Hippocrates & His Kin by Del Meyer, MD
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MISTAKES - Can We Avoid Them or just Cover Them Up? It's been said that doctors can bury their mistakes; attorneys can lock up their mistakes; but architects can only advise their clients to grow bushes and vines.
A patient was brought in by her husband with recurrent green phlegm and exacerbation of her wheezing. He asked if we "could take her lungs out, clean them real good, and put them back in?" He appeared to be a reasonably industrious blue collar worker, a sort of nuts and bolts type of man. The government may be right. Most individuals really would be unable to make their own health care decisions. But after reviewing the proposed 240-page Health Security working draft, some of us are not convinced the civil servants have a superior ability.
UC officials are proposing salary hikes averaging 21% for executives at the system's five medical centers. Hospital executives are to receive increases of as much as $60,000 with a total of over $700,000 for 25 executives according to a copy of the proposal obtained by the Bee (11/13). The SF Chronicle states that the average UC hospital director currently makes $118K to $154K. According to Medical Economics, 25% of us now make less than $100K. Relman, in the NEJM, has been telling us that administrators make 20-24% of the health care dollar (physicians are at 19%). We can hear it now, "My son, the Administrator!"
Recent Forbes headlines: "FDA's David Kessler wants to liberate us from greedy corporations. Who will liberate us from the FDA?" Kessler was bemoaning the unsubstantiated claims for vitamins in the market place. "It is time to do what needs to be done." One of our own senators is trying to make sure he doesn't do what he wants to do. "In the end, I'm a doc," Kessler told People magazine. His Chicago Law School Professor Richard Epstein recalls Kessler vividly: "He was a good student. . . You knew he wasn't going to spend his life poking around people's openings." Being a Bush appointee, he derided his chief after Bush lost the election, did a chameleon according to Kim Pearson of Food & Drug Insider Report, was the only one who refused to return the formal request for resignation sent to all political appointees, was desperate to be retained, not reappointed, because he knew he could not survive another congressional approval process. Now Clinton officials state, "He's grating already." Surgeon General Koop told 3000 plastic surgeons that the FDA investigation (of breast implants) "smelled ...there is more than meets the eye" with the authors alleging "feminist politics and Nader influence imposition on private practitioners to allow reconstructive implants for mastectomy patients but not for cosmetic purposes is obviously irrational in pure medical terms... Maybe Kessler should be looking for new openings," concludes FORBES... In a companion article, the same authors, Peter Brimelow and Leslie Spencer, suggest "As Congress mulls plans for taking over the American health care system, it might first take a fresh look at what politics has already done to the drug industry."
Science (221:1788) reports the drug companies employ about 36,000 scientists, about twice the biotech industry. Twelve firms alone have announced they will trim 18,000 jobs by 1996, including roughly 500 PhD scientists. The downsizing appears to be driven by three factors. One is the failure of lead products. The second is loss of revenue due to shrinking tax credits and larger Medicaid rebates to states. Original rebates were $3.4 billion and recently were increased to $6 billion. (Isn't that illegal for the rest of us?) The third and biggest damper is the threat that the government will impose price controls on drugs as part of the Clinton Administration's health care reform. This has unnerved Wall Street and led to a decline in public investment in biopharmaceutical firms. The drug pipeline looks barren according to analysts... I guess we won't have to learn a new antibiotic every month in the future.
Getting back to those mistakes we all make them. Some more than others. This may be a product of dealing with sicker more complicated patients, a stressful day, or invalid patient data. To admit to mistakes can be construed as humility, or in a hostile situation, an admission of guilt. A Professor of Surgery once remarked that he'd hate to see the number of his mistakes buried in the local cemeteries. There was an actual case in this community in which a chief of medicine told a colleague, "If you had admitted you made a MISTAKE, you would still be practicing and we would not have had to suspend you." The attorney had advised that in this hostile situation, since out side review had supported his care, not to admit to MISTAKES since there was no documentation of MISTAKES. This destruction of medical practices is made possible by PEER REVIEW that is biased. Let's keep it honest and not give immunity to hospitals and physicians doing incompetent review... I understand that Surgery Professor no longer admits to his mistakes that are buried.
George Roche, President of Hillsdale College, the institution that does not accept any government aid and does not allow it's students to accept government aide, was in town recently giving a number of business and professional people a historical review. His title was "Ideas Have Consequences." All received a copy of his recent volume One by One. He pointed out that in the eighteenth century there was a professor at the University of Glascow, Adam Smith, who was researching the IDEA of freedom and turned to the colonies. Meanwhile there was a man named Thomas Jefferson who was toying with the IDEA of limited government. These two IDEAS produced an economic and industrial explosion that would have been impossible in any other system. Hence, Adam Smith's title, Wealth of Nations ... In our era, we have seen freedom curtailed and oppressive governments collapse, with GATT held back because it won't work until many governments' subsidies are reduced, with numerous governments looking for a way to privatize industry, farming, and medical care, we have lost sight of the two IDEAS that gave us an enviable standard of living and health care while other nations are searching for ways to implement our high standards.
The Justice Department settled their health care fraud case with MetWest laboratories (along with MetPath) with payment of $40 million for intentionally submitting claims for unnecessary tests. Physicians were cautioned that they could be held responsible for the laboratory doing more tests than they ordered.
ABCs 20/20 reported on December 3, 1993: A child who was 6 months in the hospital on IVs was discharged to continue home infusions. When the parents were told their insurance was running out they asked for the statements. After a year, they found out that the home infusion company, Critical Care America, was charging their insurance company over $3000 per day totaling about $100,000 per month. Another example that when health care is free at the point of delivery, costs are exorbitant and nobody is in charge. It takes a massive amount of time and energy, extending over years, to just research one claim. They found 3,000% markups. We again conclude that there should never be an insurance benefit in which the patient is not financially responsible out of his or her own pocket for a minimum of 10% so that there will always be an evaluation of the cost/benefit analysis at the point of service. If the patient has co-insurance, there still must be a minimum, slightly painful, out of pocket expense to continue the point of service evaluation process. The usual $25, $100, or $200 copay would have no effect on $100,000 gouging. It has to be a percentage so that the patient, even before he sees the statement, has some idea of the total cost... Which reminds me, have you noticed how you're always asked to let a home care company see your patient after discharge? And when their evaluation comes back for your signature to make it legitimate, how many additional items they think need to be done? I once counted 29 separate items. Have you ever tried to find out what they charge your patient's insurance company? With all of us trying to cut costs, with hospital census down, why are health care costs continuing to increase? Are our home care companies doing what the home care company on 20/20 was doing? Are we going to be held responsible for signing the order and the next MetWest type Medicare Fraud will involve us?
John Stossel, also on 20/20, reports on the Congressional Record, an alleged verbatim report, that the record is mostly Fake. In fact, it can be changed if the congressman doesn't like the first Fake record or find that it has MISTAKES in it to make it a more acceptable Fake. They conclude that Congress is wasting $469 per page and doesn't seem to be able to keep from wasting with anything they touch... If we ever let congress destroy the health care we provide our patients it would be the most critical of all MISTAKES, one that cannot be buried or even covered with bushes and vines.
Maxis, the computer game software company based in Orinda, has produced the game SimHealth: A Democracy and Society Computer Simulation, a game that lets you construct your own national health care strategy and try it out in a simulated U. S. Economy. You can start with 1) the Clinton system, 2) the Republican alternative of free market reforms, or 3) the Canadian system. If your system draws money from other programs, the Main Street shrinks; if you cut doctors salaries too much, they decline and hospital waiting rooms overflow; if your health care plan inflates the federal deficit, the government buildings begin to decay. . . appears to be as logical a way of doing it as any. But what happens when all those extra patients go through that high cost center?
What does health security cost? Job security, according to cartoonist Asay in the Colorado Gazette Telegraph.
Speaking of Canada, K. L. Billingsley, (Freeman, 44:2-3, 1994), suggest that as we talk about the Canadian Health Plan, that we be sure to look at the entire picture. He reports that as Eastern Europe was throwing off the chains of socialism in 1990, Ontario, Canada elected a Socialist government. In May, 1993, Ontario increased tax levies by $1.6 billion: added a sales tax on auto insurance; increased the state taxes to 58% of the federal; increased the surtax (tax on the tax) to 20% on incomes over $51,000; increased the surtax an additional 10% for those earning over $67,000 (double tax on tax); a tax on charitable contributions of 5%. The workers are now asking for non-taxable benefits such as more vacation time. People began swapping services to avoid tax, so the government slapped a tax on barter services. Can you believe if your neighbor helps you out, you would have to pay a tax on the services he gives you free? That should put a damper on being neighborly. He estimates the underground economy at over $100 billion. Isn't that making tax evasion criminals out of ordinary citizens?
Former State Senator Alan Robbins, Inmate No 05957-097 at Lompoc Prison Camp, wrote an open letter to the new California state legislators of 1993 in the Sacramento Bee, Sunday December 12, 1993. After 19 years in the Senate, lead author on 448 bills that became law he states: "How long can you kid yourself into believing you are so perfect that you can accept large contributions without being influenced?"
Herbert A. Sample of the Sacramento Bees Washington Bureau, reports Citizen Action found the following recipients of health industry moneys in the House: No. 1 was Jim Cooper, D-Tenn with $163,846; No. 2 was Fortney "Pete" Stark, D-Hayward with no amount given; No. 6 was Robert Matsui, D-Sac, with $54,500; Vic Fazio, D-W Sac, trailed at $32,350. Among the Senators was Dianne Feinstein with $59,000 and Barbara Boxer with $16,500. The health care industry donated $5.6 million this year, a jump of 31%. Maybe Robbins should send the same open letter to the federal lawmakers?
The Chronicle staff writers state that industry watchers predict an eventual link-up between California Health Systems, Health Dimensions (who hired Dr. Molly Coye) and Sutter Health. Not long before our own hospitals won't even know us because they are somewhere else.
The legislature passed and the governor signed over 1300 bills last year with over a 1000 going into effect this year. Aren't we reaching a point of diminishing returns? Many of our patients have difficulty remembering even 10 recommendations including medications. Who can remember 1000 new laws and regulations per year? Do you suppose a lawyer can remember 1000 new laws a year? Or 40,000 new laws per legal career? Maybe big cuts in the law making machine would balance our budget.
A lady called one of our surgeons recently requesting a brochure on hernia repair to send to her brother in Norway. He had been on the waiting list for a hernia repair for two years and called to see how he was progressing up the list. He was told there were still over 2,000 ahead of him. When they asked his age he was told that he probably would not be able to have the hernia repair in his lifetime. . . We always knew that government medicine had a secret way of dealing with cost containment.
Marc S. Micozzi, MD, PhD, a physician and anthropologist who directs the National Museum of Health and Medicine in Washington, D.C., recently brought from Berlin the exhibition, "The Value of the Human Being: Medicine in Germany 1918-1945." He notes that socially minded physicians placed great hope in a new health care system, calling for a single state agency to overcome fragmentation ... Medical concerns changed from the private domain of the nineteenth century to a concern of the state... The physician transformed into a functionary of state-initiated laws and policies. He states that it is one thing to see oneself as responsible for the "nation's health" and quite another to be responsible for an individual patient's health. The mentally ill having been released from their chains in the nineteenth century and placed in community and family contact, were returned to state institutions to become the ultimate victims of state "solutions."
The exhibit continues with a pamphlet, The Sanctioning of the Destruction of Life Unworthy of Living, published in 1922 by Alfred Hoche, a neuropathologist, and Karl Binding, a lawyer. This set the stage for the mentally ill and the mentally retarded to be sterilized and subjected to euthanasia in large numbers... And to think that doctors supported all this with their desire for a single-payer health system!
Dr. Alain Enthoven from the Stanford Business School recently spoke at the California Health Forum at our convention center. After pointing out that the federal government wastes 48 cents of every tax dollar, Enthoven presented data that socialist nations around the world are turning to market based economies because they work better than government controlled economies. He stated we must move promptly to universal coverage primarily by people who can afford their own coverage. We must have accountable health plans. Fee for service medicine with remote third party model pays more for more, not better care. He pointed out many failures of the Clinton plan, that would be disastrous to care, rather like, "Other than that, Mrs. Lincoln, how did you enjoy the Play?"
Enthoven also touched upon the predictable failure of proposition 103. Remember this was the assault of some citizens, who obviously never passed junior college economics 21, on the auto insurance industry by trying to reduce their income by 20%. Many of us in the business/professional strata of society are more worried about insurance companies being able to pay their liabilities to us, e.g., a $1 million liability judgement, or a $100,000 CABG, or a $25,000 car that was totaled by an uninsured driver. I appreciated my insurance agent taking me out of Executive Life two years before its bankruptcy because he recognized that they might not be able to pay my wife a quarter million to cover my obligations should I check out. In this country as long as we have a market environment, we can rest assured if someone sells a product at a price that's too inflated or of inferior quality, there will be someone that will enter the market with a better product or policy at a reduced cost. Remember the foreign car companies across the Pacific that gave Detroit a run for its life?
RADAR, the newsletter on radar and transportation issues, states that insurance companies are now giving communities free "Photo Radar" devices. In our community, Roseville and Folsom had "Photo Radar." However, Roseville did not renew their initial two year agreement. Although there are 13% of drivers that knowingly exceed the speed limit, it has been estimated that 75% of drivers may exceed speed limits briefly without intent, and thus if they live or work in Folsom, eventually will be cited. The car insurance companies that in the past allowed two or three moving violations before they doubled your insurance premium, now, after proposition 103, are able to rate you a "bad driver" after one violation, even though you are an excellent driver, and can double the insurance premium. The proposition 103 assault on insurance companies has been a gold mine to them and an assault on citizens.
Not unlike the government making an assault on us under the pretext of decreasing health care costs. If we don't articulate our position well on behalf of our patients, the final assault will be on them. We will be working for the government and our patients will essentially be wards of the state.
Congratulations to Sutter General and Mercy Hospitals on their accolades from the Office of Statewide Health Planning and Development for having a lower than average complication rate for several forms of back surgery. To have several competing hospitals singled out in one community suggests a common denominator among them. Could it be the surgeons are the key element for these excellent surgical results? (Bee 12/9/93)
Recent headlines in the Wall Street Journal stated "The VA declares War on Health." In the staff room discussion that followed one surgeon mentioned that when he was a resident in surgery in the VA, a nurses aid complained to him that the patient wouldn't swallow. The food just ran down the side of his mouth and onto his shirt. The surgeon did a quick assessment and found the patient dead. Thank God for government medicine--otherwise this poor lady would not have a job.
The Northridge 6.6 Earthquake at 4:31 a.m. on January 17, 1994, was not the "Big One." But it did have a death toll of over 60 with16 of those deaths occurring in one apartment building. That building not only had parking spaces on the first floor but living units as well, making them death traps. Hospitals were severely damaged and physician's office buildings were destroyed including all patient and financial records. It was suggested that physicians begin computerizing patient records in addition to their financial records so medical files will be not be lost. Local TV stations received calls to quit covering the quake and get back to broadcasting the "soaps."
Two hospitals collapsed during the 1971 Sylmar quake killing 50 people. Two-thirds of California's hospital buildings don't comply with the current seismic safety code. When the coming "Big One" predicted as a "Big 8" arrives, will physicians and the health care industry be ready? Do our hospitals have earthquake insurance? Do we as physicians have earthquake insurance on our homes? Can you imagine paying for two mortgages for 15 to 30 years, one on a house in which you live and one on a house that you lived in previously on the same lot?
The National Cancer Institute has now changed its stance on mammograms, saying their benefits for women under age 50 are not documented and women should look at the facts and make up their own minds. (Is the government really recommending that patients should be involved in their own health care decisions?) Reminds me of Dr. Eugene Robin, Stanford Professor of Medicine and Physiology Emeritus, who wrote a weekly column, "Second Opinion," in the SF Examiner. When he presented evidence in his column in February and March 1991 that mammograms below age 50 were not helpful and routine mammograms below age 40 was actually detrimental to the woman's mammary health, his column was pulled on June 24, 1991. Now, it looks like he was ahead of his time. The public couldn't accept something that was shaking its faith in medical technology.
When Dr. Robin testified in a Peer Review hearing in this town, a physician stated, "He was just an out-of-date old fogey." The same physician also stated, "Can't we decide that there is some blood gas where we would all agree that everyone should be intubated? Like a PO2 of 55?" Any respectable pulmonary practice will probably have 5% of its patients with a PO2 below 55, many refusing oxygen even into the 40s. Taking this physician literally, would we put these ambulatory patients on life support? How would they eat? How could they go to work or shopping or drive a car pulling a cart with a ventilator behind them?
Art Hoppe's parody on Managed Care: When smoke wafted from his basement, he called the local fire station. When asked if he had called them before and had insurance, he said "no" and "yes, Sweetpea Mutual." Then he got the response, "Oh, that's an FMO--a Fire Maintenance Organization. I'm afraid we're a fee-for-service engine company. Let me give you another number." As the smoke was getting thicker, Hoppe complained he didn't think he had time. "Well, perhaps we can help. Do you have a referral form from your primary fire care provider?"
Inflation is down to less than 3% this year. SF Chronicle reports that California State University campus presidents received salary increases of $9,000-$22,000. Meanwhile, student fees will increase by another 24%. Enrollment will decrease by 8%.
The University of California Regents, having completed the controversial hospital administrators salary increases, embarked on retroactive increases for other administrators and vice-chancellors, and approved a sabbatical leave worth $181,000 for departing UCD chancellor. The president of the University Professional and Technical Employees called this move "morally reprehensible and fiscally irresponsible." The Regents raised undergraduate fees by $620, from $3727 to $4347, a 17% increase. In addition they imposed an additional fee of $2000 for the 9000 students attending UC's professional schools in law, medicine, business, dentistry, and veterinary sciences. For the first time these fees for 163,000 students will officially be called "tuition." It looks like everything that is or was "free" to the user, will eventually have costs that go out of control and exceed the taxpayers' ability to pay.
SF Chronicle reports that liberal and conservative economists knock the Clinton Record for many different reasons. MIT's Dornbush, who supported Clinton on most major issues, did not spare his biggest agenda item for 1994: his national health plan, with it's emphasis on price controls and bureaucratic mandates instead of competition. He charged, "It's recklessly expensive and murderously ineffective. It's so far from good economics, it's frightening."
Gun-related deaths are approaching those from motor vehicles. Since hand guns are now registered, and there are 200 million weapons in this country, maybe we should combine the two and change the DMVs to DMVWs, Department of Motor Vehicles and (other dangerous) Weapons?
After 70 years of secret research on Lenin's brain, dissection into thousands of slices, with extensive studies by the scientists of the Moscow Brain Institute, the director stated "In the anatomical structure of Lenin's brain there is nothing sensational." He also stated, "In Stalin's brain, we didn't find any special features at all." Government control is certainly efficient in directing 70 years of research into such important endeavors. But we have our own subterfuge with the cold war radiation experiments by our own federal government, the one that a lot of people seem to trust, some even to manage their health care.
Larry Burkett, author of The Coming Economic Earthquake, was in town recently. He states the entitlement programs as they continue to expand send "tremors" into the economic world. It took 150 years to build up the first $1 trillion debt, only 8 years to get the second trillion, and now a trillion every three years. He points out that increasing taxes only brings in extra money the first year or two after which people, having less purchasing power, slow the economy and then decrease government income. All tax increases have to be coupled with spending decreases to be effective.
Burkett continues that with 70% of the budget being entitlements, and a move to increase the entitlements with the take over of the $800 billion health industry, we will feel more "tremors" until one day the government's spending will exceed it's economic ability to fund its deficit. Just as one can't predict an earthquake, except the tremors remind us that it's coming, he feels The Economic Earthquake will come in the next decade unless the government reduces spending across the board including entitlements which, he feels, Congress is unable to do. When Burkett polled people to see if they were willing to reduce their entitlements to assure their children of an equivalent lifestyle, they said no. They felt they had earned them.
The average Americans net worth decreased another $5000 to $36,000. The national debt per American has increased to over $15,000. Won't be long before the inheritance we leave our children will be a debt instead of assets.
During the Northridge earthquake tragedy it was heartening to see the TV cameras pick up on the children in the tent cities playing and enjoying their "camping out." Before long the parents were getting involved. Parents began meeting people that they lived near. Neighbors that never met were being neighborly and enjoying establishing new bonds of friendships. Every tragedy has a positive side.
Oh yes, just what did Senator Barbara Boxer mean when making a pitch for federal tax funds for quake relief when she declaimed, "California deserves a fair shake?"
Mr. Burkett's books will never reach the masses probably because he ties in a call to religious re-awakening with his call for economic re-awakening. Even so there have been over a half million copies of this book sold. But as the Wall Street Journal stated in their review of his book, his statistics are valid. Burkett talks about the Economic QUAKE which he feels will bring about the biggest riots and crime wave we've ever experience. We can't stop the big QUAKE. But will we be able to stop the more destructive economic earthquake? The current national dialogue on what's happening to our patients is a good start. Let's keep it going on behalf of those we serve.
Everybody wants to right the world; nobody wants to help his neighbor. Henry Miller
Doctors on the whole desire to cure the sick, and if they are good doctors, and this choice were fairly put to them--would rather cure their patients and lose their fee than to lose the patient and get their fee. John Ruskin
Did you know that lobbyists outnumber our Senators 74 to 1? Boyd's Grab Bag
Professionals least like to abandon their careers for other lines of work
are doctors, lawyers, dentists, pharmacists, architects, engineers and physicists.
Research suggests that bill collecting is most likely to be abandoned. One debt detective
said, "I couldn't make enough money, so quit when I was inadvertently assigned to go
The influenza epidemic has come and gone. The primary physicians have done a "humongous" job in restraint by keeping patients out of the hospitals. This particular virus seemed to cause various pains, some times in the right chest, some times in the left chest, some times in the head, and usually all over. To exchange one or three office calls at $40 or $50 is a tremendous cost savings over a few days in the hospital at $4-5,000. Hats off to the men and women in the trenches of patient care for allaying the anxieties of patients by taking time to listen to the specifics of their complaints, establishing that the ailment wasn't cardiac in origin, and determining that they should best be followed in their homes. This service to patients resulted in huge health care cost savings for our nation.
The Sacramento Bee ran an ad from one of our hospitals entitled "Don't Die of Embarrassment." It stated, "The pain could be in your left chest, your right chest, an arm. . . intense. . . or mild, like heartburn. . . These are all heart attack symptoms. And all too often, they're ignored. People tell themselves, `Why bother the doctor? I'd be so embarrassed if it turned out to be indigestion.' If you're having chest pain and you're not sure what it is, find out fast. Get help. If you can't get to a hospital, call 911."
Of course, 911 gets the patient to the hospital, the highest cost center via the highest cost travel mode. An ambulance ride for 6 miles to the hospital exceeds the 6,000 mile airflight ticket I hold to the international ATS meetings in Boston and back. The managed care networks tell us the average ER visit is $5-600, about 10 times as expensive as a doctors outpatient office evaluation. While doctors are trying to conserve health care costs, trying to reduce them 10 or 20% as safely as possible, spending time with patients, carefully analyzing their symptoms, allaying their anxieties, the hospitals are increasing health care costs by 1000%, increasing our patients anxieties, and reversing all our efforts with $1000 advertisements. Is it too much to ask that our hospitals show restraint, cooperate and be reasonable in trying to reduce health care costs and not trade on common patient anxieties about health?
Restraint in medical practice is not new. David B. Reuben in the NEJM 310:591-3, (March 1, 1984) was already calling for "diagnostic restraint." A 73-year-old woman with known hypertension, diabetes, hypothyroidism on therapy, and with a prior stroke was admitted with abrupt congestive heart failure. Reuben was in agreement with his resident on the therapy and concurred that ischemic or diffuse cardiomyopathy were the most probably pathologic diagnosis. The more likely of the two was unclear. The resident ordered a radionuclide study to which Dr. Reuben objected since the results were unlikely to influence the patient's therapy or prognosis. The resident finally conceded that she ordered the study because she wanted to know with a greater degree of certainty, the cause of the patient's heart failure. Dr. Reuben pointed out that advances in diagnostic technology have allowed us to establish diagnoses with accuracy beyond the capacities of therapeutic intervention. Even in 1984 he concludes that there is not enough money in the health care coffers to support such "need to know" expenditures. Managed care, an interim obfuscation, was obviously necessary to get our attention to point out diagnostic restraint, but will not begin to do the whole job.
Congratulations to SEDMS for spear heading the REACH OUT Physician initiative to improve care to underserved Americans representing the Sacramento County Health Department, UCD, Sutter Health, Mercy Healthcare, MedClinic, SMG, PMG with a $100,000 Implementation Grant.
District Attorney, Steve White, spoke to the Medical Society, PSR, & Capital Discussion Group on violence. He mentioned that crime is slightly down in California and in the USA. Violent crime is up. Crime by adults is down. Crime by juveniles is up. Two-thirds of crime is unreported or undiscovered. In only 22% of the one-third that is reported is the offender caught. California has 133,000 inmates locked up. We have a 455 per 100,000 incarceration rate in our country. S. Africa is second with 311 per 100,000. England is third with 97 per 100,000. France is fourth with 81, Japan has 45, Netherlands has 40 per 100,000. California is in a massive prison bed building program adding 12 prisons to the current 28. With the "three strikes you're out" initiative, some estimate we'll need 20 more prisons. Remember when we furiously built hospital beds? Now some administrators feel we will close one-third to one-half of those. Something is missing in the crime equation. Are we really the most violent people on earth? Will we go through the same sequence with prison beds as we did with hospital beds when we figure this out?
The medical staff at Agnews Developmental Center overwhelmingly rejected the department's proposed by-laws which would have placed psychologists on its medical staff. The Medical Director at Agnews then returned the rejected by-laws to the Department of Developmental Services with her signature on the document unilaterally approving the rejected by-laws.
UAPD attorney Richard G. McCracken wrote a strong letter to the director which states in pertinent part, "a physician engages in unprofessional conduct by practicing in a hospital, public or private, which does not have rules providing for self-governance by the medical staff. The medical staff is not self-governing if its own bylaws can be unilaterally dictated by the governing body of the hospital. If the hospital were to force the changes to the bylaws that have been disapproved by the medical staff, it would deprive the staff of self-governance and render all the members of the medical staff subject to disciplinary proceedings for practicing at the hospital."
Joseph Califano, Jr, Secretary of HEW under Carter, spoke at the Health Forum at our convention center recently. He outlined important developments in health care in this country: a) the Kerr Mills bill which increased the nursing home industry from $1B to $50B per year; b) the Health Planning Act of 1974 requiring certificate of needs for hospitals; c) DRG's which required numerous revisions; d) managed care which did decrease cost but increased management costs to the insurance company by $200 billion trying to document every admission and procedure which has resulted in discouraging our best minds from entering medicine and causing our best specialists to retire early. During the Q & A session remarks included: We won't see a central payer in our country because we are not homogenous like countries that have it; it would put the $trillion health industry in the federal budget; the health industry is the largest and fastest growing industry in this country and it will take 10 years to bring it under legislative control. In regards to campaign reform, it won't happen until we have a major scandal. We've allowed legal bribery of our elected officers. Others would go to jail for doing the same thing. There are other issues on the horizon such as euthanasia which will make the abortion issue seem like a tea party. He suggested we pay for the health care of the poor and the old and put our resources there. We should be able to second that one. Let's keep Medicare and MediCal solvent. . . His ninth book, Radical Surgery, is out soon.
What's better than being a doctor...? Becoming a computer systems analyst, according to Money magazine (23-3, pg 70 ff). There are no more dreaded words in corporate America than these: "The system is down." Your boss is screaming, your clients are whining. What can you do? Call a computer systems analyst, that's what. Systems analysts are the indispensable people who install, customize, and supervise computer operations at offices and factories across the nation. And now, with their services increasing in demand, it's no surprise that they have the best job in America. Job growth 110%, job security excellent, prestige good, and stress low. Physicians are still ranked No. 2. But their stress is rated as "high."
Retirement dreams may be just that. A recent survey (Colonial Life & Employers Council on Flexible Compensation) find workers are saving 28% less for retirement than a year ago. Workers expect Social Security (if still available) and company pension (if any) to provide 63% of retirement income. Maybe Larry Burkett's advice of restraint is good. "Don't buy anything on credit, pay off your debts and be sure you can continue your present job past the age of 65 or have an alternate job or one that you are preparing for so that you can continue to work indefinitely."
A professor of medicine told his students, "Make your textbooks and journals your friends. And always read one popular publication such as Reader's Digest to keep up with your patients." This has now evolved into "you better watch American Medical Television (AMT) for two hours every Saturday morning to keep up with your patients." They come in wanting that new drug for the treatment of asthma, arthritis, cholesterol, prostate, and other problems, you know the one that replaces the one you have given the patient.
The American Medical Writers Association annual West Coast conference at the Asilomar Conference Center in Pacific Grove has concluded. There were a number of groups having conferences on the grounds, including the Youth Authority and psychologists, and the dining room was very efficient in serving high cholesterol meals at the rate of 30 per minute. It was a rewarding experience to meet with medical writers, editors, and authors from across the country and from Europe, and a privilege to meet Ed Huth, the recent editor of the Annals of Internal Medicine. We interfaced with editors and writers from the Cleveland Clinic, Mayo Clinic, and managing editors from other medical societies, as well as in house editors from the larger hospitals around the country. AMWA was started by Physician writers about 40 years ago and now includes any medical writer and editor that is interested. The faculty for the conference included professors from Stanford, UC Berkeley, UCSF, UCLA, USC, and Tufts.
The opening keynote address at the AMWA conference was by Dr.Ingram Olkin, PhD, Stanford Professor, who spoke of Meta-Analysis, the quantitative method of combining multiple scientific results. The "Info explosion" is beginning to confuse even the researchers. The sheer weight of Index Medicus has gone from 30 kgm in 1976 to 45 kgm today and will be 100 kgm by 2017. There are now 40,000 scientific journals with one million articles per year. The psychology literature has increased 10-fold in the last decade. It is estimated that 60% of articles are either trivia or duplication. New information will come from a large number of similar and diverse studies over a wide geographic area. The statistical combination of all this is what meta-analysis is all about. Meta-analysis is now being used to plan new studies.
The AMWA conference had a number of excellent seminars. In addition to biomedical illustrations (illustrations of accident victims designed for attorneys in order to demonstrate injury and thereby sway a jury seemed open to abuse), and FDA submissions (never receive a phone call from a government bureaucracy without a written confirmation of the conversation as you recall it), a popular seminar was Discerning "Right" from "Wrong" at the frontiers of life and death by Dr. Ernle` W. D. Young, PhD, clinical professor of Medicine and Pediatrics and Coordinator of the Center for Biomedical Ethics at Stanford. He covered major issues: Conception (the women's movement could not have happened without birth control); Abortion (No meeting of the minds. Dr. Young felt abortions should only be allowed until the time when personhood occurs; when no one could agree as to when personhood occurs, a woman near the back stated that in her family her older brother was not thought to have arrived at personhood until he was accepted into medical school); Infertility (no law has ever said that fertilized ova are human beings); Surrogate motherhood (Is the purchase of a human body for parenthood any different than the purchase of a human body for other purposes, e.g., sexual gratification? Some felt Surrogate Motherhood was OK if done by a family member, free); the Genome Project (the critical line between treatment and enhancement--is it different than breast implants for treatment after cancer vs enhancement?); Persistive vegetative state (no consensus at this time--expressed concern about the Netherlands extending euthanasia when they were so close to the extermination camps.) He pointed out the positive aspects of law which allow society to get on with its business. In 1965, the federal courts ruled that States may not prohibit sale of contraceptives to married couples. This was later extended to unmarried couples and subsequently without restrictions. Society through law states that a conflict is now legal and the issue, e.g. contraception, is settled. Society can continue to fight about the other issues until further law (consensus) is developed.
The seminars which I looked forward to as a writer and editor were on the business of editing, medical writing, paragraphing in writing, issues in writing, etc. This was complemented by the informal evening fireside meetings. How does one write an opinion, an editorial, a column? It turns out the plans others used were similar to the ones we had developed. Where does one get his ideas? How long does it take to write a column? As long as it takes to make the deadline which for this journal is the first Friday of the month before publication. Since I send my columns out for independent review, my deadline is the previous Friday. How far ahead are columns stockpiled? Varies. Information comes from a wide variety of exposures and networks. Ideas which early on seem to meet the needs of a particular column may not hold muster as the deadline nears when 3000 words have to be reduced to 1500 words. This means that half of the ideas may get pushed down into computer memory for another day. On one occasion, with a sudden change in the "medical winds," the entire column got pushed down one week before the deadline and a new one was written. This is made possible with a topical file and networking which was vastly expanded at the AMWA meeting and continues to provide us information and exchange of ideas for future articles and columns.
Coming home to the realities of life with seven SactoBEES on one side, seven SFChrons on the other, and a foot of mail in front of me, we received a call from a contributor, the journal's lifeblood, who was insistent on talking for 30 minutes about a proposed article. It is interesting to get to know one's colleagues on a different level during the challenges of being an editor and writer. It can be all engrossing. Like the practice of medicine.
Vertical Health Care
California once had a Governor who felt there should be vertical mobility in the health care field. He stated that if a nurses aid wants to become a doctor, there should be a training program to get there... Aren't those determinants essentially fixed when two gametes become a zygote?
Arnold S. Relman, M.D., Editor NEJM since 1967, and Editor-in-Chief Emeritus since 1991, spoke at the California Health Forum recently. This was his first venture to Sacramento. He was introduced by Richard Ikeda, MD, MPA, the Chief Medical Consultant at the Medical Board of California and Executive Director, Health For All. Dr "Bud" Relman (Cornell 1946) said that in his 48 years in medicine, there have never been more turbulent times than these. He quoted Yogi Berra, "When you come to the cross-roads, you've got to take 'em..." Change is in the wind. President Clinton could relent (he won't) and congress could go home (dream on); but health care reform would continue. People who say there is no crises in health care either don't understand the issues or are unaware of them. Our best health care is clearly the best in the world. American doctors on the average are better than any place else. Unless we understand how we got to where we are, we won't understand where we're going. We have to find an American solution to our problem. Dr. Relman outlined: 1) The Era of Expansion: since WWII we doubled the number of medical students; patients paid in cash, those that couldn't were charity; wages were frozen and employers on their own began to pay health insurance benefits; LBJ implemented Medicare by promising not to interfere in the practice of medicine, paid the UCR fees, essentially saying, "Here's the key to the treasury--just leave a note stating what you did with the money." 2) Rise of the Medical Industrial Complex in the 1970's: The best investment was the health care industry, inflation proof, and a continuous Bull Market. Our health care budget grew to exceed the entire budget of nearly every country in the world. 3) Revolt of the Payors: this began with Richard Nixon although the first HMO was actually started by the Boston Dispensary in 1790. 4) Outcome Evaluation & Quality Control: We began to show what services are useful and what facilities are needed. 5) We are now in the Reorganization Phase of the Health Care Delivery System with a decline in fee for service and private practice, increasing networks, managed care, and prospective pricing all unrelated to Clinton's program... During the Q & A session Relman stated "it is not if managed care will continue, but who will control managed care." However, he did not predict a disappearance of fee for service or that indemnification insurance will disappear. Auto salesmen will sell you a car even if you don't need one. We cannot do that in Medicine. He says he is against socialized medicine. "We're talking about a delivery system under private control." But he felt government would be required. Semantics? Relman said just pay him the 14% of the GDP and he would design an excellent system.
According to a report in the SFChron, in Italy the national health care has been a showcase of corruption, fraud and waste. Even with local control exorbitant expense has driven the cost of health care to 11% of their GNP--the highest in Europe.
Overheard: an Amway distributor asked a physical therapist, "How would you like to make a quarter million a year?" He answered, "I already do." That quote is a little dated, but it occurred when a large medical group had a top salary structure for physicians of about $60,000 per year or one-fourth of an allied health specialist.
Speaking of Governor Moonbeam's vertical health care integration, he reduced nursing standards by having two year colleges produce RN's, the same as the four year colleges. We missed a golden opportunity to give all the three year hospital nursing programs an academic back ground by affiliation with junior colleges and maintaining the third clinical year. What if he had been governor long enough to shorten medical training. Maybe he could have also shortened medical school to three or even two years and also shortened the residencies. Just think, a family neurosurgeon in four years after college? Imagine what he could have done for Medicine nationally if the electorate in other states had taken him as seriously as the majority of the voters in this state did... We could work a few years as a hospital orderly, progress to a LPN, and then on to nursing school to become an RN. After a few years of burn out, psychology would look interesting, especially if they are successful in getting hospital privileges and the license to prescribe tranquilizers. But not liking to play second fiddle to psychiatrists we could switch over to become a podiatrist so that we could prescribe any drug. After paying over $1500 a year for Podiatric society dues which never got us above the ankle, we could take an orthopedic residency which had been shortened to three years (Moonbeam felt nothing could be more complicated nor take longer than law school) and then become a practicing orthopedist. At that time we'd realize that the political hostilities to MD's aren't worth the effort, and physical therapy would look very appealing, especially since we'd make those big bucks between 8 and 5, Mon thru Fri. And what perks: exercise equipment and swimming pool right outside the consultation room.
Psychology Today begins a new column, "Ask Dr. Frank" (Pittman,M.D. author of Man Enough: Fathers, Sons, and the Search for Masculinity, and Private Lies. The questions seem to be the same ones we observe in practice. In the same issue (27-2), Susan Baxter gives us the last word on Gender Differences. "Once upon a time, men were men and women were women, and anyone who rocked the boat got eaten by sharks... Fast forward to a time of fax machines and heart transplants, when real men change diapers and real women carry guns... A time when it's not always easy to pin point what traits are strictly male or female. So today how should we differentiate between sex (innate, physiological) and gender (socialized, learned) differences?" She quotes Mark Twain, "There are three kinds of lies--lies, damn lies, and statistics," as she takes us through all kinds of "intellectual and statistical rubbish." She concludes that "if there are neuropsychological sex differences, clearly, we don't know what they are or what causes them. Don't bet real money on ever predicting who'll be the better nurse or engineer. Because however much we yearn for simple truths, there aren't any here."
Researchers at the University of Indiana state that physicians who use computers to order drugs and tests for hospital patients can significantly reduce medical costs. In a study of 5,000 patients at an Indianapolis hospital, the researchers found that charges to patients treated by computer-using doctors were nearly 13% lower, a savings of $900 per admission. This was the result of doctors immediately seeing the cost of tests and treatments as they are ordered. They noted that when a doctor ordered a heavily promoted antibiotic and the cost seemed high, it would promptly be changed to a less costly and equally effective antibiotic. The computer work stations may also have improved quality of care by immediately flagging allergies, cross reactivity to other drugs and possible adverse effects immediately compared with patients diagnosis... Information is always the first step to changing behavior which then becomes automatic without laws which have the side effect of making us criminals. Physicians can't begin to evaluate the cost-benefit analysis until the costs are available. Maybe if we computerized our office and hospital medical charts, with a 13% reduction which would put health care at 12% of GNP, (which is close to Italy & Canada) the whole national health care cost debate would evaporate. These costs are certainly being hidden from us now. When I asked a therapist assisting me in a bronchoscopy what were the hospital charges for the endoscopy room and his assisting me, I was told not to worry because the hospital worries about such details. But the patients complain to me about the bill, not mine but the one that is ten or twenty times mine.
Congratulations to the twenty-two faculty members across town who have been named to the 1994 edition of The Best Doctors in America. Four volunteer faculty were also included.
The AMA states that 33% of doctors' offices fail to cover their staff with health insurance. However, 77% offer their employees health insurance. Some have spouses with health insurance and therefore decline coverage. The AMA states that still is three times as high as other small businesses with 25 or fewer workers.
At a surgery conference in SF, my surgeon reporter roaming across the hall, states that the speaker told his audience that a chiropractic office practice is inefficient if it's not grossing at least a million dollars a year. So the epitome of a varied vertical mobile medical career after physical therapy could then be to become a chiropractor, reduce one's working hours to 40 hours per week, (isn't that close to retiring after a lifetime of 60-80 hours per week) and enjoy the golden years without significant malpractice premiums, no night or weekend call, and yearly international vacations. But physicians, who are used to living on much less, would only need to work three months a year, take a nine month annual vacation, and still make twice as much as the average doctor. Too bad it took 30 years to figure this one out.
The American Thoracic Society meetings are being held in Boston this week. I'm writing this on a Macintosh while learning the "Mac" at my daughter Julie's apartment a short distance from the Hynes Convention Center. The 11,000 registrants represent 4000 international guests including three air bus loads from the UK. Many countries in Europe, Asia, S. America, Africa, Australia, as well as Canada and Mexico were represented. The ATS membership of 11,500 includes Pulmonary Internists, PhD's doing research in lung disease, Pulmonary Pediatricians, Pulmonary Surgeons, Pulmonary Allergists, Environmental and Occupational Medicine Specialists, Pulmonary Nurses, as well as Pulmonary Veterinarians. In addition there are 1200 fellows in training. This was the largest pulmonary meeting in history, even exceeded last years meetings in SF by a thousand.
Over heard at Lindburg Field after a research seminar in San Diego: The really wealthy rich man died and opened his eyes and found that he was in Abraham's bosom. He saw Moses afar off and walked down the diamond studded gold lined velvet path towards him and said, "There must be some mistake. I was a health care CEO. I wasn't a very honest man. In fact, I made life quite miserable, not only for the doctors, but also for the patients. I subverted much of their premium dollar to my personal fortune."
Moses said, "Let me look for your name in the Book Of Life."
The extraordinarily rich CEO said "I know you won't be able to find it. I kept the doctors so busy getting pre-authorizations that they didn't even have enough time to write down everything they did for the patient."
As Moses kept scanning, he said, "Here's your name."
"I really can't believe that," the filthy rich CEO said. "The doctors even got investigated by MediCal and MediCare and were charged with fraud because the records couldn't substantiate their charges. I found some doctors that testified that `if it isn't written down, it wasn't done.' What a travesty. I'm the one who should be felon."
"Well you may be partially right," Moses said, "I see you are authorized a three day stay here, and then you will spend the next three eons with Lucifer in the fiery furnace."
The noticeable difference in meetings these days seems to be the number of sessions devoted to health care reform. Of the eight concurrent sessions at the ATS meetings, one always seemed to be devoted to political/practice issues. The other new wrinkle is the emphasis on practice guidelines, a necessary requirement as the government takes over the purse strings of our practices. One evaluation is that this poses no medical legal liability as long as one follows the guidelines. However, it is not clear what happens if you don't. Some felt that departure from guidelines makes one automatically guilty of malpractice, because the evidence confirms that there was a departure from the standards of care. Hence, no trial is needed except to assess damages. Others felt that it could cause automatic loss of hospital privileges and/or licensure for incompetence... In another session, National Jewish, a TB & Resp tertiary center, reviewed their treatment of TB for the past decade. This revealed that there was an 80% departure from standards of treatment and an average of 4 errors per case. If the superspecialist still make errors, will the malpractice attorneys and juries as well as state medical boards and hospital peer review committees be persuaded that there are huge variations in practice patterns and deviations from standards of care that don't reflect malpractice or incompetence?
The pages of the Boston Globe are filled with the passing of Jackie Kennedy Onassis. She was indeed a saint according to all local reports. She was the epitome of grace, charm, grandeur, and culture. She didn't redecorate the White House, she restored it. President Clinton stated, "She seemed always to do the right thing, in the right way." Bill Buckley recalled when asking her to do ten minutes for the Sistine Chapel, her negative was charmingly delivered, "Bill, the only time I ever appeared on television was when I took the camera around the White House after the renovations. I was so awful I decided never to do it again." The Globe editorial that caught my eye was, "She taught us how to live." To which I would add, "She taught us how to die." When the medically related quality of life (MRQL-a frequent topic at this conference also) was no longer acceptable, Mrs. Kennedy bade her doctors and nurses good-bye, asked to be taken home so she could die with her family and friends, with only her personal nurse to attend to her physical needs and comforts.
"Lenin Untombed" by Gorov & Mashberg of the Globe staff cerebrate on what to do with "The Body, the Mummy forever young." Devoid of his brain and his internal organs, they make a number of suggestions for the use of Lenin, the Mummy. Number six stated, "Long sucked dry of all things living, he's an ideal spokesman for a 1996 Dukakis for president campaign--or the perfect chairman of a Senate committee--any Senate committee." Rostenkowski, a former ward boss from Chicago who leased to Congress unused space in an office building he owned, and put on payroll friends who never had to report for work, was indicted and lost the Chair of the House Ways and Means. Could we propose a House committee chair in charge of the Clinton health care reform as a perfect fit for Lenin out of the tomb?
I met the former Medical Director of Tuberculosis for Chicago at the ATS Harvard Club reception. He supported Mayor Washington in the elections and when Mayor Daley took over after Washington's death, the doctors were told that the Mayor would like his own doctors in office. However, doctors can't be fired for political reasons, and since he didn't resign, he was transferred to a small TB office in the highest homicidal area of Chicago. He still continued to work. He was then told he would report to a "facilities manager," a new position to which they appointed the custodian of the building. The next time he went to meet his consultant at O'Hare, he was cited for leaving the "facilities" without permission which could cause "great jeopardy to the citizens of Chicago." When he told the "facilities manager" that he had told the nurse he would be absent to pick up a consultant, he was told she was not in the administrative hierarchy. He was brought to full hearing and suspended without pay for two weeks for not following the rules and regulations of the city of Chicago. After eight years of public service, he reported to work after the two weeks, resigned the following day, collected his vacation and benefits and returned to the practice of pulmonology.
Also at the Harvard Club reception, a Pulmonologist from Japan, stated that he thought Japan's socialized medicine was the best in the world. When asked for the reason, he stated that currently the government is flushed with money and the doctors are doing well. He recognized that it would change with a change in financial winds... A pulmonologist from the UK stated that with all the cost cutting by the British government, the doctors would probably do better. So many benefits were being eliminated by the government's financial crunch that patients would probably pay physicians cash outside of the National Health Service for these lost benefits. Doctor's welfare improves with black market medicine? Most pulmonologists that I was able to talk with from other European countries seem to repeat the UK experience... With the financial crunch of the USA, deficit spending, trade deficit, national debt increasing by almost a quarter trillion per year and may exceed our GNP and national assets by the end of this decade, haven't we left our senses to even consider placing the one trillion dollar health industry into the federal system, even if sneaked "off budget?" Especially when there are health insurance reforms that would achieve essentially more with no direct federal costs or controls. A History professor once told us that those that can't be objective about history in the making because they emotionally can't handle it, are destined to repeat the mistakes. Or the UK physician stating, "As we try desperately to privatize and you are trying to nationalize, we'll probably meet somewhere in mid Atlantic and both drown."
Dr. Sylvester, president of the ATS reported that our lay organization, the American Lung Association, has essentially agreed to allocate 10% of their contributions for lung research. This increase he stated would essentially double the support to fight lung disease. The membership gave a round of applause.
The 50th anniversary of the chemotherapy of TB was celebrated with the reading by Jason Robards from Dr. Ryan's book, THE FORGOTTEN PLAGUE, How the Battle Against Tuberculosis was Won and Lost. He then joined a panel of the great phthisiologists of our day as he recited personal experiences from his military service days when he encountered TB. It was a real pleasure to listen to H Corwin Hinshaw, albeit on video. Dr. Hinshaw went from Oakland to Weimar for their Chest Conferences for many years.
Before leaving Boston we saw Isaac Bashevis Singer's Shlemiel, the First at the American Repertory Theater. Spreading wisdom is hard work for Shlemiels as they are cautioned to "Just tell the truth, it's the best swindle."
Returning to Sacramento, we saw Moliere's The Imaginary Invalid which was playing at the Sacramento Theater Company. Mark Cuddy, the Artistic Director, did an excellent job of adapting and directing. He also added a modern epilogue which included Dr. Elder, Dr. Koop, Hillary, and Willie Clinton. The protagonist of The Imaginary Invalid believes, as the title implies, that he is critically ill, when in fact he is quite well. This was Moliere's last play, and he himself often acted the role of the protagonist. During this time, he believed himself to be healthy, but was actually dying and indeed hemoptysized to death from his tuberculosis after a performance.
Several years ago I took a one week course in Internal Medicine at UCSF. It turned out to be a very intensive review of what's new in all the subspecialties of medicine. The ten 50-minute lectures a day for five days sequentially nonstop from 8 a.m. to 12:10 p.m. and 1:00 p.m. until 5:10 p.m. were palatable only because of an unusually large syllabus with the fifty lecture outlines and literature reprints. When recently a course brochure arrived entitled, "History for Health Care Professionals," with a subtitle "Perspectives, Research Approaches, and Writing Skills," I thought it would be rewarding experience to help understand the present health care dilemma. I was not disappointed.
A prospectus for a research project had to be written and sent in two weeks before the course for faculty review. There were three daily lectures at 9 a.m., 12, and 1:30 p.m. followed by workshops each morning and afternoon on historical research and writing. We were on the university computer by the second day with access to a million and a half volumes. The library was opened until 11 p.m. for the more industrious. The basic research was done during these four days and an abstract to be sent within six weeks.
My topic "History of Health Insurance," had tens of thousands of references in the literature. I narrowed the field to come up with a few hundred significant original articles. After this primary source search, I researched the secondary sources. These are books by authors who have researched the literature. I found six excellent books on the subject. Since four were two or more years old, and I had to deal with certainty, I simply xeroxed these and got the other two at the university bookstore.
Dr. Guenter Risse, an Internist, Professor and Chairman of the Department of History of Health Sciences, began the conference with a presentation on "Medicine and Society: The American Hospital Past & Present." Hospitals initially had a shelter function (if you didn't have a home), a caring function (if you didn't have a mother), and a teaching function. They were religious institutions with monks developing surgical skills. Dealing with pain was an important function. They had water beds, basically baths, in which patients were suspended for wound healing. Patient stays were measured in terms of weeks and months.
The hospitals were laid out similarly to a church in the shape of a cross with all four corridors facing a worship center. Then a quadrangle was developed. Moffet Hospital at UCSF, built in the 1950s was designed in the late 30s. It was one of the first high rise hospitals. Stanford, however, continued the medieval quadrangle concept with wings extending laterally. This resulted in a lot of internal rooms without daylight which they have now solved with computer controlled electronic "windows" which change during the course of the day to follow your circadian rhythm.
In the late nineteenth century with the advent of anesthesia, laboratories, and drugs, hospitals became more important. John Hopkins developed private rooms which accommodated the entry of the middle and upper class into hospitals which provided services that could no longer be done at home. The revenue structure changed. Hospitals became dependent on paying patients. One of the first cost analyses by Uncle Sam revealed that hospitals spent $4.81 a day. The patient became important to the extent of his pocket book. Hospitals then had to find out who would be able to pay them. They developed a Santa Claus who worked 365 days a year, known as the social worker, who could tell them who would pay. Hospitals told the doctors they shouldn't have to worry about the finances of patients, since these gatekeepers would keep them informed. Early technology, manifested in laboratories, along with surgery, became more important because it was the most direct way to diagnosis, cure and discharge. It also increased costs.
As costs increased, this country developed private health insurance, mostly through fraternal societies, which no country had ever done prior to government medicine. This insurance was paid for in large part by employers. This was one way employers could give employee benefits because of wage and price controls during the war. Hence, health insurance in this country was a historical accident.
But of even greater historical interest is that prior to health insurance, this country already had a health maintenance organization as early as the late eighteenth century. In Sacramento we have felt that HMOs are a phenomenon of insurance out of control. The historical pendulum swings again.
UCSF and John Hopkins are the oldest History of Medicine Departments having begun in 1929. Courses in the department are now totally elective. Historians cannot make pronouncements on the future just because they analyze and evaluate the past. They cannot predict. History, however, can be useful in understanding the present and for self awareness. Historical knowledge will have a relevance to present realities. Risse observed that transplant patients at UCSF are being discharged to motels after four days returning to the hospital daily for treatment. As hospitals are unable to care for post-transplant in-patients, maybe it is time for hospitals to return to a shelter and caring function.
Dr. Risse feels that years from now people will speak 1994 as one of the more important years in the history of medicine. A secretary of state remarked that in academia the battles are so great because the issues are so small. In government the battles are routine even though the issues are huge. Questions that will be asked will include the following: Where was organized medicine in this historical debate? Where is their historical perspective and why weren't they relevant to the moment? Why were they edited out of the presidential policy planning table?
Since we had an historical accident which got us health insurance prior to government medicine, would it not be a stroke of genius if we could capitalize on the process and reform health insurance so that we could preserve the highest standard of medical practice ever envisioned?
Some studies have suggested that people having two drinks a day live longer than those that have none or those that have four or more. It just so happens that all the basic drinks have the same alcohol content and thus are interchangeable. Twelve ounces of 5% beer, 5 ounces of 12% wine, or one and a half ounces of 40% (80 proof) liquor all contain 6/10 ounce of alcohol.
We live in a state that produces almost as much wine as the rest of the world combined. And we live within one hour of the greatest wine producing valley in California. The Napa Valley had nearly two hundred wineries when prohibition (how could that happen?) came along. The feds only allowed five wineries to continue producing wine for liturgical and medicinal use. Two of those were in Napa Valley, Beringer and Beaulieu Vineyards. It has taken nearly 50 years since prohibition to come close to 200 producers again.
A medical politician was asked if he was against alcohol. He replied it all depends on what you mean by alcohol. If you're talking about alcohol that causes drunkenness, debauchery, and uses up family income so that children don't get fed and clothed; that causes loss of job and income with increased welfare and homelessness, causing divorce and breaking up of families; that causes delirium, dementia, and cirrhosis with esophageal varices resulting in a bloody projectile exsanguination in front of a hysterical spouse, I'm very much against it. However, if you're talking about the fruit of the vine that relaxes couples before a fine dinner, improves conversation, conviviality, sharing, and relationships; the aromatic hops that improves neighborly relations in the back yard, and around the barbecue; or the aged distillate of our fine grains that provide relaxation during heated debates, after intense business negotiations, and before a political speech; that provides tax money to educate our children and build schools, I'm very much for it.
The fruit of the vine is particularly pleasing to see during and shortly after the Labor Day weekend as we recently experienced. To go vineyard touring and wine tasting with grape sampling can indeed be a pleasurable and learning experience. Grape sampling is only available as grapes are nearing press time.
An acre of vineyard has 400 vines, each vine has about 40 clusters, each cluster has about 75 grapes, and each grape weighs 2 grams which equals 2.6 tons of fruit, which makes 403 gallons of wine, which is 160 cases or 2,034 bottles per acre.
Tours are available in most vineyards on a walk in basis with a maximum wait of 30 minutes until the next tour starts. Beringer is a major exception with several tours filled in advance. The winery was founded by brothers Frederick and Jacob in 1876 and is popular because of the historic nature of the tour. A chief attraction is a visit to the tunnels which are dug deep into a mountainside where the temperature is always 58 F, perfect for aging wine in 60 gallon oak barrels. The vineyard was sold to Nestles of Switzerland when the fourth generation of Beringers couldn't pay the inheritance tax and continue the cost of operation.
Recent tax advice coming across my desk (to the circular file) for estate planning cautions that physicians with wine cellars may want to give up to the annual maximum $10,000 tax free gift in wine to children since wine increases in value and can cause an inheritance tax bind.
Robert Mondavi Winery (Robert Mondavi is now 81 years old and has managed to keep his vineyard family owned) gives a very informative tour of modern computerized wine making. Mrs. Mondavi, an artist, has placed Beniamino Bufano sculpture around the grounds.
Touring a sparkling wine cellar and vineyard is a totally different experience. Seagrams bought out the G H Mumms champagne cellars and vineyards in Reims, France in 1952. Seagrams established their Mumms Napa Valley vineyard and cellars in 1986, building the current visitors center in 1990. Included at the winery is the Alinder Gallery dedicated to the appreciation of photography as art. Seagrams has also established a permanent Ansel Adams exhibit which contains Adams commercial photos of Napa Valley wineries.
The WSJ reports that wine production is leveling off and shipments decreased slightly in 1992. Three fourths of wine consumers are over 40 and half are over 50. The wine industry is planning a major advertising and marketing campaign that would promote wine drinking. The Wine Institute is directing its efforts to lobbying in the eight states where wine is sold only in government controlled stores and to get wine into the supermarkets nationwide.
Through the marvels of modern architecture, the tours always end up in the gift store. Lovely volumes on the colorful history of some of the vintners complement the purchase of the wines that were sampled. Yes, Labor Day in Napa Valley is a relaxing and enjoyable experience and appears to be a good time to see wineries in action.
Getcha - Gotcha
In grade school, children play games of "Hide and Seek" and "TAG." When they are found or caught, they say "Gotcha." Then the child that has been caught must find and catch another one. One can hear shrieks of "I'm Gonna Getcha" and "I Gotcha." Now adults are playing that game through the legal system. Only the "I'm Gonna Getcha" and "I Gotcha's" aren't verbalized. Just realized. Especially when they "Gotcha."
Reuters, sent a release entitled: "Lawyers do a study, decide they're needed." The Int'l Assn of Defense Counsel bravely released the study "Law and Society Following the Demise of the Legal Profession." They put a quote from Shakespeare's "Henry VI" on the cover: "First thing we do, let's kill all the lawyers." The study concludes that if all 800,000 lawyers were eliminated, they would eventually return. Their absence would speak highly of the value of their profession more than their remembered presence. Society would want to return to the basic human needs for order and fairness. "Gotcha."
A year or so ago when Carmichael had a large number of Peer Review hearings, we asked Dr. Verner Waite, President of the Semmelweis Society, for an article detailing his experience with Peer Review. We thank him for his frank comments about the darker side of medicine. The seven Peer Review hearings at that time did not appear to have much to do with Quality of Care. In some cases records were sought to make it a legally sanctioned professional assassination with immunity for all the perpetrators. That outside reviews of the charts upheld the quality of care didn't matter. "Gotcha."
A federal district court case sent a warning to hospitals seeking to expand into home-medical-supply business: Such moves could violate antitrust laws. The case carries important implications for the nation's hospitals, which increasingly are venturing into other businesses such as home health care, nursing homes, and equipment leasing. William Kopit, a Washington lawyer states the case presents "an enormous legal risk" for hospitals that diversify because other juries might be less sympathetic to hospitals. Hospital officials have been nervous that courts might view these activities as illegal attempts to gain monopoly power in the health-care market... What if they also gain control of physician groups? Could physicians then also be subject to triple damages by being participants in the monopoly? "Getcha?"
Modern Healthcare (Cover story: Don't Cry for Hospitals--Profits Peak by David Burda) states: "Surplus. Excess revenue. Money to reinvest...Call it any thing but profit...Hospitals are generating more of it than ever before. They don't want to talk about it because they're afraid someone will take it away." In 1992, aggregate profits earned by acute-care hospitals were up nearly 19% from 1991 (the highest since 1983). Hospitals in every bed-size, ownership and geographic category posted aggregate profit margins in the black in 1992. The AHA's hospital revenues and expenditures data (it doesn't call the difference profit) for 1993 won't be available until later this year, but based on its monthly survey of hospital samplings, "profits" could rise another 13% in 1993, the fifth consecutive year of double-digit jumps in profits... Since hospitals and their homecare and equipment companies are the single largest item in health care expenses, it looks like the profit percentages of these mostly nonprofit institutions look very similar to the health care inflation percentages. Have we found the reason for what congress and the president consider an unacceptable increase in health care costs? "Getcha?"
While healthcare administrators maintain and increase their salaries (20-24% of the healthcare costs), the AMA in a special study of physician salaries (19% of costs) reports that physicians in Sacramento have had double digit drops in income. "Gotcha."
One of our hospitals sent out contracts to their physicians reducing the reimbursements for their health plan. "Gotcha."
Grace-Marie Arnett, president of Arnett & Co. in Washington, D.C., wrote in The Washington Post opinion page that the Clinton plan creates a new "All-Payer Health Care Fraud and Abuse Control Program. The Clinton plan gets universal coverage with an intricate system of enforcement. Put simply, if you or your doctor don't comply, both of you could end up in jail." If that plan weren't dead, the Feds could say, we'll "Getcha." Later this month we'll know if the California Health Czar will be able to "Getcha."
Rena Weeks won a $50,000 award against her former law firm Baker & McKenzie, the world's largest law firm where she worked 3 months in 1991, for compensatory damage for emotional distress from alleged sexual harassment. The jury then awarded Weeks an additional $6.9 million punitive damage, twice what she had asked, based on the $69 million (of the $512 million in fees) that the attorneys kept available to finance operations. "It's a great day for women in the workplace," said her attorney Philip Kay as Weeks walk out hand in hand in boy girl fashion with Kay and associate lawyer Alan Exelrod. Careful boys or she'll "Getcha" too.
Herb Caen (SF Chronicle) reports that the same night a skunk sprayed the Baker & McKenzie's Palo Alto office where the involved atty practiced. The SPCA (which Caen renames Society for Prevention of Cruelty to Attorneys) apparently was summoned. "Gotcha?"
As we get more legalistic, everyone is out to "Getcha" and sooner or later everyone will be a "Gotcha." Brigid McMenamin in a recent Forbes article entitled, In Bed with the Devil, points out that HMO's feel the best way to control doctors is through Vertically Integrated Service Networks. Is it time we show our professionalism, do what's best for the patient, and not have any entangling business alliances with hospitals, insurance companies, or the government? We have to get our house in order first, take over the leadership of health care reform, and control costs tailored for each patient. If not, they'll "Getcha" if they haven't already "Gotcha."
Wrapping Up the Year
P. J. O'Rourke, author of Give War a Chance and Parliament of Whores (concerning the US Congress) states, "If you think health care is expensive now, just wait until it's free." Congressman Vic Fazio during his election campaign in our Carmichael neighborhood, said that the issue will only be subject to window dressing in 1995. He couldn't predict what might happen in 1996.
Robert S. Eliot, M.D., Chairman/Director, Institute of Stress Medicine International in Colorado states that 72% of what happens to us in health and in illness is within our control... Maybe we should just start working on that part we all can control.
Just how fluid the cost of care is was exemplified by a cardiologist noting that his patient's cholesterol was in the high normal range. He pointed out that some researchers presented data that would justify nearly half of the population taking lipid reducing drugs since the lower the level the better. But having an extra hundred million adults taking a drug that costs about a $1000 per year would add a hundred billion dollars to health care costs. There must be dozens of other similar instances. To keep health care costs to a trillion dollars per year reflects a lot of restraint on behalf of all physicians. How government reduces the level of care is exemplified by the MediCal program which continues to restrict such basic drugs such as H1, H2, Ca Channel, and Beta blockers. And to think that the state almost became one giant MediCal program. But the sad part is that not only would the level of care have decreased, the costs would have increased as with any government program.
The WSJ Headline by staff writer George Anders: The next Get-Rich-Quick Idea: Starting HMOs in New Markets. Last year 29 new HMOs were formed--more than double the 1992 rate. This year HMOs are being started at the rate of almost one a week. Bob Atlas, a consultant of Lewin-VHI Inc. in Fairfax, VA., says "There's pretty good money to be made by owning an HMO." Start up costs can be as low as $2 million in small markets. Many HMOs turn profitable within 2 1/2 years, and some HMOs with fewer than 30,000 members have been sold lately at prices exceeding $1500 per member...That's a $45 million return on a $2 million investment plus 2 1/2 years work. Not bad for an investor. But sad that over a half year of 30,000 members' premium just went for profit! Isn't that rather like trading stocks on our patient's health?
Arthur M. Louis, staff writer for the SF Chronicle reported that Foundation Health Corp of Rancho Cordova purchased Intergroup Healthcare Corp, (in Arizona) and its majority shareholder, Thomas-Davis Medical Centers, for $720 million. This adds 382,000 subscribers. That appears to exceed the WSJ estimate of $1500 per member. Which is also more than I pay in a full year for the FHP premium on my employee.
The Friday noon conference at MSJ by FHP stated that this acquisition move was necessary should the California single payer initiative pass and their California business evaporate. I guess they're breathing better now that the elections are over.
Several of my patients recently stated that an HMO representative visited their homes trying to sign them up for their insurance plan and to also change doctors to one of their physicians. Wasn't patient stealing considered unethical, or at least bad form in private practice when we all got along consulting with each other?
The quarterly Sutter medical staff meetings have really been one of the best in the community. Not only were the speakers more renowned, it was always a treat to see Patrick Hayes perform while giving his report. He was so clear and insightful in his thinking. Once while he and I were walking down the buffet line together after a meeting, and American River Hospital was on the block, I asked him why he didn't buy AR? He immediately listed five reasons why it was such a bad buy. As I recall, he stated it was overpriced; it would take $10 million just to bring it up to community standards; the facilities would eventually have to be rebuilt; the surrounding community was hostile and would fight such an effort all the way; and it would probably cause an antitrust problem. Scott Ideson at the MGH Townhall meeting essentially confirmed Pat was right when he stated that Mercy Healthcare Sacramento had 1158 beds and would have to reduce that to 600 beds by 1997. ARH would be the first to "go." We were saddened to hear of Pat's resignation. We wish him well.
Francis A. Davis, MD, bade us farewell after 25 years of publishing Private Practice, working together for excellence in medical care. His final editorial included five parting comments. To doctors: You have failed your patients by letting third parties make their medical decisions. To medical organizations: You should be supporting programs that put the patient and doctor back in charge of the patient's medical care. To pharmacists: The freedom you thought you would gain by having the authority to substitute what is written on the prescription eventually allowed prescriptions to be filled out of state where the writer of a prescription doesn't even have a license to write prescriptions. To hospitals: You should get out of the practice of medicine and limit your work to hospital care for the sick patients. To the research pharmaceutical companies: Spend your public relations money at the grassroots level to educate both doctors and patients because medical research is the key to quality medical care. He then ends by adding to an old quotation: "I am sorry that I only have one life and one fortune to give to my medical profession and country."
Have a Happy Holiday Season and a Professionally Pleasant Practice in 1995.
Contact Del Meyer, MD
Phone: (916) 488-5864