What's a Pound of Prevention Really Worth?

As another example of what is wrong with the current US health care system, here is an article from today's New York Times describing how insurance companies would sooner pay for an expensive coronary stent than for a patient to sit down and talk with their healthcare provider about low cost changes in diet and exercise.

"We have made major improvements in prevention," Dr. Gregg W. Stone, the director of cardiovascular research at Columbia University, says. "But it's difficult. It takes frequent visits, a close relationship between a physician and a patient and a very committed patient."

Which is exactly the atmosphere Dr. Agatston's practice tries to create. Nurses there give patients specific cholesterol goals to meet and help them deal with the side effects of the drugs they are taking. A nutritionist, Marie Almon, meets with patients frequently enough to discuss real-life issues like how to stick to a high-fiber Mediterranean diet even on a cruise or a business trip.

There is only one problem with this shining example of a medical practice: it is losing money.

What's a pound of prevention really worth?

To a primary care doctor, it is the difference between vitality and disability, between having happy and healthy patients vs. long medication lists and repeated hospitalizations.

To a patient, it could be the difference between seeing your grandson's wedding vs. not living to see your daughter's 1st day at school. It could be, to quote a well-known commercial slogan, priceless.

But to many insurance companies, it ain't worth squat.

The Other Shoe Finally Dropped

The North Dakota Supreme Court has finally ruled in favor of that state's medical board and said it had the right to revoke the medical license of Dr. George Hsu because of what it considered inappropriate care.

A quick summary of the case (detailed version here):
An anonymous complaint was made to North Dakota Board of Medical Examiners against Dr. George Hsu. After an investigation they determined that there was poor recordkeeping and that he had a bad attitude when brought before the board. A judge recommended that his practice be monitored. Instead, the medical board revoked his medical license. His patients rallied behind him and with their support, Dr. Hsu appealed. After one year of the appeals process, a district judge ruled that Dr. Hsu's license should be reinstated if he agreed to be monitored. The medical board ignored the ruling and revoked his license again, forcing the judge to order them to reinstate his license. The medical board appealed to the state Supreme Court, arguing that it alone has the right to decide not only what is appropriate care but how to discipline doctors. And the state Supreme Court agreed.

This story brings up a lot of troubling questions for me. Should a doctor lose his license because of bad record-keeping without proof of actual harm? Should a doctor lose his license because of a "bad attitude"? If the answer is yes to both of these, then a whole lot of doctors in this country should be losing their licenses soon.

During the course of the appeal to the state Supreme Court, some startling allegations were made against the process by which Dr. Hsu was prosecuted. The initial investigator in the case may have had a significant conflict of interest in the case. From the appellee brief filed with the North Dakota Supreme Court:

The Board has an obligation to appoint investigators who do not have a conflict with the doctor being investigated. The investigator in this case, Doctor Craig Lambrecht, had a conflict with Doctor Hsu. Doctor Lambrecht's mother was denied a position as an occupational health nurse with the North Dakota National Guard only after Doctor Hsu complained to General Macdonald that Doctor Lambrecht's mother had been sleeping with the command Sergeant Major. In his August 1, 2005 affidavit, General Macdonald confirmed that the accusations were made and that, in his opinion, "...it was inappropriate for Doctor Craig Lambrecht to investigate Doctor George S. Hsu. (See Appellee's Appendix at pages 22-23). An affidavit from a nurse formerly in the North Dakota National Guard also confirmed that Doctor Hsu made the allegations to General Macdonald and that she informed Rolf Sletten of Doctor Lambrecht's conflict of interest prior to the Board hearings against Doctor Hsu.

Dr. Craig Lambrecht also happened to be the chairman of the North Dakota State Board of Medical Examiners that determined that Dr. Hsu should lose his license. Rolf Sletten is the executive secretary of this same Board.

Besides the clear personal conflict of interest described above, Doctor Lambrecht also had the financial motives as described in Johnson. For instance, Doctor Lambrecht is employed by Medcenter One in Bismarck, North Dakota, an institution that had much to gain if the farmers and ranchers in the Elgin, North Dakota area switched from Doctor Hsu's clinic to Medcenter One's Elgin clinic.

........

As the trial hearing counsel argued, complaints should arise from the public and not from the Board's investigator, but the Board could not rely on the public's help in this case as Doctor Hsu has never even had a medical malpractice suit brought against him at any time during his career and has, in fact, enjoyed wide community support during the entirety of these proceedings. (August 17-18, 2004 hearing transcript at page 677 and Appellant's Appendix at page 21).

Doctor Lambrecht's conflicts with Doctor Hsu violated Doctor Hsu's right to due process as protected under the United States and North Dakota Constitutions. N.D.C.C. Art. 1, §9. "A license to practice medicine is a property right deserving constitutional protection, including due process."

As I have said before, I don't know Dr. George Hsu. I've never met him, although he did leave a comment to one of my entries about him. But when there is a shortage of good primary care doctors, you don't start taking medical licenses away because of bad recordkeeping. And in the interest of justice, you shouldn't have anyone investigating or judging him who might hold a grudge against him. I haven't heard it brought up, but I have wondered if Dr. Hsu's ethnicity had anything to do with him getting singled out.

Medical boards serve a purpose. But like the Spanish Inquisition, having the combined power of investigator, judge and jury at the same time seems like a little too much power to me. And you know what they say about absolute power.

Does a medical board alone have the power to decide what is appropriate care/conduct and what the sanction should be? If the medical board decides that a sloppy appearance is unprofessional and worthy of license forfeiture, is that their unquestionable right? What if they decide that pregnancy termination or withdrawal of life support is malpractice? Dating a former patient? Cheating on a spouse? Voting Libertarian? Belonging to the Church of the Flying Spaghetti Monster? Where does one draw the line? Is there a line?

The reason why this story concerns me so much is because, as a fellow family physician, "there but for the grace of God, go I." If something like this can happen to him, it could happen to me or any other physician. Nobody is safe.

Best of luck to you, Dr. Hsu.

Word of Mouth

Date: Monday, January 22, 2007
Radio Station: KSOR, Jefferson Public Radio, Ashland, OR
Program: The Jefferson Exchange

Host: Jeff Golden
Guest: David Carroll, Research Director for the California Budget Project and former director of finance policy for the California Association of Public Hospitals.
Caller: Jan

Jeff: Let's take a call from Jan in Eugene. Jan, you're on with David Carroll of the California Budget Project. Go ahead.
Jan: Yeah, hi, good morning. I just wanted to describe very briefly a doctor I know in Eugene who manages her practice in a very, very different way. She has no staff. When you come into the office, she's the only person there. She's an MD, board certified, all of that. And she has arranged her practice to keep costs down because she doesn't have staff. She wants to enjoy her medical practice. One of her key items is to keep her overhead low, just a small little office, and she passes that on to her patients. I went in there a couple of weeks ago and it was a $40 visit for just a minor item i wanted to have looked at. And she advocates this kind of medical practice. She enjoys her practice a whole lot, she's going to stay in practice because she likes it. She's not burned out because she has to turn her practice into a mill where, according to her, a typical doctor is spending 80 percent of their time over the period of a year just covering their overhead.
Jeff: Mm hmm. So she takes no insurance, she takes basically--
Jan: She does.
Jeff: She does?
Jan: She does. Yeah.
Jeff: How does she...?
Jan: But she provides a discount for people who pay cash.
Jeff: I'm puzzled how she can do this with literally no staff. Do you just walk in?
Jan: (laughs) It's radical. And she loves it.
Jeff: Do you make an appointment?
Jan: Yeah.
Jeff: You do?
Jan: And she'll spend a longer time with you because she doesn't have this huge overhead to cover. And part of it is almost somewhat preventative because patients don't have to feel like they have to rush in and rush out because they've been given, like, 12 minutes. And it's far more personal, far more sociable, and she spends more time. "So okay, is there anything else you need to tell me about?" I found it to be quite an enjoyable experience. I haven't had a medical visit --of course I don't go to the doctor very much-- that was half social and half, you know, what my condition was that I wanted her to look at.
Jeff: Are you hearing more of this, David?
David: No. What's going through my head is, hats off to this doctor. I share your sentiments. It's very hard to imagine many doctors being able to do this given all of the hoops that offices typically have to jump through in order to secure payments from insurance companies. So for doctors that rely heavily on insurance companies and that's most doctors, it's hard to imagine this being very widespread.
Jan: Well, she has been invited to speak at a series of medical conferences where she will be talking with literally thousands of doctors about what she is doing. It's seems like almost a grass roots revival of medical care where the doctor actually has a personal relationship with their patients.
Jeff: She must be a talented multitasker.
Jan: She's very high energy and very excited about what she is doing. When she started out, she actually went around Eugene and holding little small forums to ask people -- and I went to one of these, there were about 30 people -- she asked what would be the attributes of your ideal relationship with your doctor and she's put it into practice.
Jeff: Well, she sounds remarkable.
Jan: Yeah.
Jeff: Thank you very much, Jan.
Jan: Sure.

You can listen to the complete podcast here. The above starts at about 1:33 into the show.

Me and My Shadow, Part 3

As before [1] [2], when I have a medical student do a rotation with me, I ask them to give me a write-up about their experience working with me in my micropractice. Even though he doesn't mention anything about UCLA's defeat of USC in this year's annual football melee (which took place during the rotation), it still shows some insight and thoughtfulness. (Just kidding, Anto!)

Family medicine is a fertile haven where all questions and concerns are welcome. It has been a tremendous experience to be able to take part in such a setting where tremendous gratitude is extolled for alleviating symptoms affecting daily life and solving questions and offering solutions to medical problems that had perplexed patients for prolonged periods of time. I had a tremendous opportunity with Dr S to make an impact in my patients' lives. This opportunity not only allowed me to greatly supplement my medical knowledge but it also allowed me to appreciate the art of medicine.

We have always been told that a physician's words carry a remarkable amount of weight for a patient. I had not really understood what that meant until this rotation. Instead of ending my encounter by presenting to my preceptor and letting him take it from there, I was able to go back into the room and plan a course of treatment for my patient's problems. Most of the time this involved recommending a given medication, however there were times where counseling and caring was enough to alleviate the problem.

I have had a number of valuable experiences throughout my 3rd year. Each rotation made me feel more and more like a true physician. However during this rotation I did not feel like a physician, I was a physician. From GERD to cellulitis, I had a great amount of autonomy, more than I ever had before. Therefore, I was able to inject more of my personality and care into everything I did. To have a patient say: “I came in with a minor problem, but I would have felt comfortable with you if you were treating me with a more severe medical condition” is an indescribable feeling.

I am certain I had such a valuable experience because of the unparalleled patient care and warm atmosphere created by Dr S. It is a place where patients' concerns take precedent over any other matter. It is remarkable the amount of care and attention given to each patient. Prior to my rotating through the practice I was used to 15 minute interviews and physicals with cursory follow ups. There was no time for establishing rapport or treating the patient as a whole. After seeing what Dr S does, I have not seen a better way to practice medicine. To integrate the amount of knowledge he has with the care provided is something I will strive to emulate as I become a physician.

All in all, my experience was overwhelmingly positive. It not only allowed me to expand my knowledge base but it allowed me to appreciate the tremendous value of caring and listening which is often overlooked in providing medical care. I will be ever grateful for the patients I encountered and who impacted my life more then I ever could by recommending a NSAID or antibiotic to relieve their transient pain. During these four and a half weeks I grew more as a person, learning how compassion is just as effective as a given drug. I now have a better understanding of what is meant by the phrase: “the art of medicine.” I owe a great deal of what I learned to Dr S and his practice.

Anto Hindoyan, MS3

Thank you for your thoughts, Anto, and I wish you great success in your future. I wish all medical students, and physicians for that matter, could experience what it is like to have no time constraints and no hurried rushing when talking with a patient about whatever ails them.