Sunday, November 30, 2003

There is no medicine like hope

Charlie died last night. At home, in the presence of his loving family, peacefully.

He and his wife had seemed resigned, accepting of the inevitable when I met them 4 days ago at his home. Sitting upright in an armchair, hooked up to an oxygen tank, he was having a hard time breathing then, because of the mets to his lungs and the resulting fluid buildup in the pleural space. But he had been at peace, spending his time meeting friends and family who dropped by to say hello, and a final goodbye. The hospice team was wonderful, they said, and couldn't have been kinder. It occurred to me that Charlie was lucky in a way, because he had had a chance to say goodbye to those nearest and dearest to him before he died. How many people, I wondered, got a chance to do that?

That day I explained again the information I had found about the clinical trials on pancreatic cancer, and encouraged him to enroll in the study. Also, I told them that I had ordered a bottle of enzymes for him to try, but unfortunately it was "out of stock" and wouldn't arrive until the day after Thanksgiving. Charlie and his wife were very appreciative of my concern and efforts on his behalf, even though I wasn't his doctor, or even his friend. I just wanted to help him buy a little time, and have a little hope when there was little chance of either. I guess I didn't know it at the time, but I was trying to practice "chivalrous medicine". Coincidentally, the current issue of Family Practice Management has an article on this subject:

Chivalry is not merely a civil duty meant for young men of yesteryear. Rather, it is a lost art that physicians - both male and female - can practice today. Being chivalrous requires effort, self-sacrifice and giving of oneself without expectation. A chivalrous physician respectfully places patients' concerns before his or her own (within reason). Fundamentally, being chivalrous demonstrates to others that you are a person who actively pursues the moral high road and realizes your character, perpetually evolving, is linked to your deeds. Chivalry is simply acting with kindness.



I brought the bottle of enzymes by two days later, on Friday evening. Charlie had had a rough day and could barely speak because he was so short of breath. As I handed the bottle to his wife, she asked me, "What do you think?" And I said, "You've got nothing to lose." She nodded her head with a hopeful smile. "What do I owe you for this?" she asked. "Nothing," I said, and I meant it. "Thank you so much," she said as I left. "It's my pleasure." And it was. The next night, he passed away.

It occurred to me that I might have done a disservice to Charlie and his family by offering false hope when there was none, instead of allowing him to accept his eventual death without a fight. Normally, I don't believe in futile treatments. But there was something about Charlie's situation that made me want to try to help him no matter what. Probably because he was so young, a few years older than me, and I could identify with him more than usual.

I believe that even though I didn't help Charlie live one second longer, I still helped him with the only treatment I had left: Hope. As Orisen Swett Marden said, "There is no medicine like hope, no incentive so great, no tonic so powerful as expectation of something tomorrow."

This website on bladder cancer discusses end of life care and the value of hope as a treatment option:

Some practicing oncologists consciously uses hope as a treatment tool. In ancient times, when medical technologies were more limited, the physician's appreciation of the therapeutic uses of hope was much more refined than it is today.

Even if one has no difficulty accepting the prospect of death, human beings need hope. To hope for a miracle is something we are capable of doing until the very end. There is no such thing as false hope.



This is the kind of medicine I want to practice, medicine that doesn't end when pills and drugs and knives can't do any more good.

Charlie, I hope you're doing fine.

Countdown: 36 days until target start date

Sunday, November 23, 2003

Medicare: Opt in or Opt out?

I spoke with Charlie's wife today (see previous entry). He is hanging in there, helped with some steroids. But he is very weak and getting out of bed is very hard for him. They haven't pursued any other course of treatment, I suspect because it is all so overwhelming. I got info from the clinical trial using pancreatic enzymes, and while it looks like he could be a candidate, I'm not sure he can wait for them to reply if we sent in all the info now. His family is more or less resigned to the inevitable and are trying to enjoy their time with him.

So I went ahead and ordered some pancreatic enzymes myself ($300) and am having them shipped overnight. I believe it's worth a try, and if it buys him some extra time, then it would worth more than $300. I charged it out of my business charge account, so I figure I can write it off as a business expense even though I don't intend to ever make any money from this. I have arranged to go over to Charlie's house on Wednesday since I have never met him, and just wanted to say hello (and I figured that would be a good time to bring over the enzymes, too). Isn't this what being a doctor is all about? Helping others for the sake of helping, rather than financial gain. Wouldn't that be a wonderful world if it could work just like that all the time?

This is my final (regular) work week at Kaiser. After this week I am taking a "terminal vacation" until my final resignation day on Jan. 5th, although I did agree to work 3 days in December as an urgent care doctor to help handle the expected spike in colds and flus. I am looking forward to the end of this week very much, mainly because it is the beginning of the end for me. I'll be able to finally catch up on everything, without accumulating any new patients or labs or calls.

I'm in a holding pattern with my solo preparations. Awaiting to hear from the malpractice insurance company, so that I can tell the hospital credentialing department, so that I can submit my applications for participation in Aetna/Blue Cross/Healthnet, etc. I've been waffling back and forth over Medicare participation. I'm not so concerned about the low reimbursement; it's more the fear of being prosecuted for minor unintentional violations of one of Medicare's regulations.

From a 1997 article in Family Practice Management:

The Medicare reimbursement system for physician services is complex, contradictory in the dual worlds of fee-for-service and managed care, and dangerous for those who would ignore its pitfalls. Because the rules continually change, Medicare offers a full plate of management challenges for physicians who seek its benefits but also must guard against its threats. Although the prospect is daunting, preventing false claims is manageable when taken in small bites. Physicians who had to be good students to become doctors need only approach this system the same way.



And that's from a positive take on Medicare. There are lots of negative opinions on Medicare such as this. But I have to say, this "fringe" group of the Association of American Physicians and Surgeons (who are these guys anyways?) would seem more credible if they didn't also call for a halt to requiring new vaccinations.

On the other hand, I do want to help elderly patients with their healthcare. But not at the cost of my future livelihood or career. Maybe I'll be like Gordon Moore and just not charge Medicare patients. Which way to go? Opt in or opt out? I'm getting a headache.

OK. This doesn't look so good. Medicare's Resident and New Physician Guide is only 168 pages long. Migraine alert!

I asked one of my patients at Kaiser last week what he would consider to be a reasonable fee for a regular office visit (if he didn't have insurance). He said he thought $40-50 would be a fair price. And that seems fair to me, too. I have a hope that there might be enough patients in my local area who may or may not have insurance but feel that $50 is a fair price for a 15 minute office visit, too. And if I opt out of Medicare, perhaps that is not too much for seniors to pay? I could offer a senior discount. That is something I could not do if I accepted Medicare. Even if a Medicare patient wants to pay me more than the reimbursement limit of their own free will, I would be forbidden from accepting it. How much sense does that make?

Part of the reason I'm leaving Kaiser is for greater autonomy. I'm trading Kaiser's job security for professional freedom. It would appear that in accepting Medicare, I lose both security and freedom. Perhaps it's not such a tough choice after all. Now where's my Extra-strength Tylenol?

Countdown: 43 days until target start date

Sunday, November 16, 2003

Time = Medicine

I went into work today, even though the clinic is closed. This is a time when I can go in undisturbed and call patients back ("I didn't expect you to be calling on a Sunday, doc"), take care of abnormal test results, catch up on all my charting. But today I spent about 3 hours trying to help someone who isn't even my patient.

The parents of one of my daughter's classmates have a brother-in-law who was diagnosed a month and a half ago with a tumor, and it wasn't until a couple of weeks ago that a 2nd biopsy showed that it was metastatic pancreatic cancer. I got involved because he has Kaiser insurance, and his relatives were hoping that, as a Kaiser physician, I could help him figure out the best way to get action. I guess they felt like they weren't getting enough communication from his doctors.

I've never met Charlie. The only time I spoke with him about a month ago, he sounded pretty normal and he was grateful that I could answer some questions for him. My wife is a pathologist and she also reviewed his biopsy slides as a favor, but she could only confirm his diagnosis. When she saw him he appeared strong and healthy. Today he requires an oxygen tank because he gets short of breath with even mild exertion. Such is the nature of pancreatic cancer, one of the deadliest cancers because it is so hard to identify. Most of the time, by the time it is diagnosed, it is too late to treat because it has already spread to other parts of the body. In medical school, we were taught that most patients with pancreatic cancer have less than 6 months to live.

In his case, I think Charlie would be grateful if he could last another 6 months. His doctors told him that they didn't think chemotherapy could help him at this stage, plus he is already weak and short of breath. His wife told me today that he doesn't want to spend his remaining time suffering from the effects of chemotherapy, especially when it is unlikely to help him anyways.

This is so unfair. Charlie is only 49 years old. As his wife said, they know there is a reason for everything, but right now they can't understand why this is happening. I don't think anyone can.

I remembered one of my patients who was diagnosed with liver cancer a few years ago. Probably because he is Chinese, he also consulted with a traditional Chinese medicine doctor who treated him with herbs and acupuncture. His cancer regressed and has not shown any signs of return ever since. His hepatologists and oncologists can't explain it, and have used his remarkable case as a topic of discussion at their conferences. I called him up so I could get the name and phone number of his Chinese medicine doctor. Charlie's wife was grateful to take the information. At this point, what did they have to lose?

I also remembered reading about a small study from a few years ago. A doctor treated 11 patients with inoperable pancreatic cancer with high dose pancreatic enzymes. The average survival time was 17 months, or three times the usual survival time. The longest survival time was 4 years. It was intriguing enough to warrant further study, so now there is an NIH study looking at the use of nutritional therapy to treat pancreatic cancer. I left a message with the principal investigator to see if they were still enrolling patients.

I dug deeper on Google and located a website that claimed to have the exact same formula as the enzymes used in above study, and was selling them for $275 for a bottle of 360 pills. The "ideal regimen" requires 6 bottles a month. I also sent this info to Charlie's wife today and told her that there was no way to know if this enzyme therapy really works, or if the pills being sold were the same ones used in the study. But because doing nothing is equivalent to accepting death, I told her that if it were me, I would try it.

This reminds me of Laetrile, a controversial anti-cancer treatment that we used to discuss in a medical ethics class in college. What can you do when modern medicine has no answer? Is it right to recommend treatments that are unproven, yet expensive, for a terminal condition? Are they just taking advantage of the desperate? Perhaps.

And yet, this is also about hope, a necessary part of medicine and healing. If I hadn't been able to spend 3 hours researching this stuff, I would've had to shrug my shoulders and say, "I'm sorry, but there's nothing more that can be done." I like to give people choices. I want to be able to spend this much time finding those choices for all my patients, not just the sickest. I want time to think, to look up evidence-based answers to clinical problems. Time is what is in short supply in my practice now.

This is another reason why I want to start a solo practice. To have the time to practice better medicine, to know that I've tried my best. Because everybody deserves the best. Especially Charlie.

And now, there is only one other investigational medical treatment I can do for Charlie, and that is to pray.

Countdown: 50 days until target start date

Thursday, November 13, 2003

Forms, Forms, Everywhere are Forms

I hate filling out forms. FMLA forms, DMV physicals, employment physicals, worker's comp, nursing home clearances, insurance forms, disability. I don't mind doing the exams and evaluations. It's filling out the forms I hate.

So it's a major accomplishment for me to finally complete and send in my application forms for:

1) malpractice insurance.

It was a tossup between The Doctors Company, Norcal Mutual and SCPIE. They all had good track records. SCPIE had a slightly lower rating on A.M. Best, an insurance rating company. Norcal seemed pretty good, but I didn't like how the sales rep badmouthed the competition. The Doctors Company is physician owned, so I figure they should have my best interest at heart (more than an insurance company would), so I went with them.

Three years ago, I was named in a malpractice suit because, even though I hadn't seen the patient in 2 years, I was the patient's primary care physician. The woman who had had asthma diagnosed for years ended up having a rare bronchial adenoma which acted like a ball valve and caused shortness of breath. A transfer to another hospital for surgery was delayed, and she ultimately developed pneumonia and died despite having the adenoma removed. I was named, I guess, because a physician reviewer thought I should have diagnosed it earlier, even though all her chest x-rays were always normal, even though this kind of benign tumor is very rare, even though she saw many other doctors during that time. After my thorough review of my notes, I felt that I did nothing wrong. But the defense attorneys hired by Kaiser were pushing hard for a settlement, telling me that if I didn't agree to a settlement that I could end up being liable for a lot more than the settlement amount of $250,000. I even asked a colleague physician (who was also an attorney for Kaiser) if he thought I should settle or not. He said I should settle, so I reluctantly did. I've regretted it ever since, more for the principle than anything else. The attorneys and my colleague did not have MY best interest at heart, it was all about what was best for the organization.

But now whenever a form asks, "Have you ever been named in a malpractice case?", I now have to say "Yes" and explain the whole thing. I've never really had to worry about malpractice before. Kaiser provides its own malpractice insurance. But now that I'll be on my own, it's an area I'm very much concerned with. The more I read about malpractice, the more I realize how broken this system of jackpot justice is.

2) Supplemental info for disability insurance.

They wanted proof that I made the income I said I did. So last year's tax forms and paystubs were copied and sent. I was reminded last night how important disability insurance can be when I dislocated my left pinky finger while playing basketball. I spent an hour and a half in the ER getting x-rays, then reduction (YEEOWCH!), then a splint put on. While I was waiting, I thought about how lucky I was to have a relatively minor injury, and felt reassured that I have good disability insurance for now. If I didn't, would I have to stop playing my weekly basketball? I also wondered what price people would be willing to pay for medical attention if they don't have insurance. It cost me nothing, but a visit like this could easily run someone without insurance over $200, I think. And I feel guilty wondering if $50 is too much to charge for a 15 minute office visit.

That's the thing about working at Kaiser - I don't have a good sense of what physician time is worth. I only know how much I get paid. Once I calculated my pay taking into account ALL the extra time that I put in, not just scheduled clinic time, and it worked out to about $50/hr. But of course, I don't have to pay for overhead. A survey in Medical Economics magazine found the average FP charge for a level 3 visit was $105 for new patients, and $65 for established patients. Hmm, maybe it wouldn't be so bad if I asked for $60 for an office visit.

3) Hospital privileges

I dropped off the forms to Huntington Memorial Hospital, the best known hospital in the area. So much stuff to assemble: CV, DEA, medical license, board certification, 2 passport-sized photographs, list of CME credits. They said it would take about 6 weeks to process, but I'm still missing proof of malpractice coverage, since I just mailed that in yesterday, so it will probably take longer. I had to wait until I got an address for my office before I could send in the applications.

One part of the application I couldn't fill out was the part where they asked who will cover my patients during any absences or vacations. Since I have only been with Kaiser for the past 13 years, I have had very little contact with any non-Kaiser physicians. The only ones I know, in fact, are the ones I play basketball with. So the medical staff personnel gave me a list of family physicians on staff whom I could call to ask if we could arrange some kind of cross coverage, so I could get my application approved.

I would really rather not cover someone else's patients, and I had been planning all along to not have to ask anyone to have to cover my patients. It takes a lot less work to take care of someone you already know. I figured that even if I go out of town, it wouldn't be for very long, and I would still be accessible by cellphone and/or email. In a true emergency, I'd tell the patient to go to the local ER anyways, or call 911. So I left a message with one FP's receptionist, and will await his callback to discuss possible arrangements for coverage. This is a new culture for me, and I don't know what is the norm here. I guess I'll find out.

Next up: forms for participation with Aetna, Blue Cross, Blue Shield, etc. Arrrgghhh! Did I mention how much I hate filling out forms?

Countdown: 53 days until target start date

Monday, November 10, 2003

Swimming Against the Current

I ordered a laptop computer over the weekend. A new Apple PowerBook G4 12 inch 867 mHz for $1299 from smalldog.com. I had thought at first that I would get one of the new 15 inch G4 laptops, but there have been reports of "white spots" on the screens, plus the cheapest 15 inch model costs $1999. Does the extra few inches of screen space and small increase in processor speed warrant an extra $700? Especially when I've realized that I will also need to get a second computer to act as a server? I decided it didn't.

I have used the demo of my future EMR program on my wife's laptop, a 400 mHz PowerBook and it seemed fast enough, so I'm not worried about processor speed. I could have gotten a refurbished PowerBook from the Apple Store for $1199, but I figured an extra hundred bucks for a new machine is worth it to me. Although my experience with Apple computers is that they are very well made and last a long time, longer it seems than comparable PC computers. For example, the computer I'm typing this on is a 4 year old Blue and White G3, which I upgraded to a G4 and is still going strong. In fact, I plan to use it as the server for my medical office, while I buy a new G5 for my home office.

One of the email messages on the Practice Improvement listserve today is from a doctor having problems with his PC computer. He can't move received faxes from one computer to another, is having trouble using an OCR (optical character recognition) program, backing up data is a "nightmare". He writes:

does anyone know what the error message "not enough server memory" means? i have hired a computer wizard (formerly of intel) to fix everything, and he is stumped. he even called microsoft, and they don't know what's going on. yes, i have run virus scans (norton and others, all up to date), and the system is clean. i have un-installed roxio, iomega, omnipage and have even re-installed the operating system, all to no avail.

the good news is that business continues to grow, but if i don't get this problem fixed, i can't get paid.

send help!

ps-- is this an object lesson about our dependency on computers?



I think this is an object lesson about our dependency on Microsoft which has used its monopoly power to force the acceptance of its inferior computer products. I have used Macs since they first came out, and while they have their share of problems, too, they are MUCH easier to use and fix than PC's. I am forced to use a PC at Kaiser, so I know how inconvenient they are to use. As a physician who will become dependent on his computer for medical record keeping, financial records, medical billing, posting payments, email and fax communication, medical education/references, and basically my livelihood, I think my choice of computer platforms is one of the most important ones I can make.

Sure, I could choose fancier EMR and billing software if I went with a PC, but is that enough to make up for the hassle factor of keeping up with patches to guard against viruses, worms and bugs that can bring down my system at any time? Why would I want to get a computer system that requires a technician to fix (if they even can), when I can fix any problem my Mac has? I just need something that works, and doesn't get in the way. Macs just work.

This is consistent with the concept of a low overhead practice. It is a myth that Macs are overpriced compared to PC's. Actually Macs are the same price or cheaper when compared to a PC equipped with the same features. And how much overhead (time, money, hair) goes into maintaining a PC network? More than a Mac network.

Okay, enough prosletyzing.

It feels strange to be a double revolutionary. Going solo in a managed care world is hard enough. Going solo with a Mac is really swimming against the current.

Countdown: 56 days until target start date

Thursday, November 06, 2003

OK, first, let me point out how hard it is to write an entry every day. At least, for me it is. I have a newfound respect for those bloggers who are able to write every day.

Next, I'll explain that the folktale in the previous entry was inspired when my wife told me about our daughters' visit to a relative's house last weekend. We had been having a lot of wildfires (we're in Southern California) and the relative commented that there was a lot of dust and ash and she was concerned that it might trigger her daughter's asthma condition. When my wife asked why she didn't close all the windows and doors, the relative said that their fung shei expert told them that they had to keep the windows open to allow for the positive flow of energy. It just reminded me how much influence others have even when it flies in the face of common sense. And not just those in alternative or complementary health. Even the most uninformed person's opinion will command attention by others, as long as they're really sure they're right.

All doctors have come across this scenario: A patient tells you they stopped taking all their medicines because their brother or cousin or co-worker or friend told them that their medicine is dangerous. We may ask rhetorically, "Are they a doctor?" If this were TV, the patient would reply, "No, but they did stay at a Holiday Inn Express last night."

I am counting down my last days here at my job. After today, 11 more working days until I take a "terminal vacation." In the past few days, I've opened a business checking account (Washington Mutual had the lowest monthly fee - $8 - if you go below $2500 balance); yesterday my notice got published in the local newspaper; I submitted my application for a city business license ($350). I and a friend rented a U-haul van and we picked up the used exam table, which is now sitting in my garage.

I've been looking at new and used laptop computers, trying to figure out if I need a fixed computer server. I think I'll get a high speed scanner just because I don't want to stand there and scan individual sheets of medical records into the computer EMR. I definitely want the fax machine hooked up to the computer so it gets downloaded once. I did call ATT and got my telephone numbers already, even though I won't move in until next month. Now, I can get business cards, which people are already asking for.

Still a lot to do. But looking forward to doing it.

Countdown: 60 days until target start date

Monday, November 03, 2003

The Doctor (a folktale updated)

Not so long ago there lived a doctor who went every day to her clinic. There she saw patients with various complaints. She listened to their hearts and lungs with her stethoscope and checked their reflexes with her reflex hammer. She helped many patients feel better. She was happy with her work, and never thought she wanted anything more.

One day the doctor advised a very rich man that he should lose some weight and get more exercise. But the rich man told her that he didn't need to lose weight and exercise because he just bought a bunch of fat burners from the clerk at the health food store. And not only that, he stopped taking his blood pressure and cholesterol medicines because the health food clerk told him that if he took a special blend of garlic, ginseng, vitamin E and co-enzyme Q-10, then he would have an optimal level of health that he had never even dreamed of. The next day the doctor's work seemed harder. Her stethoscope and reflex hammer seemed heavier. She thought to herself, "If only I were a clerk at a health food store, I would not have to work so hard."

Her wish was heard by the spirit who lived in the clinic. That next day, when the doctor returned to her little clinic, she saw instead a beautiful health food store! She saw rows and rows of shelves filled with shiny bottles of blue-green algae, pycnogenel, chromium picolinate and antioxidants. She had dozens of customers lining up to buy their supplements. As she was furiously ringing up their orders, she could overhear a women telling the rich man down one of the aisles, "Don't waste your money on those fat burners! Don't you know how dangerous they are? My psychic healer told me about this noni juice. Look at me, I've lost 15 pounds already! I bet I could get you a 20% discount." As the rich man left the health food store with the woman, the doctor thought, "If only I were a psychic healer! Then I wouldn't have to work so hard."

The clinic spirit heard her. Suddenly the doctor was dressed in a flowery bathrobe and fuzzy slippers, eating a breakfast of pancakes, bacon and eggs. She had cases and cases of noni juice piled high in her kitchen, living room, bedroom and garage. She was quite happy collecting checks and cash from the comfort of her own home for more orders of noni juice until one day, she got a call from the rich man demanding a refund because he had not lost any weight. The rich man said he was switching to Body Solutions because the radio traffic reporter had lost 25 pounds with it. The doctor was outraged. "No matter how much money I make, the radio traffic reporter's power is by far greater. If only I were the radio traffic reporter!"

With a flash of light the clinic spirit turned the doctor into a radio traffic reporter. From her place in the sky she could look out over the entire world. To show her great influence, she described how long it would take to get to work, which freeways to avoid, and why you should copper repipe your plumbing. Day after day she pitched Body Solutions. Then one day her traffic report was pre-empted for a feature story on an author of a bestselling diet. Her voice could no longer reach the rich man. The doctor thought, "Is it possible that this author of a bestselling diet is even stronger than a radio traffic reporter? If only I were an author of a bestselling diet!"

No sooner had she spoken these words than the clinic spirit turned her into an author of a bestselling diet. She could now reach the rich man even with the radio turned off. Before long her wallet was once again filled with green. The speaking opportunities bloomed and her schedule was filled with bookings on all the major talk shows. But the doctor was overcome by her new power. She began to publish book after book. She was on Oprah 17 times. She went to the Oscars. Soon everybody had bought a copy of her book, except for one person. The rich man's great aunt. She told her great nephew that this fad diet stuff was a bunch of hooey. After all, didn't she live to be 92 on her daily diet of sardines and pickles? "You're right, Auntie," said the rich man as he flushed his Body Solutions down the drain. "Besides this stuff tastes like crap."

The doctor was astonished. "Everyone has been swept up by the force of my bestselling books except for the rich man's great aunt. Perhaps the rich man's great aunt is even stronger than an author of a bestselling diet. If only I were the rich man's great aunt!" The clinic spirit heard her wish and turned the doctor into the rich man's great aunt. Proudly she stood up. Then she lost her balance and fell on her hip.

She was rushed to the hospital, and as she lay in the emergency room she heard a strange noise at her feet. She looked down to see what it could be. She saw a woman raise her reflex hammer and strike it against her knee. She felt her painful leg twitch all through her aged body. A chill swept over her as the cold stethoscope pressed against her chest and listened to her heart and lungs. "Don't worry. We'll fix up that hip so it's as good as new," said the surgeon, reassuringly. At that moment she realized that a doctor might not be the strongest of all anymore, but could still be counted on to make a difference when it really mattered.

adapted from The Stonecutter, a folk tale retold by Martha Hamilton and Mitch Weiss (Beauty and the Beast Storytellers) from Stories in My Pocket: Tales Kids Can Tell.

Countdown: 63 days until target start date