Warnings of the New Millennium January/February 2000

Macon, GA; Jamestown, NY; San Francisco, Santa Clara, and Orange California

In a recent issue of the Medical Sentinel devoted to Futility of Care and Duty to Die, Miguel Faria, Jr, MD, cautions us with a history lesson from Germany. Although Hitler issued his first order for euthanasia in Germany on September 1, 1939, the road to active euthanasia had been paved before the Nazis came to power. Physicians in the Weimar Republic as early as 1931, had openly held discussions about the sterilization of undesirables and the euthanasia of the chronically mentally ill. Before the Final Solution of the Holocaust was officially implemented, 275,000 German citizens had been put to death. Doctor Leo Alexander, an eminent psychiatrist and Chief U.S. Medical Consultant at the Nuremberg War Crimes Trials, in his classic 1949 New England Journal of Medicine article, described how German physicians became willing accomplices with the Nazis in Ktenology, “the science of killing.”

An article in the New Oxford Review reported: “People in the United States’ hospice programs are not dying fast enough to satisfy federal government auditors. Washington is conducting special reviews of hospice records and call for repayment of money spent under Medicare for patients who lived beyond the expected six months after they had enrolled in hospice care. . . . A dozen hospice programs have been notified by the Inspector General’s office of the Dept of Health and Human Services that they improperly spent $83 million caring for people who lived more than 210 days after enrolled for hospice care.”

Lawrence R Huntoon, MD, PhD, neurologist from Jamestown, New York, reviews and projects the killing fields of the future. The HCFA and Medicare accused him of providing medical care to a dead person. The patient was unable to convince Social Security, with identification in hand, that she was alive. It took his congressmen to convince the bureaucrats to resurrect his patient into their system. He then quotes Dr Marcia Angell, executive editor of the New England Journal of Medicine in a May 1994 article, who says that the legal presumption in favor of life, as applied to patients diagnosed with permanent unconsciousness, should be removed. Dr Angell suggested the next logical step would be to change the definition of “death” to include a diagnosis of permanent unconsciousness. A November 1, 1997, article in the British medical journal Lancet, took the next “logical” step by urging that such “dead” patients have their hearts stopped by injection so that organs could be harvested.

San Francisco Medicine has published a guest editorial by Cynthia A Point, MD, titled “California Dreaming.” She has this recurrent nightmare that you are very sick, and have just found out your doctor has left the area, and none of the other doctors are taking any new patients. So you go to your nearby hospital and find their emergency room on “divert” because they have no beds and you find the same situation at the next hospital you try. The local IPA is under FTC restriction to add new doctors to its panel. She then points out serious inequities in Medicare, which uses historical costs of care basis, and thus pays in SF about half that paid in Florida. She then suggests legislative solutions so the “nightmare” will not come true. (Maybe if we allow the nightmare to come true, the solution would come faster?)

James G Hinsdale, MD, FACS, president of the Santa Clara County Medical Association, states in his President’s Column that the issue that alarms him most in the forthcoming millennium is the MBC’s current 5-year trend in prosecuting physicians—in order to pull their medical licenses—-by using one single bad outcome to justify the legal action. Dr Hinsdale feels this tactic of “single incident prosecution” is wrong, abusive, and has to stop. He notes that physicians with spotless records are receiving complaints of “repeated acts” of negligence that refer to only one patient. He warns his society members, if approached by a friendly MBC investigator, to excuse yourself and then run, do not walk, to an attorney. “You are profoundly ill-advised to talk to an MBC investigator without having secured legal counsel.” He believes that the NORCAP insurance to cover your defense against the MBC is the best benefit of society membership.

Arthur D Silk, MD, Editor of the Orange County Medical Association Bulletin, asks in his editorial, “Why do we still pay hospital dues?” Isn’t it inane to contribute up to $200 to hospital staffs for the privilege of sending them patients from whom they make their corporate profits. How did we get into these topsy-turvy economics? He feels that in the days of charity care, doctors started contributing $10 or $15 a year so hospitals could provide this care free of charge. Now that hospitals have metastasized into megaliths headed by officers whose salaries exceed those of the highest paid physicians, they still need our patient referrals but they don’t protect our professional needs. Silk says it is time for doctors to reassess their financial priorities and make collective decisions so that hundreds of dollars they are now contributing to hospital staff coffers might be better used to maintain those organizations to which they must turn for professional survival. (You may contact him at bulletin@ocma.org)


Suisun, Fresno-Madera & the AMA May/June 2000

While filing my 1996 NEJM, I noticed an interesting letter to the editor: “Compensation of Lawyers and Doctors.” Richard G Williams, MD, from Suisun, California, reflects on seeing two lawyers. The first was his own attorney who charges Dr. Williams $185 per hour.. The second attorney was a patient. whose health maintenance organization pays Dr Williams $156 to provide comprehensive medical care for an entire year. Dr Williams concludes: “An hour of legal work is now worth more than a year of medical care.”

By a narrow margin of six votes, delegates at the June AMA meeting approved new ethical guidelines for selling nonprescription, health-related products in a physician’s office. Critics of the guidelines took opposite stances—some declared the guidelines were too rigid; others cried that they were too lenient.

Using the report of the Council on Ethical and Judicial Affairs (CEJA) (which called for an almost total ban of such sales in the office) as a basis for its decisions, the House ended up taking a middle-of-the-road position. The guidelines laid down for selling nonprescription, health-related products, including nutritional supplements, safety devices, and skin-care products are summed up as follows: the physician 1) must validate the product’s medical efficacy; 2) offer the products to his patients free or at cost; 3) must not participate in distributorships where products are available only through doctors’ offices; and 4) let their patients know, in full, about their financial arrangements with the manufacturer or supplier and also the availability of similar products elsewhere.

Stephen Grossman, MD, continues to dialogue about “Fraud and Abuse” in Vital Signs, the monthly bulletin of the Fresno-Madera Medical Society. His previous article was so abrasive that it was relegated to the “Letters to the Editor” page. (Dr Hinsdale, president of the Santa Clara Society warned us not to talk with friendly Medical Board investigators–see VOM last issue). Dr Grossman received so many positive responses to his “abrasive letter” that he was asked to write “Round Two.” He points out that Janet Reno has made Fraud and Abuse in health care the number one priority for white-collar crime. Our patients are being tracked through our UPIN number to investigate our bills, labs, and DMEs. He points out that most physicians do not fully appreciate that an erroneous statement sent through the US Mail is MAIL FRAUD with penalties of $10,000 per line item error. In an undercover FBI sting, an officer posing as a patient asked the doctor on the way out to sign a form for diapers for his grandmother who was to become a patient the next week. The FBI returned the next day with guns and badges for charges of failure to do a good faith exam, conspiring to defraud the government (over diapers), signing a form on a patient that did not even exist. Another colleague in Fresno got a $53,000 fine and accepted it rather than fight it. Dr Grossman fears when they implement the new [AMA & HCFA] E & M codes: “GOD help us all.”


On Charles Schulz, Hattie, Lully, Mozart, et al July/August 2000

Reports from the Society of Anesthesiologists, and Humboldt-Del Norte, Alameda, San Joaquin, Kern, and San Joaquin Counties.

Stephen H Jackson, MD, editor of the California Society of Anesthesiologists Bulletin, commented on the passing of Charles Schulz. His kind-hearted stories and human commentaries ran in 2,600 newspapers in 75 countries, making him the most widely read of all human beings. Schulz gave us Charlie Brown who resonated the feeling of the underdog, a role that our patients, and many of us, have experienced with increased frequency and intensity during this past decade.

There seems to be an endless line of legislators and regulators who degrade and denigrate the medical profession, treat us as commodities and empower those who want to practice medicine without having a medical degree. Jackson sees Charlie Brown as a role model who should strengthen our resolve to protect the sick, the infirm and the vulnerable in our society, and doggedly (like Snoopy) serve as their last line of advocates and protectors.

George Ingraham, MD, President of the Humboldt-Del Norte County Medical Society, describes the rewards of inefficiency. He saw a glossy flyer from a “chap” in the Midwest who had hired an efficiency consultant (three-piece suit, blow-dry haircut).

He was struck by the final paragraph in which the doc in question—proudly, mind you—announced that he is now able to spend just five minutes with each patient. He accomplishes this by having many exam rooms, someone taking notes, a portable phone, and never sitting down unless absolutely necessary (this inefficiency breaks the flow).

Dr. Ingraham likens this routine to a starving, methamphetamine-crazed honeybee in a florist shop. He concludes that his Midwestern colleague doesn’t realize that the folks behind the Redwood Curtain are trying to establish a relationship with patients, something that can’t be done in five minutes standing up, except maybe in a singles bar if you’re really good.

It may be inefficient to sit and get to know the patient, but isn’t it worth it? That feeling of being trusted, sometimes liked, gives you that marvelous personal high. And you realize you would not trade places with anyone on this whole wretched planet.

The ACCMA Bulletin, monthly Journal of the Alameda-Contra Costa Medical Association, has a series on “Reflections.” The anonymous author cites his experience on starting his OBG residency: “My first patient had stage IV carcinoma of the cervix. After rounds I noted dehydration, hypokalemia, and anemia. I felt you couldn’t get into heaven with electrolyte imbalance and so started an infusion, corrected her potassium, and transfused blood.

“The next morning she was alert and went home two days later. Hattie returned a month later. Laying comatose, she was surrounded by nine people dressed in clean sharecroppers clothes. One women introduced me. As they came by to shake my hand, Hattie’s daughter said, ’Doctor, you don’t have to do anything more. My momma had four real good weeks and now she’s ready to go. We all said goodbye.’

“During those weeks Hattie seemed happier than anyone could remember. The family had a reunion. A brother whom Hattie hadn’t seen since 1943 attended. The woman then said, ‘Doctor, the time with my momma that you gave me and my family we can never repay.’ She handed me a box from her battered purse. I unwrapped a watch fob engraved with my initials and the date. Hattie died the following morning.

“I Remember You, Hattie. . . and when I do, I cry.”

The San Joaquin Physician pays tribute to Dr Richard Nickerson, a remarkable doctor-lawyer. He decided to take up law in the 1960s and passed the bar in 1969. From 1970 to 1975, he juggled his life as a practicing lawyer and a surgeon.

After 1975, he realized that being a physician was ;more fulfilling and he decided to stop his law practice. His advice to new physicians is, “Be a people person. Be devoted to patient care, and have great compassion for human suffering.”

Elsa P Ang, MD, president of the Kern County Medical Society, addresses professionalism in her monthly column in the Bulletin. She lists the components as knowledge, learning pursuit, service to your patient, and conscientious adherence to the Medical Code of Ethics.

She discusses psychologists who want to prescribe, optometrists who want to operate, physician assistants who want to play “doctor,” as well as professional ball players arrested for gambling as lacking professionalism. She hopes never to be addressed “Professional Physician.” “Just Call me DOCTOR,” she says.

San Joaquin Medical Society member Moris Senegor, MD, shares “Medical Anecdotes from Music History” in the feature story of the San Joaquin Physician. Dr Senegor became interested in the medical conditions, ailments and deaths of the great composers and other colorful characters.

For instance, there was Jean Baptiste Lully (1632-1687) an opera pioneer, who was known to break players’ violins over their backs. He stabbed his big toe with a billiard cue while trying to beat time for his 150 performers. He refused to have his infected and gangrenous toes amputated and died. He was considered the first case of music related death.

Wolfgang Amadeus Mozart (1756-1791) was a child prodigy whose early talent was recognized and cultivated by his father, Leopold. He began composing by the age of six, and wrote his first opera at the age of 11. He was a sickly man with upper respiratory infections, body lesions, toxemia, typhoid, rheumatism, small pox, yellow jaundice, dental abscess and various other ailments. His premature death at age 36 was officially given as “heated military fever,” an 18th century euphemism for “we don’t know.”.

Felix Mendelssohn (1809-1847) who wrote the popular “Midsummer Night’s Dream,” had a stroke shortly after his sister did and died at age 38. Franz Schubert (1797-1828) led a Bohemian lifestyle, contracted syphilis at a young age, suffered through its various flare-ups and died of typhoid fever at the age of 31.

Frederick Chopin (1810-1849) met an early death at 39 of tuberculosis.

Johann Sebastian Bach (1685-1750) a church organist, and George Frideric Handel (1685-1759), who composed operas and oratorios (Messiah and others), were both killed by the same surgeon. Chevalier John Taylor performed the same cataract operation on both composers, nine years apart, which resulted in their deaths. He earned a place in music history as a most infamous surgeon. Dr. Senegor states that this is just the tip of the iceberg and gives an excellent bibliography of books and lectures in which to indulge.


On World Ratings, the Future, Social Justice November/December 2000

WHO, CMA, Los Angeles County Medical Association and Sonoma County Medical Society.

The World Health Organization has listed the best healthcare systems in the world. The USA ranks 37th out of 191 and France heads the list.

I recall the time I was leaving Paris and a gentlemen with a bandaged eye lay on a stretcher in front of me. He was risking an emergency flight home to repair a detached retina, rather than the increased risk, according to his wife, of interfacing with French medicine. Why would someone want to flee the world’s best healthcare system for one 37 down the list?

Anthony Daniels, a British physician, responds in the WSJ to the WHO report stating that we rank just below Costa Rica, just above Slovenia and 15 places below Colombia. On his visit to Colombia he saw many advertisements concerning healthcare facilities in the US. He was unable to find advertisements in American periodicals concerning healthcare facilities in Colombia. He felt it curious that people are prepared to travel long distances and spend large sums to be treated by a worse healthcare system than the one they have at home.

He suggests that we imagine two societies, both with 20,000 people who will die without a heart operation. In one society no such operations are done; in the second, 10,000 are performed on the half who are most able to afford them. From a fairness point of view, the former system, in which everyone died prematurely, is clearly superior. But it would surely be an odd person who preferred a system in which everyone died. He feels fairness is not an important feature of a healthcare system, and should not be used to make comparisons between them.

He also points out that it is unfortunate that these lists, once distributed and memorized along with the periodic table of elements by school children, have essentially no useful meaning. However, it will be almost impossible to liberate minds from the prejudice that these must mean something.

Meanwhile our California Medical Association has a Re-Engineering Task Force precipitated in part by a decline in CMA membership below 50% of practicing physicians in California. A broad survey found that a majority of respondents indicated that the CMA of the future should be a more effective and efficient professional organization focused on legal, legislative and economic advocacy. Reasons for failure of prior efforts included insufficient grassroots involvement and the conservative nature of the CMA leadership. The top three recommendations included that the CMA implement a program for introducing and advancing economic advocacy legislation throughout the legislative session to improve physician reimbursement, establish an Economic Advocacy Task Force to serve as a think tank to improve economic advocacy for physicians, and establish a “quick response” Economic Advocacy SWAT Team to take immediate and direct economic advocacy action when necessary.

With the AMA stating that the average physician income is equal to that of the President & Commander-in-Chief of the worlds most powerful country, the proposals concerning inadequate compensation and reimbursement of physicians could have an even greater negative effect on our professional status. If we’re speaking of the financial consequences of MICRA, HCFA, CMB, or protection from attorneys in general, we should be more specific.

Sharon A Ferrell, president of the California Medical Billing Association has an article titled Code Blue! in LACMA Physician. She points out that there are hundreds of intermediaries, commercial carriers, trade unions, HMOs, PPOs, and IPAs, each with its own reimbursement regulations, making up their own codes; changing rules; losing your claims, delaying, denying, reducing payments; and disputing your appeals. This causes physicians to unnecessarily write off billions of dollars annually.

She cautions that any billing error may be considered fraud and abuse, thereby subjecting physicians to fines, penalties, and sanctions by federal and state authorities. Billing for a test that may not be medically justified may be deemed fraud. She lists over a dozen areas that could end our medical careers.

In The Future of Medicine, an editorial in the Sonoma County Physician, Heather Furnas, MD, points out advances made during the 20th century, when life expectancy increased from 47 to 76 years and may go to 100 years in this century. Cloning could allow for the birth of a thousand Hitlers and genetic engineering could produce an exclusively Aryan world.

Technical advances have allowed us to increase the exactitude of our diagnosis with increasing patient safety so that we could return to the practice of diagnosing without touching the patient.

However, she feels that if bureaucrats continue to bleed the lifeblood from the health care system, we may return to diagnoses made solely by palpation, percussion, and auscultation.

Marcy Zwelling-Aamot, MD, Los Angeles County Medical Association (LACMA) Treasurer, discusses Laurie Zoloth’s book, Health Care and the Ethics of Encounter: A Jewish Discussion of Social Justice, in the current issue of L. A. Physician. She was elated to be given the task of reviewing the book and then discovered the contents were more like oatmeal turned to cement and proceeds to dispute Zoloth’s premises one by one.

She disputes Zoloth’s premises, starting with the first one – that health care is a scarce resource and thereby a rationed good. Zwelling-Aamot feels the scarcity of health care results, in part, from the marketplace that has left those involved in “the encounter” in the dust.

Zoloth fails to see the role of government or business in the health care encounter as a negative force. In fact, Zoloth states the simplest act of “caring for the vulnerable ill person is a social encounter” and “the provision of healthcare is a necessarily social good; it cannot be otherwise.” Zwelling-Aamot agrees that the Talmud is a wonderful demonstration of Jewish discourse and does provide insight into Jewish social justice, but it doesn’t describe health care as a social right . . . The story of Ruth . . . does not apply to issues of diabetes or hypertension.

Zwelling-Aamot concludes that there was no discussion of . . . a true medical encounter: that between a patient and a physician. The encounter remains a private moment. . . It is not about justice or social obligation.. . . If God wanted healthcare to be a social issue, He/She would have made it one of the 10 Commandments: “Thou shalt have a Pap smear and spread thy shanks for the world to pass judgment” or “Thou shalt share thy hemorrhoids with thy neighbor.”