|
MEDICAL TUESDAY . |
NEWSLETTER |
|
Community For Better Health Care |
Vol XI, No 2, May 15, 2012 |
In This Issue:
1.
Featured Article:
How Medicare
Traps Doctors
2.
In
the News: Women, Teens Take Longer to
Recover From Concussions
3.
International Medicine: The
Rest of the Story
4.
Medicare: 2012 Medicare Part B
Changes
5.
Medical Gluttony:
ObamaCare
6.
Medical Myths: Can Government learn?
7.
Overheard in the Medical Staff Lounge: Pharmacy phone calls and their solution
8.
Voices
of Medicine: Death of Clinical
Judgment
9.
The Bookshelf: A Voice for the
Generations
10.
Hippocrates
& His Kin: Government
really does NOT want to LEARN
11.
Related Organizations: Restoring
Accountability in Medical Practice and Society
12.
Words
of Wisdom, Recent Postings, In Memoriam, Today in History . . .
* * * * *
Chancellor Otto von Bismarck, the father
of socialized medicine in Germany, recognized in 1861 that a government gained loyalty by
making its citizens dependent on the state by social insurance. Thus socialized
medicine, any single payer initiative, Social Security was born for the benefit
of the state and of a contemptuous disregard for people’s welfare.
We must also remember that ObamaCare has nothing to do with appropriate
healthcare; it was similarly projected to gain loyalty by making American
citizens dependent on the government and eliminating their choice and chance in
improving their welfare or quality of healthcare. Socialists know that once
people are enslaved, freedom seems too risky to pursue.
* * * * *
1.
Featured
Article: How
Medicare Traps Doctors
How
Doctors are Trapped
By John Goodman Filed under Health
Alerts on January 16, 2012
Every lawyer, every accountant, every
architect, every engineer — indeed, every professional in every other field —
is able to do something doctors cannot do. They can repackage and reprice their
services. If demand changes or if they discover a way of meeting their clients’
needs more efficiently, they are free to offer a different bundle of services
for a different price. Doctors, by contrast, are trapped. Read more . . .
To see how trapped, let’s look at
another profession: the practice of law. Suppose you are accused of a crime and
suppose your lawyer is paid the way doctors are paid. That is, suppose some
third-party payer bureaucracy pays your lawyer a different fee for each
separate task she performs in your defense. Just to make up some numbers that
reflect the full degree of arbitrariness we find in medicine, let’s suppose
your lawyer is paid $50 per hour for jury selection and $500 per hour for
making your final case to the jury.
What would happen? At the end of your
trial, your lawyer’s summation would be stirring, compelling, logical and
persuasive. In fact, it might well get you off scot free if only it were
delivered to the right jury. But you don’t have the right jury. Because of the
fee schedule, your lawyer skimped on jury selection way back at the beginning
of your trial.
This is why you don’t want to pay a
lawyer, or any other professional, by task. You want your lawyer to be able to
reallocate her time — in this case, from the summation speech to the voir dire
proceeding. If each hour of her time is compensated at the same rate, she will
feel free to allocate the last hour spent on your case to its highest valued
use rather than to the activity that is paid the highest fee.
In a previous Health
Alert, I noted that Medicare has a list of some 7,500 separate tasks
it pays physicians to perform. For each task there is a price that varies
according to location and other factors. Of the 800,000 practicing physicians
in this country, not all are in Medicare and no doctor is going to perform
every task on Medicare’s list.
Yet
Medicare is potentially setting about 6 billion prices across the country at
any one time.
Is there any chance that Medicare can
get all those prices right? Not likely.
What happens when Medicare gets them
wrong? One result: doctors will face perverse incentives to provide care that
is costlier and less appropriate than the care they should be providing.
Another result: the skill set of our nation’s doctors will become misallocated,
as medical students and practicing doctors respond to the fact that Medicare is
overpaying for some skills and underpaying for others.
The problem in medicine is not merely
that all the prices are wrong. A lot of very important things doctors can do
for patients are not even on the list of tasks that Medicare pays for. Some
readers will remember our Health Alert on Dr. Jeffrey Brennan in Camden,
New Jersey. He is saving millions of dollars for Medicare and Medicaid by
essentially performing social work services to reduce spending on the most
costly patients. Because “social work” is not on Medicare’s list of 7,500
tasks, Brennan gets nothing in return for all the money he is saving the
taxpayers.
We have also seen that there are other
omissions — including telephone and e-mail consultations and
teaching patients how to manage their own care.
In addition, Medicare has strict rules
about how tasks can be combined. For example, “special needs” patients
typically have five or more comorbidities — a fancy way of saying that a lot of
things are going wrong at once. These patients are costing Medicare about
$60,000 a year and they consume a large share of Medicare’s entire budget.
Ideally, when one of these patients sees a doctor, the doctor will deal with
all five problems sequentially. That would economize on the patient’s time and
ensure that the treatment regime for each malady is integrated and consistent
with all the others.
Under Medicare’s payment system,
however, a specialist can only bill Medicare the full fee for treating one of
the five conditions during a single visit. If she treats the other four, she
can only bill half price for those services. It’s even worse for primary care
physicians. They cannot bill anything for treating the additional four
conditions. . .
Take Dr. Richard Young, a Fort Worth
family physician who is an adviser for the federal government’s new medical
Innovation Center. As explained by Jim Landers in the Dallas Morning News:
[When Young] sees Medicare or Medicaid
patients at Tarrant County’s JPS Physicians Group, he can only deal with one
ailment at a time. Even if a patient has several chronic diseases — diabetes,
congestive heart failure, high blood pressure — the government’s payment rules
allow him to only charge for one.
“You could spend the extra time and deal
with everything, but you are completely giving away your services to do that,”
he said. Patients are told to schedule another appointment or see a specialist.
Young calls the payment rules
“ridiculously complicated.”
That’s an understatement.
http://healthblog.ncpa.org/how-doctors-are-trapped/
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* * * * *
2. In the News:
Study: Women, Teens Take Longer to
Recover From Concussions
By Beth Carter,
Wired.com
Email Author,
Categories: health, Medicine, Research
A study finds that females and youth require more time
to recover from concussions, a finding that could help coaches, trainers, and
doctors how to diagnose and treat head trauma among athletes.
For many professional athletes,
preventing and treating concussions is part of the job. But sports-related head
trauma is common in amateur and youth sports as well, and evidence suggests
high-school and female athletes take longer than men to recover from it.
The findings, from
Michigan State University, suggest coaches, trainers and doctors must consider
an athlete’s age and gender when diagnosing and treating concussions and
determining when they’re ready to resume playing.
“Typically what we’re finding is that
the high school brain is still developing,” said Tracey Covassin, the associate
professor of kinesiology who led the study. “There is more cerebral fluid
within the brain, making it more susceptible to injury and causing it to take
longer to recover. With the NFL they come back the next week, and they
shouldn’t do this with kids.” Read more . . .
More than 150,000 sports-related
concussions occurred among kids age 15 to 19 between 2001 and 2005, according
to statistics published in Pediatrics in 2010. The true number may be
higher, because the stats reflect only injuries treated in an emergency room.
Covassin and her colleagues administered
baseline neuropsychological tests to athletes from several states over the
course of two years. Three hundred of those athletes eventually suffered
concussions and were quizzed using three computerized neuropsychological tests
— which asks test subjects to recall words and designs — that the NFL and NHL
use to assess head trauma.
They found females between 14 and 23
years old performed worse than males of equal age on the visual memory tests
and exhibited more of the common concussion symptoms, including headaches,
confusion, imbalance, dizziness and memory loss. This may be due to anatomical
and hormonal differences, Covassin said, but further study is needed to
understand why women are at greater risk of concussions and take longer to
recover from them. Cheerleading, for example, has a high rate of concussion, as
does high school volleyball.
“Most of the literature talks about
football and hockey players,” she said. “People don’t realize that female
athletes are more at risk. People are slowly starting to realize the difference
between males and females.”
The study also compared the recovery
times of high school and collegiate athletes and found younger athletes can
take twice as long to recover. High school athletes’ verbal and visual memory —
the ability to remember words and letters and remember spatial tasks like
football plays — remained impaired between seven and 14 days following the
injury. Collegiate athletes recovered within seven days.
Covassin also found that young athletes
who aren’t given ample time to recover are at greater risk for second-impact
syndrome, where a second concussion can bring more severe symptoms and a
greater risk of brain damage. . .
“If you are on the fence of, ‘Should I
return the kid or not return the kid,’ don’t return him,” Covassin said. “Play
it safe.”
Read
the entire article on Wired.com . . .
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* * * * *
3.
International Medicine: The
Rest of the Story
By John Goodman Filed under Health
Alerts on March 25, 2009 with 16 comments
Today
I’m going to give you access to a paper with as many as 100 references that you
almost never see cited in Health Affairs, or in the Journal of the
American Medical Association (JAMA), or in the New England
Journal (at least not in their public policy articles). In fact, if you
are a regular reader of these publications, I think you are going to be very
surprised.
My
colleagues Linda Gorman, Devon Herrick, Robert Sade and I discovered that
public policy articles in the leading health journals (especially the health
policy journals) tend to cite poorly done studies over and over again in
support of two propositions: (1) Our health care system needs radical reform
and (2) the reform needs to be modeled along the lines of the systems of other
developed countries. At the same time, these articles tend to ignore
contravening studies – often published in economics journals and subject to much
more rigorous peer review. Read more . . .
In our rest-of-the-story literature review, we focus
on eight questions:
- Does the United States spend too much on health
care?
- Are US outcomes no better and in some respects
worse than those of other nations?
- Is the large number of uninsured in the US a
crisis?
- Does lack of health insurance cause premature
death?
- Are medical bills causing bankruptcy?
- Are administrative costs higher for private
insurance than public insurance?
- Are low-income families more disadvantaged in the
US system?
- Can the free market work in health care?
This paper was written over a year ago, in response to
JAMA’s call for papers on health reform and may not include the most
recent material. Nonetheless, since the national health care debate is well
underway, since the peer review process (at least for our paper) is so
inordinately long, and since the issue is so important, we are taking these
unprecedented steps:
- We are ignoring the journals and publishing the paper online.
- We are posting the reviewers’ comments from Health Affairs so
that readers can see why the critics thought this paper should not be
published at all, and a link to the JAMA issue that excluded our paper here.
- We are inviting everyone – regardless of
political views – to comment and cite additional evidence that has bearing
on any of these questions.
In a completely independent effort, Stanford
University Professor Scott Atlas has made many of these same discoveries. His
findings are summarized in this NCPA Brief Analysis.
- Devon Herrick, National Center for Policy
Analysis says:
What
is most shocking is how advocates of National Health Insurance ignore the poor
state of cancer care in many developed countries. Cancer is primarily a disease
of old age. Thus, rationing advanced cancer treatments should be considered a
subtle form of age-discrimination.
Other
countries fare worse than the United States when it comes to cancer survival.
Their data is somewhat dated but according to the report “Diffusion of
Medicines in Europe,” there are only 0.14 oncologists per 100,000 population in
Britain and 0.24 in Germany. The corresponding figure for the United States is
2.28. Innovative (cytotoxic) cancer medicines are also used much less abroad.
The U.S. spends nearly 17 times more per capita that Britain, seven times more
than Germany and five times more than France on cytotoxic medicines.
Read The
Rest of the Story
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Canadian
Medicare does not give timely access to healthcare, it only gives access to a
waiting list.
--Canadian
Supreme Court Decision 2005 SCC 35, [2005] 1 S.C.R.
791
http://scc.lexum.umontreal.ca/en/2005/2005scc35/2005scc35.html
* * * * *
4.
Medicare: 2012 Medicare Part B
Changes – (CMS) published updated payment
policies
San Mateo
County Medical Association
by: SMCMA Executive
Director
On November 1st the Centers for
Medicare and Medicaid Services (CMS) published updated payment policies and
payment rates for physicians’ services furnished in 2012.
According to CMS, more than one million providers of health services to
Medicare beneficiaries are paid under the Medicare Physician Fee Schedule
(MPFS). An estimated $80 billion will be paid under the MPFS in 2012.
Changes in the fee schedule that impact payment policy and physician billing
include: Read more
and see if they are geared to a grade school or a professional mentality . . .
Expanding CMS’ misvalued code initiative
Using a health risk assessment
(HRA) in conjunction with Annual Wellness Visits (AWV) for which coverage began
January 1, 2011 under the Affordable Care Act (ACA).
Expanding the list of services
that can be furnished through telehealth to include smoking cessation services.
Changes in the way additional services are added to the telehealth list will
focus on the clinical benefit of making the service available.
Updating physician incentive
programs including the Physician Quality Reporting System (PQRS), the
e-Prescribing Incentive Program and the electronic Health Records Incentive
Program.
Establishing a new value-based
modifier that would reward physicians for providing higher quality and more
efficient care.
Implementing the third year of a
four-year transition to new practice expense relative value units, based on
data from the Physician Practice Information Survey that was adopted in the
MPFS CY2010 final rule.
E-Prescribing
CMS finalized the rules for the 2012 and 2013 e-prescribing incentive payment,
and the 2013 and 2014 payment penalty programs. To qualify for incentive
payments, physicians: a) may use claims, registry or electronic health
record-based (EHR) reporting methods; and must electronically prescribe on the
same day as the denominator service, and submit 25 claims containing the
e-prescribing measure code (G8553) with one of the denominator codes. The
incentive payment for 2012 is 1 percent, and for 2013 it is .5 percent of the
total estimated allowed charges for professional services covered by Medicare
Part B and furnished by an eligible professional.
Physician Quality Report System (PQRS)
As in prior years, there have been changes to the individual measures and
measure groups. The final rule lists 211 individual measures, including 25 new
ones; retains 44 EHR measures currently reportable in the EHR incentive
program; and finalized 23 new measure groups, including eight new measures
groups for reporting: Cardiovascular prevention; COPD; inflammatory bowel
disease, sleep apnea, dementia, Parkinson’s, elevated blood pressure, and
cataracts.
A complete listing of the 2012 measures is posted on the CMS website: www.cms.gov/PQRS/.
CMS will provide interim feedback reports for physicians reporting individual
measures and measure groups through claims-based reporting for 2012 and beyond.
These reports will be a simplified version of annual feedback reports that CMS
currently provides and will be based on claims for the first three months of
each program year.
CMS will use 2012 as the reporting period for the 2015 PQRS penalty. If CMS
determines that a physician or group practice (a group of 25 or more) has not
satisfactorily reported quality data for the 2013 reporting period, then its
2015 payments will be reduced 1.5 percent.
Lab Test Signatures No Longer Required
CMS has retracted the requirement for physicians to sign paper lab requisitions
for clinical diagnostic laboratory tests.
Annual Wellness Visit Changes
Criteria for a health risk assessment (HRA) to be used in conjunction with the
annual wellness visit (AWV) has been adopted. The HRA is self-reported
information which can be done by the patient alone or with assistance, takes no
more than 20 minutes to complete and addresses demographic data, psychosocial
risks, behavioral risks, activities of daily living (ADL)*, and instrumental ADLs**.
The payment for AWV codes has been increased to recognize the additional office
staff time required to administer the HRA to the Medicare population. CMS
continues its policy of not covering a routine physical exam as part of these
services.
http://www.smcma.org/article/2012-medicare-part-b-changes
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Dear
Colleagues:
We have had
digital records in our office for nearly a decade as well as E-prescribing. Our
patients ask us if anybody can access their digital records in our office. We
tell them that no one can. They say thank you and return. We can access our
patient records from any computer. However this is not what Obama’s ACA had in mind. They cannot access our
patients’ confidential records electronically. Big Brother Cannot Watch us like
they would like. Hence we are not eligible for the one percent incentives this
year or the one and one-half percent next year, but are eligible for all the
Medicare Penalties.
But have no
Fear. Big Brother is always near. They demand that we make copies of a
representative sample of entire medical records and send them to Medicare for
their review.
Eight hours
of Office Manager’s time nearly each month does add up $240 a month for police
work which is not reimbursed! This is essentially a $2800 per year Medicare tax
on doctors.
It also
treats us as grade school children. How long are physicians going to take this
abuse?
Government is not the solution to our
problems, government is the problem.
- Ronald Reagan
* * * * *
5.
Medical
Gluttony: ObamaCare
.
. . The body politic still remains suspended between recognizing the
unsustainability of the current welfare model and deciding what to do about it.
This was always the fatal problem of ObamaCare. Read more . . .
Reality
could not have instructed President Obama more plainly: The last thing we
needed, in a country staggering under deficits and debt, a sluggish economy and
an unaffordable entitlement structure, was a new Rube Goldberg entitlement. The
last thing we needed was ObamaCare. The nation and the times were asking Mr.
Obama to reform health care, not to double-down on everything wrong with the
current system. . .
.
. . Reality will pass judgment on the Affordable Care Act and it won’t be
favorable–Holman W. Jenkins, JR., WSJ
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Medical Gluttony thrives in Government and Health Insurance Programs.
Gluttony Disappears with Appropriate Deductibles and Co-payments on
Every Service.
* * * * *
6.
Government
Myths: Can Government
learn?
Viewpoints: Can government learn whether its
policies have been successful?
Read more here: www.sacbee.com/2012/04/28/4449250/can-government-learn-whether-its.html#storylink=cpy
By David Brooks
Published: Saturday, Apr. 28, 2012 -| Page 11A
Government
doesn't profit from experience because of the way it goes about testing out its
policy problems. It should try learning the way businesses do.
In
2009, we had a big debate about whether to pass a stimulus package. Many
esteemed and/or Nobel Prize-winning economists like Joseph Stiglitz, Larry Summers and Christina Romer argued
that it would help lift the economy out of recession. Many other esteemed
and/or Nobel Prize-winning economists like Robert Barro, Edward Prescott and James Buchanan argued that
positive effects would be small and the package wouldn't be worth the long-term
cost.
We went
ahead and spent the roughly $800 billion. What have we learned?
For
certain, nothing. The economists who supported the stimulus now argue the
economy would have been worse off without it. Those who opposed it argue that
the results have been meager. It's hard to think of anybody whose mind has been
changed by what happened. Read more . . .
This is
not entirely surprising. Nearly 80 years later, it's hard to know if the New
Deal did much to end the Great Depression. Still, it would be nice if we could
learn from experience. To avoid national catastrophe, we're going to have to
figure out how to control health
care costs, improve schools and do other things.
Jim Manzi has spent his career
helping businesses learn from experience – first at AT&T Laboratories,
then as a consultant with Strategic
Planning Associates and then as founder of Applied
Predictive Technologies, a successful software firm.
In his
new book, "Uncontrolled," Manzi notes that many experts tackle policy
problems by creating big pattern-finding models and then running simulations to
see how proposals will work. That's essentially what the proponents and
opponents of the stimulus
package did.
The
problem is that no model can capture enough of the world's complexity to yield
definitive conclusions or make nonobvious predictions. A lot depends on what
assumptions you build into them.
In
"Uncontrolled," Manzi looks at two celebrated model-building
exercises. Larry Bartels
of Princeton produced a model
finding that presidential policies exercise the single biggest influence on income distribution.
The authors of "Freakonomics" produced a model showing legalized
abortions subsequently reduced crime
rates.
Manzi
argues that by slightly tweaking the technical assumptions in these models, you
eliminate the headline-grabbing results. He also points out that regression
models that try to explain crime rates have not become more accurate over the
past 30 years. All this model-building hasn't even helped us get better at understanding
the problem.
What
you really need to achieve sustained learning, Manzi argues, is controlled
experiments. Try something out. Compare the results against a control group. Build up an
information feedback loop. This is how businesses learn. By 2000, the credit
card company Capital One was running 60,000 randomized tests a year – trying
out different innovations and strategies. Google ran about 12,000 randomized
experiments in 2009 alone. . .
Businesses
conduct hundreds of thousands of randomized trials each year. Pharmaceutical
companies conduct thousands more. But government? Hardly any. Government
agencies conduct only a smattering of controlled experiments to test policies
in the justice system, education, welfare and so on.
Why
doesn't government want to learn? First, there's no infrastructure. There are
few agencies designed to supervise such experiments. Second, there is no way to
conduct a randomized experiment to test big economy wide policies like the
stimulus package.
Finally,
the general lesson of randomized experiments is that the vast majority of new
proposals do not work, and those that do work only do so to a limited extent
and only under certain circumstances. This is true in business and government.
Politicians are not inclined to set up rigorous testing methods showing that
their favorite ideas don't work.
Manzi
wants to infuse government with a culture of experimentation. Set up an
FDA-like agency to institute thousands of randomized testing experiments
throughout government. Decentralize policy experimentation as much as possible
to encourage maximum variation.
His
tour through the history of government learning is sobering, suggesting there
may be a growing policy gap. The world is changing fast, producing enormous
benefits and problems. Our ability to understand these problems is slow. Social
policies designed to address them usually fail and almost always produce
limited results. Most problems have too many interlocking causes to be
explicable through modeling.
Still,
things don't have to be this bad. The first steps to wisdom are admitting how
little we know and constructing a trial-and-error process on the basis of our
own ignorance. Inject controlled experiments throughout government. Feel your
way forward. Fail less badly every day.
Read more: www.sacbee.com/2012/04/28/4449250/can-government-learn-whether-its.html#storylink=cpy
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Medical Myths Originate When Someone Else Pays The Medical Bills.
Myths Disappear When Patients Pay Appropriate Deductibles and
Co-Payments on Every Service.
* * * * *
7.
Overheard
in the Medical Staff Lounge: Pharmacy phone calls and their solution
Dr. Edwards: It seems that I’m being deluged with pharmacy phone calls.
Dr. Milton: I think they are hiring a lot of foreign pharmacists. Many seem
to be struggling with the English language.
Dr. Edwards: There seems to be a combination of problems. Some don’t understand
the usual pharmacy abbreviations for AC, before meals, PC, after meals, and HS,
at the hour of sleep? Read more . . .
Dr. Rosen: It’s very
disturbing to patients to be constantly interrupted during appointments with
phone calls, from pharmacies asking questions “what are the directions?” I pull
out my copy and read off, Prilosec 20 mg before dinner. (ACD). “It’s all there,
isn’t it? as I confirm my copy.
[Pharmacist: My copy of the prescription doesn’t say
that!]
Dr. Rosen: My copy
seems to say that explicitly. AC means before a meal and D means that meal is
dinner. Just like PC means after a meal and PCD means after dinner. PCL would
be after lunch and ACB would mean before breakfast like diabetic drugs. The
Prilosec was ACD because you need to take that before a meal to stop the
stomach from secreting acid in preparation to digest the coming meal and
prevent acid indigestion such as GERD (Gastro-esophageal-reflux-Disease) by
reducing the available acid to regurgitate into the esophagus and burn the
lining. The same process works on the other end of the stomach where the excess
acids burns a hole in the duodenum and causes a duodenal ulcer or peptic ulcer
disease (PUD).
Dr. Ruth: You spend
a considerable time teaching the young or foreign pharmacist. Is it time well
spent?
Dr. Rosen: No
teacher or professor always has a good idea of how well his efforts are
received and appreciated. But don’t you think we should continue to make that
effort?
Dr. Ruth: I guess
it’s the same when I have medical students in my office. Sometimes I get very
discouraged. And then a response makes me realize my efforts weren’t in vain.
Dr. Dave: I guess
maybe I should change my attitude. I frequently just tell them off.
Dr. Sam: I just
tell them what they need to know to fill my prescription so I can get on with
my work.
Dr. Dave: I’ll also do what I
need to in order to get my patient’s prescription filled. But I remember the pharmacy and the next patient that
doesn’t have a favorite pharmacy; I send the prescription to their competitor.
Dr. Rosen: (smiling) Did
you learn that from Adam Smith’s Wealth of Nations?
Dr. Edwards: Isn’t it
amazing how free enterprise works to correct all inequities? If one doesn’t
provide good service, their income will slowly drop off.
Dr. Dave: I think
I may have diverted up to a hundred customers from the pharmacy next door to
the one a few blocks down the street.
Dr. Rosen: One wonders
if the pharmacy staff understands free enterprise as the solution to the
distribution of healthcare.
Dr. Milton: One must
also wonder how many physicians understand free enterprise as the solution to
healthcare costs.
Dr. Paul: Here we
go again. Free enterprise is the solution to all that is wrong with medicine.
Dr. Edwards: Actually it is!
Dr. Milton: If I’d seen
you at the next table, I probably would have avoided the subject today
Dr. Edwards: Have you read
Adam Smith?
Dr. Paul: I think
I may have read it in college. I don’t remember that it made sense then. And I
certainly don’t think it makes sense in these complicated economic times.
Dr. Milton: You
liberals only have Faith in Government. Government is not consistent enough for
anybody to have faith in it.
Dr. Rosen: You got
that right. It’s a good thing that the framers of the constitution and father
of our country had a Divine faith. Otherwise we wouldn’t have the freedom and
privileges we now enjoy. We hope our next president has such Faith as our fore
Fathers had. Otherwise the end of our worldwide exceptionalism may be near.
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The Staff Lounge Is Where Unfiltered Medical Opinions Are Heard.
* * * * *
8.
Voices of
Medicine: From
the San Mateo County Medical Assn Bulletin – Nov 30, 2011
Death of Clinical
Judgment
by:
I recently reviewed a CT scan with one
of our young stellar radiologists. He was interrupted twice by the Peninsula ER
doctor who needed the information on two seriously ill patients. I watched as
the radiologist immediately retrieved the digital images on these two
abdominal scans. He reviewed the results with the ER physician over the phone
and gave him invaluable, specific information which allowed a prompt and
correct disposition to be made. The anatomic accuracy and specificity of the
images is nothing less than awesome.
I reflected to my own experiences
working as the Peninsula ER Doc 41 years ago (many of the new docs covered the
ER before there was an official ER specialty).
I remembered how we would agonize over a
patient with “unclear” abdominal pain and examine the abdomen over and
over, rechecking the WBC and UA. We would then ultimately decide if the
patient needed to go to surgery, not knowing if we made the
correct decision. Read more . . .
We used clinical skills to arrive at the
decision - the senses of touch, sight, sounds, even smell and the subtle
changes in patients reactions to our examinations and interviews. The sum of
all of this represented clinical judgment – a skill we all needed to practice
our craft. While some physicians were better at it than others, we all possessed
“it”. Those who excelled at it were “master” clinicians.
I recall my years of cardiology
training, spending hundreds of hours learning to examine the heart, going to
rheumatic and congenital heart clinics and attending auscultation courses in
distant cities. As a medical student, if I could not hear the murmur elucidated
by the professor on morning rounds, I went back at night to reexamine the
patient to train my ear and become a competent diagnostician.
I spent the last 40 years trying to
teach these physical diagnosis skills to generations of medical students at
UCSF. They will never have to achieve the skill levels that our
generation needed. Why waste all that time learning a skill that can be
bettered by the technology of ultrasound? The echocardiogram not only diagnoses
the lesion, it quantitates it as well. I now know how the 19th century
physicians felt when the chest x-ray was invented.
All their skills in percussion of a lung
cavity were no longer needed now that one could “look into” the chest with
Roentgen’s rays.
The engineers and technical people have
transformed our profession by devising and perfecting radiation, ultrasound,
nuclear techniques - all modern ways to look into the body and get
the answers that eluded physicians for centuries.
Alas, clinical judgment is a
double-edged sword, since it is no longer taught, needed or wanted with
technology making the diagnosis. Physicians will (or already have) become
health care managers who coordinate the various modalities of diagnosis.
Perhaps they too will someday be replaced by artificial intelligence.
In my fifty years of participation in
the study and practice of medicine I have witnessed the evolution of this
art/science that has gone from the “horse and buggy stage” to the space age:
electrical cardioversion; pacemakers and defibrillators (first external and
then miniaturized and implantable); balloon angioplasty, followed by bare
stents and drug eluting stents; ablation of arrhythmias; coronary angiography
and cardiac surgery, both coronary and valvular - just to mention a few
advancements in my own specialty.
It has been an “exciting ride” to
witness and participate in the evolution of medicine over the last half
century. Clinical judgment may be dead, but the medical world is now a better
place as our diagnoses and treatments have become more accurate and
precise. Nonetheless, I mourn the loss of clinical judgment.
I was fortunate to span both worlds. I
am a “dinosaur” with the latest generation 4G IPhone. Ω
Dr. Goldschlager is an internist and cardiologist
and practices in Burlingame and Daly City.
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VOM Is an Insider's View of What Doctors are Thinking,
Saying and Writing about.
* * * * *
9.
Book
Review: A Voice for
the Generations by Scott Eberle, MD
The Santa Rosa Reader: A Personal Anthology from the Family
Medicine Residency,
by Rick Flinders, MD, Sonoma County Medical Association, 95
pages, $9.95.
Some
artists’ work speaks for itself. Some artists’ work speaks for a generation.
--Jack Nicholson,
introducing Bob Dylan at the first Live Aid Concert in 1985
I was on faculty at the Santa Rosa Family Medicine
Residency from 1989 to 2001. A few years into my tenure, one of the faculty’s
more senior members told me that you could only be an effective teacher of
residents for about 10 years out from your own training. “After that,” she
said, “you’ve forgotten what it’s like to be a resident.” At the time I vowed
to never forget, and to stay beyond that 10-year mark. Turned out she was
right: I left the faculty after 12 years of teaching. In the flow of residency
time, it seems, a generation is about a decade long.
All the more remarkable, then, that Dr. Rick Flinders
has been teaching at the residency for more than three decades. With the
release of his new book, The Santa Rosa
Reader, it becomes clear just why Rick has stayed and why he has continued
to flourish--as physician, teacher and writer. Much like his great muse, Bob
Dylan, Rick has reinvented himself over and over. The one constant is that he
has been a leading voice for the Santa Rosa residency, generation after
generation. Read more . . .
I mark the start of Rick’s first “generation” of
teaching as 1985. After five years of part-time faculty work, that was the year
he became full-time director of the residency’s inpatient medicine service.
It’s also the year he wrote “Hour of the Intern,” the first essay in this
anthology from Rick the practicing physician.
Clarion (1985-1995)
I know best this phase of Rick’s teaching and writing
career. We first met in 1983 at UCSF medical school. I was a fledging medical
student, he a fledgling faculty member. At this young age, I had an inkling of
an idea about (or maybe it was just a longing for) what it might mean to be a
physician. Rick was the first person to give me words to describe this youthful
vision. During a small seminar for medical students, Rick offered story after
story from his private practice in Petaluma. I can see now how, with each
story, he was trying to bring to life the immortal words of poet and physician
William Carlos Williams:
“[S]o for me the practice of medicine has become the
pursuit of a rare element the patient may reveal at any time. It is always
there, just below the surface. From time to time we catch a glimpse--and we are
dazzled … it is magnificent, it fills my thoughts, it reaches to the farthest
limits of our lives.”
Some of the best essays in this anthology--“Prologue:
First Patient,” “House Call: What Doctors Learn” and “Epilogue: On the Road
with Daisy Mae”--are stories that capture Rick’s rare and dazzling moments.
When he and I first met, he wasn’t writing these stories yet; but in that small
UCSF seminar room, he was already the consummate bard: Rick the storyteller,
and me the rapt listener. . .
This
book review is found at http://www.scma.org/magazine/articles/?articleid=576
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The Book Review Section Is an Insider’s View of What
Doctors are Reading about.
* * * * *
10. Hippocrates & His Kin: Can
Government Learn?
David Brooks makes a great point on whether government can learn which
policies are successful.
Read the long answer by David Brooks in Section Six above.
The short answer: Government really does NOT want
to LEARN.
Q. What’s the difference
between the American Dream and every one’s dream?
A. Everybody else’s dream is
to come to America.—the promised land.—the land of opportunity.
But opportunity seems to be fading into
history.
To read more HHK
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read more HMC . . .
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Hippocrates
and His Kin / Hippocrates Modern Colleagues
The Challenges of Yesteryear, Yesterday, Today & Tomorrow
* * * * *
11. Restoring
Accountability in Medical Practice,
HealthCare, Government and Society:
•
The National
Center for Policy Analysis, John C
Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick
wrote Lives at Risk, issues a weekly
Health Policy Digest, a health summary of the full NCPA daily
report. You may log on at www.ncpa.org and register to receive one or more
of these reports.
•
Pacific
Research Institute, (www.pacificresearch.org) Sally
C Pipes, President and CEO, John R Graham, Director of Health Care Studies, publish a monthly Health Policy Prescription
newsletter, which is very timely to our current health care situation. You may
signup to receive their newsletters via email by clicking on the email tab or directly access their health
care blog.
•
The Mercatus
Center at George Mason University (www.mercatus.org)
is a strong advocate for accountability in government. Maurice McTigue, QSO,
a Distinguished Visiting Scholar, a former member of Parliament and cabinet
minister in New Zealand, is now director of the Mercatus Center's Government
Accountability Project. Join
the Mercatus Center for Excellence in Government.
•
To read the rest
of this section, please go to www.medicaltuesday.net/org.asp.
•
John and Alieta Eck, MDs, for their first-century solution to twenty-first
century needs. With 46 million people in this country uninsured, we need an
innovative solution apart from the place of employment and apart from the
government. To read the rest of the story, go to www.zhcenter.org and check
out their history, mission statement, newsletter, and a host of other
information
•
Medi-Share Medi-Share is based on the biblical principles of
caring for and sharing in one another's burdens (as outlined in Galatians 6:2).
And as such, adhering to biblical principles of health and lifestyle are
important requirements for membership in Medi-Share.
This is not insurance. Read more . . .
•
PATMOS
EmergiClinic - where Robert Berry,
MD, an emergency physician and internist, practices. To read his story and
the background for naming his clinic PATMOS EmergiClinic - the island where
John was exiled and an acronym for "payment at time of service," go
to www.patmosemergiclinic.com/
To read more on Dr Berry, please click on the various topics at his website. To
review How
to Start a Third-Party Free Medical Practice . . .
•
PRIVATE NEUROLOGY is
a Third-Party-Free Practice in Derby, NY with Larry Huntoon, MD, PhD, FANN. (http://home.earthlink.net/~doctorlrhuntoon/)
Dr Huntoon does not allow any HMO or government interference in your medical
care. "Since I am not forced to use CPT codes and ICD-9 codes (coding
numbers required on claim forms) in our practice, I have been able to keep our
fee structure very simple." I have no interest in "playing
games" so as to "run up the bill." My goal is to provide
competent, compassionate, ethical care at a price that patients can afford. I
also believe in an honest day's pay for an honest day's work. Private
Neurology also guarantees that
medical records in our office are kept totally private and confidential - in
accordance with the Oath of Hippocrates. Since I am a non-covered entity under
HIPAA, your medical records are safe from the increased risk of disclosure
under HIPAA law.
•
FIRM: Freedom
and Individual Rights in Medicine, Lin
Zinser, JD, Founder, www.westandfirm.org,
researches and studies the work of scholars and policy experts in the areas
of health care, law, philosophy, and economics to inform and to foster public
debate on the causes and potential solutions of rising costs of health care and
health insurance. Read Lin
Zinser’s view on today’s health care problem: In today’s proposals for sweeping changes
in the field of medicine, the term “socialized medicine” is never used. Instead
we hear demands for “universal,” “mandatory,” “singlepayer,” and/or
“comprehensive” systems. These demands aim to force one healthcare plan
(sometimes with options) onto all Americans; it is a plan under which all medical
services are paid for, and thus controlled, by government agencies. Sometimes,
proponents call this “nationalized financing” or “nationalized health
insurance.” In a more honest day, it was called socialized medicine.
•
Michael J.
Harris, MD - www.northernurology.com
- an active member in the American Urological Association, Association of
American Physicians and Surgeons, Societe' Internationale D'Urologie, has an
active cash'n carry practice in urology in Traverse City, Michigan. He has no
contracts, no Medicare, Medicaid, no HIPAA, just patient care. Dr Harris is
nationally recognized for his medical care system reform initiatives. To
understand that Medical Bureaucrats and Administrators are basically Medical
Illiterates telling the experts how to practice medicine, be sure to savor his
article on "Administrativectomy:
The Cure For Toxic Bureaucratosis."
•
David
J Gibson, MD, Consulting Partner of Illumination Medical, Inc. has made important contributions to the
free Medical MarketPlace in speeches and writings. His series of articles in Sacramento
Medicine can be found at www.ssvms.org. To read his "Lessons from the Past," go to www.ssvms.org/articles/0403gibson.asp. For additional articles, such as the cost of Single
Payer, go to www.healthplanusa.net/DGSinglePayer.htm; for Health Care Inflation, go to www.healthplanusa.net/DGHealthCareInflation.htm.
•
Dr
Richard B Willner,
President, Center Peer Review Justice Inc, states: We are a group of
healthcare doctors -- physicians, podiatrists, dentists, osteopaths -- who have
experienced and/or witnessed the tragedy of the perversion of medical peer
review by malice and bad faith. We have seen the statutory immunity, which is
provided to our "peers" for the purposes of quality assurance and
credentialing, used as cover to allow those "peers" to ruin careers
and reputations to further their own, usually monetary agenda of destroying the
competition. We are dedicated to the exposure, conviction, and sanction of any
and all doctors, and affiliated hospitals, HMOs, medical boards, and other such
institutions, which would use peer review as a weapon to unfairly destroy other
professionals. Read the rest of the story, as well as a wealth of information,
at www.peerreview.org.
•
Semmelweis
Society International, Verner S. Waite MD, FACS, Founder; Henry Butler MD,
FACS, President; Ralph Bard MD, JD, Vice President; W. Hinnant MD, JD,
Secretary-Treasurer; is
named after Ignaz Philipp Semmelweis, MD (1818-1865), an obstetrician
who has been hailed as the savior of mothers. He noted maternal mortality of
25-30 percent in the obstetrical clinic in Vienna. He also noted that the first
division of the clinic run by medical students had a death rate 2-3 times as
high as the second division run by midwives. He also noticed that medical
students came from the dissecting room to the maternity ward. He ordered the
students to wash their hands in a solution of chlorinated lime before each
examination. The maternal mortality dropped, and by 1848, no women died in
childbirth in his division. He lost his appointment the following year and was
unable to obtain a teaching appointment. Although ahead of his peers, he was
not accepted by them. When Dr Verner Waite received similar treatment from a
hospital, he organized the Semmelweis Society with his own funds using Dr
Semmelweis as a model: To read the article he wrote at my request for
Sacramento Medicine when I was editor in 1994, see www.delmeyer.net/HMCPeerRev.htm. To see Attorney Sharon Kime's response, as well as the California
Medical Board response, see www.delmeyer.net/HMCPeerRev.htm.
Scroll down to read some very interesting letters to the editor from the
Medical Board of California, from a member of the MBC, and from Deane Hillsman,
MD. To view some horror stories of atrocities against physicians and how
organized medicine still treats this problem, please go to www.semmelweissociety.net.
•
The
Association of American Physicians & Surgeons (www.AAPSonline.org), The Voice for Private
Physicians Since 1943, representing physicians in their struggles against
bureaucratic medicine, loss of medical privacy, and intrusion by the government
into the personal and confidential relationship between patients and their
physicians. Be sure to read News of the Day in Perspective: Don't miss
the "AAPS News," written by Jane Orient, MD, and archived on
this site which provides valuable information on a monthly basis. Browse the
archives of their official organ, the Journal
of American Physicians and Surgeons, with Larry Huntoon, MD, PhD, a
neurologist in New York, as the Editor-in-Chief. There are a number of
important articles that can be accessed from the Table of Contents.
•
The AAPS California
Chapter is an unincorporated
association made up of members. The Goal of the AAPS California Chapter is to
carry on the activities of the Association of American Physicians and Surgeons
(AAPS) on a statewide basis. This is accomplished by having meetings and
providing communications that support the medical professional needs and
interests of independent physicians in private practice. To join the AAPS
California Chapter, all you need to do is join national AAPS and be a physician
licensed to practice in the State of California. There is no additional cost or
fee to be a member of the AAPS California State Chapter.
•
Go to California Chapter
Web Page . . .
Bottom
line: "We are the best deal Physicians can get from a statewide physician
based organization!"
•
PA-AAPS is the Pennsylvania Chapter of the Association
of American Physicians and Surgeons (AAPS), a non-partisan professional
association of physicians in all types of practices and specialties across the
country. Since 1943, AAPS has been dedicated to the highest ethical standards
of the Oath of Hippocrates and to preserving the sanctity of the
patient-physician relationship and the practice of private medicine. We welcome
all physicians (M.D. and D.O.) as members. Podiatrists, dentists, chiropractors
and other medical professionals are welcome to join as professional associate
members. Staff members and the public are welcome as associate members. Medical
students are welcome to join free of charge.
Our motto, "omnia pro aegroto"
means "all for the patient."
12. Words
of Wisdom, Recent Postings, In Memoriam, This month in History . . .
Words of
Wisdom
We contend that for a nation to try to tax
itself into prosperity is like man standing in a bucket and trying to lift
himself up by the handle. –Winston Churchill
Giving money and power to government is
like giving whiskey and car keys to teenage boys. –P. J. O’Rourke, Civil
Libertarian.
Government is the great fiction, through
which everybody endeavors to live at the expense of everybody else. –Frederic
Bastiat, French Economist (1801-1850)
Some Recent
Postings
In The April Issue: