Hippocrates & His Kin by Del Meyer, MD
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The Third Millenium
News Flash of the Century: Norcal recently announced that starting in January 2000, they will provide physicians with administrative defense coverage, up to $25,000, at no additional cost. This should be the first step in leveling the playing field where the Medical Board, hospitals, and other third-parties have financially depleted physicians of income and retirement funds for two decades. Many of these organizations not only have large budgets, but they also have business liability insurance that allows them to attack physicians until the doctor runs out of money. The physician then admits to a small offense, not realizing that they have actually admitted to committing a felony. And to make the situation worse, after having paid a $600 license fee, which our professional organizations have worked out to pay for these investigations, the Medical Board can still send us a bill to cover the wrongful prosecution costs that exceed Norcals $25,000 ceiling.
Live & Learn: Last week I saw a patient in pulmonary consultation who spoke no English. He handed us a card from an interpreter agency and motioned to us to call them for him. About two weeks later we received a bill from the agency for an interpretation fee, for which the two-hour minimum was $130 and the mileage charge $11, for a total of $141. Expected reimbursement for the consultation is about $96. Such a deal. Spend twice as much as you get paid to see a patient and for helping him with his asthma. He was from the Ukraine where, I understand, such deals are the norm.
A reflex answer: Last month a surgeon was bemoaning the fact that he had provided outpatient care for a fracture, and a week later the patients mother called to tell him her son had died of a massive pulmonary embolus. She demanded to know why he didn't warn her son of this possible complication. The surgeon couldn't remember if he had warned the patient of that specific complication and seemed apologetic. The reflex answer should always be, "He was told." It is impossible for a patient to get through the hospital permit and informed consent process without being adequately warned. We are so concerned about our patients and we feel so guilty, that we forget that we have to answer like a lawyer when the other side has already retained one.
Sign on the door of a law office: Hire an attorney. Get a second one free. (You suppose the third one is half price?)
Paranoia or Just Good Sense for the Telecom Century: Remember when people who avoided electronic debits from their banking accounts and refused to acquire credit cards were thought to be a little paranoid? Well, The Economist, the British news magazine, doesnt think they were and gives more advice along this vein. Use cash when you can. Do not give your phone number, social security number, or address, unless you absolutely have to. Do not fill in questionnaires or respond to telemarketers. Demand that credit and data-marketing firms produce all the information they have on you, correct errors, and remove you from marketing lists. Check your medical records and never sign a release for those records unless absolutely necessary. If you suspect a government agency has a file on you, demand to see it. Block caller ID on your phone, and keep your number unlisted. Never use electronic toll booths on roads. Never leave your mobile phone onyour movements can be traced. Use your cellular only when you are first paged. Do not use store credit or discount cards. If you must use the Internet, encrypt your e-mail, reject all "cookies," and never give your real name when registering at Web sites. Better still, use somebody else's computer. At work assume that calls, voice mail, e-mail, and computer use are all monitored. . . .
This advice, offered by the more zealous of today's privacy campaigners, is no longer considered extreme. These precautions only restore the level of privacy available to all people 20 years ago. Only recently did Microsoft remove a code from its operating system that allowed one's computer to be monitored on each activity. Attempts to protect privacy through new laws will fail--as they have done in the past. Fortunately, the same technology that is destroying privacy also makes it easier to trap stalkers, detect fraud, prosecute criminals, and hold the government to account. Thus, less privacy may also lead to more security for the law abiding.
And one last thing: Remember, cath labs, and other rooms in hospitals are video monitored. Don't get into a compromising situation at work. The administrators just love to pour over these videos. But that's good advice to live by. You don't ever want to hear those three loving words while making love, "Honey, I'm home!"
Drugs, More Drugs, More Criminals, More Prisons
The new Y2K Medicare Bulletin was received in November. Except for the first page, all subsequent pages listed the year as 1900. The revised Y2K Medicare Bulletin had a special letter inserted stating that this was NOT a Y2K error, but ""a printing oversight."" Unless the intelligence of a bureaucrat is in the imbecile range, not even they would enter 1900 as the year that succeeds 1999. The government, which has never made an accurate prediction nor ever admitted to any inaccuracies, can't even admit to an error when caught red handed in an obvious and glaring Y2K error. Those that trust the government for healthcare are in the same intelligence category.
New Mexico Governor Gary Johnson, who used drugs in college but none since, is the second governor to pronounce the war on drugs a dismal failure. He told the Taos Chamber of Commerce, "We are putting more and more money into a war that we are absolutely losing." He suggests that we legalize it, control it, regulate it, tax it. This might actually produce a healthier society. David Boaz, Executive Vice President of the Cato Institute, a Washington, DC, think tank, in an editorial in The Philadelphia Inquirer, states that after spending $30 billion a year in arresting one and one-half million people a year and creating 60% of all federal prisoners (violent prisoners are only 12%), we haven't made much of a dent in the flow of dope. This, he feels, is why more and more thoughtful people have been questioning the war on drugs and calling for decriminalization . The Cato Institute suggests that we have an honest debate on the subject. Congress should deal with drug prohibition the way it dealt with alcohol prohibition. The 21st Amendment did not actually legalize the sale of alcohol, it simply repealed the federal prohibition and returned to the states the authority to set alcohol policies in-tune with the preferences of their citizens.
Thanks to Dr John McCarthy of our own editorial board for raising our consciousness on this subject in the pages of this journal over the last several years.
A high-school-aged patient told me last week that it is harder for a teenager to obtain a can of beer than crack cocaine. It does sound like California's alcohol control policies are more effective than federal drug policies. Maybe taxing drugs like we tax alcohol could eliminate the income tax? But that would produce so much wealth that people could again afford private healthcare and HMOs might disappear. Then organized medicine wouldn't have much left to do except become a professional organization once again. And we could once again fill twenty tables at the Martinique Room at the Sacramento Inn the third Tuesday of every month.
The Political Football
"The Doctors Dilemma," an article featured in a recent issuer of The Economist, discusses the outcome of a fortnight of frenzied debate about the state of the National Health Service (NHS). There are, apparently, two things that "everybody knows." The first is that Britain spends too little on health; the second is that Prime Minister Tony Blair has promised a vast increase in health spending.
In America, socialists want to increase state control of medicine and base their argument on the two things that "everybody knows." The first is that America spends too much on health; the second is that the current administration and candidates have promised a vast increase in government control of medicine. Although sold as cost containment, the experience in America is usually the reverse.
Perhaps a closer look at medical care in Britain is called for. Britain spends a much smaller proportion of its GDP on healthcare as compared with the United States, Germany, France, and Canada - but this may not be a problem inasmuch as life expectancy in Britain is as long or slightly higher than that in the United States.
Life expectancy measures, however, are a crude assessment of health. The relatively small amount Britain spends on health shows up as poor survival rates from some serious diseases - British women with heart disease are four times more likely to die from it than women in France are; British women with breast cancer have one of the worst survival rates in Western Europe. Patients in Britain are also subjected to long waiting lists for surgeries. Saving money takes precedence over patient comfort.
The poor record in heart disease and cancer and long waiting lists are not the only factors that contribute to making the NHS so cheap to run: a relative paucity of doctors and nurses in Britain, allied with the difficulty of getting access to specialist treatment, also keeps down costs. Britain has the lowest number of doctors per 1,000 patients among the G7 nations, and Britain has about half the number of beds per patient as France or Germany, and fewer nurses as well.
In most Western countries, public funds, taxes forcibly taken from citizens under threat of coercion, account for two-thirds of health-care spending. Only in America do private citizens control half of health care spending. We are the last hope on earth for optimum healthcare determined by the recipients of such care. Otherwise we will join socialist-government-controlled paternalistic schemes, such as the one a British doctor told me about: This year eye exams are in and teeth exams are out. Last year allergies were covered. Orthopedists are still waiting for the time when hips will be in bloom. One can never predict what a politicians family is suffering from - which will then become next years priority disease.
What a shambles for our once noble profession. Are we on the goal line stance with the world watching the last hope for patient based medicine? Are we committed enough to place the medical football between the goal posts?
Happy 224th Birthday
This month is the 224th anniversary of the most successful experiment ever --The United States of America. Harry Newton, editor of Technology Investor, now in its sixth month, states we are presently enjoying the longest peacetime boom ever. A higher percent of us are working. Unemployment is at its lowest in 30 years. Productivity is booming. Companies are reporting record earnings. Except for physicians in practice, salaries are rising.
Physicians incomes are in disarray with a 100-fold variation between the two ends of the bell curve. Unless youre a Wintrobe that can charge a $5000 fee for a one hour consultation, that difference, if made from tax or premium dollars, is totally untenable. We will come to grips with that problem as soon as we agree that if we deal solely with patients and patients deal with their insurance carriers, our incomes will again be related to the quality of care we individually give our patients. We will no longer be castigated for what others are making.
We are living ever more comfortably in a stable democracy. After winning the Cold War, we are the envy of every country we dominate in the world. From Beijing to Buenos Aires, governments are privatizing state-owned companies and dismantling regulations. Privatizing social security seems to be working in Chile and is being seriously considered in the USA.
The book of the Judeo-Christian tradition, on which this country was founded, can again be used in our schools as a source for literary study on par with those of the Eastern and mid-Eastern religions. Clubs can again be formed in our schools representing all persuasions.
Fareed Zakaria, in his review in the New Yorker, traces the liberal and conservative dilemmas of the last three-quarter century. As conservatives have moved towards center, the two most successful left-of-center politicians in the world, Bill Clinton and Tony Blair, routinely cite balancing the budget as their proudest accomplishments. The late Bob Casey, former Democratic governor of Pennsylvania and champion of the weak, who then championed the weakest of the weak and became pro-life, beat his pro-choice Republican rival by over a million votes. He said abortion was not a question of when life begins, but when love begins. Casey told his fellow Democrats, who had once stood for these same ideals, that they had made a fatal political compromise. This is totally out of sync with their respective parties which some feel may no longer serve a useful purpose.
The sixties generation is now driven by work, money, and family particularly the children. Sue Shellenbarger points out, in her column, the creative return of families and the re-emergent importance of parenting ones own children.
Bernard Nathanson, MD, the abortion king who presided over 60,000 abortions, found himself bonding with the pre-born as ultrasound became common in the 1970s and he was observing the heart beat in a human fetus. In an article for the New England Journal of Medicine in 1974, he stated that there was no longer any doubt in his mind that human life exists within the womb from the very onset of pregnancy.
The same journal subsequently published an article about 10 pregnant women who came to an abortion clinic and were shown ultrasound pictures of their fetus. Only one went through with the abortion. The others bonded with the human in their body and left the clinic pregnant. George Will stated in his column, when Roe v Wade can be repealed it will no longer be an issue.
Ron Unz, a Silicon Valley software entrepreneur and author of Proposition 227, stated in his Wall Street Journal article that "Anti-Roe Doesnt Mean Anti-Abortion." Of all countries, the U.S. is best equipped to manage irreconcilable ideological differences. Thanks to our federalist political structure, the country has been able to accommodate a level of ethnic, cultural and religious diversity that under different institutions would have led to Balkan-style violence. Thus in libertine Nevada, gambling and prostitution are legal, but both are unlawful abominations next door in Mormon Utah. He states that overturning Roe v Wade would not mean the end of legal abortion in America. Rather it would allow each state or even each local community to reach its own equilibrium on the issue. Twenty seven years of animosity and killing would come to an end. In the process we would not only be reaffirming that the words of our Constitution actually mean what they say, but invigorating the democratic process.
The recent public support by 22 Republican members of the California Legislature (including those most ardently pro-life) of a federalist solution gives hope that this approach is gaining political momentum, at least on the right. If we extend this federalism to all areas of ethnic diversity, moral behavioral and ethical differences, we could then say, "Happy Birthday Uncle Sam. Youre good for another 224 years."
The Obesity Epidemic
When I had my annual physical examination earlier this year, my doctor told me that I should lose 25 to 30 pounds. Having recently listened to an audiotape on the subject, I remembered that it takes 10-12 calories per pound to maintain ones weight.
I calculate that my current diet was about 2500 calories per day. With one pound of body fat equal to 3500 calories, I knew if I removed a fifth of the food from my plate, I should then lose one pound a week.
I must have decreased my intake by more than 500 calories; in eight weeks I had lost 12 pounds and in 16 weeks I had lost 20 pounds. We then had guests and the process had to be delayed. It allowed my body about a month to readjust and gave my clothiers time to take in the waist on my slacks by a couple of inches. I will have no difficulty removing the remaining 5 or 10 pounds when I return from my summer vacation. Losing weight is simple, even if it isnt easy.
Searching the archives in my study, I found an audiotape from 1985 titled, Diets Dont Work by Bob Schwartz (Breakthru Publishing, $9.95). Schwartz owned 16 health clubs at age 30 when he put on an extra 40 pounds. Ten years and 100 diets later, he had lost more than 2,000 pounds and gained back 2,001 pounds. He decided it made as much sense to study fat people if youre interested in losing weight as to study poor people if youre interested in making money. So he began to study the club members who seemed to stay thin without any effort.
He came up with a number of tips. Eat only when you are hungry. Stop eating when youre no longer hungry rather than when youre full. Dont dine out more than once or twice a week; restaurant food is usually higher in fat, calories and salt. Avoid sweet rolls, donuts, pastries, most desserts and candy.
He points out that people exercise for the wrong reasonto lose calories. Exercise is important in the overall health program, but it takes 30 minutes of aerobic exercise to work off 12 corn chips. Very few exercise enough to even work off one dessert. The slowest eater can eat more calories than the most vigorous exerciser can lose.
According to Schwartz, the diet industry was spending $33 billion in 1985 to convince us that the only way to lose weight is through dieting. He cited a statistic that 190 people out of 200 do not meet their first goal in the weight reduction programs. Of the 10 that do, nine regain the weight lost and only one of the 200 maintains the weight lost. This, he felt, proved that diet's don't work. The diet industry countered that all 200 had lost weight, 10 reached the first goal and, therefore, diets do work its people that dont.
Ive had many patients who have joined various programs, lost an expected amount of weight and then are rewarded with a "decadent dessert," which, of course, perpetuates the industry and keeps half of Americans overweight.
This idea was highlighted in a book which appeared about the same time, Does Dieting Make You Fat? by Geoffrey Cannon and Hetty Einzig (Simon & Schuster, $15.95). It pointed out that, all too often, dieting contributes to the very condition it is meant to cure. Many people think of diets as a temporary unpleasant experience before they can return to their previous eating habits.
More recently, patients turn to the web for diet information. Email comes in weekly offering free diets, how to lose weight while eating everything you want, or even ow to get paid for dieting and losing weight.
The Tufts University Health & Nutrition Letter, in a recent supplement, rated the weight-loss web sites. Of the free sites, Tufts chooses the easy-to-use "Shape Up America" site, www.shapeup.org, operated by former Surgeon General C. Everett Koop, MD, who also operates the fee-based "Shape Up and Drop 10" site. However, of the fee sites, Tufts recommends the "eDiets" site, www.ediets.com.
Brown University researchers found that people who had regular online interaction with a dietitian lost more weight than those who simply down loaded a weight-loss plan to follow themselves.
There is a lot of misunderstanding about diets. For instance, a retired bank executive recently couldnt understand his 18-pound weight gain over the previous 12 weeks. He had obtained dietary counseling and was told that fruit was a free addition. We determined that the fruit he ate contained 750 calories per day, or 5300 calories a week.
Some people wonder how they are supposed to know what to eat if their doctor doesnt tell them. So I gave my largest diet (2000 calorie) to one of my sleep apneic patients whose weight has always been above 350 pounds. Her initial response was that she doesnt come close to eating that much. However, within one month, my scale weighed her at 344 pounds. I guess well see if diets sometimes work.
Received the following note from the Department of Health Services: Dear Dr Meyer: Medi-Cals Medical Case Management Program has been coordinating the medical services needed by your patient, xxxx since August 6. Effective October 28, Medi-Cal will no longer provide case management for the following reason: PATIENT EXPIRED. This decision does not affect your patients Medi-Cal eligibility or his/her ability to receive medical services from you. If you would like further information, or if you feel at a future date that your patient needs medical case management, please feel free to contact Jane xxxx, RN, at 916-255-xxxx. . . . I guess that says it all.
Two patients discussing their last appointment: How long does an office call take these days? Well before I could say, "health main-te-nance org-an-i-za-tion," my check up was over.
Reminds me of a doctor some decades ago who designed his office with two doors and no chairs. He stated that in many cases, he could glad hand the patient at one door, put on the smaltz, listen to the heart and lungs while walking, write the Rx at the standing desk and usher the patient right on through. He bragged that only about one in ten required the use of the examining table presumably for the occasional abdominal exam. This efficiency was only superceded by the one-line entry on the 4 x 6 inch medical record card which never caused him to break his stride. . . Wonder if today he has a desk outside the second door for the required lengthy medical record to cover the E & M guidelines?
Overheard at a business round table discussion: Sending money to Washington is like pouring blood to sharks you have a feeding frenzy.
A fellow member called to me across the parking lot at Mercy San Juan Hospital recently asking me why we let the society close the library? With MSJH reducing their library staffing by 50% and decreasing the number of journals, he felt that eventually all the hospitals would be essentially eliminating this nonrevenue-producing function. He felt that a medical library benefits doctors primarily, and the doctors should always be assured that they own their repository of medical information.
Just received the latest issue of California Physician. Nice looking journal with lots of pages. Too many to read as it comes in the mail so it is placed on the stack for later, more-serious reading. Unfortunately, for many physicians, this comes after retirement. I noted that California Physician has been quarterly for over a year, and six issues had accumulated on my credenza unread. I then started asking the doctors in the staff room what they thought of the new format and if they are reading it. The majority response was similar more than can be quickly read with time never increasing. In the past they were able to spend five or even ten minutes with it every month before being interrupted, but that was still an hour or two per year. Everyone I spoke with had not spent an hour on the new format during the past year. Another case where our administrative leadership comes up with a more beautiful, cost-effective, although less useful product. Will the same fate await our Sacramento, El Dorado and now Yolo readers? Will we get out of the monthly habit and lose touch even more? Feel free to email your comments.
Contact Del Meyer, MD
Phone: (916) 488-5864