Thursday, September 17, 2009

Majority of Doctors Support the Public Option

A survey published 3 days ago in the New England Journal of Medicine says that 63% of doctors support the public option.

When you compare this to the American Medical Association's stand opposing the public option, it is no wonder that groups like Sermo, a growing online physician community, say that "the AMA does not speak for me".

Friday, September 04, 2009

All Generalizations Are Lies

All politicians are crooks. All lawyers are dishonest. All doctors are rich. All insurance companies are greedy. All government is incompetent.

When a significant proportion of the population hold these views, is it any wonder there is no confidence among some that healthcare reform can succeed? All that the forces of the status quo have to do to keep their gravy train going is to just keeping fanning the flames of discontent and prejudice.

These types of views are prejudicial, as prejudicial as thinking that all women are inferior to men, that all blacks are poor, that all Mexicans are lazy, that all asians are nerds, that all Jews are greedy, that all whites are Nazis. These blanket stereotypes are no different than the prejudice that uninformed people hold against a particular profession or institution.

We have seen the signs of protesters saying "Get your government hands off my Medicare!" and wondered if these people were somehow so senile that they forgot that Medicare **IS** run by the Federal Government.

Even Arthur Laffer, former economist under President Reagan, champion of supply-side economics and someone who should know better conveniently forgets this fact:
“If you like the Post Office and the Department of Motor Vehicles and you think they’re run well, just wait till you see Medicare, Medicaid and health care done by the government.”
To counter this anti-government prejudice, two-time Pulitzer Prize winner, Nicholas Kristof, wrote an article in the NY Times recently pointing out that:
The part of America’s health care system that consumers like best is the government-run part.

Fifty-six to 60 percent of people in government-run Medicare rate it a 9 or 10 on a 10-point scale. In contrast, only 40 percent of those enrolled in private insurance rank their plans that high.
Even though the status quo side keeps dragging out the "Obama wants to turn our healthcare system into Canada or England" argument as if that is a bad thing, studies have shown that patient satisfaction is higher in Australia, Canada, New Zealand and the United Kingdom compared to the US.

Oh but we don't want socialized medicine, the status quo backers argue. Because we all know that anything that's socialized is (gasp!) evil.

But Kristof writes:
Until the mid-19th century, firefighting was left mostly to a mishmash of volunteer crews and private fire insurance companies. In New York City, according to accounts in The New York Times in the 1850s and 1860s, firefighting often descended into chaos, with drunkenness and looting.

So almost every country moved to what today’s health insurance lobbyists might label “socialized firefighting.” In effect, we have a single-payer system of public fire departments.

We have the same for policing. If the security guard business were as powerful as the health insurance industry, then it would be denouncing “government takeovers” and “socialized police work.”

Throughout the industrialized world, there are a handful of these areas where governments fill needs better than free markets: fire protection, police work, education, postal service, libraries, health care. The United States goes along with this international trend in every area but one: health care.
Here in Southern California, the socialized, single-payer, government-employed firefighters have been doing an extraordinary job knocking down the largest brushfire in Los Angeles County history. If the status quo backers treated public fire safety like they treat public healthcare, they'd let the free market forces figure out how to make a profit out of charging people for fire insurance and then cutting off their coverage as soon as their houses burned down.

I'm not arguing that a single payer option is the only way to go, but I would argue that we need more choices. And one of those choices should be a government-backed option that will give the private insurance companies some competition.

Kristof closes with:
A public role in health care shouldn’t be any scarier or more repugnant than a public fire department.
I heartily agree, and I have confidence that the American public can see this too. Because not everyone is stupid.

Saturday, August 29, 2009

Sign of the Times

Last night, when I drove past the corner where the anti-war protesters show up every Friday night, I saw some new signs. Instead of the usual "US out of Iraq!" anti-war signs, they were now holding up "Health Care For All!" signs. Is health care reform surpassing Afghanistan and Iraq as the most important issue right now? I see this as a good thing. Maybe something will actually get done.

The Only Wrong Way to Go is Staying Put

According to some people, the only possible choices we have for healthcare reform are bad ones. And not just simply bad. Horribly, maniacally, twisted-evil, crimes against Nature bad.

So let's just keep everything the way it is and keep our eyes focused down at the ground and ignore that large boulder rolling down the mountain towards us. Sorry, I meant boulders with an "s" because it's actually an avalanche. But it's too dangerous to run to the left because there's a cliff there and there might be some bears or poison ivy to the right, so let's just stay put and maybe getting crushed won't be as bad as it looks.

This article discusses the generation gap in the healthcare reform debate".
“Obama’s plan is most popular among younger Americans and least popular among senior citizens,” CNN Polling Director Keating Holland said. “A majority of Americans over the age of 50 oppose Obama’s plan; a majority of those under 50 support it.”

This is despite the fact that the largest group of Americans with single payer government-funded health care are those with Medicare. The thought is that those with Medicare are afraid of losing any benefits that they already have. I think it is because older people are naturally risk-averse and uncomfortable with change, even when it may benefit them the most. That's why the lies, no matter how ridiculous, opposing health care reform work to scare people into staying put when they need to move.

Wednesday, August 12, 2009

Thoughts while packing

Tonight there was a local town hall meeting with my Congressman but I didn't go because I was packing to leave for IMP Camp tomorrow. Hopefully it was a civil affair with thoughtful discourse and respect for differing viewpoints. Not like the scuffle in St. Louis (via Daring Fireball):
Anti-health-care-reform activist, reportedly injured in a fight at a town hall meeting last week, is collecting donations to pay his medical bills because he was recently laid off and lost his health insurance.
It gets even stranger:
UPDATE: The man’s lawyer says he’s just unemployed, but has health insurance through his wife, and that he’s collecting donations to profit from the alleged attack.
Daring Fireball also points out the editorial (before it was edited) that claimed that a physically disabled genius like Stephen Hawking "wouldn't have a chance" had he lived in the UK where their nationalized system rations healthcare. Except that he has lived in the UK. His entire life. And is still alive. At age 67.

Does anyone get the sense that the anti-healthcare reform people are getting desperate? I mean, evil death panels and Nazi-style healthcare reform? Godwin's Law, anyone?

It's as if some people actually like the status quo.

Anyways, time to go to sleep and dream of a better healthcare plan for America. And then go to IMP Camp to help make it come true.

Monday, August 10, 2009

Slice of FP Life

NY Times piece about a day in the life of a family doctor, in this case, Dr. Timothy Malia.

Sounds about right to me. I've had days (and weeks) like that, too.

Monday, July 20, 2009

The Prime Beneficiary of Our Health Care System

Unfortunately, under the current system, it's not patients. Or doctors.


Thursday, July 16, 2009

Worse than McAllen?

If anyone wants to know why we need healthcare reform yesterday, all they have to do is read this newspaper article about a patient who spent 12 hours at the Fort Walton Beach Medical Center in Florida and racked up charges totaling $211,941.50 before being transferred to a 2nd hospital where an additional $400,000 in charges were run up in 12 more hours.

Granted, this case sounds like the patient was very ill because they ended up dying. But still. These charges are ridiculous.

I mean, $354 for 2 mg of Lorazepam? You can get a 2 mg tablet of Lorazepam at Costco for 37 cents.

When Dr. Atul Gawande wrote about the high healthcare costs of McAllen, TX, who knew there were actually places even more expensive to get medical care?

Friday, July 10, 2009

A Medical Revolution

One of my patients posted this article about my practice, I am sorry to confess, back in February. I have been meaning to post a link to it, but always put it off, waiting for an opportune time to write a decent entry for this well-written article about alternative practice models, including the Ideal Medical Practice movement:
There is a revolt afoot across the land.

Doctors are rebelling against the burden of health care insurance paperwork. They are rebelling against having to deal with upward of 12,000 procedure and drug codes that add expense and time to their practices, keeping them from giving full attention to patients.

This means fewer and fewer doctors are going into general practice, opting instead for specializations, which double their income and insulate themselves, to some degree, from the burden of health insurance paperwork.

He compares and contrasts my practice vs. a traditional medical office.
Your doctor: you have to wait some time for an appointment. Your doctor spends less than 15 minutes with you before referring you to a specialist who, in turn, takes a long time to see.

My doctor: I can have an appointment the same or next day or whenever is convenient for me. My doctor will spend as much time with me as we both feel is necessary.

Your doctor: You check in with a receptionist who gives you forms to fill out. You stew in the waiting room for some period of time before being ushered into an examination room by a nurse who asks all the same questions you already provided. You wait for another interminable time (without the out-of-date medical journals and golf magazines that were outside).

My doctor: He meets me at the door since he has no nurse, receptionist or other staff, which keeps overheads -- and his charges -- low.
He has been a big supporter of my practice for years, and I appreciate his efforts in helping to spread the word about alternatives to the current dysfunctional healthcare system we have now. He is a much accomplished man, a veteran, a captain of the financial industry, a man of letters with a sharp wit, a loving husband, a doting father and grandfather, and a friend.

Unfortunately, all good things must come to an end. And so, I say, "Well done, Mr. Sharp."


Monday, July 06, 2009

Moses Explains the US Healthcare System

Well, it's as good an explanation as any, and frankly more comprehensible than most.

From Gods Playing Poker:

Sunday, June 21, 2009

Not Dead Yet

It is not necessary to change. Survival is not mandatory.
--W. Edwards Deming

“The superior doctor prevents sickness; The mediocre doctor attends to impending sickness; The inferior doctor treats actual sickness.” --Ancient Chinese quotation

I haven't been posting regularly for a while because, well, it takes a lot of work to keep up a blog. I mean, I do have a day job. And that day job has changed a little.

I started this blog on September 25, 2003 in order to "chronicle my attempt to replicate what family practitioner Dr. Gordon Moore has pioneered in his "solo-solo practice" (Going Solo: Making the Leap) in the hopes of regaining some control and sanity in my professional (and personal) life" and to "help anyone else who might be attempting the same foolhardy stupid insane brave endeavor".

I am as surprised as anyone that this blog has survived. For those of you who are considering, or have started your own medical blogs, know that, like everything else in life, medical blogging is not without risks.

For those who are interested in starting your own solo micropractice, there are risks, too, but I still think it is possible under the right conditions and with a lot of help.

I am still a solo family doctor. I started off as a solo-solo operation (aka the Gordon Moore model) about 5 1/2 years ago, in February 2004, and have been trying to figure out how to make this thing work for me and my patients ever since. I signed up with a bunch of PPO insurance plans and Medicare, but chose to avoid Medicaid and HMO because of the low reimbursement/high hassle factor.

What have I learned?
1. Submitting claims to insurance companies is easy, but collecting payment from them is sometimes very, very difficult, and in some cases, impossible.

2. The more time you spend with a patient, the more there is to document in the progress note.

3. Perfect progress notes are the enemy of timely progress notes.

4. EMRs don't save time in charting, but they do when retrieving notes.

5. There is no perfect EMR so get the cheapest one that does what you need it to do.

6. The ideal personality to run a solo-solo office is someone who is either in a permanent manic phase or who has the energy of a hyperactive kid on Pixy Stix and caffeine.

7. I live in a "dead zone", an area with conditions (in my case, high cost of living and low insurance reimbursement) that makes it very difficult, if not impossible, for an Ideal Medical Practice to survive.

8. The fixed low reimbursement of primary health care coupled with relatively high expenses means that the current American Healthcare System forces primary care doctors to continue following the business plan of the Underpants Gnomes:


Phase 1: Provide primary care (or collect underpants, your choice)
Phase 2: ???
Phase 3: $Profit$!
It's that Phase 2 part that's killing off primary care.

Changes I have made in my practice since 2004:
1. I got a part-time biller. My first biller was a lifesaver for me in that she is able to follow up on denied and "forgotten" claims that I didn't have the time or energy for. I call her my "pitbull" because once she gets hold of a claim, she doesn't let go until they pay up or all options have been exhausted. She has since moved on due to other obligations, and I have a new biller who is still learning the ropes. Still, it is better than when I was submitting (or not submitting) claims on my own.

2. Changed my practice name from a "Family Practice" to "Family Medicine". I should have done this at the very beginning, but that was right around the time that AAFP was changing our specialty name and I guess I didn't have the foresight to see what a hassle it would be later to change business cards, stationary, phone book listings, insurance contracts, etc. People still aren't really sure what Family Medicine is, but it's better than being confused for a daycare center.

3. I opted out of Medicare. I had been thinking about opting out of Medicare for a long time, basically ever since I opened my solo practice. Medicare's reimbursement level was low but usually no lower than the PPO payers and sometimes even higher than them, which is pretty depressing. They usually paid quickly and it wasn't that difficult to talk to a live person when we had a problem. But after my first 3 years in practice, only 4% of my patients had Medicare.

My main concern with Medicare has always been about accidentally running afoul of Medicare regulations and being tossed in jail or fined. When you first enroll with Medicare, they send you a CD with their rules and regulations. I have never opened that CD. In book form, it is over 500 pages long.

Medical coding is probably 2nd only to income tax calculations in complexity. In a study with 300 coding experts given 6 hypothetical cases to code, there was only 57% agreement on the correct E/M code. And this was with coding experts. It's got to be even worse when physicians do it but as physicians, we are ultimately responsible for any errors.

Medicare can fine you if you waive a patient's copay. They even sell Medicare supplemental fraud insurance in case you get hauled in. Under the False Claims Act, you can be fined up to $11,000 per claim and liable for 3 times the actual damages. Kind of like having a rich, beautiful and famous girlfriend who will cut your arm off because you didn't compliment her new shoes.

And while I realize that the few horror stories are rare and unlikely to ever affect me, they were enough to make me question, as for this physician, whether I should continue taking Medicare. Since dropping Medicare wouldn't affect my income significantly, I decided it wasn't worth it for me so I opted out.

4. I started charging an extra fee to help me survive the dead zone. More on this next time.

So anyways, both my practice and this blog are not dead yet.

In fact, I'm a lot happier and more satisfied as a physician, with the freedom to practice medicine the way I was trained to. I have the flexibility to pick up my kids from school every day and drive them to get braces, or wait for the plumber, or run errands. I don't make as much as I used to at Kaiser, but my income has been growing every year and I anticipate it will keep growing.

One of the reasons I went into medicine was because I knew I didn't want to go into business. But when I got into medicine, I discovered that it had turned into big business. So I started my own business to rediscover the art of medicine. Funny how that worked out, huh?


Friday, June 19, 2009

Steward's Foresight

Even as physicians, patients, insurers, business leaders and politicians converge on Washington, DC to focus on healthcare reform, Ideal Medical Practices are making the news, this time in Anchorage, Alaska:
During a typical visit to the doctor, most people spend more time in the waiting room than in the examination room.

On average, a physician spends about 10 minutes with a patient, according to one doctor in Anchorage who's working to change that.

At Steward Family Medicine, Dr. Daniel Steward makes time for every patient -- the shortest appointment lasts 30 minutes.

"You have so much time to talk with him and can cover any issue that you could possibly have because he doesn't rush you out of the office," patient Tahneta Stroh said. "He's a fantastic doctor."

Steward has jumped on board a grassroots movement sweeping across the nation known as an "ideal medical practice."
Unlike the glacier-like progress of healthcare reform taking place in Washington, DC, Ideal Medical Practices are bringing a better and more satisfying experience to patients NOW and will continue to do so regardless of what changes eventually take place.

To see where other Ideal Medical Practices are in the lower 48, go to the IMP Map.

Tuesday, June 16, 2009

An Open Letter to President Obama

Dr. John Brady runs a successful micropractice in Newport News, VA, and was Virginia's 2008 Family Physician of the Year. He has written a letter to his state legislators and President Obama regarding the healthcare crisis that is so well written that I am reposting it here, with Dr. Brady's kind permission:


Dear President Obama,

I feel obligated to express my opinions on health care reform. I am a solo family physician working in Newport News, Virginia and am part of a nationwide collaborative of physicians dedicated to providing great care to their patients (

I am experienced working on the front lines of health care for the past 15 years, and I have dedicated my last six years to trying to understand how to provide superior care to my patients. I am independent, I have no axes to grind, and I represent no interests except those of my patients.

There is no question we need reform. The health care system is disintegrating daily and taking a lot of wonderful patients and doctors with it. Patients are literally dying from both not having access to good primary care and from the poor quality care they receive once they get through the door. Doctors are imprisoned by mounds of administrative minutia which strip away their freedom to practice medicine individualized to the patient’s wants and needs (patient-centered collaborative care) and serve as a wedge between them and their patient.

Study after study has shown that the stronger the relationship between a doctor and his patient, the greater the quality and the lower the costs, but our system is set up not to enhance but to destroy this cornerstone of medicine. Unless the reform ideas being proposed address this fundamental flaw in our system, they are doomed to increase healthcare costs while remaining unable to enhance quality. Indeed, it is the failure of the doctor-patient relationship over the past twenty years which has been the true reason behind the cost escalation and the quality chasm.

Doctors are paid for quantity. The faster we push our patients through, the more money we make. The problem is that the faster we push our patients through, the less we know each one and the less we know each one, the more we rely on testing and specialty referrals to augment our clinical judgment.

Over the past 20 years, reimbursement has not kept up with overhead costs and so doctors have had to see more and more patients a day. The number of tests being done has exploded with the resultant explosion of costs. Insurance companies, seeing this trend, have tried to put roadblocks up to halt testing and referrals, but all this does is increase the administrative costs of the office forcing the doctors to see even more patients per day.

Harried doctors become burned out and begin to lack empathy leading to worsening quality and increased liability. Medical students see the trend of increasing workload, flat salary, and miserable physicians and have begun to avoid choosing primary care as a life choice. All this is occurring at the exact time the population is aging, which puts the country on the precipice of a complete meltdown of the medical system.

Clearly, the toxic reimbursement system needs to be fundamentally changed such that policies are adopted which enhance the relationship between doctors and patients. A simple solution would be to offer doctors the ability to opt out of the current nightmare payment scheme into a new system where the physician gets a dollar a day for every patient who chooses him/her as their primary care doctor. That reimbursement is then adjusted up or down quarterly based on the patient’s experience of care. Questions surrounding access, efficiency (waiting time), continuity, information exchange, and coordination can all be easily attained through a simple survey like How’s Your Health (

By doing this, doctors will be encouraged to provide the best service to their patient, and the resulting happier, healthier patients will be much less likely to go to the ER or have to get admitted to the hospital. Doctors, vying for high satisfaction grades, will quickly adopt quality initiatives like secure e-mail, online appointments, etc. Primary Care salaries will become much closer to that of the specialists, but more importantly as the relationship with their patients strengthen, overall medical costs will decrease, physicians will have higher job satisfaction, and medical students will flock to primary care. Truly this becomes a win-win situation for everyone.

I know this solution does not involve covering the uninsured or forcing the implementation of new tools or cool (expensive) technology, but that is why it will work. Covering the masses is a laudable goal, but doing this prior to fixing primary care is the equivalent of giving everyone a car and not building any roads.

Turning to computers and electronic medical systems to try and make a medical office a “medical home” is similar to thinking that adding the internet or a flat screen TV to a house will make it a home. It is the relationships, not the furniture, which makes a house a home. Similarly, to encourage the development of medical homes, we have to start by encouraging the development of strong relationships and only then worry about where the furniture (computers, integrated systems, etc) should go.

I appreciate you taking the time to read this letter, and I hope it resonates with you. I fear the potential harm to my patients and my country if we decide to do what might be politically easy instead of what is right. I remain willing to discuss any part of this in more depth if you desire and I can forward many good studies supporting everything I have stated.

Providing high quality, cost effective care is possible in today’s environment—I do it every day. But, in order to encourage quality care to become mainstream, we have to change the way doctors are paid. If that cannot be accomplished, nothing else will matter.


John E. Brady, MD, FAAFP
The Village Doctor
2008 VAFP Virginia Family Physician of the Year

Sunday, June 14, 2009

Positive Deviants

Dr. Atul Gawande is a general and endocrine surgeon at the Brigham and Women's Hospital in Boston, MA, who also writes wonderful articles for New Yorker magazine. One of his recent articles, The Cost Conundrum, is a disturbing in-depth exploration into why health care costs in McAllen, TX, one of the highest in the US, are twice as high as those in El Paso, TX, despite its similar demographics.

His most recent article was his commencement address to the graduating 2009 class of the University of Chicago Pritzker School of Medicine.

In his address, he related the story of a friend who ran a program to reduce malnutrition in Vietnamese villages but, like many humanitarian enterprises these days, had little funding. So instead of the usual methods advocated by outside experts, they used a low-tech approach.
They went to villages in trouble and got the villagers to help them identify who among them had the best-nourished children—who among them had demonstrated what Jerry Sternin termed a “positive deviance” from the norm. The villagers then visited those mothers at home to see exactly what they were doing.

Just that was revolutionary. The villagers discovered that there were well-nourished children among them, despite the poverty, and that those children’s mothers were breaking with the locally accepted wisdom in all sorts of ways—feeding their children even when they had diarrhea; giving them several small feedings each day rather than one or two big ones; adding sweet potato greens to the children’s rice despite its being considered a low-class food. The ideas spread and took hold. The program measured the results and posted them in the villages for all to see. In two years, malnutrition dropped 65 to 85 percent in every village the Sternins had been to. Their program proved in fact more effective than outside experts were.
Gawande then goes on to explain how the United States is now that village, with our crumbling economy, rising unemployment, and auto, financial and housing industries in serious trouble.
More than that, though, we in medicine have partly contributed to these troubles. Our country’s health care is by far the most expensive in the world. It now consumes more than one of every six dollars we earn. The financial burden has damaged the global competitiveness of American businesses and bankrupted millions of families, even those with insurance. It’s also devouring our government at every level—squeezing out investments in education, our infrastructure, energy development, our future.

As President Obama recently said, “The greatest threat to America's fiscal health is not Social Security, though that's a significant challenge. It's not the investments that we've made to rescue our economy during this crisis. By a wide margin, the biggest threat to our nation's balance sheet is the skyrocketing cost of health care. It's not even close.”
While a large part of those costs are administrative costs, the bulk of extra spending is due to extra tests, procedures, specialist visits and treatment—things that doctors control.
Yet studies find that in high-cost places—where doctors order more frequent tests and procedures, more specialist visits, more hospital admissions than the average—the patients do no better, whether measured in terms of survival, ability to function, or satisfaction with care. If anything, they seemed to do worse.
He points out that, like the researchers in Vietnam, we need to look for successful outliers if we are to solve our healthcare crisis. But while he zooms in to some degree of some unique models, he doesn't zoom in close enough. I think the "positive deviants" he and the rest of the country are looking for are IMPs—Ideal Medical Practices.

Small, low-overhead, cost-effective practices with unfettered access that have both highly satisfied patients and healthcare providers, with reproducible measures of success. Definitely outside the norm. I'm not talking about solo no-staff micropractices such as mine, although that could be part of the solution. I'm not talking about all primary care physicians becoming IMPs. As has been pointed out before, we don't have enough primary care doctors to take care of everybody if we adopted that model for the entire nation. It is the underlying principles behind the IMP model that need to be looked at more closely.

IMPs focus on that "secret ingredient" that has been disappearing from our current healthcare system for quite some time. Namely, the doctor-patient relationship. Study after study has shown that when patients have a relationship with their primary care doctor, quality rises and costs fall.

When I have the time to know my patients, their histories and symptoms, I can order appropriate, targeted tests rather than a scattershot battery of tests hoping to hit something. When patients have easy access to me, we can wait and see if symptoms get better rather than get that MRI or refer to a specialist on the 1st visit. When patients know and trust their doctor, they are more likely to get preventive screening tests and feel motivated to follow through with lifestyle changes. When patients know who is in charge of their healthcare, they are less likely to end up in the ER or hospital. Healthier patients mean less disease or at least better controlled disease, which results in lower healthcare costs.

Whatever healthcare reform ultimately looks like, it has to include the doctor-patient relationship as a centerpiece in order for it to succeed.

Gawande ends his address to the future physicians with these thoughts:
No one talks to you about money in medical school, or how decisions are really made. That may be because we’ve not thought carefully about what we really believe about money and how decisions should be made. But as you look across the spectrum of health care in the United States—across the almost threefold difference in the costs of care—you come to realize that we are witnessing a battle for the soul of American medicine. And as you become doctors today, I want you to know that you are our hope for how this battle will play out.
I graduated from medical school in 1987. One of the reasons that I went into medicine was because I didn't want to go into business. I never thought that medicine would turn out to be one of the biggest business battlegrounds ever. And yet, as in Tolkien's epic Lord of the Rings, the battle may ultimately be decided by someone small and seemingly insignificant.

You might even say, IMPish.

Tuesday, June 09, 2009

The Best Health Care System The World Has Ever Known

From the Washington Monthly, this article quotes Senator Richard Shelby's (R-Ala) June 7th comments about the current healthcare reform efforts:
One, we don't know how much [a reform package is] going to cost and who's going to pay for it," he said. "Secondly, it will be the first steps in destroying the best health care system the world has ever known."
The best health care system the world has ever known?

Do you suppose he is referring to:

• the one with 18 percent of the population under age 65 being uninsured?
• the one that spends more in healthcare than any other country in the world ($2.4 trillion in 2007)?
• the one that is only ranked 37th among industrialized nations by the World Health Organization for health care quality and performance?
• the one where 61% of bankruptcies are due to high medical bills?
• the one that wastes $31 billion a year just so doctors can get paid by insurance companies?
• the one that contributed to the collapse of the American auto industry ($1500 per car gap between GM vs Japanese vehicles)?

Oh, okay. I get it. Just like Gigli is the "best" movie the world has ever known. And like the 1972-73 Philadelphia 76ers were the "best" NBA team the world has ever known.

He's just kidding, right? Right?

Because if he's not, then Senator Shelby is the "best" Senator the world has ever known, where "best" actually means "worst". Just like our healthcare system.

Sunday, June 07, 2009

If All Doctors Had More Time To Listen

From today's New York Times:
LILI SACKS, a primary care doctor in Seattle, says she began thinking differently about her work on the day she realized she was beginning each appointment with the words, “Sorry I’m late.”

Scheduled to see as many as 25 patients a day at a large clinic, she lacked the time for thorough examinations and discussions. Because of this, she said, primary care doctors are often forced to order tests and send patients to specialists.

“Could I have helped some people without specialists and tests? Absolutely,” said Dr. Sacks. “Would it have saved the patient and the insurance company both money? Absolutely. Is the system set up for the best care and cost efficiency? Absolutely not.”

Dr. Sacks said she worried that seeing so many patients would lead to errors. Last year, she moved to a clinic that focuses on longer patient appointments, 30 to 60 minutes. This translates to 10 to 12 patients a day. Patients also communicate directly with her by phone or e-mail.

I am reading a book right now called The Tipping Point by Malcolm Gladwell which talks about what factors are involved in causing trends to change, whether that trend is an epidemic, fashion, crime. In it he describes a study that is relevant to today's practice of medicine.

Two Princeton psychologists, John Darley and Daniel Batson, did a study where they asked theology students to prepare a talk on a Biblical theme and then walk to another building to give the talk. They were not told that along the way they would pass by a man slumped over in an alley with his eyes closed and groaning. They wanted to see what factors would increase the likelihood that the theology students would stop to help the man, and in effect emulate the parable of the"Good Samaritan".

What determined whether these otherwise caring and conscientious students would stop and help was not their desire to help others, how recently they were reminded of the Good Samaritan parable or even whether they were about to give a talk about the Good Samaritan. What made the difference was how much time they had. If they were told that they were running late, only 10 percent stopped to help. If they were told that they had a few minutes to spare, 63 percent of the students stopped to help.

From The Tipping Point:
What this study is suggesting, in other words, is that the convictions of your heart and the actual contents of your thoughts are less important, in the end, in guiding your actions than the immediate context of your behavior. The words, "Oh, you're late" had the effect of making someone who was ordinarily compassionate into someone who was indifferent to suffering -- of turning someone, in that particular moment, into a different person.

So I don't blame doctors who are harried and rushed to see 20+ patients a day if they are less thorough or even less caring. The current dysfunctional healthcare system will harden even the kindest hearts.

But more and more doctors are choosing a different path, the same one that I chose 5 years ago. One that allows for more time to listen, to think, and to do what we have been trained to do. For a directory of where to find like-minded doctors, go to the IMP Map.

If all doctors (or even just primary care doctors) had more time to listen, then we would have better healthcare. The question is, will the new healthcare reform that is shaping up in Washington give us that time?

Sunday, May 10, 2009

Fake Medical Journals

Like many other physicians, I get free medical journals. Not as many as I used to get, but still more than I have time to read. Every now and then, I get one that I've never heard of, and I wonder why I am suddenly getting it. Most of the time, I toss them without a second thought. Strangely, I never seem to receive another copy of those once-appearing journals. Maybe now I know the reason why.

It turns out that pharmaceutical companies have been coming up with their own fake medical journals (via Slashdot):
This time Elsevier Australia went the whole hog, giving Merck an entire publication which resembled an academic journal, although in fact it only contained reprinted articles, or summaries, of other articles. In issue 2, for example, nine of the 29 articles concerned Vioxx, and a dozen of the remainder were about another Merck drug, Fosamax. All of these articles presented positive conclusions. Some were bizarre: such as a review article containing just two references.
Things have deteriorated since. It turns out that Elsevier put out six such journals, sponsored by industry. The Elsevier chief executive, Michael Hansen, has now admitted that they were made to look like journals, and lacked proper disclosure. "This was an unacceptable practice and we regret that it took place," he said.
At least drug companies have stopped giving out free pens, notepads and other trinkets. Hopefully I'll never again have to see a sight as embarrassing as when I saw a physician carrying 8 bags loaded with drug company freebies at a meeting a few years ago. (Yes, she was Asian and female and probably shares the same gene that causes my mom to hoard free bananas from the hotel breakfast buffet when on vacation, but it's still mortifying.) Anyways, anything that decreases drug company influence (and the need for a shame transplant) is good to me.

Friday, May 01, 2009

A Potentially Critical Hole

From the Los Angeles Times: Hospitals swamped amid flu fears
At Loma Linda University Medical Center near San Bernardino, emergency room workers have set up a tent in the parking lot to handle a crush of similar patients. In Chicago, ER visits at the city's biggest children's hospital are double normal levels, setting records at the 121-year-old institution.

So far, few of the anxious patients have had more than runny noses. But the widening outbreak of swine flu, also known as H1N1 flu, is exposing a potentially critical hole in the nation's defenses.

Across the country, emergency care facilities are straining at the seams even though the outbreak is relatively small and the federal government has launched a mammoth disease-control effort -- dispatching antiviral drugs to states, attempting to contain the limited number of cases and beginning to develop a vaccine against it.

"It is a major Achilles' heel in our state of readiness," said Dr. Irwin Redlener, director of the National Center for Disaster Preparedness at Columbia University. "If we get a situation that is really out of hand with large numbers of people affected, I fear that our hospital and healthcare facilities simply won't have the materials or even the staffing to respond," he said.
I can't help but wonder what this situation would look like if patients had a personal primary care doctor they could go to or call or e-mail, instead of going to the ER.

Hey, you know that impending health care collapse that they've been talking about for years? Maybe there's some connection with that and the shortage of primary care doctors. Ya think?

Thursday, April 23, 2009

A Little Help Please?

Vaccinations are an important tool for keeping people healthy. Like many family physicians, I give vaccines to my patients. Unfortunately, also like many other family physicians, giving vaccines is often not cost-effective and in some cases, a money-losing endeavor.

Part of the problem is that some vaccines cannot be purchased as a single dose. That leads physicians to decide if they should buy 10 doses of one vaccine just to immunize one child, and hope that they can use up the rest before they expire. This becomes a problem when a vaccine's wholesale costs run over $80 per dose, such as for Prevnar.

This is an e-mail I got from Dr. Jean Antonucci to her physician friends asking for some help. She has been trying to buy a single dose of Prevnar to finish immunizing one of her patients. But Wyeth, the manufacturer, only sells Prevnar in boxes of 10 doses:
So help me out here. I got a call from Wyeth — from a David Ross. Wyeth sells single dose Prevnar in other countries where "there is low demand". They are not very open to doing that here.

I told this man, "Look, this is a win-win. You want to sell Prevnar, I want to buy it." He goes on and on about how he cannot believe practices would need so few doses over a few years. So I say, OK, look, help me out here! I tell him about primary care. I point out that I ANSWERED the phone!! He repeatedly tries to deflect me — "This is about reimbursement". Well, no it isn't. Blue Cross pays for the vaccine just fine. It does not pay for 9 doses sitting in the fridge rotting.

SO anyway I say, here is an alternative. Sell it to Cardinal Health. THEY supply my drugstore. The drugstore will buy 10 doses from you and lots of us can use them.

He then says, well, he would have to know that there was more than one doctor in the USA who had need for small amounts of Prevnar. So aha! I say, oh really?? How many do you need to hear from? I have 700 friends.

"Uh uh, I dunno."

So PLEASE call up David Ross (484-865-6057) and plead the case to sell Prevnar EITHER to drugstores OR in single dose units to physicians. PLEASE?

Love, Jean

I called Mr. Ross and left a voice message saying I am a family doctor who would also like to be able to buy Prevnar in a single dose. If anyone else out there is in a similar situation, you might want to give him a call, too.

If nothing else, it may help one child get their Prevnar. And if he gets a lot of calls, maybe a lot of children across America will finally be able to get their vaccines from their local primary care doctor.

Saturday, April 18, 2009


I met Beatrice (not her real name) a little more than 2 years ago. She had just turned 90, and her daughter brought her in because she had been feeling a little more tired and short of breath lately. As she put it, she was having problems "getting going" in the morning. She had rarely been to a regular medical doctor, preferring homeopaths, in line with her beliefs as a Christian Scientist.

Up until a year before, she had been living for 19 years in Ojai, CA, 9 of them with her husband who passed away 10 years earlier of lung cancer. She had been active and doing yoga up until 1 year earlier when she fell and broke her arm. Ever since then, she had been living in an assisted living facility closer to her daughter. She had also been developing signs of Alzheimer's dementia over the past 4 years.

Beatrice was a pleasant and cheerful woman who acknowledged having some memory problems but kept repeating over and over again how “grateful” she was for her life so far. She proudly told how she was one of the first female bank tellers before she became a permanent homemaker. She also mentioned how throughout her life she never liked to take medicine or see doctors.

After examining her, I discovered that she had atrial fibrillation causing mild congestive heart failure, which was also the cause of her shortness of breath and fatigue. She also scored 13 out of 30 on her Mini-Mental State Exam, consistent with moderate dementia. Beatrice went home without any medications because her daughter wanted more time to think about what to do next. This first visit took 90 minutes.

After a series of e-mail communications and a follow up visit, we agreed to start Beatrice on some medication to help her breathe better. Over the next few months, she gradually improved with medication to the point where she was breathing comfortably again. Her daughter told me that while Beatrice couldn’t remember anything about what we had talked about, she did remember me and liked me.

I would see Beatrice several times for follow up over the next 12 months, and even though she couldn’t remember what she had for breakfast, each time she would smile and say how “grateful” she was for everything. That seemed to be the one thing she would never forget. She remained stable as far as her breathing but her dementia continued to worsen ever so slowly, and eventually she started having trouble with agitation and even remembering who her daughters were sometimes.

Unfortunately, this happens all too often with many elderly patients in this day and age. Even as you wonder if this is the kind of life they, or anyone, would want to have, it is often too hard to stop giving medications that you know are helping to keep someone alive.

In a typical busy doctor’s office, there just isn’t enough time to talk about what is really important to her or her family. It would just be assumed that we should just do our best to keep her heart from going into rapid A-fib and developing congestive heart failure, and to do otherwise would be unmerciful. And so, Beatrice would continue to take her Digoxin and Lasix, and her mind would continue to gradually wither away, losing bits and pieces of herself as time went on.

And eventually she would get a stroke and lose her ability to walk, speak or feed herself. Or she would fall trying to get out of bed in the middle of the night and break her hip. And she would end up bedridden and develop pressure ulcers on her fragile skin. And finally, if she didn't die of something else first, she would end up in a “persistent vegetative state”, her self-awareness gone, left with only a thin, frail body curled up in a nursing home bed, kept from malfunctioning further with well-intentioned medications, waiting to die.

That is, she would have if she had received care as usual.

Instead, I had long discussions with Beatrice’s two daughters that started 9 months ago, in person, by phone and by e-mail. We discussed the likely outcomes of continued treatment along with that of stopping treatment. We discussed adding medications to treat her agitation and anxiety and their potential side effects. We discussed what Beatrice valued in life, what her preferences would have been and what she would have chosen for herself, if she were able. We discussed their concerns that their mother not suffer.

After 4 months of discussion and reflection, her daughters decided that a palliative approach was what their mother would have wanted and started inquiries into hospice programs. A month later, she had enrolled with a hospice program, and I stopped directing her medical care, since the hospice program already had a physician.

Yesterday, I received an e-mail from Beatrice’s daughter saying that, after a few weeks of terminal agitation, her mother had passed away peacefully.

I’d like to think that Beatrice was grateful to go this way.

I'd be grateful if every primary care physician could be given the time and paid for the time to do the right thing for their elderly patients, rather than give "care as usual".

Friday, April 03, 2009

Pre-existing condition of being human

This article by syndicated columnist Ellen Goodman from yesterday's Washington Post gives a nice summary of what ails our current US healthcare non-system: "The Care in Health Care":
I was tickled to hear that the insurance industry is beginning to commence to start to think about lifting bans on the pre-existing conditions that keep a slew of Americans from getting health coverage. This has always been on the deep end of a pretty wacky system.

But there is a pre-existing condition that hasn't garnered nearly as much attention in the health care debate. It's the condition we all share: being a human being. As opposed to, say, being an organism subdivided into parts and scattered over the medical landscape from neurology to podiatry.

The current system makes it hard for people to get care for their whole body, much less their whole self (mind and body). The balance between splitters and lumpers has been tipped to the splitters by a wide margin for some time now.

Consider one of the least secret medical records in the country: the erosion of primary care doctors. A half-century ago, we had an equal number of generalists and specialists. Today there are two specialists for every generalist.

In clear view and with all undeliberate speed, we developed a system that rewards procedures over primary care. As analyst Robert Blendon puts it bluntly, "It's absolutely clear that payment systems have been negotiated that reward specialty time and use of equipment." The incentives tip toward the kind of medicine that is performed with hands, tools and technology over the medicine that is practiced with eyes, ears, and mind.

The average generalist now earns 55 percent less than the average specialist. Many students apply to medical school to connect with and take care of sick people. They graduate to become what one doctor slyly calls "proceduralists." They enter with a strong desire to look after families and exit with a ticket to X-ray femurs.
Read the entire article here.

She gets it. More and more people are finally getting the message that no meaningful healthcare reform will take place without fixing primary care first. And to fix primary care, you need to fix the system so that it will encourage, and not discourage, doctors from going into primary care. Otherwise we will continue to have too many doctors who look at you primarily as a body part rather than a human being.

Saturday, March 07, 2009

Keep The Faith

When I arrived this morning in Sacramento, I wasn't sure why I was here. I am attending the California Academy of Family Physicians 2009 Congress of Delegates. I am one of many family physicians who have come from all over the state. They are leaders in their community, faculty in academic medicine and residency programs, department chairs, chapter presidents.

I am here because I happen to show up at most of the meetings. If you go often enough, you get nominated to be a delegate. This year especially there weren't enough of us coming from the Los Angeles Chapter so they asked for volunteers. At the registration table, my name was not listed as one of the delegates. Maybe I don't belong here.

The guest speaker is Dr. Ted Epperly, the current president of the American Academy of Family Physicians (AAFP). He notes the current national crises (crisises? crisii?) and says that he believes that, after many years of failed attempts, healthcare reform is finally going to take place in 2009 because of a miracle. According to Epperly, that miracle was the election of Barack Obama.

He said that he was at the White House 2 days ago, invited along with representatives from the 3 other primary care specialties (American College of Physicians, American Academy of Pediatricians, American Osteopathic Association) and a host of legislators, insurance representatives and stakeholders. They were part of a White House Health Care Summit there to discuss how to fix what ails our nation's medical non-system.

During the summit, Obama asked for the cooperation and participation from all the interested parties. And when he came to physician participation, he called on Epperly (who was taken by surprise and only had about 20 seconds to speak).

What he said was:
"Speaking on behalf of over 100,000 doctors, we're ready to do our part. We very much believe that we need to expand coverage in this country to everyone, and we need to fix the work force, sir, so that all those patients have a place to go.

We'll roll up our shirtsleeves and do everything possible to make this work. Because it is the right thing to do, and I applaud you and this body for doing this today, to do it this year. And we must do it. Thank you."

Epperly said he feels it was not by accident that Obama chose a family physician to speak for American physicians. It’s because he understands that primary care is broken.

He also said the president made it clear that everyone must be at the table, everyone must listen and everyone must give up a little something. Epperly quoted Victor Fuchs, a noted Stanford economist, as saying US healthcare reform would only come about if there was a war, an economic depression or major civil unrest. (We got 2 out of 3 so far.)

The Patient Centered Medical Home (PCMH) has become more than a model of healthcare, Epperly said. It has become a symbol of a movement to restore healthcare to this country.

Epperly observed that the current healthcare system is totally unsustainable, especially in this recession. Healthcare spending rose to $2.4 trillion in 2008 and is projected to rise to $2.5 trillion in 2009. But Epperly is hopeful that reform will finally take place under the Obama administration. "More has been done in one month than has been done in the past decade as far as healthcare reform," he said. "We can't afford to keep putting it off. President Obama recognizes that if there isn't enough investment in our domestic policy, this country will fall apart."

Epperly also called on family physicians to take a more active role in advocating healthcare reform. "If you're not at the table, you're on the menu," he said. "We family physicians are in the position we are in, not because the work we do is not worth it, but because we didn't step forward when we needed to."

Even though family physicians may feel like they're not getting the respect or the payment that they deserve for their work, Epperly feels Obama recognizes the value of family physicians to care for patients and their community. "Don't lose faith," Epperly said. "It won't be easy, but a better day is coming."

At the end of Epperly's talk, I felt re-energized and motivated, hopeful that our healthcare system can and will change for the better, sooner rather than later. I will continue to try to improve my solo practice using the principles of the PCMH. And while I don't have the charisma, eloquence or leadership of Obama or Epperly, I can blog.

I guess I figured out why I am here in Sacramento after all:

To keep the faith. And to help Save Primary Care.

Tuesday, February 10, 2009

But Is It Covered By My Insurance?

An ad for a longevity-enhancing product in today's Washington Post:
INDICATIONS AND USAGE: Marriage is the therapy of choice for treatment of the condition of being unmarried. Marriage is approved to manage the dread of growing old alone and missing the opportunity to have dinner every night with a special someone, but without talking. Clinical trials indicate that marriage is recommended if you have found either a true soul mate or someone who has an excellent 401(k).

"It may also cause children."!!! Well, that explains how the kids got here.

At least it's probably more effective than multivitamins at extending lifespan.

Friday, January 23, 2009

Getting There From Here

Dr. Atul Gawande has a thoughtful article in the New Yorker about the transformation of healthcare in other countries and how it might happen here in the US. He feels that Massachussetts' new law that requires everyone to get health insurance is a good but imperfect start:
For all that, the majority of state residents would not go back to the old system. I’m among them. For years, about one in ten of my patients—I specialize in cancer surgery—had no insurance. Even though I’d waive my fee, they struggled to pay for their tests, medications, and hospital stay.

I once took care of a nineteen-year-old college student who had maxed out her insurance coverage. She had a treatable but metastatic cancer. But neither she nor her parents could afford the radiation therapy that she required. I made calls to find state programs, charities—anything that could help her—to no avail. She put off the treatment for almost a year because she didn’t want to force her parents to take out a second mortgage on their home. But eventually they had to choose between their daughter and their life’s savings.

For the past year, I haven’t had a single Massachusetts patient who has had to ask how much the necessary tests will cost; not one who has told me he needed to put off his cancer operation until he found a job that provided insurance coverage. And that’s a remarkable change: a glimpse of American health care without the routine cruelty.

I also believe that healthcare reform will be evolutionary, not revolutionary, with many twists and turns, well-intentioned but misguided actions, quiet successes, loud opposition. But eventually we will get to where we are going, and when we get there, I hope that is where we will want to be.

Monday, January 19, 2009

I have a dream

I have a dream . . .

. . . that I can post regularly to my blog again.

In the meantime, here is what I wrote on the Ideal Medical Practices Blog, a new blog with contributions from others in the Ideal Medical Practice (IMP) Movement.