Medicine's Parasite

In the The Bulletin of the Humboldt-Del Norte County Medical Society, October 2007, Dr. Emily Dalton discusses "Leeches in Medicine."

"According to Stedman's medical dictionary, a parasite is an organism that lives on or in another and draws its nourishment there from. Leeches suck nutrients from the host - not enough to cause death - yet they have no beneficial effects for the host…. Insurance companies are the parasite of our times, and like the leeches, it is time for insurance companies to get out of healthcare.

"Twenty percent of the money spent on health care premiums gets pocketed by the insurance companies. They collect the money and they dole out medical care (also known as the "medical loss ratio") in capricious and self-serving ways. Insurance companies create barriers to care by denying payment to doctors and by denying medical care to patients…

"The insurance model does not apply well to medical care. Insurance works best for catastrophic problems that are unlikely to actually happen. For situations such as home-destroying disasters or automobile crashes, the insurance model works well. Most people do not have damaging house fires or severe auto accidents on a regular basis. People get covered for losses that could be financially ruinous, insurance companies make their profits, and it all works out fairly well. Healthcare is different! Healthcare is something that everyone needs on a regular basis. Preventative care, treatment for minor illnesses, and treatment for catastrophic illnesses are basic human necessities.* Serious illnesses will occur for each one of us at some time in our lives. We deserve better than to be at the mercy of a cold-hearted insurance company when that time rolls around.

"The insurance model is a poor way to structure the delivery of efficient and sensible healthcare. The time has come for medicine to become leaner and more efficient, which can only be accomplished by eliminating the parasitic growths that insurance companies have become, and replacing them with a single payer system."

Go to www.humboldt1.com/~medsoc/images/bulletins/OCTOBER%202007%20BULLETIN_for%20web.pdf for the original article.

*[If Dr. Dalton had continued the analogy so nicely made with houses and autos, the article would have ended on a positive, instructive and optimistic note: "Serious illnesses will occur for each of us at some time in our lives. But only serious illnesses are insurable. Treatment for preventative care, minor illnesses and routine health care should be paid out of pocket, like car maintenance and home repairs. Then health insurance would be appropriate and affordable just like car and home insurance." - D.M.]

Art and Science of Medicine

Dr. John Toton reviews the book, "How Doctors Think," by Jerome Groopman, MD, in Sonoma Medicine, the Magazine of the Sonoma County Medical Association.

"In How Doctors Think, the much-published Dr. Jerome Groopman uses multiple case histories (all of them initially misdiagnosed or mistreated) to highlight the perceived inability of doctors to think and communicate effectively with their patients - an issue of great importance in these times of medical stress and change. Groopman is a reluctant apologist for this issue, and he argues for corrections that he feels are needed. The case histories he presents are a sad journal, particularly since - from his perspective - all were preventable. Groopman also chronicles his own experiences with 'aggressive back surgery' and a long effort to diagnose scaphoid-lunate ligament injury as the source of his own chronic wrist pain.

"After much patient suffering or risky delays, the cases Groopman describes are almost always resolved by 'open communication,' including listening, open-ended questioning, systematic thinking, patient activation and engagement in the process, and exclusion of good patient-bad patient prejudices…

"Groopman accepts that we are in a time of rapid change in how we practice the art and science of medicine. The 'older' generation, he explains, acquired their skills primarily by the Socratic method of sharing knowledge, questioning and responding, learning from our experience and that of our mentors, and on-the-job honing of these skills. We trust our experience; we learn from our errors. We search for the ONE diagnosis that seems to fit the data and explain the symptoms (Ockham's Razor). We always look for patterns and similarities so we can shortcut to the diagnosis. From there, it's just a short leap to developing 'confirmation bias,' often based on recent experiences, leading in turn to 'diagnostic momentum.' As a result, we sometimes give short shrift to atypical symptoms, especially with alcoholic, diabetic, or other stereotypical patients.

"The 'younger' generation is in transition, but with much the same burden. They are taught to depend on algorithms, 'diagnostic certainty,' evidence-based diagnosis and treatment, computerized records and formulas, all available in one nice BOX (PalmPilot or Blackberry). They may be worshiping the science and ignoring the art of medicine…" For the complete review, go to www.scma.org/magazine/scp/Fall07/toton.html.

The Numbers Game

Thomas H. Lee, MD, writes on "Dangerous Numbers: Misconstrued Data Hazardous To Health Care" in Vital Signs, official publication of the Fresno-Madera Medical Society and Kern County Medical Society

"$2 trillion. Forty-four million uninsured. Sixteen percent of gross domestic product. Respectively, that's how much the U.S. spends on health care each year, how many people are uninsured and the portion of the GDP that health care consumes. To those of us who follow health care, these numbers are more than just familiar - they are macroeconomic symbols of our woeful health care system. As health care reform continues to burn near the top of political issues in the U.S. presidential race, these numbers increasingly are being used as weapons. Weapons against insurers, pharmaceutical companies and providers.

"These numbers can be somewhat misleading. For example, just a few weeks ago, the New York Times published a controversial article - 'Sending Back the Doctor's Bill' by Alex Berenson - about how many health care economists believe that both political parties were missing the real source of cost savings: physician incomes. The article argued that physician incomes were more than double those of their European counterparts and that health spending could be reduced significantly if doctors were paid less and were salaried rather than being paid per procedure.

"Not surprisingly, the article drew plenty of criticism, including some from noted economist Uwe Reinhardt. Reinhardt counter argued that physician take-home incomes represent only 10 percent of health care spending and that even a 20 percent reduction in incomes would reduce national health care expenditures only by two percent.

"Regardless of how you think physicians should be compensated, health care reform inevitably will be determined by the politics and economics of change…. Numbers increasingly will be wielded as fact, argument and weapons of ideology…" The entire article is on page 8 of www.fmms.org/pdf/Oct07_VS_FINAL.pdf.

"And Now-A Minute with Andy Rooney (With Apologies to 60 Minutes)" by Stephen Kamelgarn, MD, discusses the ICD-9 codes, in the December issue of The Bulletin of the Humboldt-Del Norte Country Medical Society:

Dontcha just hate little five digit numbers. I know I do. Little numbers that comprise the ICD-9 - this three pound paperback book I'm holding in my hand. (Camera pans into Andy fanning the pages of a huge tome) A five digit code that supposedly encompasses the full gamut of medical diagnoses that may ever have entered the mind of humankind. Isn't that a bit of hubris, thinking we can classify all diseases with a five digit code? But people keep trying.

Here's an example: 711.4 Arthropathy associated with other bacterial diseases.

The fifth digit is Code for the underlying disease, as: diseases classifiable to 010-040, 090-099, except as in 711.1, 711.3, and 713.5 leprosy (030.0-030.9) tuberculosis (015.0-015.9) Excludes: gonococcal arthritis (098.50) meningococcal arthritis (036.82)

It's nice to know that we can separate out tuberculous arthritis from gonococcal arthritis. It also makes no sense at all: is leprosy 030.0? or is it 030.9? or is it somewhere in the middle? What happened to the 711.4 code, which was the original number I looked up?

When the folks keeping track of the numbers were mostly medical people (and actually understood this stuff) those five digits were (and still remain) an important way of tracking diseases and disease trends. But somewhere along the line the bean counters and the insurance 'droids and the government bureaucrats hijacked those five digits for their own nefarious purposes. Now those same five numbers have taken on a life of their own and have become a tyranny. Nothing moves anymore without that five digit code accompanying it; and they'd better be the right code, or you can forget it…

"I'm sorry doctor, the patient's insurance plan doesn't pay for the code 'V77.91; Screening for Lipoid Disorders.' I'm afraid the patient will have to pay out of pocket." This, despite the fact that the American Colleges of Everybody say that all adults should be screened for this problem at age 40, or whatever.

"I'm sorry doctor, you've only put down 493, the first three numbers. We need the fourth and fifth." Do they really need to differentiate "extrinsic" asthma from "intrinsic" asthma to pay for a nebulizer? Not only that, but the online reference I've been using icd9.chrisendres.com doesn't even carry 493 out to five places. "I'm sorry doctor, Incontinence, ICD 788.30, doesn't qualify your patient for adult diapers. We need a code for why the patient is incontinent." Does it matter? The patient has a problem with his/her bladder, and just needs the damn diapers, for goodness sake!…

When did we allow this to happen to us? As medical costs rose, the insurance industry, out of a sense of their perceived necessity, intruded more and more into our autonomy and our ability to advocate for what is right (as opposed to what is cost effective). We found our time slowly being chipped away, as slowly, relentlessly more and more forms and insurances started demanding that we supply the appropriate code, and now we can't put a halt to it as more and more of our office time gets taken up by having to look up and provide the appropriate damn code.

It's become a growth industry unto itself. Just Google ICD-9 and see how many hits one gets: dozens of web sites devoted to telling us the appropriate code for whatever ails us. Our mailboxes (both email and snail-mail) are flooded with junk mail, advertising "coding" conferences, so that we may make the best use of these abstruse codes to obtain, or heaven forbid, increase reimbursement. This must be a financial boon to the companies putting on these dog and pony shows….

I guess that it is nice to know that I've found some part of the economy that's profitable and growing. When I get out of medicine I can always get a job as a coding consultant.

The entire article is at www.humboldt1.com/~medsoc/images/bulletins/DECEMBER%202007%20BULLETIN_for%20web.pdf.

They Want What?

Lytton W. Smith, MD, editor of the Orange County Medical Association's Bulletin, urged "Dare to Say No!" in the December 2007 issue.

A presentation on peer review and medical staff issues became a discussion on insurance contracting.

While at the California Medical Association House of Delegates, members of the Solo and Small Group Practice Forum (SSGPF) invited me to attend a presentation by Howard Lang, MD, dealing with peer review and medical staff issues. The evening evolved into a self-confessional discussion about insurance contracting.

At the House of Delegates, the SSGPF represents physicians practicing alone or in a small group of four or fewer. The CMA has more than 8,000 members fitting that category. Other practice forums include the Medium Group Practice Forum (5 to 150 doctors), the Large Group Practice Forum (150 to 1,000) and the Very Large Group Practice Forum (1,000 plus).

After a short presentation about a messenger model developed in Los Angeles County, various members spoke about dropping contracts. The sharing of personal experiences with contract termination has become chic. The solo practitioner sitting beside me made the observation that he felt like an Alcoholics Anonymous meeting erupted. "My name is H-----, and I terminated my contracts!" In response, know-ing sighs from attendees filled the room. Those still afflicted with insurance contracts listened in admiration…

Now shift to the floor of the House of Delegates. We learned that legislation had been passed to study the peer review process in Cali-fornia, and that the Medical Board of California had contracted with Lumetra to perform the as-sessment. Further, we learned that medical staff offices across the state had received letters from Lumetra demanding confidential peer review information.

What? They want what?!? Calls from medical staff offices to chiefs of staff and medical staff attorneys ensued. What information could, should or would be released? Was this information about peer review protected by SB* 1157? Most hospitals collect reams of data about peer review. Physicians participating in review of other physicians assumed SB 1157 protected them from discovery. Hospital administration feared that exposure of cases with severe criticism of patient management could lead to increased legal liability. Who pays for the collection, copying and mailing of confidential patient and peer review data? Faced with another unfunded mandate from the state, what would medical staffs do? Could they dare to say no?

The House of Delegates passed a resolution requiring that the CMA legal department immediately look into the legality of the Lumetra demands…. It's not that we physicians are a bunch of naysayers. We gladly say yes to proven innovations, evidence-based medicine and new surgical techniques. Yet over the past 20 years, demands by insurers, legislators, regulators and even specialty boards have increased physician angst - and in that environment we must dare to say no.

The article is at www.socalphys.com/article/articles/625/1/OCMA-Viewpoints---Dare-to-Say-No/Page1.html.

I am happy being a doctor, I am well compensated, I am...

Kate McCaffrey, DO, discusses "Re-scripting Our Profession" in the President's Message column of The Bulletin of the Humboldt-Del Norte County Medical Society, March 2008:

I have been re-scripting my self-talk lately. It helps being around optimistic medical students who aren't jaded by the storms of practice and the insurance sharks.

Instead of saying, it's hard practicing medicine I say to myself, I am happy being a doctor, my patients and colleagues respect me and I am being compensated well for my efforts and expertise. I have committed to re-scripting my thoughts for one month. As a scientist, I like to test my hypotheses. I'll let you know how the re-scripting goes and what changes, if anything!

On the larger scale, I think our profession needs to re-script itself. The public still has the highest regards for doctors. When we complain, we erode this reputation. If any of you has had the unfortunate experience of being injured or ill, you know how important the opinion of your physician can be…

As the Touro University medical students arrive in Humboldt and Del Norte this June, I will think about how I am portraying our profession with my words. Yes, it is broken, but am I living in the problem or in denial or am I living in the solution? Am I calling and emailing my representatives?

Am I involved locally? I will become aware of my version of the torch I am passing on to the next generation. How can I involve them in the local and state political process early in their careers? What hope and reassurance can I give them that they still entered one of the most important and revered professions in the world?...

The entire column can be read at www.humboldt1.com/~medsoc/images/bulletins/MARCH%202008%20BULLETIN_for%20web.pdf.

Electronic Health Records

"Nine Strategies for Successful EHR Adoption" by John C. Whitham and Steve Davis, DO, appears in the January 2008 issue of Vital Signs, published by the Fresno-Madera Medical Society and Kern County Medical Society:

If you are going to implement an EHR system, following are 9 guidelines to managing the art of successful system adoption:

1. It is imperative to minimize the impact to a physician practice's cash flow... Regardless of how well the system works or how spectacular the other components are, if income to the practice stalls, the physician's perception is that the whole implementation is a disaster. Practices will always assume it is the implementer's fault, no matter the circumstances...

2. Include an evaluation of the practice's billing, business, and clinical processes and practices in your preimplementation evaluation. Each practice has its own unique processes and business and clinical practices, and the practices need to understand that a new system will not allow them to always do things the way they have always been done...

3. Make sure that the practice's lead physicians are "leading" staff and other physicians to effectively manage change and that their motives are understood. Each practice needs to have good leadership to get the rank-and-file to follow and be enthusiastic...

4. The practice management system is a tool for billing, not a system that "does" the billing...

5. If an office is unreliable and difficult in the training and implementation process, then they will be unreliable and difficult in using the new system...

6. Find the reliable and enthusiastic individuals within the practice to be the super-users for the practice...

7. Allow adequate opportunities for "practice" between training and go live...

8. Develop a post-implementation follow-up process for both the practice management system and the electronic health record...

9. Understand that the electronic health record implementation is difficult...

John C. Whitham is a partner who chairs the Clinical Integration Practice in the JHD Group. Dr. Steven Davis is medical director of Physician Associates Clinical Integration Services (PACIS), and a Board Member of Physician Associates, an 800-member IPA based in Pasadena, California.

Details of the nine strategies appear at www.fmms.org/pdf/Jan08_VS_FINAL.pdf.

Can You Hear Me Now?

Basil Meyerowitz, MD, who is hearing impaired, writes "A Plea to the Hearing Intact: Advice to the Auditory Challenged," in the San Mateo County Medical Association Bulletin of March 2008:

...Those that don't have this disability often don't recognize our plight and do not try to alleviate the problem…and some treat the hard of hearing as if they are intentionally plotting to not hear (although, in some circumstances, it may be an advantage not to hear some things, but this is rare indeed).

We sufferers are able to recognize that hearing aids do help, but they are not a panacea, particularly in areas that have poor acoustics or are occupied by large crowds. And sometimes, hearing aids work a little too well! For example, wind noise is greatly enhanced, and raindrops falling on an unfurled umbrella sound very loud indeed.

A hearing aid's basic principal is to maximize sound waves as they reach the ear. However, hearing aids accentuate ALL sound waves (even extraneous ones), which frequently overwhelm the voices of those one wishes to hear. It is possible to adjust one's hearing aids to try to pick up selected sounds, but this is difficult to engineer: For example, when sitting in a restaurant, background noise is impossible to filter out.

At public meetings or lectures, if the sound system is good - although most often it is not - it is relatively easy to follow the speaker. However, some lecturers and lay speakers are not always familiar with the proper use of microphones.

Moreover, even in normal discourse, too many people are careless with their speech. A good many speak softly or indistinctly; some speak very quickly without enunciating their words. At mealtime, speech is often garbled by food in the mouth of the speaker…

Tips for the Hearing Impaired...

When conversing in person or by telephone, it's a good idea to immediately announce that one is hard of hearing and to request the speaker to please speak louder and a little slower.

Conversations on cell phones, even in the best of circumstances, are often awkward. Instead, request using a landline phone.

A speakerphone permits the listener use of both ears at the same time…

There are innumerable web sites that offer advice to the hearing impaired…or for those that want or need to have a sensible dialogue with somebody that is hard of hearing. One that I found... [is ] The Hearing Exchange (www.hearingexchange.com)...

Perhaps my plea should be directed to unite those of us with hearing problems (and it appears there is no shortage of fellow sufferers) instead of those that do not. We need to have our disability taken more seriously.

The complete article is at www.smcma.org/Bulletin/BulletinIssues/March08issue/BULLETIN-0803_Meyerowitz.pdf.