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Voices of Medicine by Del Meyer, MD
Jan/Feb | March/April | May/June | July/Aug | Sept/Oct | Nov/Dec
| Payment for quality performance, legislators practicing medicine, similarities of sex and medical care, the consequences of not receiving timely care. |
In the President's Point of
View column of Santa Barbara County Medical Society’s Medical Society News of July/August 2005,
Dennis H. Baker, M.D., wrote:
“In 1999, when the Institute of Medicine published its reports, ‘To Err is Human’ and ‘Crossing the Quality Chasm’ pointing out the high prevalence of medical errors. Since then, policymakers at all levels have been looking for ways to repair the situation where, it is said, tens of thousands die unnecessarily and where billions of dollars are lost each year due to mistakes made in hospital and outpatient settings. While many argue the basis and methodologies used for these figures, the fact is there are wide variations in the quality of care provided in this country and, that efforts to remedy the situation can save valuable lives and resources.
“Clearly, the leadership for these efforts must come from medicine itself. Only the profession and its physician leaders can properly balance the factors that directly impact quality and cost of care. Leaving this work to payers or the government will only result in harm to patients, physicians, and the profession of medicine. It is increasingly likely that the federal government will soon mandate performance measurement and payment for quality performance. Called ‘pay for performance’ (P4P), or as it is known in proposals on Capitol Hill, ‘value based purchasing’ would tie Medicare payment to physicians to objective measures of improvement in the quality of care we provide.”
To read more of this article, go to www.sbmed.org/webpages/publications.asp.
In his “Mert’s Musings” in the Fresno-Madera Medical Society’s Vital Signs, Executive Director Mert Scholten wrote to legislators:
“Quit trying to practice medicine! OK, So you don‘t really practice medicine, but many of the decisions you make on legislation proposed (and too often adopted) have a direct influence on the way in which medicine is practiced. And that may not be good for either patients or doctors.
“A case in point: requiring 12 hours of continuing medical education in pain management for virtually all physicians other than pathologists, anesthesiologists, and radiologists. This law grew out of a professional liability, case wherein the family of a dying, patient charged that the doctor did not properly manage the gentleman’s pain though the patient himself did not seek additional pain relief nor complain that his pain was unbearable.”
Read more at www.fmms.org/default.asp (membership required).
As physicians, we well know that simply seeing a loved one in bed and maybe even unconscious causes the family member more pain than the patient is experiencing, just as in the example that precipitated this unconscionable law. The rest of the article details the downside of legislators practicing medicine without a license and how it harms both physicians and patients. Physicians are well able to determine their Continuing Medical Education (CME) needs. Should the legislators that voted for this law be prosecuted for this offense of making medical decisions without a medical license? They are not experts in medicine; it seems difficult to find any field in which they have any expertise.
While legislators reduce us and our practice to hard facts, we would do well to remember a comment in last month's Mars Hill Audio Journal: Twenty years ago, writing in The Wilson Quarterly, the literary critic Cleanth Brooks noted that: “A world reduced to hard facts would thereby become a dehumanized world, a world in which few of us would want to live. We are intensely interested in how our fellow human beings behave — in their actions, to be sure, but also in the feelings, motives, purposes that lead them into these actions.” In this case, even the facts were not factual.
In the Humboldt-Del Norte
County Medical Society Bulletin, Luther F. Cobb, MD, started The President’s Message: with a
one-word headline: SEX. He continued:
“Now that I have your attention, it occurs to me that there are several similarities between the average American’s attitudes toward sex, and their attitudes toward medical care. In the spirit of David Letterman’s famous Top Ten list, I offer my modest version of a Top Five list on the subject.
“REASON #5. Although not everybody is interested at all times in getting some, at certain critical points of their lives it becomes a very prominent concern.
“REASON #4 Most Americans believe that obtaining it is a basic human right, to which they are entitled just for being here.
“REASON #3 Most Americans agree that their usual and customary provider doesn’t give frequent enough, prompt enough, or good enough quality service.
“REASON #2 Many people think to get the exotic, high-tech, cutting-edge level of service they have to leave town, but they’re often disappointed to find once it’s over that the attention received was a lot less personal.
“AND THE #1 REASON IS:
“People think it’s a sin to pay for it.
“While the above is definitely offered in the spirit of good humor, it does occur to me that it’s a lot more truth than joke. We really do have a different attitude in this country toward medical care than we do about any other economic enterprise, other than warfare. There is a serious disconnect… "
Internist Mark K. Belknap, MD, President of the
Wisconsin Medical Society, argued that
society must lead the way in reforming health care. He used this example in his
article:
“A 50-year-old female convenience store manager from the Upper Peninsula of Michigan was recently referred to me from the emergency department (ED) for evaluation of heart failure. She had presented to the ED with progressively severe shortness of breath and leg edema. She had no health care insurance and had not seen a physician for several years. Following an episode of rheumatic fever as a teenager, she had a history of a murmur. An echocardiogram was performed, and it showed severe mitral stenosis and severe pulmonary hypertension. I referred her for cardiac catheterization, which confirmed the findings of the echocardiogram, and she underwent mitral valve replacement. Several aspects of this patient’s case are typical in patients without health insurance. Because she had no personal physician, she initially presented to the ED, where care is much more expensive. Her costs exceeded $60,000 and she has since applied for “compassionate care.” She presented at an advanced stage of her disease because she had not had regular ongoing health care. It is likely that she developed rheumatic fever and, subsequently, mitral valve disease because of lack of access to care for her initial episode of streptococcal pharyngitis. As a consequence of her need for mitral valve replacement, she will need lifelong anticoagulation with warfarin, with its attendant cost and risks. It is uncertain at this point how much of her pulmonary hypertension is reversible, and she may continue to suffer the morbidity of this condition because she did not receive care in a timely manner.”
| Measuring quality care, another society’s history, and a boost in license fees |
From the President’s Message
in The Bulletin of the Humboldt-Del
Norte County Medical Society, by Luther F. Cobb, M.D:
“The elephants are dancing in
Washington, but it’s a minuet, not the jitterbug. As I write this, only two months
remain until the SGR (Sustainable Growth Rate) formula is due to operate to reduce
Medicare reimbursement by about 5%. As you probably know, the SGR formula links
Medicare reimbursement to the gross national product, which basically has nothing to
do with the growth of the Medicare population or their medical needs. The good news,
we are told, is that Congress really, truly does understand that this is a bad
formula and doesn’t want to let this reimbursement rate fall at the level that is
scheduled. The bad news is that Congress is demanding ‘something in return.’ This
appears, will be Pay For Performance, or P4P for you lovers of hip-hop style
acronyms.
“Paying For Performance. That
sounds like something we should all get behind, like apple pie, motherhood, and the
flag. (Come to think of it, even those are controversial these days). The basic
underlying idea is that, as Medicare is currently run, every ’provider’ (I hate
that word!) is reimbursed at the same rate for the same (CPT –coded level of
service, Of course with fudge factors added in for geographic variations, etc. (And
again those are the source of much consternation as well — see
GPCI.) So, shouldn’t we reimburse the ones who do the very best work at a
higher rate? Won’t that save lives, add to quality, and reduce all those
preventable deaths we all know are out there being killed by less competent
’providers’?
“Well, to re-use a very trite
phrase, the devil is in the details. How exactly do we measure ‘quality’? It’s
not as if it is a new concept, or that physicians and lay groups haven’t been
trying for a very long time to do exactly that. Now, of courts, if it’s going to be
worth MONEY, it’s going to be worth a fight too. I have talked with folks at the
CMA who are intimately involved with this process, including Ron Bangasser, M.D., a
former CMA President and a really smart and energetic guy…
“Well, Ron confessed, the
working groups couldn’t come up with a single criterion for surgery that they
thought would withstand scrutiny. So, there will be NO criteria for surgery, at least
as things currently stand. Well, maybe that’s a good thing…
“Because these criteria must
be objective and verifiable, they almost have to be limited in impact. I also think
they’re highly likely to be unfair. I could be wrong, and maybe this really is the
best thing that could happen. But it reminds me of the debate at the time of he
original passage of the Medicare legislation. When AMA representatives expressed
concern about the control that was being given up over the practice of medicine, they
were reassured that ‘“the only thing that will change will be the signature at
the bottom of the check.’”. I think we all know how that turned out. What will be
reimbursed under these rules will be things that will be quantifiable and clear-cut,
which will practically demand electronic medical records and data retrieval. This
could well be a huge unfounded mandate, because whatever the P4P reimbursements, I
really doubt they’ll cover the cost of the currently available EMR systems, which
still, of course, aren’t interoperable. A lot of this information will go whizzing
over the Internet also. Despite HIPAA, I suspect a lot of this information will get
out; after all, we hear almost weekly of equally sensitive information, like credit
card numbers being stolen by hackers. This criteria may be simple and straightforward
now, there’s a huge potential for creeping imperceptibly into more basic areas that
may threaten our independence as physicians. In a lot of ways, this concept reminds
me of the ‘“No Child Left Behind’” federal education legislation, which is
wreaking havoc in public education as we watch from the sidelines…
“So, maybe I’m just a
technophobic curmudgeon. Certainly my skepticism won’t be the deciding factor in
whether this gets through Congress or not, because it’s pretty much a done deal. I
just suggest we watch out, pay attention, and consider whether there is some level
beyond which our tolerance for intrusion will be exhausted.”
The full article is on the society’s website. Go to www.humboldt1.com/~medsoc/images/bulletins and click on November 2005.
Excerpts from a Foothill Medical Bulletin, by Ted Bacharach, MD, .First Centennial
Edition of the History of the Placer- Nevada County Medical Society 1889-1989:
“In the annals of medicine
and surgery, 1889 was not a particularly memorable time, but it was the year
Physicians in Placer County organized a local medical society comprised of Placer and
El Dorado counties. Nevada County had its own organization, the Grass Valley Medical
Association, founded in 1865. They merged with Placer County to form the
Placer-Nevada Society in 1904.
“In the years to follow
membership extended…into Sierra County, and the society was renamed the Placer,
Nevada, Sierra, El Dorado Medical Society. In those days, the meetings were held at
noon because the doctors had to come by horseback or by horse and buggy, and many of
them stayed overnight in Auburn. Because the roads were so poor, physicians in El
Dorado County joined the Sacramento Society for Medical Improvement in 1940 and in
1961 Sierra County doctors became affiliated with the PlumasModocPlurnasModoc Medical
Society….
"Physicians apparently
were preyed upon by insurance companies even during the l800s, as evidenced by a
resolution passed in 1896 refusing to examine candidates for life insurance for any
fee less than $5 per applicant.”
The full article, at www.pncms.org/mc/page.do, unfortunately can be accessed only by society members — an increasing hindrance to a wider audience for physicians’ messages.
Excerpted from New Laws 2006:
Elimination of Medical Board Cost-Recovery, by Catherine I. Hanson, Esq.
“CMA was also successful in
eliminating the ability of the Medical Board of California (MBC) to charge individual
physicians for the costs the MBC incurs in investigating and prosecuting disciplinary
actions. After monitoring the impact of this practice for over a decade, CMA
determined that ’cost recovery’ improperly increased the potential for abusive
prosecutions and unfair settlements, as the financial stakes were increased to the
point that it was virtually impossible for physicians to challenge even baseless
accusations of wrongdoing. The revenue impact on the MBC will be moderated by a
modest increase in fees spreading the amount previously collected in cost recovery
across all physicians.”
My comment: CMA supported the
astronomical increase in licensure fees to $600 some years ago because that would
cover the cost of physician investigation and prosecution. It was justified because
it would distribute that cost among all physicians. Almost immediately, the MBC began
extracting the cost of physician investigation and prosecution from individual
physicians, in addition to these exorbitant fees. Let’s hope this increase in
license renewal fees again by nearly $200, under the same pretense, isn’t a replay
of past subterfuge.
| A hospital crisis, an epidural that wasn't and the curse of interesting times |
Luther F. Cobb, MD, wrote on
"Crises" in his president's message in The Bulletin" of April 2006, published monthly by the Humboldt-Del
Norte Medical Society. [This is an important message for our medical society. For
background of the hospital crises in Humboldt, and how important the issues are to
physicians who can only speak effectively through their medical societies, and read
one of the Op-Ed articles at www.humboldt1.com/~medsoc/images/bulletins/APRIL%202006%20BULLETIN%20for%20web.pdf.]
"I'll admit that I don't speak or read Chinese, and
it may just be an urban legend. But I've been told that the Chinese character for the
concept of 'crisis' is the conjunction of the pictographs for 'danger' and
'opportunity.' This strikes me as an appropriate metaphor for the recent events
locally with St. Joseph Hospital. I'm sure we all have our own ideas about the
reasons for the current difficulties, and many of us in the medical profession, as
well as elsewhere, are only too happy to point out our own candidates for scapegoat.
However, I don't think that gloating over others' misfortunes or misjudgments will
get us very far, even though it may be a personally satisfying exercise in
Schadenfreude.
"We often talk about being
behind the 'Redwood Curtain,' but I think a more appropriate metaphor may be a
goldfish tank. You may have noticed while feeding your (or in my case my college
kid's) fish in an aquarium that while you're putting fish food in the top of the
tank, the fish have to swim around in water containing the ultimate processed residue
of the food you put in over the last days and weeks. It seems to me that we often
battle over issues pertaining to our own little share of the medical universe, trying
to look out for our own. Certainly, there must be a goodly amount of attention paid
to our own turf and responsibilities. But I also believe that we ought to be
considering the future welfare and viability of the system as a whole. We are
participating in building and maintaining the system that will be around this area
for a long time to come. When we need medical, hospital, and yes even nursing home
care for ourselves and the rest of our family, we will have to contend with the
system that we have created together…
"I have discussed the
participation of the Medical Society with Joe Mark, the new CEO of St. Joseph
Hospital, who is open and welcoming to our organization's help and advice.
"This apparently dangerous
situation may turn out to be a great opportunity for ourselves, our patients, and the
whole community. I certainly hope so."
To read the entire message, go to www.humboldt1.com/~medsoc/images/bulletins/
An Epidural to Remember
The Spring 2006 Sonoma Medicine, the magazine of the Sonoma
County Medical Association was devoted to clinical empathy. One article, The Saline
Solution by editor Steve Osborn, began this way:
"The
placebo effect has been defined as 'a physical or emotional change, occurring after a
substance is administered, that is not the result of any special property of the
substance.' As part of this theme issue on clinical empathy, we decided to
investigate the placebo effect, so we sent local physicians an informal survey
consisting of the following question: 'What experiences, if any, have you had with
the placebo effect when caring for your patients?'"
This was one response.
"The most amazing placebo
response I ever witnessed was as a scared first-year resident doing OB. A very obese
woman came in with active labor. When I went to check on her, she was already
completely dilated, and the head was well within the vagina.
"'Time to push,' I said.
"'No way, not without my
epidural!' she exclaimed adamantly.
"'Please!' I begged.
"'No!' she replied, and laid
down and groaned and screamed for her epidural.
"'OK, OK!' I shouted, and
demanded the nurse bring me the epidural cart.
"The patient sat up
obediently. With trembling hands, I cleaned the skin and proceeded to push a spinal
needle through the layers of fat toward what I prayed was an interspace. No luck:
bone. I withdrew the needle.
"Before I could say anything,
the patient promptly laid down, said, 'Thank you,' and proceeded to push out a
healthy 9-pound boy.
"'Thank you, doctor, for
giving me the epidural,' she said. 'My friends were right: it really helps.'
"Speechless, I merely
stammered, 'You're welcome.' —Herb
Brosbe, MD"
To read the
other placebo stories, go to www.scma.org/magazine/scp/sp06/osborn.html
In the Santa Barbara County Medical
Society News, president Christopher V. Lambert, MD' wrote A Point of View.
"'May You Live in Interesting
Times…' Ancient Chinese curse
"…We are living in
interesting times for medicine, needless to say. Change and challenge approach us
from many directions. My focus this month is on the ever growing influence of
government on the practice of medicine, and our need to be involved.
"Lee Hamilton spent 34 years
in the United States Congress. He chaired the 9/11 Commission, and now heads the
Center for Congress at Indiana University. He is in his early 70's and still actively
involved in leadership. He was interviewed recently on CSPAN, where the discussion
turned to the Abramoff investigation. Hamilton was asked what changes he had observed
in Congress over his 34 years.
"He replied, 'There has been a
sea change in the mindset of people about government. When I was elected to Congress
in 1964, the constant theme I remember was "get government off my back,"
which I heard from everyone. Now, what you hear is, "what can government do for
me?"'
"…This observation certainly
holds true for health care. The federal government first intervened in healthcare
with Medicare and Medicaid, then with EMTALA (Emergency Medical Treatment And Labor
Act) and other unfunded mandates, now with Medicare Part D. Meanwhile in California
the number of legislative bills involving health care sent to the State Assembly
expands ever more rapidly. Issues of reimbursement, contract dispute resolution,
scope of practice, even continuing education mandates all have the potential to be
passed into law. While one can wish for a simpler local solution to many healthcare
issues, the size and complexity of the health care system makes government
legislative solutions the 'arena of last resort.' We must acknowledge this reality,
while insisting that decisions at the legislative level need to be made in the best
interests of our patients and our physicians, and that in order for this to happen
the legislators must receive accurate and timely information, guidance and opinions
from us. This requires constant diligence on our part. We must accept the importance
of lobbyists and political contacts to move our agendas forward."
The entire President's message, is
at www.sbmed.org/public/components/societytools/admin/viewNewnews.asp?newsjob=ArticleID&ArticleID=6820&ArticleName=President%27s+Point+of+View++January%2FFebruary+2006
| Opinions on Ads by Physicians, Patient Contact by Anesthesiologists, and Best Doctor lists |
Dr. Emily
Dalton does not like physician advertising, as she makes clear in “Physician Advertising: Compromising Ethical
Standards in Surrender to the Relentless Capitalistic Model of Corporate America.”
The article is in The Bulletin of May 2006, a monthly publication of the Humboldt-Del Norte County
Medical Society.
"Is medicine a profession? A business? A calling?
All three? What is it that distinguishes a profession from a simple trade? Most
experts agree that the difference lies in a code of ethics. When professionals are
required to adhere to a strict ethical code, that profession, in return, receives a
special trust from the public. In medicine, everything we do depends on trust.
Imagine a patient encounter fraught with mistrust: they don’t go very well. A
medical professional is perceived as being bound by ethical rules that prevent
exploitation of his/her special skills and knowledge, and this creates trust.
Advertising undermines that safe haven of trust.
"There is a difference between
the doctor-patient relationship and other types of business transactions. Physicians
have a moral obligation to provide the best and most appropriate medical care
possible, regardless of financial profitability. Patients need health care;
their lives depend on it.
"Patients are not in a
position to able to shop around — they lack the financial resources to flit from
office to office to compare doctors, and they lack the medical
knowledge to know good medical
practices from bad ones. In fact, businesses that help physicians advertise their
healthcare practices recognize this well and do not hesitate to take advantage of it.
Healthcare Success Strategies is one such business that comes up easily on Google.
They note that: 'The practical reality of clinical care is that most patients cannot
judge the quality of clinical care unless it’s really bad and/or painful. Patients
generally assume most providers to be of roughly equal quality or you wouldn’t have
a license to practice…. Truth be told, the public has a hard time distinguishing
your quality of care from anyone else. Fortunately you can now borrow the best
techniques from corporate America…(to better market your practice).'”
The entire
article is at www.
humboldt1.com/~medsoc/images/bulletins/MAY%202006%20BULLETIN%20for%20web.pdf
J.
Antonio Aldrete, MD, MS, writes about “Quality vs. Quantity of Patient Contact” in the
Winter 2006 bulletin of the California Society of Anesthesiologist.
"While interviewing numerous medical students
contemplating anesthesiology as their future specialty, one definite concern
frequently surfaces. In their abstract idealism they expressed, in one way or
another, a genuine pre-occupation for the amount of patient contact afforded by
anesthesiologists in their daily practice. Though the acute care and prompt problem
solving of our specialty attracted them, what they have seen and/or heard in their
experience at medical school regarding anesthesiologists being in contact only with
sleeping patients caused them alarm. That image hangs on us, justifiably or not, but
it does and must be changed.
"In reality, our contact with
patients, though perhaps shorter in duration when compared to other specialties,
occurs at a time crucial for our patients, at a moment when major events in their
lives are about to happen. When we first see them in the preanesthetic interview,
they are concerned about a number of unknowns. Do they have cancer? Are they going to
be able to walk? Is their sexual activity going to change? Are they going to be left
without a breast, a leg, a hand, et cetera? How much longer are they going to live?
Will they survive the operation? [This is] only to mention a few of the more frequent
worries that surgical patients may have the day before their operation.
"Our visit must provide
assurance and confidence and not produce more worries. This is indeed a precious time
when we may alleviate some of the patient’s concerns about their operative and
anesthetic experiences. What better time to explain our role in watching over their
vital functions, to explain the careful administration of potent medications used
during anesthesia, to warn over possible complications, to emphasize how our
technique may ameliorate immediate postoperative pain, et cetera?
"It may be a short contact,
but if properly conducted, that interview may play not only a valuable support of the
patient’s emotional status but also an informational activity of what we do and how
we do it, at a moment when the patient’s attention is all ours. This can be
extended during our encounter with them in the operating room; there, we have from
five to 30 minutes, depending on the preparation for the operative procedure. While
performing our functions we can literally 'chat' with them, explaining what we do and
why we do it and then they will be more willing to accept the pain of a needle stick,
the removal of a gown, the discomfort of lying on a hard operation table…. Finally,
let’s make the post-anesthetic visit more than a 'hi' meeting; let’s make it a
real visit…
"So, there is my answer to the
inquiring potential resident candidates; the contact with our patients may be brief
(as measured by units of time), but it is in crucial moments of the patient’s life,
dealing with life and death matters; thus, we can make it one for them to remember
and appreciate, if we just take the time.
“The preanesthetic interview, the
O.R. encounter and the postanesthetic visit(s) are what we make of them, as short or
as lengthy as we wish; as important or as irrelevant as we want to think they are.”
The entire article may be viewed at
www.csahq.org/pdf/bulletin/issue_11/Quality054.pdfA
Few Good Doctors: Don't look for them on a magazine top-10 list.
Kent
Sepkowitz, a physician in New York City who writes about medicine, has some choice
words about magazine “best doctor” lists.
"About this time every year,
doctors across New York City begin to cast a wary eye at local newsstands. When the
bundle of New York magazine’s 'Best Doctors' issue drops onto the
pavement, torture commences for the city’s prim and laconic physician class. (Other
cities get their chance at other times of year.) It’s high school all over again, a
life lived at the mercy of cruel arbiters of who is up and who is down. To their
credit, I suppose, the compilers of the Best Doctors list define worthiness with more
objectivity: They poll local doctors and ask whom they would refer a family member
to. With this quasi-statistical information in hand, they go behind closed doors and
construct the dreaded list.
"To my expert eye, every year
the New York survey gets it about half right: Half of the selections are
first-rate doctors, no doubt about it. Another 25 percent are people whom I don’t
know well (though I have my doubts), and 25 percent are certifiable duds — doctors
who (hopefully) haven’t seen a patient in years but have risen to the lofty realm
of high society and semi-celebrityhood.
"Of
course, the list isn’t really about accuracy or quality. It’s about sales — not
only of doctors’ services but also of fancy plaques, directories, and
pen-and-pencil sets fitted into paper weights…" To see the entire article, go
to www.slate.com/id/2143506/
| “Time’s fun when…”, the three S’s of insssurance companies, liability risks of team docs |
“Time Flies” was the title the president of
the Humboldt-Del Norte County Medical Society, Luther F. Cobb gave to his
farewell message in The Bulletin of
May 2006
“As the saying goes, time flies while you’re having fun. Or, as I’ve
been told Kermit the Frog pointed out, time’s fun when you’re having flies. In
either case, it is somewhat of a surprise to realize that this is the last column I
shall write as the incumbent president of HDNCMS…
“I suppose it can be said in almost any day and time that things are tough
and that the good old times were better, but I really do believe that our noble and
beloved profession faces a set of challenges unprecedented since the days of the
Flexner Report a century ago. As you all know, great forces are arrayed against the
interests of medical practitioners and their patients, mainly in the service of the
various corporate greed of Big Pharma, insurance companies, and the government. None
of these malfeasors appear to believe that the medical goose that laid the golden egg
of modern scientific medicine can be slain. (Please pardon the tortured metaphor.)
Well, there are a lot of us who refuse to go down without a fight. My successor as
president, Dr. Ellen Mahoney, in addition to being the only person in the world able
to put up with me as a spouse, is a terrific organizer and thinker. She and Dr. Ann
Lindsay, another phenomenal talent we are fortunate to have in her many roles in our
community, are hard at work on a truly audacious and innovate project that has the
potential to revamp and revitalize the practice environment behind the Redwood
Curtain…
Dr Cobb’s complete article, including his plan to
campaign for CMA office, appear in www.humboldt1.com/~medsoc/images/bulletins/JUNE%202006%20BULLETIN%20for%20web.pdf.
In the same issue of the Bulletin, Stephen Kamelgarn, MD, wrote an
opinion piece:
“The May 25, 2006, issue of
the New York Times had an interesting little article titled ’The Check is
not in the Mail.” This article did a good job illustrating how doctors are not getting
reimbursed by insurance companies for legitimate services rendered. The companies
engage in all sorts of stalling, shenanigans and subterfuges (the 3 S’s) to avoid
paying the bills.
“The companies will
’lose’ claims, even those submitted electronically (a tough thing to do). They
will obfuscate. They will dispute. They will delay payment. If any of us tried that
trick when we have to pay our own health insurance premium watch what would happen;
do the words ’cancelled policy,’ strike a familiar note?...
“When we couple the poor
payment practices of the insurance companies with their generally abysmal
reimbursement rates, is it at all surprising that more and more of us are opting out
of the insurance game altogether: we become contract workers, or we accept cash only
(thereby limiting our services to those who can afford to pay), or we opt out of
medicine altogether?
“In a nation where over 45
million people have no health insurance, and many of the rest of us are under insured
in the form of high co-pays and deductibles and exorbitant premiums, it is no wonder
that, far and away, the largest source of personal bankruptcy in the United States is
from costs incurred from severe illness. We spend more money, per capita, than any
other nation on Earth for health care, yet we are at the bottom of the list of
industrialized nations for how well that health care is delivered — we’re getting
less bang for our healthcare buck. Poll after poll shows how the American public is
overwhelmingly in favor of some form of single payer health care.
“Many, if not most,
physicians are in favor of single payer, and even organized Medicine is officially
entertaining the notion of a single payer healthcare system. Yet we remain with this
sadly broken system that solely benefits the insurance industry and their
investors...
The complete article is at the website above.
[But, Doctor Kamelgarn, don’t we have a
choice? We can stop taking Blue Cross, we can stop taking Medicaid, we can stop
taking Medicare, we can stop taking any HMO we desire. But if only Uncle Sam were
responsible for paying us, like in Medicare, many physicians may have a great deal of
difficulty getting Uncle Sam to write that check on time or ever. — D.M.]
Dr. Stephen S. Hurst, MD wrote on “Assessing
Liability Risk For a Team Physician” in the June issue of the Bulletin of the San Mateo County Medical
Association.
“The discussion of the sports
team physician’s medical liability risks begins with a question. Who pays the team
doctor?
“The answer, of course, will
differ depending on the level of competition, the sport, and the sports market. At
the high school level, where I have enjoyed my role as team physician for nearly 40
(seems like only 10) years, and teams junior to it, any stipend offered should be
waived so that the physician may enjoy the umbrella protection provided by the Good
Samaritan laws of the state of California while on the field. If the physician
continues to follow the patient after having provided on-the-field emergency care,
fees can be charged and the liability game is ”on”…
“Physicians who act as team
doctors must also be ready to treat on-the-field emergencies that may [not] be
covered by our normal job description. It is hoped that the immediate stress of the
situation will allow us to recall some basic facts from our medical student and
internship rotations. As an orthopaedist, I have had to provide pre-participation
physicals that require some knowledge of medicine, infectious disease, cardiology,
neurology, urology, dermatology, and pediatrics, just to name the most commonly used
disciplines…
“At the college level, the
selection of the team physician is often the result of past political networking.
Fortunately, the job usually goes to that person who has shown an interest in the
care of athletes and has earned a sports medicine reputation by enabling the athletes
to return to competition rapidly and safely. The medical care usually is provided on
a fee-for-service basis and most college athletes are insured by the university or a
student athlete health plan. Occasionally, there also may be a small retainer fee.
Again, these college communities rarely have a shortage of subspecialtists and often
have affiliated medical schools to provide the required expertise. This greatly
reduces the potential for legal action…
“Payment arrangements for the
treatment of the professional athlete may be very different from those described
above. I am certain that you, my medically sophisticated and informed audience, will
be surprised to learn that in most major sports markets for the high profile NBA,
NFL, MLB teams, the orthopaedist pays for the privilege of providing these
services because it is the best advertising and practice-building tool available.
These positions are very high-profile marketing "dream" deals that almost
guarantee a large, lucrative practice…. On the flip side of the equation, this is a
very high-risk occupation with tremendous public and media scrutiny. Professional
team physicians are subject to medical practice suits at a higher rate than the
general orthopaedic population...
To read the entire article, please go to www.smcma.org/Bulletin/BulletinIssues/June06issue/Assessing%20Liability.html
| A Critical Response Team of Physicians?, and Re-evaluating the Role of Doctors. |
George Ingraham, MD, calls his
article “A Missed Opportunity,” in the In My Opinion column of the August 2006
issue of The Bulletin, published monthly by the Humboldt-Del Norte County Medical
Society.
“On April 27 of this year
Cheri Lynne Moore, a 48 year old woman suffering from a bipolar disorder, ran out of
medication and decompensated. She began playing her stereo at high volume, yelling
insults at the people walking along G Street outside her apartment, and threatening
them. At some point she displayed a weapon (“brandished” is the term used by law
enforcement), which brought her to the attention of the Eureka Police, who evaluated
the situation from a law enforcement perspective and brought the Critical Incident
Response Team into the picture. After making attempts to end the situation by
negotiation, the team forced entry into the apartment upon being told that Moore had
appeared at her window and appeared at that moment to be unarmed. Unfortunately, she
did, in fact, have her weapon in her hand and the CIRT opened fire.
“We can fault Moore for
letting herself run out of medication; but we’ve all done that, and we’ve all
forgotten to take our meds, or left them home when we went on a trip. Human beings,
doing their level best, can make mistakes.
“We can fault the police. In
a perfect world, the response team entering the apartment would calmly evaluate the
situation, perceive that the weapon was a flare pistol, probably not dangerous, and
would not touch their triggers. In a perfect world. Last April, on G Street, young
men, their adrenalin and steroid levels pegging the meter, waited for the go signal
while wondering what it would feel like if a bullet hit them in the next few minutes:
maybe the last thing they would ever feel in this life. Suddenly they saw in front of
them a wild eyed crazy person with a gun in her hand. They looked death in the eye.
Their training kicked in. They killed her. Human beings, doing their level best, can
make mistakes. There were... there always are... opportunities to prevent the death
of Cheri Lynne Moore. She called public health asking for more meds. A friend offered
to try to talk her down, but the police judged the possible risk not acceptable.
Perhaps the CIRT could have waited a little longer or tried a different negotiation
strategy. We are all Monday morning quarterbacks. It makes no sense to try deciding
who is at fault: we can’t help Cheri Moore. But we can perhaps help someone in the
future if we decide to fix the problem instead of the blame.
“Even given that these things
don t happen often (the last similar incident was in 2000, when an armed man
threatened an officer in a downtown parking lot and was shot to death in the
confrontation) we could still give a thought to “next time.” Perhaps the Medical
Society could give some thought to a Critical Incident Response Team of its own: a
panel of physicians and mid level practitioners with expertise in psychiatric crisis,
triage, critical injury management in the field and so on; who would volunteer to
make themselves available to drop what they were doing and be available on the scene
of situations like this if the first responders or authorities on site needed them.
These folks would need to do some familiarizing work, maybe participating in training
drills and classes with police, sheriff, and fire departments so as to be familiar
with the way these folks work and communicate, and to be on greeting terms with the
people they’d be working with. Of course, we could have thought of this a long time
ago. But we didn’t. Perhaps we made a mistake. Human beings do that.”
This and other August issue
articles are at www.humboldt1.com/~medsoc/images/bulletins/August%202006%20Bulletin%20for%20web.pdf
In the Fall issue of the Bulletin of the California Society of
Anesthesiologists, Donald J. Priolo, MD, wrote on “Hippocrates Upended: A Cause for
Revaluation of the American Physician.”
“What the earthquake of 1906
did to the Bay Area, World War II in 1941 and the advent of Medicare in 1965 did to
the American physician. Let us look at the parallels. Before Hippocrates, physicians
could be hired as assassins to do in an enemy or facilitate the premature demise of a
parent for early inheritance. Now physicians are paid to perform according to the
bureaucratic formulas and edicts of the federal government, business groups,
insurance companies, HMOs and IPAs. Lost in this third-party deluge of financial
forces is the primacy, prestige and freedom of a properly educated and licensed
physician to act and advocate entirely for the patient, as well as the patient’s
freedom to choose a physician and to expect that physician to honor a sacred bond of
trust. American medicine has been reduced to considerations of what percent of gross
domestic product can be spent on healthcare, how many forms can reasonably be
completed before a third party will pay, whether an insurer will allow an assistant
at surgery, and how fast a patient can be rushed through an examination or discharged
from the hospital.
“The impact of these
exactions on the value of both the patient and the physician is enormous. Our
contemporary ethos is to devalue patients, their physicians, and their bond of trust
in order to legitimize payer coercion. The patient becomes a pawn, the doctor becomes
a wage slave, and both lose their freedom to aspire to and achieve their highest
hopes and calling.
“If the dignity and stature
of physicians are not universally idealized societal values, then patients cannot be
healed. A sick, fragile human, ravaged by physical and/or emotional illness,
surrenders himself or herself to the mercy and unmitigated loyalty of a physician.
This experience is not analogous to standing in line awaiting service from a
bank teller or a grocery clerk. This profound act of self-exposure and trust by a
patient to the skills and mercy of a physician is a difference in kind from all other
human interactions, not a difference in degree.
“Societies do not grant this
privilege casually: Consider the rigorous and prolonged educational process, national
board examinations, licensure, specialty training, specialty board certification, and
maintenance of certification and recertification. Paradoxically, the federal
government and its echoing chorus of commercial business and payers now expect the
physicians to behave as drones, groveling annually to the Congress for their share of
a diminishing handout. The fact is that it is only collectively through our
professional associations that we can respond in an effective manner. It has been
stated, “Medicine is, at its center, a moral enterprise grounded in a covenant of
trust. This covenant obliges physicians to be competent and to use their competence
in the patient’s interests. Today, this covenant of trust is significantly
threatened. By its traditions and very nature, medicine is a special kind of human
activity—one that cannot be pursued effectively without the virtues of humility,
honesty, intellectual integrity, compassion and effacement of excessive
self-interest. Our first obligation must be to serve the good of those persons who
seek our help and trust us to provide it.1” “Ask not what organized medicine can
do for you; ask what we can do for our patients.” The strangulating grip of
third-party influence destroying health care over financing issues must be broken.
“Let us insist on revaluation
of the American physician as the cornerstone critical to the healing power of
physicians.
“Let us pledge eternal
warfare against influences and health systems that violate our calling.
“Let us renew our commitment to the
2,400-year-old Oath of Hippocrates, immortalizing the patient-physician
covenant.”
To read the original along with
the references, please click on Hippocrates at www.csahq.org/pageserver.cgi?tpl=internal.tpl§ion=publications&name=bulletin_view&idx=14
Dr. Priolo is a neurosurgeon practicing in San
Jose, California. He is the past president of the California Association of
Neurologic Surgeons and the president of the Santa Clara County Medical Association.
He also serves on the Executive Committee of the Specialty Delegation to the
California Medical Association.
Contact Del Meyer, MD
Phone: (916) 488-5864 |
Email: DelMeyer@HealthCareCom.net |