Perspectives January 1995

Congratulations to Mercy Healthcare Sacramento for embarking on Process Redesign. The first of an ambitious series of customer/ vision conferences lasting 24 hours each were held in November. The conference attendees of physicians, nurses, administrators, managers, health care workers, and patients discussed the organization’s history, the current situation, and the kind of organization that’s desirable to create in the future; the external customer/provider relationships, how they work, and what’s required for the future. Three hour “walk throughs” of the distillation of this information were held in December and January. The next three day sequence, the internal customer/technical conferences will occur this month. Sister Bridget is establishing her leadership and innovation in addressing the current healthcare dilemma.

Gary Stix in Scientific American (7/94:20) reviews managed care, circa 1300. He notes that Bernat de Berriac, M.D. received five to 20 sous a year from each of several dozen men of modest means from a village in Catolonia. For this paltry sum, the youthful doctor agreed to treat these men and their wives, children and servants “for every illness that requires the art of medicine.” In Medicine Before the Plague, McVaugh shows that a major preoccupation of this era, not to mention the 20th century, was who was covered and how a physician would get paid. Quality of care was an issue… Practitioners entered into a contractual arrangement–in effect, a form of managed care… Count-kings paid a lifetime retainer to… physicians… Society worried about coverage for its less fortunate. Combing through old histories, contracts and wills, McVaugh found that physicians agreed to become service providers in what were inexpensive, prepaid health insurance plans. Many towns set up a post-Dark Ages version of a public health service by simply putting a doctor on the payroll… Edward H. Davis replies (10/94:10): Managed care involves a feature not entertained by our medieval forebears: the control of medical care by an entity other than the patient or the patient’s physician. Such control serves to restrict diagnostic and treatment options, based on the financial interests of the manager, which is usually a commercial insurance company. Permit me to doubt that our medieval predecessors would have tolerated such “management.”

Oregon passed the physician assisted suicide initiative which then was discussed on American Medical Television rounds chaired by George Lindberg, MD, Editor, JAMA, with Roger Bone, MD, Pulmonologist, Dennis O’Leary, MD, Internist, Pres of the Joint Commission, Leon Kass, MD, JD, Jack Bierig, JD. The entire spectrum of total agreement with the initiative to opposition in crossing a line physicians should never cross was discussed. The Health Forum in Sacramento has noted that the euthanasia issue will pale the whole abortion debate… I’m sure most physicians prescribe medications which allow patients to end their suffering by simply taking a one to three months’s supply on retiring. Most cardiopulmonary meds (glycosides, antihypertensives, theophyllines, etc) will do the job before arising and prevent arising… One of our member physician told me when interning at LA County, a young lady came in who was committing suicide regularly. He explained to her that to be successful, she should take a full bottle of both her tranquillizers and her sleeping pills and she should NOT make that phone call to a friend after taking the pills. He stated she never returned.

Forbes (11/21/94): “Expatriation has been called the ultimate estate plan.” Are taxes that oppressive that many of our greatest entrepreneurs are giving up their American citizenship to avoid taxes? And I thought American citizenship was as important to us as Roman citizenship was to Paul of Tarsus.

Vice President Al Gore translated the US motto, E pluribus unum, as “out of one, many,” rather that its proper translation, “out of many, one.” If his predecessor had made the same reversal of meaning, we probably could have read it in the media rather than in a medical editorial in Kansas Medicine.

Dr. Marion Jenkins, anesthesiologist, who declared President Kennedy dead on November 22, 1963 at Parkland Memorial Hospital ER died on November 21, 1994, at the age of 77. He also treated Lee Harvey Oswald and Jack Ruby… One physician treated the assassinated, the assassin, and the assassin of the assassin.

The budget of the medical staff distributed at the last American River Staff meeting included the following staff salaries (half paid by the hospital) Chief of Staff: $50,000; Chief Elect: $25,000; Chair of Surgery: $15,000; Secy/Treas, Chairs of Med, ObGyn, Peds, FP, QAC, URC: each $10,000… One comment overhead at the meeting, “No wonder our leaders are hospital whores…” Perhaps we ought to move forward to the time when we again donate a year or three for medical staff services to maintain our integrity. We can not have it both ways.

Alan M. Garber, M.D., Ph.D., internist and health care economist at the VA Medical Center, Palo Alto, and Stanford, states that cutting waste is not going to solve all the issues of health care reform. There has been a dramatic growth in the number of medical procedures being performed. A detailed breakdown of Medicare expenditures from 1985 to 1989 show payments for office visits grew by only 11%, but for selected procedures, e.g. CABG, by 17%; PTCA, by 79%; and MRI, by 407%. He feels that cutting waste will come down to cutting procedures. The feds won’t say, “We won’t cover bone marrow transplants because they cost too much.” They will say, “We won’t cover it because it hasn’t been proven effective.”

Harold Fine, a former federal auditor with the Dept of Energy’s inspector general, alleged that UC Berkeley and its two nuclear weapons labs fraudulently diverted $232 million from their intended projects during the late 1980’s and 1990’s. The Feds dismissed their own audits and refused to press charges. Fine then sued the university on behalf of the nation’s taxpayers in 1991. The Feds then joined UC in fighting Fine saying an employee is not eligible to sue. Fine has now obtained court permission to sue on behalf of us, the taxpayers.

We recently had GE come out to service our dishwasher. It took about 15 minutes of the service man’s time and about $25 worth of parts. The bill was $188 including travel and one hour minimum… An elderly lady reported that she called a service man to change a light bulb in her cathedral entry way. It took him only a few minutes. But the $45 travel plus $45 minimum charge did add up to $90 to change a light bulb… Do all service people make more than physicians for making house calls? If you have other examples, please telephone or fax them to my private office number, 488-5880, day or night.

The British Columbia Medical Assn reports an unusually large return on their membership survey with a margin of error of 1.4%. A majority of 62% believe their current system is headed for trouble and 67% take issue with the government’s scheme for change–regionalization. An overwhelming 88% favor reducing universal coverage to a defined, limited set of essential “core” services with the private sector filling in the rest… Unfortunately, those are the same services that insurance can best cover. Elective hospitalizations and surgery always lead to abuse and can’t be insured. That’s like expecting our car insurance to pay for a paint job because we’re tired of the present look.


Law, Lawyers & Politics February 1995

Congratulations to our own UCD School of Law with 94% of its graduates passing the state bar the first time, the highest in the state, out performing both Boalt Hall (UCB) and Hastings (UCSF).

Chicago, known for its organized crime and its politicians becoming felons, may be reversing the process with five felons running for City Council. They took their cue from Marion Barry who was re-elected as Mayor of Washington, D.C. after his narcotic conviction and jail term. Although the felons stated that armed robbery, burglary, murder for hire done in youth shouldn’t hurt them when they grow up, many Chicagoans and the Feds are concerned.

After hearing that medicare and medicaid are so over funded that we could sneak our $trillion health care system into the federal budget with the hundreds of billions we’d save, we are now hearing that medicare is so under funded that the medicare eligibility age may have to be advanced along with the social security eligibility to perhaps age 70. What a difference a day makes, especially if elections are held that day.

Univ Press Synd: In New York City recently, Bartolome Moya, 37, charged with kidnaping, drug dealing, and six murders, skipped town after being released on bail. In 1993, Moya was jailed pending trial on the same charges but was in such poor health from heart disease that a judge thought his death was imminent and dismissed the charges so Moya could go home to die. He later obtained a Medicare financed heart transplant. Prosecutors learned of the transplant, re-indicted Moya and jailed him. Then a judge released him on bail on the condition that Moya wear a beeper. Moya has not been heard from since.

Joycelyn Elders, MD, made some statements that offended a lot of people. The Lancet editorialized that Elders’ dismissal was an “example of the triumph of politics and prejudice over common sense.” Knowing that physicians are frequently quoted out of context, which changes the meaning of what we said, can we give our colleague credit for trying to state that autoeroticism should be placed in the courses variously labeled as sex education? Then we can proceed with the more relevant discussion of whether what the Surgeon General of the US Public Health Service is promoting is a matter of Public Health.

Edmund Faltermayer reporting in Fortune under the title, “Will the cost cutting in health care kill you?” quotes Harvard’s Dr. Lucian Leape, a contributor to a new book, Human Error in Medicine, who estimates that iatrogenic hospital deaths…may total 100,000 a year nationwide. That’s more than twice the number who die in automobile accidents… Should we now warn our patients that hospitalizing them may be twice as hazardous as driving a car before an attorney wins a case against us because his client was not sufficiently informed of the hazards of hospitalization?

Attorney General Dan Lungren stated that Californians donated $192 million through 161 registered professional fund raisers but only 33% of the money actually went to charities. The rest went to solicitation expenses and profits. He also said that 516 commercial fund-raising campaigns turned less than half of their donations over to charities. He noted that some medical charities only got 10% of the donations. He suggests that we ask a solicitor if he or she is being paid to solicit, the name of the fund-raiser, proof of registration, and what percentage of your donation actually will go to the charity.

Psychiatrist Judith Cohen lost a $272,000 malpractice suit for failing to investigate allegations of sexual abuse by her 19 year old patient Nicole Althaus. When did investigation of our patient’s medical history become the practice of medicine? Let’s see, physicians are playing attorney, judge, jury, and now criminal investigator? Will somebody get us organized? Or are we “gazelles grazing on the plain unconcerned about the intense struggles going on about us?”

AMT, American Medical Television, which has been giving us “Second Opinion” and “House Call” every Saturday went off the air with a repeat performance of one of their most noteworthy out-of-control session on December 31. The JAMA Editor, George Lundberg, MD, had been having increasing problems keeping his panel under control. Frequently there were three of panelists composed of physicians and lawyers speaking at the same time and he was left with calling for a commercial break. The replacements, so far, appear to be less interesting.

Another 1359 laws were passed by the Legislature again last year, about the same as the previous year. Of those, 294 took effect last year and 1065 took effect January 1, 1995. Of note, is that fund raisers must give at least 50% to the charity; lawyers now have a truth in advertising law; sexual harassment has been extended from the work place to anyone with whom anybody has a professional relationship; women can select an OB/GYN as their primary care physician (Why was that ever restricted?); and a law that prohibits job discrimination against women who wear pants (Why was a law required to prevent discrimination?)

Steven A. Schroeder, MD, President of the Robert Wood Johnson Foundation, and a frequent participant on AMT, was in Sacramento recently for the Health Forum. He deplored the fragmentation of American medicine. He found it hard to understand why it’s so hard to write health care legislation. He defined “Demosclerosis” as the inability of post war democrats to adapt, to eliminate programs that no longer serve a useful purpose. Only two countries have been able to do that–Japan & Germany. Americans are so confused about government medicine that he hears statements such as “Get the government out of Medicare.” He concludes that market forces rather than government will serve as the catalyst for health care reform, and asks “What happens to medical care when the doctor/patient relationship is reduced to a business relationship?” He didn’t seem to have an answer. Perhaps physicians (organized medicine) should be the catalyst and focus on the doctor/patient relationship. The window of opportunity seems to be closing.


The Big Squeeze March 1995

Congratulations to Sister Bridget McCarthy for being selected by the Sacramento Metropolitan Chamber of Commerce as the businesswoman of the year. Sister McCarthy, former CEO of Mercy General Hospital, is president and CEO of Mercy Healthcare Sacramento and was lauded for dedication to community health care through memberships on a variety of boards and committees. She chairs the California Association of Catholic Hospitals’ Board of Directors. She currently is spearheading Process Redesign, an ambitious reform effort of MHS. The second series of three day 24 hour sessions was held in January and February. The segments of the team present included administrators, managed care, doctors’ offices, MedClinic, Psych West, nurses, physical therapist, dietitians, home care, hospice, other hospital departments, and patients. The discussion covered interfacing of our offices with all these different departments, variances in care, priorities, what added value, what added no value, what was repetitious, the norms, beliefs, and assumptions of our current health care design and what they should be for a new design. One of the goals of the series of conferences is to have all segments of the health care establishment participate in Mercy’s effort to squeeze $30-35 million out of their operating expenses by 1998. It is indeed a noble effort and we hope that eventually doctors will also take ownership in the reduction of health care costs.

Squeezed out of this conference were the psychiatrists who were represented by the Business Developer from Psych West who said it was too expensive to bring them. He said they had to stay in the office to continue earning the money for the group.

Patrick Hays, former CEO of Sutter who resigned, was not “squeezed” out. He has obtained the position as CEO and Prez of the National Blue Cross and Blue Shield Association. We knew that whenever he resurfaced, he would have an even more prestigious position. Congratulations and best wishes, Pat.

Mary Gooderham of the Chronicle Foreign service reports on cost-cutting in Canada. The total health care tab in Canada was $33 billion in US dollars last year; in the 1980s, their federal government picked up 40-50 percent of it, but that figure has now been squeezed down to about 20 percent… Do we really comprehend that with gov’t medicine, the federal gov’t picked up only 20 percent of the health care costs? We should be spending our efforts making sure our seniors have adequate health care (Medicare) and our poor people continue to have access to adequate health care (Medicaid/Medi-Cal in California)… It seems like all government programs always outstrip the ability of taxes to fund them. Some program or segment of society gets the “squeeze.” Do we want US healthcare to perennially be part of a national squeeze?

The IRS is planning to get to know you better according to Frank Greve of Knight-Ridder Newspapers. The IRS is planning to vastly expand the secret computer database of information it keeps on virtually all Americans. Additions may include real estate, DMV, and child support records. Agency officials concede some of the data collected will be inaccurate. But taxpayers won’t be allowed to review or correct it. This would in fact wipe out the line between the private sector and government. The IRS is in the process of creating dossiers on everybody in America as it watches our every action with computer surveillance to assist them in “squeezing” more tax dollars from us.

Recently, at one of the periodic Medicare conferences, physicians were told that the Medicare computer was so sophisticated it could reassign the CPT codes to reflect what we did for the patient more accurately than what we, in fact, thought we did and that these computers would review our records in the future. If they couldn’t be read, and no one in our office could decipher every word, sanctions would be taken against us. Sherry, the conference presenter, stated that they would be checking to see if we had all eight parts of the HPI recorded, at least 2-9 organ systems reviewed for one code and all 10 organ systems reviewed for another code, etc. Dr. Molyneaux warned the doctors that “Big Brother is Watching you.” Medicare can, at any time, begin implementing reduction of the codes, paying less, and possibly reducing codes for prior years on physicians. Medicare may then seek to recover what it determines to be prior overpayment, which may go over $100,000 on some doctors. It appears that Medicare could “squeeze” both current and prior reimbursement without due process as guaranteed by our constitution to non-physicians.

We can envision the scenario now. A patient with a 15-minute appointed requires 45 minutes to stabilize and prevent hospitalization. The $40 office call is increased to the next level of $60 to more accurately reflect the $100 worth of service to save a $10,000 hospitalization. The extra time now means that three extra patients are waiting, which then causes the documentation to be squeezed to a few salient notes… Two years later, Medicare comes by to review the record and says it is being generous to allow even a $40 call and demand a refund from the $60 extended visit. You will be forced to refund $20, which, in effect, reduces the reimbursement to $20. The $100 worth of medical services saving Medicare $100,000 was squeezed down to $20… And there are still physicians who say if it wasn’t written down it wasn’t done. Whose team are we on?

In 1987, the USSR threw out 70 years of totalitarian rule in which the KGB or “Big Brother” was watching everything they possibly could. And now we have IRS and Medicare computers that warn and threaten us with “Big Brother is Watching You,” as ominously as and more thoroughly than the KGB ever dreamed. Fellow physicians of Sacramento, of California, of America, we must unite for our common good or the welfare of our patients will be squeezed.

UCSF plans to eliminate 550 jobs over the next 18 months in response to the “squeeze” by health insurers demanding reduced costs. They have delayed all construction. Similar restructuring will occur at all 5 California medical schools according to Hospital Director Kerr. Roseanne Demoro, president of CNA representing 1600 nurses at UCSF said, “This is one of the wealthiest hospitals in Northern California. But, in the name of managed care, they are lowering the standard of care.” Kerr also is considering consolidation, or outright elimination, of unprofitable clinical programs. Will our students then only learn those clinical programs that are profitable? Don’t we have a higher mission in medicine?


Practice Pain April 1995

Fred Thompson, actor-turned-senator from Tennessee, was overheard lamenting, “I’ve still got a lot to learn about Washington. Yesterday, I accidentally spent some of my own money.” (TV Guide)

Klas of the Cox News Service reports concerning Florida’s suit against cigarette manufacturers. This is a landmark case that will seek at least $1.43 billion from several tobacco companies in order to recover the state’s cost of treating Medicaid patients with diseases caused by smoking. Florida will use 10 in-state law firms, one from Mississippi, and another from South Carolina. The law firms will keep 25% of what they win. With triple damages for fraud, Florida hopes to have a $4.5 billion award… Now perhaps there will be support for private health insurance premiums that have at least a 100% surcharge for smokers in order to partially pay for smokers’ increased health care costs. This may also avoid an increase in premium for those patients who, through no fault of their own, have diabetes, asthma, hypertension, cancer, etc.

Seen at William Glen was a specialty Birthday card by cartoonist Dr. Brian Moench, former instructor at Harvard Medical School. It depicted a surgeon in OR Greens with a black bag at his feet and a sign in his hand, “Will operate for food.”

At the annual respiration dinner of the Western Clinical Societies meeting at Clint Eastwood’s Mission Ranch in Carmel, we were seated next to a physician from Salt Lake City who had trained and practiced in England. She said that most physicians in England make about as much as nurses in this country. When asked to elaborate, she stated that fellows make about $25,000, senior consultants up to $45,000, and bureaucratic doctors up to $60,000. When asked what administrators make in England, she stated about $75-90,000. Looks like we’re headed to this same reversal of presumed importance. Administrator, boss, employer dominating the physician, underling, employee. The high point of our practice may soon be the Employee of the Year plaque.

A patient walks in and asks, “Can I see the Doctor?” The receptionist replies, “Do you have health insurance?” The patient asks, “Does he have malpractice insurance?” The receptionist replies, “I believe the doctor is busy.” (With thanks to the Parker strip)

The AMA, acknowledging that managed care is the driving force in the health-care system, announced a major program to help doctors finance their own health plans in order to battle for patients. The AMA is contending that doctors should try to beat the competition at its own game. “Physicians make decisions about how best to manage the patient,” said Denise Andresen, director of what the AMA calls its private sector advocacy and support team. “Why shouldn’t we take control of our futures?”… But no one seems to be coming up with a plan as to how doctors, who have a 400-1600 percent variation in how to treat the same disease, are going to reduce costs. Does this wide variation convince the planners that we really know how best to manage our patients? The doctors on the low end of the bell curve are more willing to eliminate a $40 test than the doctors at the high end of the spectrum who feel they need one more $1400 MRI. About as “Dead on Arrival” as anything can get.

Bumper sticker common in the eighties: “I’d Rather Be Fishing.” Bumper sticker of the mid nineties: “I’d Rather Be Working.”

American Medical Television still seems to be in limbo. The Saturday morning slots have in large part been bought up by health promotional programs. A diet guru was seen expounding the benefits of the HealthRider, an exercise instrument. An 86 year old lady stated that 15 minutes per day on the HealthRider has gotten her out of bed and back to walking and being active. Cost: $499 plus $49 S & H–slightly less than the Medicare hospital deductible…If this gets a lot of people out of their hospital beds, these new programs may be more effective in improving the public health than AMT ever thought. And reduce health care costs in the process.

John H. Fund, WSJ editorial page writer, notes that Washington can learn from the Canadian province of Alberta. Since Premier Ralph Klein took office during a fiscal crisis in December 1992, his reform blitzkrieg has touched–and cut–every corner of government. He wiped out the budget deficit he inherited, cut spending by 20%, reduced government jobs by 25%, abolished parliamentary pensions, refused to raise taxes, reduced unemployment from 9% to 7.2% and welfare caseloads have dropped almost in half. In fact, only 2% of Alberta’s population is now on welfare compared to 15% of Ontario’s. Two-income families earning $71,000 pay 31% less taxes than a similar couple in Toronto. Private medical clinics have been legalized. (Does this confirm that the government realizes that they are so inefficient that they can’t survive without making private practice illegal?). What astonishes Canadians is that Premier Klein’s downsizing agenda is popular, with a 68% approval rating. “Many people here think he’s just below God himself,” says John Friedt in Calgary. In issuing his austerity budget, Klein told voters, “You can’t leap a canyon in two jumps.”

Overheard in the doctors staff room Tuesday, Jan 31 after hundreds of registered letters of termination from a medical group were received the prior day by specialists: Last night was my “Krystal Nacht.” Perhaps offensive and insensitive to some, but heartfelt Practice Pain nonetheless.


Medicine Around the World June 1995

An overseas potentate was troubled by severe peripheral vascular disease (PVD). His local doctors recommended amputation. The desperate prince flew to London to visit Harley Street’s finest specialist. “Doctor, doctor, they say they’ll have to cut my leg off.” The specialist roared with laughter. “That’s ridiculous, my dear chap. Leave it alone for another week and it will drop off of its own accord.” (after Bagehot)

Italy’s doctors have banned “designer babies.” After injecting women with the frozen sperm of dead husbands and sperm donors, fertility specialists began engineering “designer babies” from sperm donors screened for their looks, intelligence or social status. The new code of ethics which went into effect recently prohibits doctors from engaging in biogenetic practices.

Foundation Health, a California-based health insurer, unveiled a new private-health insurance scheme in Britain called Mednet, which aims to provide health care through a network of hundreds of moonlighting National Health Service doctors. Mednet’s long-term goal, says Jackie Wiggins, Foundation Health’s British-based chief executive, is to provide services directly to the NHS itself. She believes Foundation could provide surgery and other services when NHS hospitals temporarily find themselves short of capacity, enabling Mednet to meet unexpected surges in demand or to cut waiting lists.

Hiroshi Nakajima, MD, PhD, of the World Health Organization, reminds us that tuberculosis infects 8 million new victims a year, kills 3 million people a year, infects one-third of the world’s population, and probably can no longer be controlled in the industrialized countries unless it is sharply reduced as a health threat in the developing countries of Asia, Africa, and Latin America.

The United Nations was chartered on October 24, 1945 in San Francisco with 51 original members to maintain iternational peace and security and to encourage international cooperation in solving international economic, social, cultural, and humanitarian problems. This October 125 of the current 185 nation members will come to SF to celebrate the 50th anniversary. One success of the UN with the least amount of funds has been the UN International Children’s Emergency Fund (UNICEF) chartered in December 1946. It had significant impact on the prevention and treatment of certain diseases and facilitating surplus food shipments for starving children throughout the third world. Because of its efforts, 80% of the world’s children are now vaccinated against six basic diseases. Of equal importance, now 75% of the world’s children are able to start school.

The UN charter has been on display behind bullet proof glass at the de Young Museum in San Francisco. It was never exposed to sunlight in transit from New York. There are 186 flags lining the two gallery UN exhibit which continues through the month of June. In addition to the original arm chair from the de Young, there are items from the Truman Library, the New York headquarters, the White House, and other collectors who loaned items, including The San Francisco Chronicle, the morning after the signing, which actually occurred on June 26, 1945.

The FDA my soon concede that billions of Chinese have been right for 5,000 years: Acupuncture works. There are 9,000 practicing acupuncturists in this country, fully a third are MD’s. Last November, Xiao-Ming Tian, MD, and other leading acupuncturists gathered together their best evidence and sent the 500-page document off to the Food & Drug Adm with a formal request that their needles be approved as safe and effective medical devices. A decision may come as early as this month. If approved, this will be the first time the agency had given its stamp of approval to a medical device rooted in a theory totally outside that of mainstream medicine. Bruce Pomeranz, a physiologist at the U of Toronto, found that the needles cause the release of endorphins which then reduce pain… Now we know why when we stick ourselves with a needle, our headache or backache disappears. And I always just thought our Betz cells were being diverted.


Breathless in Seattle July/August 1995

Cough is the third most common symptom and the most common pulmonary symptom that brings a patient in to see a physician. Breathlessness is not far down the list. Tom Hanks put Seattle in the theaters with “Sleepless in …” All the Seattle city tours take any willing visitor by the “Athenian,” a restaurant in Pike’s Farmers Market which Hanks frequented while he was doing “… in Seattle.”

“Breathless in Seattle” was the actual topic of one of the scientific sequences of the recent meeting of the American Thoracic Society. When the ATS scheduled its 1995 annual meeting in Seattle 6 years ago, the average attendance was less than half of the current 13,000 which arrived this year. Hotels were filled into the next towns. Those attending as well as the presenters included Pulmonary internists, pediatricians, surgeons, nurses, researchers and techs. This diversity was hailed as a positive influence on our discussions as long as we understood each other’s perspective.

One presenter tried to illustrate this perspective: An internist, surgeon, and emergency physician are waiting in a duck blind during the duck hunting season at which time pheasant, geese, quail, and grouse cannot be hunted. The internist jumps up when the first bird flies over, takes careful aim, and follows its flight. He thinks out loud, “This is probably a duck; rule out goose, rule out quail, rule out grouse, rule out pheasant,” as the bird left his view before he reached a diagnostic decision. The surgeon jumps as the next bird appears, shoots, and as it falls into the lake, states without equivocation, “That is a duck.” Finally the ER Doc jumps up as the next one appears, takes aim, shoots, and the bird drops into the water. He turns to the internists and asks, “What do you think that was?”… A physiologist later was heard to reply, “What difference does the type of bird make? Why would anyone want to shoot a feathered creature?

We went to Seattle the day before the conference having made dining reservations a month earlier for the Emerald Room in the Space Needle 500 feet in the air. It rotates about 6 feet a minute, one circumference an hour. Hence, we saw Seattle, its skyline, docks, harbor, Puget Sound with some of its islands, and the Olympic Mountains just before sundown and during sunset. All of the lights came on during our two revolutions. A circular map helped identify all the landmarks. I had my first of numerous Washington Salmon and Washington Chardonnays. (I saw of lot of people choosing midwestern beef and California wines. Why don’t they just stay home?) We reached the Needle via the Monorail from the building adjacent to our hotel. The Park Mayflower is a nongeneric hotel, with a soul. Its watering hole, “Olivers,” has a dozen different types of martinis, and wins the annual martini contest. Ever tried Stoli & Iron Horse? Its restaurant, “The Clipper,” is also an award winner with superb salmon.

This month marks the beginning of our third year with this HHK column. In one of our first ones, we reported on the medical uses of the hair dryer. The otologists says blow-dry your ear canals. The proctologist says to blow-dry your hemorrhoids. The gynecologist says to blow dry under your breasts. The urologist has now expanded the list to beyond “blow-dry behind the prepuce.” The testosterone transdermal delivery system (Testoderm patches) made by Alza Pharmaceutical in Palo Alto, has to be applied to the scrotum. Testoderm is absorbed 10 times more readily from the scrotal skin than from other skin sites. (I wonder how that works out teleologically?) Both the package insert and the video demonstration (thanks to Bud Kahl of St. George Pharmacy) point out that after dry shaving the scrotum, one can make sure the surfaces are dry by using a blow-dryer. It also suggests wearing briefs rather than shorts to keep the patch secure… Of course, otherwise it might show up at the ankles… Remember when our grandmothers were embarrassed by what fell around their ankles when the elastic in their bloomers snapped… But maybe men can now grow old, blissful and breathless?

Hope you’re having a summer of travel, fun, sports, leisure, or whatever strikes your fancy or gives you a change of pace.


Cross-Purposes September 1995

A male psychology professor was demonstrating that women and men think and communicate differently. He said, if you ask a man, “That’s a good looking suit. Where did you get it?” you’ll get an answer something like “At Patrick James.” If you ask a woman, she’ll answer, “Do you like it?” If you ask the same question a second time, you might get, “I like it too.” A woman once explained to me the thinking the professor missed. The responses could mean any or all of the following: “Why should I tell you where I bought it?” “The type of store is rather personal.” “It may give you a clue as to price.” “There may be a variety of other reasons for an evasive response.” “Women just aren’t as simple as men.”

The Friday noon conferences at MSJ are non-medical for the summer. One of the insurance carriers was featured at one of them. He sat behind the podium so only half of us could see him at any one time–depending on which side he peered out.

Evidence Code 1157–which basically states that doctors can say terrible and reasonably unsubstantiated things about each other’s care without retribution under the guise of Peer Review–may soon become history. A California Court of Appeals has said that “Code 1157” does not protect against all discovery. Federal judges never did honor “Code ll57.” When Peer Review proceedings were discovered, the court always found the legal record flawed. It didn’t follow legal logic. That was because attorneys were not allowed to be in the hearing with their client physicians to protect their rights. When physicians practice law without a license, the arguments almost never hold judicial muster. That shouldn’t be surprising. When lawyers practice medicine without a license, the treatment is also flawed. Is it time that we put our physician/ attorney hostilities aside and have attorneys fully represent us in all legal or pseudo-legal or quasi-legal proceedings? Maybe physicians should quit working at cross-purposes.

Overheard in the staff room. If we close McClellan AFB but keep the employees on the payroll, how does that decrease the federal budget or reduce our taxes?

The insurance carriers are making their rounds of private offices to see if we are complying with putting immunizations, problem lists, treatment plans, drug lists, etc. on special sheets that their reviewers can easily find. The fact that you may do it in a manner that actually facilitates your care of patients is irrelevant… Compliance without reason (except to control people) occurred in the Bolshevik revolution of October 1917. But they had a dictator at the helm. His successor was replaced 70 years later. Why are we, as physicians, trained in the scientific method of inquiry, being subjected to a forced compliance in a free society?

Lufthansa has been running a two page magazine ad which carried the caption, “It’s nice to know our mechanics train longer than some doctors.” I called the 1-800 number and three days later received a call from Frankfurt that their mechanics have up to 7 years of on the job training. I reminded them that OJT doesn’t come close. I haven’t seen the ad since.

The Wall Street Journal Sports Section had its first swimsuit issue. Not the type that stimulates your hormones, but the type that responds to the secretion of catecholamines. With swim records being won in fractions of a second, they were presenting the worlds fastest swim suits, now a $600 million market.

The price of adding to internists’ liability has just decreased. Hospital reimbursement of ECG interpretation is headed downward again. For a projected five dollars (or nine) to read an ECG, you can have your name added to the liability of a hospitalized patient. If there is a lawsuit and the patient is able to convince the jury that you are in some minuscule way culpable, you may have your name added to the prestigious national data bank registry. So be sure to read those ECG’s in the “first doctor available” box.

Are we like the man who was driving along the country side and was totally lost, but didn’t mind, since he was making such good time?


Biases, Priorities or Cultural Differences October 1995

Lynn Payer, author of Medicine & Culture: Varieties of Treatment in the US, England, W. Germany, and France, observes that these four countries have similar life expectancy rates, yet medical treatment differs greatly from country to country. She notes that although congestive heart failure is diagnosed and treated much more frequently in Germany than in the US, American physicians favor aggressive treatment whereas their counterparts in other countries often prescribe gentler approaches. She attributes the reason to the fact that medical diagnoses and decisions are greatly influenced by national character, culture, and philosophy. Susan Tannen, Editor of the new “Journal of Care Management,” in her review in the AMWA Journal quotes Payer, “What I think I have discovered is that the range of acceptable treatments for most diseases is much wider than that admitted in any one country, and a wider view of such acceptable treatments would better serve both doctors and patients… I also hope I have shown how our medical biases cause us to accept certain treatments and reject others, or to accept some too quickly and others not quickly enough. A better understanding of these biases should help to illuminate our past mistakes and perhaps avoid future ones.” Quoted by Susan Tannen in AMWA Journal

Humana sold their hospitals to Hospital Corporation of America in order to concentrate on financing Healthcare delivery. They had a contract to provide managed care for Medicaid patients, otherwise known as Medi-Pass in Florida. The State of Florida mandated that as of July 1, 1995 each Medicaid Managed Care patient had to have a complete history, physical exam, immunizations, and appropriate lab work within three months of signing up. Failure to do so made the carrier subject to a $1000 fine and a 1% assessment of profits for each occurrence. A Humana administrator in Florida stated that they withdrew from Medicaid Managed Care on July 1, 1995. They couldn’t figure out how to force compliance from either doctor or patient.

Panic: Abdominal tenesmus while stalled in a traffic jam and realizing that you had a couple of bran muffins and two cups of coffee for breakfast.

Folsom Dam’s mangled spillway gate number three is being repaired and the other seven 50 x 42 foot steel gates are being “upgraded” before the fall winter rains. Inspectors have been urging the Bureau of Reclamation to make repairs since 1988, but other government departments had higher priority. The fact that nearly a million people live below the dam did not change the government’s priority.

The UN Fourth World Conference on Women in Beijing highlighted some of the atrocities occurring, not only to grown women but also to baby girls. Because of the governmental regulation of family planning, newborn girls are being abandoned at orphanages in such magnitude that many die. Instead of crying rooms, the orphanages have dying rooms.

The AMA & Lonnie Bristow MD have had major spreads in both Sacramento and San Francisco papers recently. Dr. Bristow also spoke to our Comstock Club outlining the AMA position. We have to be cautious, however, when we recommend a $20 payment to a medicaid patient who doesn’t make an ER visit for a calendar quarter. That’s not unlike when France paid pregnant girls for obtaining prenatal care. Many held out for more money and carried the ultimate hostage. Micro-managing is not implementing marketplace forces. In fact, the Medicaid patient who understands the market would hold out for at least half the cost of the average $600 ER visit. “Pay me $300 if you want me to save you $600.”

The Calif Nurses Assn hosted a health workers’ march in SF to protest hospital cost cuts as the American Hosp Assn was meeting at the Moscone Center. The union representing “aides, orderlies, & janitors” sided with the RN’s, lamenting the discharge of patients to nursing homes for post op care. “Our workers are horrified,” stated the union president Sal Rosselli. “They have no clue how to take care of these people… their health care is at risk.”

Nurses aide’s response to RN supervisor checking on why the ventilator was turned off: “It’s so much easier to do my job when that thing isn’t going on all the time. After all, I only turn it off 10 or 15 minutes twice a shift.”


Diogenes November 1995

Diogenes, a Greek ascetic and philosopher who lived in poverty, slept in public buildings, and begged for food, intended to show that happiness and independence were possible even under reduced circumstances. He is best known for his answer as to why he walked about with a lantern in broad daylight, “I’m searching for an honest man.”

Congratulations to the BEE for reprinting Froma Harrop’s editorial, “Health insurance is for the big stuff” from the Providence Journal. Her comparison of an HMO to a CMO (car maintenance organization) is enlightening, stating that annual checkups, mammograms or allergy shots are ordinary expenses and not risks that can be insured anymore than mufflers, tires and a lube job. She also points out that the overhead costs and profits of an HMO paying for such routine care exceeds their charge. This increases overall health care costs, she continues, which eventually will be deducted from payroll. She supports catastrophic insurance, similar to car or homeowners insurance, which she states will eliminate HMOs. An honest and brave woman.

When Cal Edison’s lobbyist John Hughes was asked “What are the Utilities up to?” He responded, “Protecting the ratepayers!” Herb Caen retorts, “That’s like thinking the group that calls itself the health care industry is truly interested in health care.” He then cites Sal Rosselli’s listing of the top 10 CEOs in the “health care industry” as making billions. “That’s your wealth care industry in action,” says Herb. (Where’s that lamp?)

Delaine Eastin, state Superintendent of Public Instruction, pronounced the math and reading reforms employed in California schools over the last 10 years a “mistake.” Debra Saunders, in her column in the SFChron, stated that any teacher who has a child for over 5 hours a day, nine months a year for three years can have no excuse for that child not being able to read and write. For Eastin to admit a 10 year error is to her credit. An honest woman… The connection that may be lost is that schools are a government bureaucracy and any mistakes are magnified to the entire population of students and future generations. Can you imagine if medicine were a government program and it took 10 years to recognize an error–the suffering and loss of human life that would occur? In private medicine, mistakes are localized and self correct. The corollary is that if schools were private, any mistakes would only apply to that individual school and it would also self correct. It is to our patients benefit that we keep medicine, a most confidential professional relationships, private. The problem is the catch net. Federal medicare, state medicaid and county hospitals are still important… Just as the catch net for education, the public schools.

Matching Funds: When our alma mater solicits funds and states there is an employer or benefactor that matches whatever we give, a $1000 contribution becomes $2000 in benefits… Hills Physicians Medical Group now numbers over 400 physicians in Sacramento area. A former member is asking us to donate to a fund to sue us. If we give $1000 to this cause, obvious Hills Physicians will have to spend $1000 to defend the action and deduct that $1000 from their payment to us–a matching cost rather than a benefit–and the entire $2000 goes to attorneys even before the judge awards damages. Although I wish that HPMG would reconsider several of the physicians and surgeons they eliminated who I thought were the most cost effective of any members, I would have to echo an attorney who said, “If you were honest with yourself, you’d realize that only the attorneys win in these cases.” (This paragraph eliminated by Bill Sandberg)

Double Rock, a SF housing project neighborhood, former home of OJ, gangs, and crack dealers, adjacent to the Bay in the shadow of Candlestick, had 6 murders last year at the corner of Griffith and Fitzgerald, known as the “Kill Zone.” None of the murders have been solved even though they were committed with numerous witnesses. No one talks for fear of retribution. How to keep an honest man quiet… On the morning of the OJ verdict, the SFChron reports that a teenage girl was running down the same street shouting that “We got away with murder this time.”

Of the numerous doctors we’ve asked to tell us how they like their “new professional living arrangements,” some have responded in confidence but declined to be quoted. Do physicians fear retribution if they’re honest? But who’s getting away with murder here? Come back, Diogenes, help us; or did the lamp go out?

Peter Ustinov, who played historical characters, dreamed that he was named pope and he chose the name “Not Guilty.” When asked “Don’t you mean Pope Innocence?” He replied, “I’m NOT Innocent; I’m Not Guilty.”

Hollywood CPA: After grossing more money than any other film, Forrest Gump is still losing money. Sounds like the same accounting that doctors have, the more patients you see, the more you lose. It’s getting hard to make an honest living.

David Samuels, a graduate student at Princeton, reports in the Wash Post which was carried by the BEE, “So you want to get into an elite university? Try lying.” He chronicles a new kind of student gaining entrance to our elite universities on the strength of life-stories with which they have duped admission committees. One admissions office even embellished a cowboy story with, “On a visit to campus in March, he slept indoors for the first time in 10 years,” before they sent that story to wealthy alumni. Later in the year he was found to be an exconvict from Utah. His attorney answered Princeton’s accusations of fraud: “He tried to follow the only path available to him to better himself.” He actually was a track star, and had impressive SAT scores, which were verified as his own… Samuels gives numerous examples of campus impostors who were actually quite ingenious. They just didn’t think they had a chance on proving their skills by being honest. So they invented new characters for themselves with illustrious pasts.

Carl Sandberg is alleged to have said, “Can we be honest for just 5 minutes, even though this is Chicago?”

The medicine department of the combined staff of the Carmichael Hospitals “elected” a new chairman–his third term in a decade or so. In a department of over a hundred members, there were 10 members present and he was “elected” by a vote of 6 with 4 abstentions. Can we be honest and just call this an appointment, just like any other political appointment by the spoils system, even though this is Sacramento?

Torrance psychiatrist Irwin Savodnik, MD, PhD, has thrown his stethoscope in the ring for a seat in the US House of Representatives for 1996. He has been disgruntled with politics, so he changed his party registration in 1993 and ran for the seat until he found out that he had to be a Republican for 12 months before running in the June 1994 primaries. He returned all his campaign contributions (an honest man) and is once again getting serious. He’s reading the constitution, history, economics, and politics at the rate of 100-200 pages a day. Dr Savodnik reassures physicians, “The amount of good the average physician does in one day is more than most politicians do in their entire careers.” Can we get that lantern lit again in DC?


Code of Conduct December 1995

Being a physician whistle blower in the past has been tantamount to professional suicide which lead to loss of practice, income, bankruptcy, with rejection and humiliation terminating a career–as well as society’s investment of $500,000 to produce that physician. Nonphysician whistle blowers, however, at UC Irvine have found an additional source of income. They are now being paid what is estimated at $500,000 not to talk about what they know of UCI’s Medical Center’s famed fertility clinic where human eggs reportedly were implanted into women without the biological mother’s consent. This “biomedical rape” is now an open investigation and lawsuits have been filed. One doctor remains out of the country. This hush money has been termed “lottos at taxpayer’s expense.”

Academic ethics takes a new twist. In Money magazine’s 1994 college guide, many schools submitted false SAT scores. The schools stated this was a marketing strategy required to obtain students. The New College of University of South Florida was ranked No.1 due to inflation of its SAT scores by lopping off the bottom scoring 6% of students, thereby lifting the average score 40 points. Northeastern University in Boston excludes both international students and remedial students thus eliminating 20% of their freshman class which boosts the school’s SAT average by 50 points. Monmouth University in West Long Branch, New Jersey, was unable to give any rationale for overstating its SAT scores by more than 200 points in their College Handbook.

The mammogram debate takes a new turn. After the arguments concerning whether women in their 40’s should have mammograms (American Cancer Society recommends every other year, the US Preventive Services task Force recommends none) or whether age 50 is soon enough (almost all agreeing that over age 50 they should be done yearly,) our own academia, UCD, came out recommending annual tests for ages 40-49 and fewer after age 50… Now that should confuse the malpractice lawyers, insurance carriers, and HMOs, almost as much as doctors and their patients.

Stanford Medicine reports that their surgical teams use a little knife music. The music in each OR is programmed to each surgeons specifications. The Rockin’ Jock for the Docs were, I believe, in the laparoscopy room, Dr Miller and the Cardiac Cowboys for the 3V CABG, and Mary Chapin Carpenter for the Hip Replacement suite. The music is also programmed for different stages, e.g. there’s “opening music,” “careful dissection music,” “under the microscope music,” and “closing music.” The anesthesiologists have their choice during induction and the nurses have their choice during arousal. Studies on the surgeons reveal that choosing their own musical selections is conducive to fewer involuntary responses, better speed and accuracy, their blood pressure and pulse rates are lower than with background music the experimenter selected. But what about the raison d’etre, the patient under the sterile field? Is it possible to sustain subliminal damage under anesthesia? The author wonders, should somebody do a study?

When the government talks about cutting expenses it’s never clear what the parameters of cutting are. Projected future growth is spoken of in the past tense as if it already is a fait accompli. Recently the Sacramento Media touted the horrors of cutting $270 billion from medicare. Even congressman Matsui speaking to the Sutter staff spoke about this cut but never indicated from what inflated projection. The SF Media spoke of this $270 billion as a savings and explained that the expected 9.9% annual growth of Medicare would be reduced to 7.1%. Although no numbers were given (there possibly aren’t any meaningful ones), if a decrease in growth of 2.8% is a quarter trillion savings, couldn’t we save another quarter trillion and still maintain a medicare growth of 4-5% per year? With the total health care costs in this country approaching a trillion dollars, and we are in a critical cost containment mode, isn’t a 5% annual growth more than adequate for any government program? With our grandchildren’s marginal tax rate projected to be over 80% just to pay entitlements and federal debt interest, wouldn’t a minimal ethical political behavior for our congress be to balance the books and then pay off its debt, just like the rest of us?

The Economist says that the decreases in Medicare and Medicaid do not go far enough. They should be decreased further to be in line with the rest of the economy.

Canada’s medicare is on the sick-list. The Economist also reports that Alberta and Ontario are pushing reforms to reduce their medicare coverage. The Canadian Feds have lumped medicare in with welfare and tertiary education and cut the entire new block…let the vultures fight it out… Is there any federal government that acts responsibly or ethically with taxpayer’s money?

A three year old girl’s response after watching her mother bathe the brand new baby brother just home from the hospital as the diaper was being secured. “We’re real lucky he doesn’t have one of them on his face, aren’t we mommy?” (M. Banks)

The university teaching profession seems to be having problems according to Loren Pope, author of Looking Beyond the Ivy League: Finding the college That’s Right for You (Penguin, 1995). It seems that Ivy League students, many of which are taught by graduate students and may never speak to a professor by graduation, have not learned “how to learn” in the changing work environment. They thought that their degrees insured career success. Surveys show that after 10 years, 75-90% of some graduating classes are working in jobs different from their training, jobs which may not even have existed at the time of their graduation. Some Harvard graduating classes have as high as 25% that have been fired, looking for work, are on welfare, or getting food stamps. A Canadian observer remarked, “The American practice of judging a college by the academic records of the students it accepts is like judging the quality of a hospital by the health of the patients it admits. What happens during the stay is what counts.”