do things that don’t make any sense is nearly always safe ground. Then respond: “Yes, we’ll do everything possible that makes sense. Let’s talk about what options make sense medically, that might work to help you at this point. And please, you tell me what makes sense personally to you. We’ll work out together what makes sense medically and personally. How does that sound to you?”

Without adding on the phrase “…that makes sense,” the global “Do everything” leads to what is called the technological imperative: If it can be done it must be done. This is ethical nonsense, and can lead to avoidable tragedy…

The Disappearing Generation
“There They Go” is the title of an article by George Ingraham, MD.

On election day last month I had stopped just behind a pickup truck near the polling station. Out of the pickup stepped an old gent: ninety at least. He made his way back along the bed, supporting himself with his hands, and reached into the bed for his cane. Securing this, he walked around the back of his truck and squared up with the curb: a step up of maybe eight inches. He took several seconds to prepare himself, and then with great care and evident pain levered himself up onto the sidewalk, paused, squared his shoulders, raised his head, turned and marched (“walk” doesn’t cover it) painfully towards the poll: leftright… leftright… leftright. It took only a little effort to look back almost seventy years and imagine the soldier of twenty; the determination and the pride were still there. Oh yeah. It may not have been much of an election, but he’d fought in the war, he was going to walk to the polls, and he was going to vote. So it hurts. Tough.

Tom Brokaw called his book The Greatest Generation. And maybe they were. In and out of uniform, they took on the worst Europe and Asia had to offer, fought them on two oceans and three continents…and won.

I have wondered, thinking about those years, about the physicians of that time, and the challenges which they faced. Not the least of these was the sudden disruption of their education, their careers, and their family life…

We are to consider that they had, in 1941, only small, very small, quantities of a new drug called Sulfa, which could actually kill bacteria without killing the patient. Otherwise, there was not much they could do about contaminated wounds and compound fractures, let alone burns, beyond offering hope and comfort…

We are losing this age group; I read somewhere, at the rate of around a thousand a day. Which reminds me of a traditional Scottish toast: “Who’s like us? Damn few, and they’re all dead!”…

Why Advertising Fails
David Zahaluk, MD, discusses the “Top Ten Reasons Why Medical Advertising Doesn’t Work” in the San Mateo County Medical Association Bulletin of January 2008.

“My advertising doesn’t work!” I hear those words of lament frequently…. The incorrect use of marketing and advertising is the key reason why many practices fall far short of their potential.

Marketing is not advertising. According to Webster’s online dictionary, advertising is the “the action of calling something to the attention of the public, especially by paid announcements.” It is the broadcast of specific messages through specified media, like newspaper, Valpak and Yellow Pages.

Marketing, on the other hand, is “an aggregate of functions involved in moving goods (services) from producer to consumer,” also according to Webster’s online dictionary. Marketing is an overall process of deciding who is in your target market, what their needs are, how your service fulfills those needs and how to best orchestrate the process.

Ads send a specific message. Marketing calibrates the message to market to media match-up and delivers the right message to the intended target. Said differently, the way your receptionist answers the phone is not necessarily part of your advertising, but it is part of your marketing.

However, advertising is not bad, if it is done strategically and in the context of a larger marketing plan. So why does advertising frequently fail?

Reason #1: People Don’t Want to be Sold
Patients (and the referring doctors that send them to you) are ever-inundated with advertising messages…. The typical patient weeds out the sales messages and instantly discounts them as being “just advertising.”

Reason #2: Being Boring
Perceptual studies have been done on the behavior of reading the newspaper. The reader scans the page quickly and separates news stories from advertising content. Then, headlines are scanned, with about four seconds devoted to each headline. After that, articles of interest are read and boring articles are skipped. Finally, ads are scanned and interesting ones are read, while most are not…

Reason #3: Lacking Credibility
I have always maintained that the best advertising for a physician is a full waiting room. The public tends to ignore claims that we make about ourselves and looks to the opinion of other people like themselves as validation of their opinion…

Testimonials, third party and celebrity endorsements and guarantees all greatly increase credibility. An enormous amount of credibility is implied if you are the official physician for a local team…

To see the entire article, go to www.smcma.org/Bulletin/BulletinIssues/Jan08issue/BULLETIN-0801-Zahaluk.pdf.

Shutting down: instructions at the last stage of life, and reflections after closing a practice September/October 2008

A “Good” Ending

Drs. Wendi Joiner and Tim Nicely discuss “The Last Stage of Life Project in Humboldt County,” in the The Bulletin of the Humboldt-Del Norte Country Medical Society, April 2008..

What is a “good” death? This is only identifiable in the perspective of the patient and the patient’s loved ones. How can we consistently provide this last service to our patients, our neighbors? Communication and coordination in the last stage of life — whether this is a few weeks or many years — are the key. Communication is a personal skill set and coordination means a system including the wide variety of persons and facilities providing services.

A diverse group sponsored by the IPA has been meeting to discuss issues related to last stage of life (LSL) care in our community since October 2006. The IPA LSL Project Committee includes clinicians, representatives of all levels of local health care facilities and emergency medical responders. A common concern is that systems are not in place to ensure that patients’ wishes are consistently carried out due a lack of coordination and communication, especially between levels of care.

According to a recent survey, eight out of ten people say it is “very” or “somewhat” important to write down LSL wishes, but only 36% actually have written instructions. As a result, needless and unwanted interventions happen during the last six months of life, causing unnecessary stress and expense for patients and their families alike.

The Mission of the Last Stage of Life (LSL) Project is to ensure that all residents of Humboldt County have their choices known and preferences honored regarding the nature and intensity of last stage of life care, support and services.

The vision of the LSL Committee is to help the members of our community have a good death according to their own values and preferences by creating a collaborative system within and between all levels of care—home, RCF, SNF, acute hospital, emergency transport – to honor and implement documented patient preferences. The choice of a common documentation for clinician orders regarding CPR, antibiotics, artificial nutrition/‌hydration and hospitalization has been a key focus of work.

The Physicians’ Order for Life Sustaining Treatment (POLST) form has been selected as the tool by which patient’s LSL care preferences will be communicated within and between facilities. In November 2007 the Humboldt IPA received a grant from the California HealthCare Foundation to assist with implementation of the POLST. We became part of a statewide Coalition working with the California Coalition for Compassionate Care to implement the POLST in California, based on a model in use in five other states. This group gives us a forum by which we can share ideas, materials, and experience with others across California.

To read more about the coalitions, plans, and the POLST forms, go towww.humboldt1.com‌/~medsoc/images/bulletins/‌APRIL%202008%20‌BULLETIN_for%20web.pdf

Thoughts After the Unthinkable

Anne French, MD, writes about “Collective Health” in the summer 2008 Sonoma Medicine, of the Sonoma County Medical Association.

I’ve done what was once unthinkable — I closed down a 45 year-old solo family practice in the fall of 2006. My father ran the ship for 42 years. I came along to experience this rare dying breed for a mere three years, and then decided it was time for hospice.

Ever since residency, I’ve had the sense of holding my breath, waiting for the medical system to collapse entirely, so that it can rise anew and become a viable system that truly cares for the health of our nation. When I was mired in the muck of a frantic 16-hour day filled with hundreds of detailed tasks, often involving significant liability for people’s health and lives, it felt impossible to be part of the solution.

My original decision to take over my father’s practice took me by surprise. I left my salaried position at the Sonoma County Indian Health Project and was propelled headlong through a crash course in small-business ownership, practice management, and being the sole provider for not only 3,000 patients, but also five employees. I learned the reality of partial and delayed reimbursements from the insurance industry, and of productivity-based income. To avoid compromising my ideal of quality, I limited the number of patients to 18–20 per day. This limit allowed me to break even, but I was still working 80 hours a week.

It’s taken some retrospection to realize that I was running a private nonprofit. I loved the autonomy of solo private practice, I loved practicing my own blend of allopathic and integrative medicine, and I loved my patients. But I knew the pace was not viable, and that I was at high risk for burnout. I also could not tolerate any more incursions on my time or my income. I was getting paid for only 50% of my time and effort. Sure, my patients were happy, but the workload and the financial equation were not sustainable.

I currently work for the State of California, at the Sonoma Developmental Center. I’m on hiatus from private practice, with a strong desire to protest our current system. As long as I continued to contract with insurance companies, I was part of the problem, not the solution. I was allowing these companies to further exploit the medical system, by accepting their corrupt contracts and their delayed payments. Needless to say, a year and a half after closing my practice, I am still owed tens of thousands of dollars by the insurance companies, which still require labor-intensive redundant paperwork to refile and contest my unpaid claims…

The total amount of money going into our health care system is phenomenal, more than any other country in the world. In a typical insurance company, administrative costs range from 20% to 30%. These rates compare unfavorably with Medicare and Kaiser, whose administrative costs are less than 10%. The multiple layers of separation between patient and physician are not benefiting anyone except the insurance industry, which continues to rake in huge profits. Meanwhile, physicians and hospitals struggle to survive, and patients receive mediocre and substandard care for an ever-increasing price tag…

Many of the common arguments against universal health care continue to be recycled in repetitive campaigns to play on our fears of long lines, less choice and substandard care. Isn’t that what we already have? We can create a viable, competitive new system that we actually want to use. We’re a creative country (although a bit constipated at the moment), and we could use some of the benefits of our capitalist society (such as competition) to create a universal health care system that fills us with pride, not fear.

The power and strength of the pharmaceutical and insurance lobbies is clearly stamped on our current medical model. The only way to revamp medicine is to have physicians and patients take back ownership of the system. In fact, if we don’t find our voices, the “solutions” will continue to be dictated by industry lobbyists and politicians. The balance of power must be restored, and a set of checks and balances needs to be applied to the drug and insurance companies, just as they are currently applied to individual physicians.

The entire article can be read at http://www.scma.org/magazine/scp/sm08/french.html

Why we attract foreign-trained MDs; handling physician stress; and becoming a patient November/December 2008

American Medicine’s Attraction
Dr. Lytton W. Smith, editor for the Orange County Medical Association, wrote on “The Freedom of International Medical Graduates” in the July, 2007, issue of Southern California Physician.

America’s allure has led many physicians trained overseas to the United States.
The current debate on immigration reform has given me a chance to reflect on international medical graduates (IMGs). America’s allure of prosperity and political and economic freedom has led many physicians trained overseas to the United States, including me, a Canadian.

After we arrived, the openness of American society allowed us to assume new roles, including as top leaders in organized medicine. This month, Satinder Swaroop, MD, becomes president of the Orange County Medical Association. Originally from India, Dr. Swaroop is the third IMG in the past seven OCMA presidents.

Many IMGs assimilate into various forms of medical practice, and when established, they long to participate in determining the direction of the profession. We remember our background and culture, but have adjusted our perspectives to acquire acceptance and support from our fellow physicians.

Daily, we use the confidence that inspired us to leave our “native land” – a phrase I borrow from the song “O’Canada” – to help advance healthcare in America.

The root of American freedom is the Declaration of Independence, a document I recently reread. It is a true masterpiece expressing the aspirations of a group of determined men to free themselves of a distant tyrannical force. Yet to assure the rights of individuals, American people created a complex system of laws.

In medicine, we also have a variety of pronouncements that we label principles, ethics or guidelines. These lack the enforcement component that laws have, but they give the practice of medicine some structure.

In addition, hospitals have bylaws, which are enforced by physicians elected to uphold the rules for governing themselves within their institutions. IMGs collaborate with U.S.-educated colleagues in developing these bylaws.

On behalf of IMGs this July – the month America celebrates its independence – I thank the physicians raised and trained in America for their acceptance and support. Their willingness to allow us to participate in the difficult debate about the future of this great profession confirms the strength of the American dream.

Lead on Dr. Swaroop.

Dr. Smith’s article can be found at www.socalphys.com/article/articles/494/1/

 

Physician Stress
Dr. Stephen Jackson writes on “Physicians, Heal Thine Selves: Wellness Becomes a National Agenda,” in the Summer 2008 CSA Bulletin, of the California Society of Anesthesiologists)

…Consider that our own lives can be characterized as a chain of reactions or responses to a continuum of destabilizing demands. These stresses can originate extrinsically from our family, friends, colleagues, patients, work and other environments; or intrinsically from self-derived pressures that we consciously or unconsciously place on ourselves. A situation becomes stressful when we feel unable to cope with demands to which we feel compelled to respond.

Stresses emerging from the demands of our professional practices, if not dissipated by effective coping strategies, or counterbalanced by equanimity derived from how we live and manage our personal lives, have the propensity to make us more vulnerable to maladaptive behaviors, including, in the extreme, emotional disequilibria, burnout, chemical dependence, and even suicide. Historically, CSA and ASA have focused on drug and alcohol abuse and their more morbid sequelae. Although affecting only a small number of our colleagues, there certainly is justification for attention to these afflicted individuals, a significant proportion of whom are less than a decade out of medical school. Indeed, it has been estimated that our specialty loses over 3,500 life years from the combined mortality attributable to drug abuse and suicide! From a manpower perspective, this represents a huge loss of practice years for our specialty, but from a purely human point of view, this is a tragedy of staggering proportions, eroding the very minds and hearts of family and friends…

How do the ASA and CSA hope to accomplish their goals of achieving a satisfactory level of wellness for all of its members? A leading approach will be to develop a broad-based educational network to promote wellness and health enhancement (the basic elements of the Wellness Initiative)…

Read the entire article on the CSA website, www.csahq.org/pdf/bulletin/ednotes_57_3.pdf.

 

Impatient Patients
Dr. Allan Bernstein reviews the book, When Doctors Become Patients, by Dr. Robert Klitzman (344 pages, Oxford University Press, $35) in the Summer 2008 issue of Sonoma Medicine.

Do doctors make the worst patients? In his book, When Doctors Become Patients, Dr. Robert Klitzman begins by describing the depression he experienced after a traumatic death in his family. He was totally unable to recognize the classic symptoms. After all, he was a psychiatrist; he couldn’t have a mental illness.

Klitzman goes on to interview, in depth, 70 physicians and medical students who had illnesses that ranged from HIV/AIDS and metastatic cancer to myocardial infarctions, chronic infections, leukemias and lymphomas. His subjects describe the transition from their vision of themselves as God-like beings to the uncomfortable and often degrading experiences they endured in hospitals and emergency rooms, even in their own institutions.

Two categories of illness appear early on: “medical student’s disease” and “post-residency disease.” The former is a syndrome of trainees, who fear they have the symptoms of the conditions they are studying. The latter is a denial of illness, no matter how glaring the signs and symptoms. Post-resident physicians seem to practice selective denial in regard to their own health. Their workaholic personalities and sense of invulnerability often preclude objective assessments of their own health. Magical thinking is rampant: “If I don’t have a biopsy, I don’t have cancer.”

After Klitzman’s subjects acknowledged their illness, a common dilemma was whether to continue being the doctor, in control at all times, or to become a patient and cede that control. Many of the subjects ordered their own tests and imaging studies and prescribed their own medications. Others elected to let their physician run the show.

For those who ceded control, certain topics were difficult to discuss with their physicians. The subjects could admit to poor eating habits, failure to exercise appropriately and inconsistent medication compliance – but depression, substance abuse and unsafe sex seemed off limits. Many subjects would prescribe their own antidepressants and fill them at pharmacies where they were unknown. They would not submit these bills to their medical insurance for fear of others finding out. They knew that confidentiality, even in this age of HIPAA, is rarely observed. After all, if you’re in the hospital, your chart is at the nurses’ station, and your colleagues are making rounds and writing notes at the same site…

To read the entire book review, go to www.scma.org/magazine/scp/sm08/bernstein.html.