Day in the life of Dr. Joe

GIGO,part 2, Medical Records

2011-11-20T19:00:00.004-05:00

GIGO

Part 2 of "The Medical Record"

"Garbage in, garbage out", GIGO, is a term that computer geeks have used since the early days of computer mainframes in the 1950's. Computers make impressive charts and graphs. Computers make impressive data displays. If the information entered is wrong, so is the output.

I am concerned about the methodologies used to enter data into the electronic medical record. While the old handwritten chart was prone to human error and illegibility, the new record seems to magnify the errors and present them legibly and authoritatively.

I currently have a patient in the hospital admitted (as most are) through the emergency department. The ER is the first department in the hospital to have doctors and nurses notes computerized. In the very first doctor entry in her chart, the ER doctor's note, in the very first paragraph, she is described as in "no distress and well hydrated", as well as being "grey, comatose, and with dry mucous membranes" (a cardinal sign of severe dehydration). How can she exhibit all these contradictory findings?

The answer is twofold: templates and checklists.

Of course, in the end, it is the responsibility of the physician to ensure that that notes are not only sensible, but truly reflect his observations and understanding.

The computerized record, however, allows and enables, if not encourages, GIGO.

There are far too many men who have medical records recording their pelvic exams and make note of their previous hysterectomy, as well as women who are recorded as having normal testicular exams. Why? Surely, not because of an epidemic of hermaphroditism, but, rather, a rash of checklists. GIGO.

Despite the epidemic of obesity, and the documentation of patient weights, the record nearly always describes the individual as "well nourished". Why? Surely not because of a hesitancy to label the 400 pound patient as obese, but, rather, templates. GIGO.

Templates push square patients into round descriptions.

Checklists enable clickety-click instead of thinkety-think.

I fear that we are becoming unthinking extensions of our technology. The nursing tech recording vital signs enters a temperature of 95.3 into the computer without a second thought, and without a gaze at the flushed red flesh or a touch of the feverish forehead. GIGO.

The Design of the Medical Record

2011-11-20T18:16:00.004-05:00

The Design of the Medical Record
Part 1

The hospital medical record has existed since hospitals began. There are ancient Greek archives of Hippocrates' "Cult of Aesculapius" whose temples were the sites of the first recorded gathering places for care for the ill: primitive hospitals. Hospitals have evolved far in the past two millennia. The medical record evolved.

There was a revolution in hospital care that occurred in the sixth decade of the twentieth century, following WWII and the Korean War. Surgical care had progressed by leaps and in-patient medical care was progressing rapidly. The medical record evolved to serve as documentation and communication tool.

At the end of the sixties, the growth in hospital care was exponential. The entire scope of the medical record was carefully studied and intentionally designed. To a very great degree the medical record was standardized across America. The medical record as a tool of documentation and communication reached its pinnacle in the mid seventies.

The hospital medical record consisted of the following elements:
• Demographics
• Emergency room record
• History and Physical
• Physicians' progress notes
• Nursing notes
• Vital signs
• Consultation notes
• Procedure notes
• Laboratory reports
• Imaging reports
• Therapy reports
• Doctors' orders
• Discharge summary

A separate section of the chart held consent forms.

Each of the elements had its own tab in the binder. Other than the lab and imaging reports and the demographic face sheet the entire chart was hand-written. In some institutions, the doctors and nurses charted in the same progress note section. Sometimes the entire physician documentation, from emergency room, H&P, progress notes, and consultations were all in a single tab, written and stored chronologically sequentially.

What was most striking about the chart was the rigorous way that physicians and nurses documented their observations and their assessments. In particular, physicians delineated their diagnostic thought process and their therapeutic decision making. Everything was communicated and available in a well organized chart.

Granted, there was vast variation in compliance with this model. Physician poor handwriting was already a hackneyed joke. Some doctors just did not respect the value, beauty, and sanctity of the medical record.

The "problem oriented record", formulated by Dr. Weed, and adopted by the entire medical community in the late sixties was at the heart of the structure of the medical record. The chart contained a standardized PROBLEM LIST, with dates of onset and dates of resolution of each problem, with the problem described by the "highest degree of resolution". A problem initially listed as "abdominal pain" might later be resolved to "acute peritonitis" and later to "acute sigmoid diverticulitis with localized peri-colonic abscess". Each progress note referenced the problem list.

The progress notes were in the now famous SOAP format, summarizing the patient's subjective reporting, the doctors' (or nurses') objective observations as well as pertinent laboratory or imaging data, the professionals' assessment of each problem and a problem oriented plan.

The notes were sequential and clearly told the story of the hospitalization. The structure facilitated communication and decision making.

The initial "history and physical" had a structure that dates back to the early twentieth century. It was a careful record of the patients presenting complaint, a detailed history of the present problem, a summary of the past medical and surgical history, as well as family, and social data. A "review of systems" systematically reviewed the patients current reporting of any symptoms not clearly relevant to the presenting problem. Then came a structured comprehensive examination report, followed by a review of all the lab or ancillary data available at the time of admission. Next, the patient's condition was carefully analyzed in the assessment: the problem list was here generated. The preceding data was synthesized and a tentative series of diagnoses recorded. The thought process was delineated. The assessment was followed by the plan: how the doctor intended to proceed with treatment and diagnostics. The rationale was described.

Procedure notes and surgery notes had standardized structure and were included in the sequential flow of the chart.

At the conclusion of the hospitalization, a discharge summary was prepared, summarizing the entirety of the hospitalization.

In the design of a medical record for a new medium in a new millennium, the computerized medical records of the twenty-first century, it is incumbent on the creator to, at the least, maintain the working structures of the paper chart. Since no model has ever proven as valuable as the problem oriented record, it would seem obvious that the design of the electronic record should facilitate the production of an equally valuable record. Perhaps the high structure of database technology could even renew the values of the ideal record that have been lost, abandoned, or made sloppy by the past four decades of medical evolution. It is surely offensive and wrong for the system designer to impose models of data entry, recording, and retrieval that fit some model of program design, but that do not promote a medical record model that has been time honored by the medical profession.

Many forces in society, primarily government and financial institutions (third party payers) are placing tremendous pressure on the medical profession to conform to a model of medical practice that is foreign to our science and our traditions. It is fully acceptable for the medical record to serve as a tool for those forces if and only if the principles and values of the practice of medicine are not thereby compromised. Since the same forces are driving the institution of the electronic medical record, it is incumbent on the designers of that tool to honor our medical record.

Health Care Reform Epiphony

2011-11-01T19:06:00.002-05:00

When I was in medical school I had friends in law school. Late in our first years of training in our chosen fields, I had an epiphany. It was not at all about the information that we were learning, it was about the thought process. The medical students were being taught to think like doctors and the law students to think like lawyers. Both professions are, in most ways, about problem solving. There was a major difference in the problem solving processes taught.

In medicine we gather data, our history, physical exam, test results, and exploration. Along the way we are juggling the data and fitting to patterns. At some point we prescribe or perform a procedure to attempt to fix the problem. If the fix fails, we regroup and try again: gathering data, pattern fitting, trying to solve. All the human players are on the same team, the doctors, nurses, technicians, as well as the patient and the family: the enemy is disease or dysfunction afflicting the patient. Precision and speed are essential. Caring and compassion are essential as well.

In law the process has a different flavor. Although there is information gathering, the process is adversarial. There are winners and losers, and the battle goes to not necessarily to the best solution, but to the the best fighter. Perhaps justice is served, but all the combatants are bloodied. Surely there are "principles of law" that are based on millenia of sorting of human civilizations' wranglings with conflicts between people. But the lawyers thought process is taught about the minutia and techniques that win the battle, not for what is right, but how to win.

I watched as my law student friends became lawyers: arguing their points with ferocity and skill. I watched as my budding medical colleagues became expert in data analysis and complex human bio-psycho-social systems.

Tonight I had another epiphany.

It has been the in last forty-five years, and particularly the past thirty, that health care delivery has shifted and declined. I blame the decline on the shot-gun wedding of government/business with medicine. Under duress, medicine was forced to accept governmental intervention and control and subsequent business interference. The intrinsic thought process of physicians is incompatible with the legalisms of government and the imperatives of the marketplace. The medical model has been supplanted by a business model and legal process. I fear that the new generation of physicians will be taught to think like businessmen, lawyers, and politicians. I see it already.

My generation of physicians are retiring early, unable to practice as the physicians they were molded to be. Few physicians appreciate the interference and control of Medicare and the myriad insurers. The adversarial relationship is foreign to us: it just does not work for us. We are forced to argue with representatives over even the most trivial things.

This morning I was making rounds at the hospital. I needed to write orders, write a progress note, and obtain written consent from a patient for her blood transfusion. I had to search through racks of ninety-six (I counted) different forms to find these three sheets. Of course, half the chart information is not paper, but is in the computer. Despite the computerization there are over one hundred required forms. Thirty years ago there were less than half a dozen forms in the chart. Forms and paperwork are part of the legal mind-set, not the medical world.

I believe the ever-rising cost of health care and the ever-declining esteem and honor of my profession is a direct result of the spawn of that wrong-minded marriage.

Halloween Scary Medicare Letter

2011-11-01T12:10:00.003-05:00

I received the thick envelope from Medicare today. They are demanding I repay them because they erroneously overpaid me. The letter details the rules and regulations regarding the necessary repayment. It details my rights for dispute (but makes it clear that such appeal is hopeless). It details the penalty of 10.875% interest on the amount due if not repaid within thirty days. (I assume this is an "annual percentage rate", but it never says that. By gosh! It could be a daily or monthly rate!) If I do not pay by December 3, 2011, they will withhold all my Medicare payments. I am allowed to make an extended payment plan, and I am allowed to certify that I am bankrupt or unable to pay because of other financial difficulty (three more pa ges to so certify).

And then there are the listings of the overpayments.

There are sixty-two incidences where they overpaid me, from February until June of 2010. The amounts of overpayment range from one cent (really! eighteen of the errors were less than a nickel!!) to whopping $1.04. The average amount is forty cents.'

So I am immediately sending them back the $24.63 they demand as soon as I am able (TODAY!) lest I incur the wrath of this bureaucracy!

Their rules. Their error. Their threats. Their ridiculous recouping of this pittance.

Santa

2011-10-24T18:03:00.001-05:00

As she was leaving the office, she asked my advice:

"What should I tell my boys about Santa Claus?"

Spock-like (Mr. not Dr.) my left eyebrow rose and I asked for clarification. It was clear that her boys, eight, six and two, were asking if Santa is "real".

I took her back into the exam room and I carefully told her to tell them the truth, that of course, Santa is real. She was shocked that her Jewish doctor would make that claim.

I asked if she had read her boys "The Real Tooth Fairy". She never heard of it and I suggested she read it to the boys.

I know her to be a devout Christian so I asked her if she believed in God. And I asked, "Is God an old man with a long white beard who sits on a throne in heaven?"

That, I said, was "pediatric theology", a metaphorical description of an incomprehensible unknown. Yet we ascribe attributes and miracles to God.

Santa can be the joy of gifting, of sharing, of simple laughter, and of family: of caring and self-less joy. Santa can be a metaphor and symbol for so much good. Santa is real if we so choose.

She got the message.

I suggested that the older boys were old enough to begin to understand the difference between icons/symbols/metaphor and physical manifestations.

And then I shared my grief that a real Santa had recently died.

Bob was tall and round, with white hair, a long white beard, and a deep and resonant laugh. He had a gift of playfulness and joy and generosity. At this time of year he wore a red suit with jingling bells and personified the metaphor of Santa. He made everyone smile widely and filled hearts with warmth and joy. He died recently, and I miss that man. But Santa is still real.

After she reads them about "The Real Tooth Fairy" she can have a discussion about the REAL Santa. The eight-year-old may "get it" and the six-year-old will wonder. The two-year-old can wait for Santa to come and eat the Christmas cookies and milk.

Inspired by ASEA!

2011-07-31T17:09:00.004-05:00

I recently was introduced to "Asea".

Asea claims to be a liquid supplement containing REDOX MESSENGER MOLECULES and is marketed with amazingly slick scientific appearing websites and videos, educational materials from scientists from many fields, and glowing testimonials on how Asea cures just about everything. Asea claims to have a patented production process.

IT is AMAZING, except for one fact: it is all deliberately misleading LIES.

Asea is nothing at all but slightly salty water. Its ingredients are table salt and distilled water. The "patented process" is a clear scam: it is a patent APPLICATION with the description of a third grade hydrolysis experiment. REALLY!

Asea is a brilliant example of the ultimate in MARKETING and is linked to a vast NETWORK MARKETING SCAM.

Google ASEA and you will see what I mean.

I was inspired by Asea to invent WORRY-FREE MILK! Read all about it below! (click the link)

WORRY-FREE MILK

Much too simple: it will never work

2011-07-27T09:56:00.002-05:00

The government is in a jam. It spends far more than it "earns". Actually, it does not earn much at all: it taxes. If the out exceeds the in, the coffers run dry. So: the government borrows. As long as it pays the interest on time, the lenders are okay. If the government can't pay, the loans default. This is very bad.

The problem arises because the government has two priorities: spend more and tax less.

If you have read my prior blogs, you know that I believe that real health care reform is possible. Health care expenditures represent roughly 40% of the budget, roughly equivalent to the military budget. Before the government got into the health care funding business in the mid-sixties, the health care budget was under 3%. I believe that with real health care finance reform we can return to the days of single digit federal health care budgets.

There are myriad other examples of potential wonderfully effective savings, but they, too require radical rethinking and reform.

I am not a tax expert at all. I can do arithmetic pretty well. It is clear to everyone that there are remarkable inequities in current tax structure. The recently restructured rules are still vast and complex. Without going into all the bizarre rules and regulations., I propose eliminating them all. I propose an across the board 15% tax for every tax entity. For individuals and families, the taxes would start if earnings were above an impoverished limit. No deductions for anything. No corporate loopholes. Nothing. Stop using taxes as a means to provide support or incentives. Just tax.

Without touching the military or any "pork", I have hereby solved the most complex problems that our government faces.

Much too simple. It will never work.

Well, I did not pay for it!

2011-06-09T12:27:00.005-05:00

A gentleman in his mid 70's was in my office last week for his annual complete physical. He is a sage man, well respected in his profession. He had been found to have a mildly but significantly elevated PSA, prostate specific antigen. Appropriately, this abnormality was followed by an ultrasound and subsequent prostate biopsy. The results showed mild early prostate cancer.

The patient then went to Sloan Kettering in NYC for another opinion. Upon review of the biopsies, the conclusion was that it was NOT prostate cancer, but an early PRE-cancerous condition. None-the-less he was sent for an MRI of his pelvis and a whole body bone scan.

I expressed my concern for his problem, but I also expressed my surprise at the testing done at Sloan. It is hard to rationalize the MRI without evidence for aggressive prostate cancer. It is inexplicable to get the whole body bone scan in search of bony metastases in a case with no primary cancer.

I stated casually that I thought the tests were excessive and expensive.

He replied, "well, I did not have to pay for it!"

I emphatically corrected him, pointing out that he DID pay for it as a TAXPAYER.

And that is my main point: the third party payer system, in this case Medicare, has removed from the individual the mantle of personal responsibility for the cost of our medical care. Multiply the $5,000 (or more) in the cost of these unnecessary tests by the millions of Medicare recipients. The doctors ordered the tests without thought to the value, necessity, or cost.

The government's answer is controls and oversight and rationing: LESS personal responsibility.

My answer is the opposite: increased AUTONOMY of physicians and patients, and INCREASED responsibility.

Doctors must practice good scientific medicine. Diagnostic evaluations should be laser sharp and not shotgun splatter. Do the right tests in the right order, taking into account the impact of the tests on the decision process and the human and financial burden of the tests.

Patients must make informed choices and not just do whatever is recommended by the physicians.

DRAFT ONE: REAL HEALTH CARE REFORM

2011-02-14T09:07:00.001-05:00

The following is an intial draft of my Health Care Reform Project. I plan to hone this and then buy a full page in the NY Times and publish it big and bold. I believe that we are being governed by politicians and not by leaders. I hope to inspire the American people to restore personal responsibility, rationality, science, communication, and relationship to the center of the American health care model. I hope to inspire our leaders to lead us forward.

I invite as much comment and criticism as possible. Remeber: this is DRAFT ONE.

True Health Care Reform

The basic tenets of my proposed health care reform are:

(1) Restoration of personal responsibility
(2) Cessation of managing the mundane
(3) Cessation of catastrophizing the usual
(4) Prevention of adverse outcomes and restoration of damage and restitution of loss
(5) Restoration of pharmaceutical industry professionalism

(1) Restoration of Personal Responsibility

Twenty years ago Americans took great responsibility for their personal finances. When you went to a doctor, you paid the doctor. Simple. No middle-man. No problems. It was affordable to all. Routine doctors' fees were one-half to one-tenth the cost they are today and were not a burden. The family doctor was a part of the family and usually cared for many generations of the family. Relationship was important and was significant in the efficacy and quality of the medical care.

Shortly thereafter, the HMO's invaded and fees skyrocketed. What happened? For the hope of getting something for nothing, the cost of medical care mushroomed. Perhaps worse, the doctor-patient relationship was severed: there was a middleman, a barrier to the interpersonal dynamic.

Fear and greed were the driving factors. Fear of loss of income drove doctors to participate with the HMO's and insurers. Patients were promised that they would get care for free. Insurance companies saw new markets to penetrate and new "products" to sell. The face of medical care was changed not by science or medical art, but by intermediary fiduciary agents with no motivation but profit.

And the uninsured? In the first half of the twentieth century no one had insurance! The impoverished got care. Doctors and hospitals rendered charity care for almost one-third of their patients. They did so preserving the dignity of those in need. With the advent of insurance, the uninsured became medical pariahs unable to afford the escalating costs.

The solution is obvious: we need to empower Americans to resume personal responsibility for their health, health care, and health care dollars. We need to remove the middlemen. We need to radically deflate the costs of healthcare by ceasing to manage the mundane and make catastrophic the routine.

(2) Cessation of Management of the Mundane

What is "insurance"? Insurance is the pooling of financial resources to guard against catastrophic financial loss, born by the population at risk. Traditionally, a modest profit was earned by those who managed the pool,

Insurance companies no longer insure against catastrophe or the unanticipated unusual cost: instead they manage the mundane usual costs of medical care. With management having the opportunity to cut a piece of the pie for themselves, they choose the biggest pie and thus manage everything. It really does not matter what the cost is if they can pass the cost on to their customers. The health insurance industry grew in scale out of all proportion to the rest of the economy, consuming the health care dollar.

Employers more often than not pay the bulk of the insurance costs as an often mandated (by government or contract) benefit for employees. As health care costs rose, they sought the best bargains in order to save money. In order to reduce the cost of premiums, the insurers curtailed benefits, never by reducing profits.

(3) Returning Routine to Affordability

The care for routine care or minor illnesses has taken on the financial appearance of a health catastrophe. Emergency rooms render primary care at ten-fold the cost. Resources designed for truly emergency situations are now swamped with routine care. Costs appropriate for true emergencies are now applied to trivial illnesses. The medically indigent are forced to use emergency care services, utilizing resources without financial responsibility.

Regulations have forced simple procedures out of the office and into the hospital or outside lab. A urine culture can be competently performed in a doctor's office for under $10, but is now sent to the lab for over $100.

(4) Preventing Problems and Repairing Damage

Malpractice reform does not belong in the courts. It belongs in the hands of the medical professionals and their patients. Relationship, communication, and personal responsibility are at the center for the reduction in the malpractice problems. Physicians must practice better medicine and relate more thoroughly with their patients. They cannot be too busy nor have any motivation other than rendering the best care possible. Decisions must be made by the patient and must be well informed. Patients must own their decisions and own the risks. Adverse outcomes must be evaluated. If errors are made they must be owned. If damage is done, it must be handled. If responsibility for damage can be ascribed, then it must be done fairly.

(5) Pharmaceutical Industry Professionalism

The pharmaceutical industry has abandoned its heart, soul, and conscience and even its science in pursuit of profit. There is no doubt that there have been remarkable new pharmaceutical inventions and discoveries, but ninety-nine out of each hundred new drugs is either a trivial improvement or a clever repackaging of an older medication. Markets for prescription drugs are deceptively created and exploited by direct to lay advertising. Research is done in secrecy and guarded by federal rules to preserve patent rights, eliminating the possibility of scientific debate and oversight. Physician education is cleverly skewed by industry representatives.

To restore professionalism we need to eliminate direct-lay advertising and non-informational professional advertising. We need to re-open the channels between academia and pharmaceutical industry research. We need to demand real science with head-to-head comparisons of similar drugs, and clear risk-benefit analyses.

EMR "meaningful use"

2010-11-24T17:06:00.003-05:00

The Economic Recovery Act and The Affordable Health Care Act have mandated that all health care providers adopt electronic medical records (EMR). As proposed and mandated the EMR is a dangerous sham.

Nearly thirty years ago I began to design my ideal medical office computer system. When I began my solo family practice in 1983 I immediately designed and implemented some of the system. Over time I was able to understand the information management needs of my practice and by 1996 I was able to fully implement my ideal "paperless office".

In that year I integrated then shredded the thousands of paper charts, some dating back over fifty years to my predecessor doctor. I now had nearly instant access to my patients' entire medical record. In the subsequent fourteen years I have continued to develop the system. I have designed it for maximum efficiency and ease of use. It allows me with a small office staff (equivalent to only two full time employees) to take care of the primary care needs of over three thousand patents. They are very pleased with my care. I see patients more often than not within hours of their call. I take or return all calls daily, and the time in the waiting room is reliably less than ten minutes. I see about thirty patients daily, occasionally as many as fifty. The electronic medical record facilitates this efficiency.

The components of the system are fully integrated. They include:
1- Patient demographics
2- Appointment scheduling
3- Billing
4- Problem list
5- Office notes
6- Lab reports
7- EKGs
8- Medication lists
9- Immunization logs
10- Word processors
11- Filed external documents (scanned paper)

Every exam room has an identical terminal. The front desk has two and the work room and lab and my office each have terminals as well. For just one doc and a few office workers there are eleven computers: you are never more than a few steps away.

The speed of the system is such that any piece of information is no more than a dozen key clicks and a split second of processing away.

The database is fully relational and related elements are a key click away. The data is fully indexed and searchable. (Computer talk for it is easy to find out anything you want to know, even if you have not decided yet what that is).

The lab drawn by 5 PM and sent to two different clinical labs is filed in the patients' record by 8 AM in the morning the next day, ready and flagged for review. The office notes are dictated (full text detailed SOAP notes) then transcribed and automatically filed in the patients' record. Prescriptions are easily typed in the record and refills are a single key click. The prescriptions are legible: they are printed in full text, ready for my signature. The record is updated automatically. The patient's problem list is automatically updated from their check-out diagnoses. Their immunization log is automated and tracks the lot number of the vaccines administered. EKGs are never paper (unless they must be given to someone else): they are recorded directly into the patient's record. A wide variety of reports and notes and referrals are automatically printed. Scanned documents, filed by patient ID, date, and type (well over a quarter million pages so far) are retrieved with a maximum of a dozen key strokes, the first page on the screen within two seconds and subsequent pages in a fraction of a blink. There are lots of interesting bells and whistles (such as memo flags that appear when an appointment is scheduled or a patient is checking out). Check out and patient billing are simplified by fully searchable CPT and ICD9 codes, and simple two-letter "quick codes" for common procedures and diagnoses. No demographic information requires re-entry.

The system is designed for complete on-site security. There is no connection to the Internet. Links to laboratories are done through secure dedicated lines or via intra-office data transfer. The data is protected by on-site and off-site backup servers. Off-site access is secure: I carry a back-up of the entire system compressed in my pocket: any computer with a USB port becomes a terminal with all the data readily available!

All together it is a "way cool" system and it not only documents everything well, but frees me and my staff for the real game: taking care of people.

And yet, this system fulfills NONE of the governmental mandates for an EMR. The "meaningful use" minimal requirements are:
1- electronic prescribing
2 - sharing of records
3 - documentation of quality

Other criteria include demographic uniformity and standardized formatting.

Fully implemented, electronic prescribing may reduce prescription errors. It is, however, designed to limit the formulary, save insurers money, constrain and normalize prescribing patterns, and MONITOR WHAT DRUGS YOU GET. (Is that in caps?)

Electronic record sharing essentially means that any government agency has access to everything that was confidential. Since the Internet is the medium used to share the records, you can be assured of privacy and security -- NOT. (Oops - caps again?)

"Documentation of quality" is code for "practice according to governmental standards", with direct penalties and censure for doctors out of compliance.

There is nothing in the requirements for any real benefit to patients or physicians. As mandated it is a true threat, strike that, a true guarantee of loss of privacy.

And the cost of implementation? The Economic Recovery Act hinted at a rebate of over $40,000 per physician to implement the system. In reality, the amount is far less and is available only to those doctors who participate in Medicare. All pediatricians and over half of all other physicians will be excluded from any financial support. Full implementation will cost a lot more. And there is a financial penalty for not implementing an EMR with the above mentioned "meaningful use" criteria.

Wake up physicians: you are being forced to do things that are counter to your science, beliefs, and practices! Wake up people: your rights are about to be terminated. Wake up legislators: you are meddling in things of which you have no knowledge which will result in damages far beyond your imagination.

Our Federal Legislators are Idiots

2010-11-22T15:18:00.002-05:00

On January 1, 2011, the SGR formula once again kicks in unless fixed, reducing payments to physicians by now 30% !!!!

The Affordable Health Care Act (often called "Obamacare"), thinks that primary care needs to be incentivised (a neologism of the first order), so starting in January, we primary care docs will receive an incentive payment, up to 10% of our Medicare fees. I have appended the article explaining this incentive below. Read it if you are a masochist. My head spun when I read it.

Not that they are sending mixed messages, but the net reduction in my Medicare income will be at least 20% come January. Most physicians will not be able to afford this.

The legislators are idiots. Pure and simple.

Let's see if the new senators and congressmen prove to be otherwise. I won't hold my breath.

Incentive Payment Program for Primary Care Services, Section 5501(a) of The Affordable Care Act
Provider Types Affected
Physicians and non-physician practitioners submitting claims to Medicare carriers and Part A/B Medicare Administrative Contractors (A/B MAC) for primary care services provided to Medicare beneficiaries are affected.
What You Need to Know
This article, based on Change Request (CR) 7060, explains that Section 5501(a) of The Affordable Care Act provides for an incentive payment for primary care services furnished on or after January 1, 2011 and before January 1, 2016 by a primary care practitioner. The incentive payment will be paid on a monthly or quarterly basis in an amount equal to 10 percent of the payment amount for such services under Part B. See the Background and Additional Information Section of this article for further details regarding these changes.
Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2009 American Medical Association. Page 1 of 6 MLN Matters® Number: MM7060 Related Change Request Number: 7060 Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2009 American Medical Association. Page 2 of 6
Background
Section 5501(a) of The Affordable Care Act revises section 1833 of The Social Security Act by adding new paragraph (x), "Incentive Payments for Primary Care Services." Section 1833(x) of the Social Security Act states that, in the case of primary care services furnished on or after January 1, 2011 and before January 1, 2016 by a primary care practitioner, there also will be paid on a monthly or quarterly basis an amount equal to 10 percent of the payment amount for such services under Part B.
Specifically, the incentive payments will be made on a quarterly basis and will equal 10 percent of the amount paid for primary care services under the Medicare Physician Fee Schedule for those services furnished during the bonus payment year. (For bonus payments to Critical Access Hospitals paid under the optional method, see Chapter 4, Section 250.12 of the Medicare Claims Processing Manual at http://www.cms.gov/manuals/downloads/clm104c04.pdf on the Centers for Medicare & Medicaid Services (CMS) website.)
NOTE: The new Health Professional Shortage Area (HPSA) Surgical Incentive Payment Program (HSIP) and the new Primary Care Incentive Payment Program (PCIP) will be implemented in conjunction with one another for CY 2011. A separate article will be available at http://www.cms.gov/MLNMattersArticles/downloads/MM7063.pdf upon release of CR 7063 CR for HSIP. The former "special HPSA remittance" will now be known as the "special incentive remittance". This change is necessary as the PCIP is open to all eligible primary care providers regardless of the geographic location in which the primary care services are being furnished.
Primary Care Practitioner Defined
Section 5501(a)(2)(A) of The Affordable Care Act defines a primary care practitioner as:
•
A physician who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or
•
A nurse practitioner, clinical nurse specialist, or physician assistant for whom primary care services accounted for at least 60 percent of the allowed charges under the Physician Fee Schedule (PFS) for the practitioner in a prior period as determined appropriate by the Secretary of Health and Human services.
MLN Matters® Number: MM7060 Related Change Request Number: 7060 Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2009 American Medical Association. Page 3 of 6
Primary Care Services Defined
Section 5501(a)(2)(B) of The Affordable Care Act defines primary care services as those services identified by the following Current Procedure Terminology (CPT) codes as of January 1, 2009 (and as subsequently modified by the Secretary of Health and Human Services, as applicable):
•
99201 through 99215 for new and established patient office or other outpatient Evaluation and Management (E/M) visits;
•
99304 through 99340 for initial, subsequent, discharge, and other nursing facility E/M services; new and established patient domiciliary, rest home (e.g., boarding home), or custodial care E/M services; and domiciliary, rest home (e.g., assisted living facility), or home care plan oversight services; and
•
99341 through 99350 for new and established patient home E/M visits.
　
These codes are displayed in the following table. All of these codes remain active in Calendar Year (CY) 2011 and there are no other codes used to describe these services.
Primary Care Services Eligible for Primary Care Incentive Payments in CY 2011
CPT Codes
Description
99201
Level 1 new patient office or other outpatient visit
99202
Level 2 new patient office or other outpatient visit
99203
Level 3 new patient office or other outpatient visit
99204
Level 4 new patient office or other outpatient visit
99205
Level 5 new patient office or other outpatient visit
99211
Level 1 established patient office or other outpatient visit
99212
Level 2 established patient office or other outpatient visit
99213
Level 3 established patient office or other outpatient visit
99214
Level 4 established patient office or other outpatient visit
99215
Level 5 established patient office or other outpatient visit
99304
Level 1 initial nursing facility care
99305
Level 2 initial nursing facility care
99306
Level 3 initial nursing facility care
99307
Level 1 subsequent nursing facility care
99308
Level 2 subsequent nursing facility care
99309
Level 3 subsequent nursing facility care
MLN Matters® Number: MM7060 Related Change Request Number: 7060 Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2009 American Medical Association. Page 4 of 6 CPT Codes Description
99310
Level 4 subsequent nursing facility care
99315
Nursing facility discharge day management; 30 minutes
99316
Nursing facility discharge day management; more than 30 minutes
99318
Other nursing facility services; evaluation and management of a patient involving an annual nursing facility assessment
99324
Level 1 new patient domiciliary, rest home, or custodial care visit
99325
Level 2 new patient domiciliary, rest home, or custodial care visit
99326
Level 3 new patient domiciliary, rest home, or custodial care visit
99327
Level 4 new patient domiciliary, rest home, or custodial care visit
99328
Level 5 new patient domiciliary, rest home, or custodial care visit
99334
Level 1 established patient domiciliary, rest home, or custodial care visit
99335
Level 2 established patient domiciliary, rest home, or custodial care visit
99336
Level 3 established patient domiciliary, rest home, or custodial care visit
99337
Level 4 established patient domiciliary, rest home, or custodial care visit
99339
Individual physician supervision of a patient in home, domiciliary or rest home recurring complex and multidisciplinary care modalities; 30 minutes
99340
Individual physician supervision of a patient in home, domiciliary or rest home recurring complex and multidisciplinary care modalities; 30 minutes or more
99341
Level 1 new patient home visit
99342
Level 2 new patient home visit
99343
Level 3 new patient home visit
99344
Level 4 new patient home visit
99345
Level 5 new patient home visit
99347
Level 1 established patient home visit
99348
Level 2 established patient home visit
99349
Level 3 established patient home visit
99350
Level 4 established patient home visit
　
Primary Care Incentive Payment Program (PCIP)
For primary care services furnished on or after January 1, 2011 and before January 1, 2016, a 10 percent incentive payment will be provided to primary care practitioners, identified as: (1) in the case of physicians, enrolled in Medicare with a primary specialty designation of 08-family practice, 11-internal medicine, 37-pediatrics, or 38-geriatrics; or (2) in the case of non-physician practitioners, enrolled in Medicare with a primary care specialty designation of 50-Nurse
MLN Matters® Number: MM7060 Related Change Request Number: 7060 Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2009 American Medical Association. Page 5 of 6
Practitioner, 89-certified Clinical Nurse Specialist, or 97-Physician Assistant; and (3) for whom the primary care services displayed in the above table accounted for at least 60 percent of the allowed charges under the PFS for such practitioner during the time period that has been specified by the Secretary.
CMS will provide Medicare contractors with a list of the National Provider Identifiers (NPIs) of the primary care practitioners eligible to receive the incentive payments.
Eligible practitioners would be identified on a claim based on the NPI of the rendering practitioner. If the claim is submitted by a practitioner or group practice, the rendering practitioner’s NPI must be included on the line-item for the primary care service (identified in the above table) in order for a determination to be made regarding whether or not the service is eligible for payment under the PCIP. In order to be eligible for the PCIP, Physician Assistants, Clinical Nurse Specialists, and Nurse Practitioners must be billing for their services under their own NPI and not furnishing services incident to physicians’ services. Regardless of the specialty area in which they may be practicing, these specific non-physician practitioners are eligible for the PCIP based on their profession and historical percentage of allowed charges as primary care services that equals or exceeds the 60 percent threshold.
Beginning in CY 2011, primary care practitioners will be identified based on their primary specialty of enrollment in Medicare and percentage of allowed charges for primary care services that equals or exceeds the 60 percent threshold from Medicare claims data 2 years prior to the bonus payment year. A provision to accommodate newly enrolled Medicare providers will be released in 2011.
Coordination with Other Payments
Section 5501(a)(3) of The Affordable Care Act provides payment under the PCIP as an additional payment amount for specified primary care services without regard to any additional payment for the service under section 1833(m) of The Social Security Act. Therefore, an eligible primary care physician furnishing a primary care service in a HPSA may receive both a HPSA physician bonus payment under the established program and a PCIP payment under the new program beginning in CY 2011.
MLN Matters® Number: MM7060 Related Change Request Number: 7060 Page 6 of 6
Additional Information
If you have questions about this article, please contact your Medicare carrier and/or MAC at their toll-free number which may be found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website. The official instruction, CR 7060, issued to your Medicare carrier and/or MAC regarding this change may be viewed at http://www.cms.gov/Transmittals/downloads/R2039CP.pdf on the CMS website.
News Flash - Each Office Visit is an Opportunity. Medicare patients give many reasons for not getting their annual flu vaccination, but the fact is that there are 36,000 flu-related deaths in the United States each year, on average. More than 90% of these deaths occur in people 65 years of age and older. Please talk with your Medicare patients about the importance of getting their annual flu vaccination. This Medicare-covered preventive service will protect them for the entire flu season. And remember, vaccination is important for health care workers too, who may spread the flu to high risk patients. Don’t forget to immunize yourself and your staff. Protect your patients. Protect your family. Protect yourself. Get Your Flu Vaccine - Not the Flu. Remember – Influenza vaccine plus its administration are covered Part B benefits. Note that influenza vaccine is NOT a Part D covered drug. For information about Medicare’s coverage of the influenza vaccine and its administration, as well as related educational resources for health care professionals and their staff, please visit http://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdf and http://www.cms.gov/AdultImmunizations on the CMS website.
Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2009 American Medical Association.

a less impressive truth

2010-09-23T01:33:00.002-05:00

On September 23, 2010, the first provisions of the new health care legislation go into effect. Or do they???

The provisions are:
(1) Dependent children must be eligible for coverage under a parent's insurance until age 26.
(2) Coverage for an illness can no longer be denied if it is related to a "preexisting condition".
(3) Coverage cannot be denied by insurers if they find, after the fact, errors on an insurance application.
(4) Preventative care must be paid for without charge or deductible.
(5) Coverage decisions can be appealed either through the insurer or through and independent source.
(6) Insurance costs will be regulated.
(7) Insurers can no longer impose annual or lifetime limits on payments.

These are important and reasonable. They actually seem straight forward, but in no way revolutionary. They are adequately called reform, in that they are ethical and appropriate.

But they are very misleading and far from equitable in their application.

(1) The dependent children must not be eligible under any other coverage. The parent's coverage must be through an employer with at least fifty employees. The coverage cannot start until the next enrollment period, probably in three months.
(2) The preexisting condition coverage only applies to newly issued insurance. Insurance already in effect is exempt. This improvement only applies to children. For adults, all insurance can exclude preexisting conditions until 2018, eight years hence.
(3) Insurance currently in effect is exempted from the after-the-fact exclusion proviso
(4) Preventative care is mandated only for newly issued insurance: insurance already in effect is excluded
(5) For insurance already in effect, only the insurer is the arbiter of appeals
(6) There is no regulation for the cost of insurance already in effect.
(7) The lifetime and annual limit elimination only applies to NEW insurance. Insurance currently in effect is still allowed to limit the payments. Even for NEW insurance, the annual limits will continue to be restricted for the next four years, as the limits are raised, only to be eliminated in 2014. Furthermore, the limits will have limits on what procedures and diagnoses will be allowed… and those are not specified.

In effect, if you are already insured, you are screwed.

It is not very impressive if the truth is told.

Medicare Debacle Update

2010-04-15T12:12:00.003-05:00

Although the Sustainable Growth Rate (SGR) Formula for Medicare payments to physicians was acknowledged as flawed many years ago, it has never been fixed. It was designed to keep payments in line with a number of economic growth factors, to keep physician payments at a stable economic level. Although the formula worked for the first year, it subsequently failed: the physician fees began to fall while expenses rose and buying power fell. The legislators saw the problem and froze the Medicare fee schedule, but failed to fix it. For the past several years, as the freeze expires, the legislators have voted to continue the freeze for another twelve months. This year they voted to stay the fee drop by only a month, anticipating that it would be permanently fixed by the massive health care reform package. The drop for 2010 was now up to 21.2%!

Well: the health care reform package failed to fix the SGR problem. After a month they voted to stay the drop for another two months. On April 1, they failed to stay the drop. CMS, the Medicare administration, held all payments for two weeks, thinking that the legislature would retroactively stay the drop. After much legislative wrangling, they failed to do so yesterday, April 14, so today, the 21.2% fee reduction goes into effect. CMS has not announced their plans. They have two choices: start paying at the reduced rate retroactive to April 1st, or continue to not pay at all.

For physicians there are three possibilities: drop out of Medicare (effectively ceasing care for all over 65), accept the situation and suffer dramatic decline in income, or raise fees for everyone else to compensate for the lost income.

My practice is one-third Medicare patients, but they represent half of my fees. Sixty percent of my fees go to overhead. A twenty percent drop in Medicare fees translates to a fifty percent reduction on my actual Medicare income. To compensate I will need to raise all the rest of my fees by twenty-five percent. The fee discrepancy between the Medicare and non Medicare groups will widely diverge. What was an $80 fee for both groups becomes $60 for Medicare and $100 for all others. (For pediatrricians the effect is nil. For a gerentologist, the effect is without recourse.)

I believe that the lack of media attention to this debacle is really very scary. That the legislators have for years failed to fix this problem that hey all acknowledge as flawed is far more than just shameful, it is incompetent.

Regarding Naked Emperors.....

2010-03-31T07:52:00.001-05:00

MEDICARE FEE SCHEDULE UPDATE
March 31, 2010

On Friday, December 18, 2009, the Senate tacked onto a Defense Spending Bill an amendment that postponed the 21.2% Medicare fee reduction until April 1, 2010. It seemed sure that the President would then sign this into law before the end of the year. At the last minute it was blocked in the senate and never went to the president. On April 1, 2010, FOOLS DAY, the reduction goes into effect.

CMS, the Medicare administration, believes that a fix will be passed soon, so they are FREEZING ALL PAYMENTS TO PHYSICIANS until it passes! Starting on April 1, 2010, April fools day, this is no joke, all Medicare payments to physicians will stop indefinitely.

The massive health care reform package just signed into law does not contain a correction for the universally acknowledged as deeply flawed "sustainable Growth Rate Formula" that has resulted in this fee reduction problem. It was hoped for and promised that the health care reform package would contain a fix for this problem.

Medicare Apocalypse NOW ! (on January 1, 2010)

2009-12-13T20:20:00.003-05:00

On January 1, 2010 MEDICARE PAYMENTS are scheduled to be reduced by 21.1%.

The US Congress has already acted to cancel this fee reduction. The US Senate has failed to act.

If this fee reduction occurs, it is predicted that as many as 90% of physicians will stop accepting Medicare patients!

My practice is one third Medicare patients. One half of my charges are Medicare charges. Up until now I have felt it unethical to charge non-Medicare patients substantially higher fees than Medicare recipients. If Medicare fees are reduced by 21.2% then I would need to raise all my other fees by at least 20% to stay even and meet my expenses. I find this an indirect tax on my other patents to support the Medicare population. If I were to lower all my fees by 20% to keep parity with the Medicare fees, then I would need to close the practice. (By the way, it is likely that ALL INSURANCE COMPANIES will lower fees in accord with the Medicare reductions!)

Like many doctors, I am contemplating OPTING OUT OF MEDICARE. None of my fees would then be controlled by the government and none of my charges would be covered by Medicare. I fear this would be a burden to many of my patients over age 65 and that they would choose to leave my practice. I fear they will find nowhere to go!

I strongly urge EVERYONE to call Senators Lautenberg and Menendez (or, for those of you outside NJ your own senators!) as soon as possible and as often as possible to demand that they act to reverse this planned fee reduction before January 1 rolls around!

Senator Lautenberg: 1 202 224 3224

Senator Menendez: 1 202 224 4744

For reference: the following is the current senate.
It is in alphabetical order by last name. In parentheses is the party and state. The next code (example SH-141 for Senator AKAKA) is the building and room number. Then comes the phone number!

VP: BIDEN, Jr., Joseph R. 202-224-2424
AKAKA, Daniel K. (D-HI) SH-141 202-224-6361
ALEXANDER, Lamar (R-TN) SD-455 202-224-4944
BARRASSO, John (R-WY) SD-307 202-224-6441
BAUCUS, Max (D-MT) SH-511 202-224-2651
BAYH, Evan (D-IN) SR-131 202-224-5623
BEGICH, Mark (D-AK) SR-144 202-224-3004
BENNET, Michael F. (D-CO) SH-702 202-224-5852
BENNETT, Robert F. (R-UT) SD-431 202-224-5444
BINGAMAN, Jeff (D-NM) SH-703 202-224-5521
BOND, Christopher S. (R-MO) SR-274 202-224-5721
BOXER, Barbara (D-CA) SH-112 202-224-3553
BROWN, Sherrod (D-OH) SH-713 202-224-2315
BROWNBACK, Sam (R-KS) SH-303 202-224-6521
BUNNING, Jim (R-KY) SH-316 202-224-4343
BURR, Richard (R-NC) SR-217 202-224-3154
BURRIS, Roland W. (D-IL) SR-387 202-224-2854
BYRD, Robert C. (D-WV) SH-311 202-224-3954
CANTWELL, Maria (D-WA) SD-511 202-224-3441
CARDIN, Benjamin L. (D-MD) SH-509 202-224-4524
CARPER, Thomas R. (D-DE) SH-513 202-224-2441
CASEY, Jr., Robert P. (D-PA) SR-393 202-224-6324
CHAMBLISS, Saxby (R-GA) SR-416 202-224-3521
COBURN, Tom (R-OK) SR-172 202-224-5754
COCHRAN, Thad (R-MS) SD-113 202-224-5054
COLLINS, Susan M. (R-ME) SD-413 202-224-2523
CONRAD, Kent (D-ND) SH-530 202-224-2043
CORKER, Bob (R-TN) SD-185 202-224-3344
CORNYN, John (R-TX) SH-517 202-224-2934
CRAPO, Mike (R-ID) SD-239 202-224-6142
DeMINT, Jim (R-SC) SR-340 202-224-6121
DODD, Christopher J. (D-CT) SR-448 202-224-2823
DORGAN, Byron L. (D-ND) SH-322 202-224-2551
DURBIN, Richard J. (D-IL) SH-309 202-224-2152
ENSIGN, John (R-NV) SR-119 202-224-6244
ENZI, Michael B. (R-WY) SR-379A 202-224-3424
FEINGOLD, Russell D. (D-WI) SH-506 202-224-5323
FEINSTEIN, Dianne (D-CA) SH-331 202-224-3841
FRANKEN, Al (D-MN) SH-320 202-224-5641
GILLIBRAND, Kirsten E. (D-NY) SR-478 202-224-4451
GRAHAM, Lindsey (R-SC) SR-290 202-224-5972
GRASSLEY, Chuck (R-IA) SH-135 202-224-3744
GREGG, Judd (R-NH) SR-201 202-224-3324
HAGAN, Kay R. (D-NC) SD-521 202-224-6342
HARKIN, Tom (D-IA) SH-731 202-224-3254
HATCH, Orrin G. (R-UT) SH-104 202-224-5251
HUTCHISON, Kay Bailey (R-TX) SR-284 202-224-5922
INHOFE, James M. (R-OK) SR-453 202-224-4721
INOUYE, Daniel K. (D-HI) SH-722 202-224-3934
ISAKSON, Johnny (R-GA) SR-120 202-224-3643
JOHANNS, Mike (R-NE) SR-404 202-224-4224
JOHNSON, Tim (D-SD) SH-136 202-224-5842
KAUFMAN, Edward E. (D-DE) SR-383 202-224-5042
KERRY, John F. (D-MA) SR-218 202-224-2742
KIRK, Jr., Paul G. (D-MA) SR-317 202-224-4543
KLOBUCHAR, Amy (D-MN) SH-302 202-224-3244
KOHL, Herb (D-WI) SH-330 202-224-5653
KYL, Jon (R-AZ) SH-730 202-224-4521
LANDRIEU, Mary L. (D-LA) SH-328 202-224-5824
LAUTENBERG, Frank R. (D-NJ) SH-324 202-224-3224
LEAHY, Patrick J. (D-VT) SR-433 202-224-4242
LeMIEUX, George S. (R-FL) SR-356 202-224-3041
LEVIN, Carl (D-MI) SR-269 202-224-6221
LIEBERMAN, Joseph I. (ID-CT) SH-706 202-224-4041
LINCOLN, Blanche L. (D-AR) SD-355 202-224-4843
LUGAR, Richard G. (R-IN) SH-306 202-224-4814
McCAIN, John (R-AZ) SR-241 202-224-2235
McCASKILL, Claire (D-MO) SH-717 202-224-6154
McCONNELL, Mitch (R-KY) SR-361A 202-224-2541
MENENDEZ, Robert (D-NJ) SH-528 202-224-4744
MERKLEY, Jeff (D-OR) SR-107 202-224-3753
MIKULSKI, Barbara A. (D-MD) SH-503 202-224-4654
MURKOWSKI, Lisa (R-AK) SH-709 202-224-6665
MURRAY, Patty (D-WA) SR-173 202-224-2621
NELSON, Ben (D-NE) SH-720 202-224-6551
NELSON, Bill (D-FL) SH-716 202-224-5274
PRYOR, Mark L. (D-AR) SD-255 202-224-2353
REED, Jack (D-RI) SH-728 202-224-4642
REID, Harry (D-NV) SH-522 202-224-3542
RISCH, James E. (R-ID) SR-483 202-224-2752
ROBERTS, Pat (R-KS) SH-109 202-224-4774
ROCKEFELLER IV, John D. (D-WV) SH-531 202-224-6472
SANDERS, Bernard (I-VT) SD-332 202-224-5141
SCHUMER, Charles E. (D-NY) SH-313 202-224-6542
SESSIONS, Jeff (R-AL) SR-335 202-224-4124
SHAHEEN, Jeanne (D-NH) SH-520 202-224-2841
SHELBY, Richard C. (R-AL) SR-304 202-224-5744
SNOWE, Olympia J. (R-ME) SR-154 202-224-5344
SPECTER, Arlen (D-PA) SH-711 202-224-4254
STABENOW, Debbie (D-MI) SH-133 202-224-4822
TESTER, Jon (D-MT) SH-724 202-224-2644
THUNE, John (R-SD) SR-493 202-224-2321
UDALL, Mark (D-CO) SH-317 202-224-5941
UDALL, Tom (D-NM) SH-110 202-224-6621
VITTER, David (R-LA) SH-516 202-224-4623
VOINOVICH, George V. (R-OH) SH-524 202-224-3353
WARNER, Mark R. (D-VA) SR-459A 202-224-2023
WEBB, Jim (D-VA) SR-248 202-224-4024
WHITEHOUSE, Sheldon (D-RI) SH-502 202-224-2921
WICKER, Roger F. (R-MS) SD-555 202-224-6253
WYDEN, Ron (D-OR) SD-223 202-224-5244

More Salt

2009-11-03T11:45:00.002-05:00

NOTE: This document is Copyrighted 2009 by Joseph T. Cohn, M.D.

It is a preliminary draft

Chapter One:
INTRODUCTION:

The wonderful delicious and nutritious soup is ruined: there is much too much salt in the soup. All the delicate flavors produced by careful selection of numerous ingredients, combined and cooked carefully based on time-proven recipes and years of experience are ruined with the addition of too much salt.

A prominent visitor to the kitchen tasted the delicious soup and wanted, for many reasons, to alter it to a different taste. We offered only weak protestations to the addition of the salt. A little was added, then more and more, until the flavor of the soup was no longer discernible: it was now nasty brine. We could have said "No" and stopped the ruination at the beginning, but the arguments were persuasive and we were afraid that we would be replaced as chef if we did not allow the tinkering with the soup. We became complicit with the salter.

None-the-less, we served the soup. Our reputation as master soup-maker declined dramatically. Our patrons were no longer enjoying delicious and nutritious soup. The visitor to our kitchen who started the salting allowed other visitors to take over the serving of the soup and they took control. All the visitors caused tremendous price increases for the soup. Saltier and saltier and more and more expensive: the soup remained a necessity of life.

And now the prominent visitors are demanding that the recipe be fixed. Unfortunately, the fix is "more salt."

In the years after the Second World War, the practice of medicine was growing and changing rapidly. The model of a family doctor, a general practitioner, delivering nearly all the lifelong care for an individual and the family was evolving with the increasing specialization and sub-specialization of physicians. Surgery was becoming an increasingly valuable option for many illnesses and hospitalization was becoming a more frequent tool. Diagnostic tests were increasingly available and medications were being discovered.

By the mid-60's it was clear that the old GP needed to be replaced by a physician with much greater and broader training. Careful pragmatic and academic thought gave rise to a new specialty, Family Practice. A well trained family physician could deliver lifelong care, handling well 90% of an individual's well-being and illness issues without resort to consultation or referral. 95% could be handled with a specialist's assistance and only 5% would require ongoing subspecialty care.

The seventies showed the model to be both attractive and feasible. Family practice became the largest specialty in the country. Family physicians delivered more care, more efficieintly, more cost-effectively, and with greater satisfaction for physician and patient than ever before.

Until the mid-twentieth century medical care was not expensive. There were few medications and surgery was a rare option. Hospitalization was not expensive. Doctors made a good middle-class living, but did not become wealthy. Patients paid out of pocket for their medical care, surgery, hospitalizations and medication.

There was no medical insurance. Hospitalization insurance was available, but rarely purchased by an individual. After World War II the federal government gave companies the tax-break to offer their employees the benefit of hospitalization insurance. This became a popular benefit for companies and unions began to demand it.

Post-war physicians had served in the military and surgical care had advanced. Surgery and hospitalization were much more frequent options. Babies, previously frequently delivered at home, were then routinely delivered in hospital maternity wards (filled with newborn baby-boomers). Still, costs were affordable and were paid out of pocket.

Over the next decade, hospital care for the more ill patients, usually the elderly, became more sophisticated and more expensive. It became much more common to die in the hospital than in one's own bed. The cost of the terminal illness rose to almost 90% of a person's lifetime medical costs. Surviving spouses were becoming financially destitute because of the cost of their partner's last illness. Medicare was invented in the mid-60's as a financial safety net to protect the elderly from medical financial ruin.

Medicare contained provisions for the payment of out-patient care, but the costs remained trivial and only a small proportion of Medicare claims were filed. Private insurance companies, seeing the possibilities of a new market for new insurance began to market health-care insurance, modeled on Medicare.

The mid sixties to the mid seventies saw a massive boom in the technology of medicine. Medical and surgical subspecialization expanded as medical generalists became outmoded. The cost of the most mundane and usual medical care, previously delivered by the family doctor, now delivered by the expensive subspecialist, become expensive. The perceived value of insurance to cover these costs seemed attractive. Health insurance grew apace with the growth of subspecialization. Freed from burdening the patient with the expanding costs, physician specialist fees grew as well.

Within medicine, the birth of the specialty of Family Practice was seen as the answer to the explosion in the cost of routine health care.

Another brilliant health care concept was also born at this time: the health maintenance organization, the HMO. Originally HMO's were viewed as a way of delivering lifelong preventative medical care, healthy lifestyle support, and family-physician (primary care doctor) centered care all for a fixed annual membership fee. The cost of health care, it was thought, would be controlled by the use of physician extenders and other health professionals for the routine and mundane tasks, as well as for counseling, and that healthier individuals would engender less medical expenses.

It did not work out. The idea was totally co-opted by the insurance industry that warped it into a gate-keeper, limited access medical system. Rather than lowering health care costs and increasing access and improving physician satisfaction, the HMO movement spawned several spin-off concepts and alphabet soup: PPO's, IPA's, and so on. Each intended to compete with the HMO and to offer alternative financing schemes for medical care. Each proved successively a greater failure and more expensive. The key element to all of them was that the fiduciary agent, the insurance company, was no longer providing insurance, it was managing every health care dollar. Primary care physicians were no longer cast as the center of providing care, but rather limiting care as gate-keepers to the medical system. Patients became consumers and participants. The doctor-patient relationship was completely altered.

INSURANCE:

Spread the risk of catastrophic financial loss over a group sharing a risk for that type of loss. The larger the group and the more predictable the risk, the more accurately the risk can be spread. The central agent for the group, the insurer, may profit in two ways: (1) charging an amount in excess of the anticipated losses, and (2) investing the collected funds.

MANAGEMENT OF THE HEALTH CARE DOLLAR:

1. charge fees in excess of anticipated expenses
2. invest monies collected
3. limit services provided
4. curtail payments to health care providers
5. control types of services
6. limit provider availability
7. manage the mundane: profit from the management of anticipated and routine events
8. market not to the individuals, but to employers

Whole new concepts were added to the management and practice of medicine. All the following concepts were invented by the insurance industry:

gate-keeper
pre-authorization (prior authorization)
prescription plan
preferred medication
patient quotas
mail-order pharmacies
waiting periods
pre-existing condition limitations
non-covered procedures

None of these improved patient care. None lowered the cost of medical care. All reduced patient and physician satisfaction and all spawned an industry of non-clinical paramedical technologists.

With their deeply vested interests in the finances of health care, the federal government and the insurance industry have become very active in regulating and controlling the practice of medicine. Nearly all of the regulations that dictate how medicine must be practiced (particularly in the hospitals and nursing homes) did not exist twenty years ago. There is little evidence that these regulations actually improve anything, but they surely detract from the quality of care provided and the experience of the providers. Nurses spend the majority of their time in administrative tasks and documentation -- little of which (if any) is actually used to improve patient care. The financial burden of the administrative and regulatory requirements is staggering. The nature of many of the requirements is silly at best and damaging at worst.

(A parallel development during this same time period has been the boom industry of malpractice suits. Although there are distinct links between this phenomenon and the problems already outlined, this "crisis" will be addressed separately. I leave it not because it is unimportant, but because the causality and results are tangential.)

Shall we add more salt? I think we best dump the current batch and start anew. Can it be done? The question is, do we have a choice?

Chapter Two:

WHAT'S ON THE TABLE

( to be continued)

string of nows

2009-04-01T20:40:00.007-05:00

I know you want to fight to live. When I first told you about your cancer and that it was going to be a really tough road, you said you were going to fight with all your strength. You did. All the doctors tried. We gave you chemo and radiation and pulled you back from the edge when things looked rough. But from the beginning the cancer was tough and despite your fight and your strength and our ray guns and our poisons, the cancer progressed. And now it is all through you, and you are too weak to take our treatments. You want to fight, you are eager to live. You have not had enough. But we have nothing else to try.

So instead of talking about how to fight this beast we can talk about how to live life. You are not dead and you are not dying: you are alive. You are not healthy nor well. You are weak from this fight, from the tough road of this trip. Your mind is dulled from the strokes and the tumors and the radiation and from the drugs we give to reduce your pain. But you are alive. Now. And now. And now. And in this string of "nows", what do you want? Forget for a moment about taking care of the rest of us. Forget about what you should want or should do. Your string of "nows" is likely really short. What do you want?

I know the medicines have wreaked havoc with your senses of smell and taste. But is there anything you wish to taste or eat or drink or smell? I know the drugs have given you diabetes, but, honestly, if you want a hot fudge banana split, say the word! Anything you ask I will try to make happen.

Is there anything you want to do? Before you die and before you can no longer see or hear or speak, is there any conversation you want to have? I know you have been putting on a brave and happy face for your family and friends and even for the doctors and nurses. Do you want to take off that mask and cry? Soon it will be too late to say anything. Is there anything you want to say?

You have taught us with your courage. Are there any other lessons you want to teach? Words of wisdom from the edge of death?

What do I suggest? I suggest you forgive everyone that has hurt or disappointed you. Tell those you love that you love them. Hug them. Say thank you to everyone who has gifted you in small or great ways with kindness, skills, knowledge, or caring. Say goodbye powerfully.

Memo to the President on integrity (and "health care reform")

2009-03-22T19:24:00.001-05:00

March 21, 2009

Dear President Obama:

As means of introduction, I am enclosing a copy of the letter I sent to you prior to your inauguration. (Blogger's note: see the previous blog entry!)

I am profoundly disappointed in you.

You promised open and public discussion of issues before acting upon them. You have been specifically soliciting massive public input into "health care reform".

You signed into law the Economic Recovery Act. Within that act, specifically in Title XIII (but not limited to that section), are major provisions regarding Health Information Technology, creating agencies and plans for the centralization of all medical care. Nothing in this section of the Economic Recovery Act has ANYTHING to do with economic recovery. It is entirely about the "reformation" of health care and the marked increase in the federal government's control over medical practice.

I have queried many of my patients, with varying backgrounds and levels of information and education, regarding this situation. Only one, a retired pharmaceutical industry executive, even knew of these provisions in the legislation. Two of my patients, who are staunch believers in you and your programs and promises and who are currently active in YOUR community focus groups regarding health care reform, were shocked and dismayed when I showed them the contents of Title XIII.

You allowed this. For all I know, you planned this. You have clearly misled the American people. For you to be so very deceitful so very early in your tenure as president is truly frightening.

I feel as if you have betrayed us all. I believe you owe us an explanation.

Most Sincerely,

Joseph T. Cohn, M.D.
Family Physician
Diplomate of the American board of Family Medicine
Clinical Assistant Professor at UMDNJ
Clinical Assistant Professor at Drexel School of Medicine
Senior Attending Physician at RWJUH, New Brunswick, NJ
Senior Attending Physician at SPUH, New Brunswick, NJ

Letter to the President Elect on "Health Care Reform"

2009-03-22T19:21:00.001-05:00

December 27, 2008

Dear President-elect Obama:

I am not a guy in the bar. I am NOT "Joe the Plumber".

I am, however, known to patients, nurses, staff, the community, and fellow physicians as "DR. JOE"

I am a board certified Family physician in practice for about 30 years. I am a senior attending physician at two University Medical Centers and Clinical Assistant Professor at two medical schools.

I have many thoughts about the state of the health care crises in this country.

The first and most central issue is to clean up the current language and thought process.

There are TWO DISTINCT, albeit interwoven, situations. Only one is in crisis. The two are HEALTH CARE and the second is HEALTH CARE FINANCING. Only the latter is in crisis. We who deliver health care are doing a fine job. Surely, there is always room for improvement, and the problems with financing adversely impact on our ability to DO a good job, but, none-the-less, WE ARE DOING A GOOD JOB.

Health care financing is a major problem, and it is entirely the fault of human nature interacting with good intentions:

Post WWII governmental tax breaks to allow employers to provide medical insurance started all the problems. Hospital costs skyrocket and physicians, primarily surgeons, had a blank check for their salary. Opportunity for greed's triumph began. Insurance companies flourished and the groundwork was laid.

Medicare, a program to act as a financial safety net for the at-risk elderly compounded the problems. It took over fifteen years for the full adverse impact to be realized, but the federal budget was already overwhelmed by the escalating cost of paying for elder-care. The rules and regulations of Medicare make the IRS code look small and simplistic!

Medicaid is a state-managed patchwork of programs that force the chronically poor and disabled into a health care ghetto. These programs, despite their TV ads to the contrary, are shameful and guarantee poor care for the neediest.

The academic invention of "Health Maintenance Organizations" was brilliant. The insurance industry saw each step as a chance to market new and greater products; the concept was totally co-opted and converted in to a macabre rationing system. The abuses of the "leaders in the field" were and are rampant. Government did nothing to improve the situation.

We are left with private and government-contracted private third parties MANAGING THE MUNDANE, rationing care, and interfering with the effective practice of medicine, while vastly inflating the cost by lining their pockets while providing no value. The national budget is swollen, trying to finance and control the health care industry". The brilliant remedies of the think-tanks are either ignored or perverted beyond recognition.

Mr. Obama: you promise real change. Here is a field that needs it desperately. What you are offering at this time, what you propose is weak, ineffective, and MORE OF THE SAME. Your proposals will fail. I fear you know that already, but that you are unwilling to offer CHANGE, REAL CHANGE.

Please prove my fears wrong. This system of health care financing does not work and cannot be simply repaired.

If I may be of any assistance, I humbly offer you my expertise in the field of medicine from the front lines.

Most Sincerely,

Joseph T. Cohn, M.D.

Family Physician, Diplomate of the American Board of Family Medicine
Clinical Assistant Professor at UMDNJ
Clinical Assistant Professor at Drexel School of Medicine
Senior Attending Physician at RWJUH and SPUH, New Brunswick, NJ

My vote for president

2008-01-30T12:32:00.000-05:00

I will vote for the candidate that exhibits extraordinary honesty, integrity, and wisdom. I will vote for the candidate with those characteristics who also listens well and listens widely. My candidate takes heed of disparate views and complex information and is able to synthesize the data and viewpoints into coherence and then can either see a clear path or delineate the obstacles. Then, my candidate is able to enroll others in the vision and lead the way with efficient organization toward successful results.

My ideal president is passionate, but not zealous. The candidate does not have beliefs or creeds, nor platforms or agendas. My candidate does not belong to a political party nor subscribe to a political philosophy.

Politicians idolize my candidate and fear my candidate. They want to be viewed as like my candidate, but, somehow, cannot understand why they are not. In their envy or fear or confusion, they cannot help but support this candidate as well.

I do not believe that my candidate is an unfulfillable fantasy character. I believe that this individual has a single trait that can transform nearly any intelligent and well educated individual into this dream candidate. Courage.

Courage is far too often confused with boldness, strength, and bluster. Candidates always have these in profusion, if not excess. They lack courage. In courage we put aside our considerations and we do what is necessary. We are what is necessary.

Now, (and as far as I can tell, for all times) our presidential candidates all seek the office with a bias, to use the office to further their own agendas. My candidate has the courage to seek the office to be the office.

To be the office.

The Rationalization of War Crimes

2007-12-11T10:02:00.000-05:00

Detainees may be questioned, but any form of physical or mental coercion is prohibited (Geneva III, art. 17; Geneva IV, art. 31).

"Physical or mental coercion" is the internationally accepted diplomatic definition of torture.

A good dictionary definition is "to cause physical pain or mental anguish, particularly to obtain confession of a crime or secret information".

Torture or inhuman treatment of prisoners-of-war (or any captured and detained individuals, during any armed conflict) are grave breaches of the Geneva Conventions, and are considered war crimes (Geneva III, arts. 17, 87, and 130; Geneva IV, arts. 32 and 147).

QUESTION ONE: Is "waterboarding" torture?

Waterboarding is the process of submerging a restrained individual, with cloth gag in mouth, in an inclined, supine position into water, head first. The intent is to simulate the sensation of drowning in order to promote the cooperation of the individual with questioning to obtain military intelligence.

Waterboarding clearly causes mental anguish and physical distress. It is clearly physical and mental coercion for the purpose of obtaining secret information.

Waterboarding is clearly and unequivocally torture.

QUESTION TWO: Is "waterboarding" a war crime?

Waterboarding is clearly torture. If is done upon individuals who are prisoners of war or who are detained in relation to an armed conflict, then it is clearly a war crime.

QUESTION THREE: What is wrong with us?

Should hospitals advertise?

2007-06-25T09:05:00.000-05:00

In order for a hospital to be successful, it must fulfill its mission. To be wonderfully successful, the goals must be met with excellence. It is my contention that in so doing, the hospital will earn a well deserved reputation. It is this well deserved reputation that will guarantee that the hospital will be sought by doctors for their patients and by patients as the center for their hospital care. With careful financial management and unrelenting support for the excellent fulfillment of the mission, the hospital will be a financial success.

There is no place for solicitation of business or of self-serving publicity on the part of the hospital. Such activities are a diversion of funds at best, and at worst, are unethical. Until some thirty years ago it was universally accepted that it was unethical for hospitals to advertise and to solicit business. It was considered demeaning of the professional status of the institution and the participating health care providers. It was considered intrinsically misleading, putting forth self-aggrandizing claims. This was the practice of the medical snake-oil salesmen of the prior century, from whom modern medicine wished to differentiate and distance. For the first three-quarters of the twentieth century, the "Flexnerian Era" of modern, scientific medical practice during which hospitals grew and flourished, there was the distinction of a professional model that guided our behavior. Since the late 1970's, the forces of business, primarily the "third party payers", have shifted us, by overt coercion, into a business model. The vestiges of the professional model coexist unhappily with the business model.

The ethos of the business world is unconcerned with the ethics of the professional world. It is not only acceptable, but mandatory to compete. Competition has its own rules, a near biological imperative of eat-or-be-eaten. "Whatever is necessary" is what is acceptable. There is no accountability and no science (other than the statistical analysis of the marketplace and its applications for psychological manipulation.) Like a biological organism, there is only survival and growth. The larger the business organization, the more likely it plays by its own (self-serving) rules. Public relations and publicity are tools to distort the truth so as to appeal to the consumers. The worse the truth, the greater the PR required.

In our current world, it would take great courage to coexist with a voracious business-model-medical-center with no weapon but a rigorous adherence to an outstanding rigorously committed professional model. My final contention is that it is not only possible, but that it is the only way to survive. Real, earned, reputation for excellence will, in the long run, triumph over bigger bricks and bravado. The institution that cannot ever vie in a business model with a bigger, richer, powerful competitor, with any hope of triumph, can stop competing. The monster businesses demonstrate their inability to even see (or care) beyond the surface of their product. The professional hospital can see clearly what needs to be done and do it.

Handguns: The Real Cost of Self-Defense

2007-04-18T14:08:00.000-05:00

Once again, the public debate about handguns is hot.

Here are my thoughts. It seems very simple to me.

Handguns are lethal weapons. They are not used for hunting. They are used to kill people.

Those who are injured or die from handgun injuries fall into four categories:
(1) Suicide (or attempted)
(2) Accident
(3) Homicide (or attempted)
(4) Legal self-defense

Accurate statistics for the combined morbidity and mortality from handguns are difficult to find and vary widely by locale, but rough numbers for the whole country are about 40% suicide, 40% accident, 20% homicide, and less than 1% legal self-defense.

Ownership of a gun for either self-defense or sport dramatically increases the likelihood that the owner will successfully commit suicide, die in a handgun accident, or be a victim of homicide. The risk of these also is dramatically increased for all the members of the household. The chance that they will ever use the gun for self-defense is, essentially, nil.

I could go on (and on and on and on), but is that not enough information upon which to base an honest decision?

Insurgency or Insurrection -- Language Misappropriation

2007-01-14T20:27:00.000-05:00

An "insurgent" is someone who "rises up against". The archaic word, no longer a part of the language, for what the insurgent does, was "insurge". The modern word is "revolt". An "insurgent" is a "revolutionary". Up until recently, there was a wonderful word that described what propelled and fueled the insurgent's actions: "insurgency". "INSURGENCY: the state of being insurgent or the tendency to revolt". The work of the insurgents is (a perfectly fine word) "insurrection", a fine synonym for revolution or uprising.

Why is it that in today's world there are no revolutions, revolts, or insurrections? Why have we, instead, been told that there are insurgencies? Why is this misappropriation and misuse of the language tolerated? Why was it thought a good idea? By whom? Who thought it necessary? What spinning of ideas necessitated the warping of the language?

I fear it is too late. I fear the language is changed. Insurgency is now, officially, the label of choice for "uprisings". Language usually slowly evolves in wondrous ways. I fear that those who tell us what to think and how to feel all too often play fast and loose with language and change it all too fast, none for the better.

I work best under pressure and there'll be lots of pressure if I wait 'til tomorrow..

2006-06-29T16:41:00.000-05:00

On the first day of class we received the assignment that would be due the last week of class. We had all semester to work on it. I got started on it that first day and handed in the well researched, well written, well edited, well typed, polished paper the first day of the last week of class. I was proud of the paper and received the A+ I deserved. I did that with every assignment throughout college and I got lots of A's. And I enjoyed my classes.

In high school I frequently put things off to the last minute and with angst and drama I managed to usually get things done and in at the last minute. I still got (mostly) good grades, but I surely did not enjoy the academic process as much, and the finished products in no way truly represented what I was capable of producing.

Every year the state legislators must come up with a budget by the end of June. For some reason, they are far from having the assignment done today, June 30th. The government is going to "shut down" and we the people are going to suffer because of it. I am told that they wait to the last minute on purpose, not because they work best under pressure, but because they are playing a bizarre game of partisan "chicken" with our money and our governmental funding. I suspect there is a logic and a value to this perennial game, some covert political advantage or gain.

This last minute pressure stresses everyone and results in a haphazard and ill-conceived budget. They act as if someone told them just a few days ago, "Oh, by the way, that assignment, the budget, is due next Friday!"

For goodness sake! They knew it all along. They should have been working on it from the beginning of the year, from last July, so that at the beginning of this week, last Monday, they could have handed in a well researched, well written, well edited, well typed, polished budget. One they could have been proud of and one that would earn them an A+

Ethics and Ethos: the Fox in the Henhouse

2006-06-26T11:56:00.000-05:00

First, simple definitions:

Ethics: "right and wrong"

Ethos: "the way things are done"

Second, an example:

A recently televised discussion centered on the "ethics" of abandoning an injured colleague to die on the expedition to the top of a mountain. The choice was to abandon the expedition and to rescue the injured one, or to abandon the injured one to complete the task. The climbers said that abandoning the injured party was "the right thing to do", as all involved knew the risks, and achieving the goal was more important than anything else. The show host questioned the ethics or morality of such a decision.

My answer:

There is no question here. The only ethical thing to do was to save the life. If the quest was to climb the mountain to save MANY lives, or for some greater good, then the argument could be made that the climbers could choose to sacrifice the one for the many. To sacrifice a life for a goal of having "conquered the mountain" is unethical. It IS however, an acceptable formulation of the ETHOS of the climber. The VALUE to the climbers to achieve the goal at all cost, even life, may have been paramount. There may even have been an agreement or a contract between the climbers to abandon injured climbers to achieve the goal. This is the ETHOS of the climbers. The accepted "way things are done" is distinct from the rightness or wrongness of the act. The ethos or the tradition or the culture of the group may contradict any ethics. Ethics is about "right and wrong" in a greater sense, one that transcends ethos.

Now, the topic of the day:

Congressional Ethics

The headline in the newspaper today and the topic on talk radio was about state and federal elected officials, our congressmen, rallying to promote "ethics laws" to govern their own behavior.

I can see congress passing legislation to authorize payments for building roads, but not on how to build the roads, or for payments for medical care, but not on what medical care or how the medical care shall be done (and that is another discussion). I can see politicians passing legislation mandating ethical behavior, as if such were necessary, but they are clearly unqualified to delineate, teach, or monitor the ethics of their own behavior. Their ETHOS is far too twisted to allow them a clear vision of ETHICS.

It is pathetic that our "leaders" should need to legislate that they be ethical. Since they, and essentially ALL politicians, have proven their collective propensity to ignore ethics and to perpetuate the corrupt ethos of government, it might be of value to have ETHICISTS clarify for the elected-ignorant specifically WHAT IS ETHICAL. It might, then, be of value to have outside specialists monitor the ethics of the politicos.

Two side notes:

(1) I am fairly sure that any and all politicians will point fingers at physicians and question our ethics. The AMA is guilty of changing its "code of ethics" to suit its financial and political advantage, but that is understandable, as it is a POLITICAL organization, and subject to the ethos of organizations and politics.

The ethos of medicine, however, is intrinsically an ethical ethos. We err and are tainted, but our ethos is ethical. We struggle and grapple with ethics every moment of every day.

(2) Law is not intrinsically ethical. Law codifies the ethos, but not the ethics of the group. I am not sure that it is possible to legislate ethics. Ethics arises from philosophy and can be studied and taught and turned into practice. I am not sure if it is possible to mandate ethics. Especially if the ethos is unethical.

I wasn't always cynical

2005-09-06T20:05:00.000-05:00

I am feeling particularly cynical today, so I thought I would post a story I wrote years ago, of a boy I knew in 1977.....

Ronnie's Miracle

It was just before Easter when Ronnie was admitted to the major medical center. His family doctor in the North Carolina hills could not figure out what was causing this eight-year-old's belly pain. And the swelling in Ronnie's belly was severe. On the second day of Ronnie's hospital stay I began my intern rotation on pediatrics: Ronnie became my patient.

I reviewed his admission notes and went to talk to him and his mom, and to examine him. His abdominal exam shocked me: it felt like a huge tumor was filling his belly! Indeed, previous examiners had thought his belly swollen but my less educated hands thought it was a mass: it proved on testing over the next two days to indeed be a massive tumor. Surgery was performed and confirmed the malignant nature of the tumor.

Ronnie's mom and stepfather were paralyzed with the horror of the situation. Ron's dad had died two years before of testicular cancer at age 26. Ron's mom was in the first trimester of pregnancy. Ron was diagnosed with cancer....

At the family meeting, the oncologists explained the treatment options. Survival chances were slim to none. New chemotherapy and radiation therapy protocols could be attempted for this rare cancer. Ronnie's parents had no clue as to how to proceed. Ronnie asked, "Will the medicines hurt?" He was honestly answered that they would make him feel very sick and weak. "Will it help?" We did not know, but we thought he might live longer with the treatment. "Will it help anyone else?" We might learn from treating him how to treat others.

He said: "Let's do it!"

And so Ronnie made the decision. Every night for the the next two months, for the rest of my time on that service I sat with Ronnie, not out of compassion, but out of the need to start and restart IV's in his tiny fragile veins. I learned how to do pediatric cut-down's and central lines on his little body. He continuously coached me and encouraged my efforts. When it hurt, he cried and told me it hurt, but then said, "You're doing fine...keep going!"

His family moved from the hills to Chapel Hill to be near him. They, too, became my patients. After my rotation I continued to see Ronnie in the hospital nearly every day. I spoke to his mom frequently and took care of her during her pregnancy.

Ron kept getting his treatments. He kept getting weaker. His resolve stayed strong.

A religious little boy, he asked why God wanted him to go through all this, what had he done to deserve it? He answered his own question: "I've been good, so God must need me to do this to help somebody else." He went through all the complications of cancer therapy that a body can endure, but he died shortly before Christmas that same year of the metastases of the cancer.

I sat with his parents immediately after he died and they asked: "WHY?"

I said, "I don't know God's mind. I don't know why Ronnie had cancer, why he suffered, why he died. I don't know if God has a plan, and I'm sure I don't understand it. But Ronnie chose to live and to fight for his life. He did so with courage. He was a kid who felt kid things and did kid things. At the same time he touched me with his courage and his humanity. He touched every orderly, aide, clerk, nurse, intern, resident, and attending physician who had the opportunity to care for him. I do know that I will take what Ronnie taught me with me throughout my life. What Ronnie taught me about caring and humility and courage will touch me very day. And, I suspect, that his touch will be present with all who cared for him. Ronnie changed the shape of who I am and who I will be, and through me will go on to touch others. Ronnie changed the shape of the world."

It is almost twenty years since Ronnie lived and died. The words I intended as comfort for his parents are still clear to me today: they have proven true. Ronnie is a miracle.

the buck stops here

2005-07-18T12:41:00.000-05:00

The patient had just arrived in the critical care unit (ccu) from the emergency room. He had been well stabilized and was doing well. All was going smoothly. He was attached to the ccu's cardiac monitoring system and taken off the portable monitor used for transport to the unit.

His heart rhythm was fine. The nurse began to enter his information into the monitoring system: his name, age, and gender. Unfortunately, his last name starts with "G".

It seems the keyboard's "G" and "N" keys just do not work.

There is no way to enter him with the correct name, but the monitor strips are a real and vital part of the medical record, and wrong names on medical documents, especially key data such as live cardiac rhythm monitors, can lead to serious or deadly errors.

But a keyboard costs only about ten dollars today. I am sure the hospital has plenty of replacement keyboards, for they are the most likely part of the heavily used system to break.

The nurses were busy, so I called "IT" -- information technology department. Unfortunately, they do not handle repairs to equipment keyboards or monitors, only to computer systems. "Call maintenance".

The maintenance guy did not know ANYTHING about monitors or keyboards. He suggested, "Call IT. "

So.... I took a working keyboard off of a computer terminal and put it on the cardiac monitor system. Mr. G. could now be "in the system".

The faulty keyboard was now on the computer terminal. NOW it is IT's responsibility.

At least that was one, albeit roundabout solution to the immediate problem.

The next day I called and spoke with the hospital's VP in charge of maintenance. I told her the story. As I have suggested for, oh, 20 years, I once again suggested the establishment of a "buck stops here hot line". 24/7: a phone number that ANYONE in the medical center with ANY unusual problem can call and have a well trained and well authorized problem solver take on and handle any problem. I suspect the efficiency ad cost savings would be immediate and immense. Rather than having a clerk or nurse or doctor spend long and inefficient time and effort to solve a problem, a delegated problem solver could handle it in seconds!

She will get back to me. We'll see.

Communication

2005-06-14T20:36:00.000-05:00

Communication 101

Baby babble expands exponentially into language. Rarely, language skills develop to amazing mastery. Rarely do communication skills develop very well at all. All human interaction, all society, all relationships, all activities that involve more than one of us require communication. We spend a fair bit of our informal and formal education learning language skills, but we spend no time learning to communicate effectively. Communication majors in college are actually media majors, learning how to manipulate the minds of the masses with communication media tools. No one studies good communication.

Here is a primer on communication. I have been working on this for a long time and I still do not have it all right. But it is a start.....

There are three type of communication: (1) news, (2) instruction, and (3) enrollment. All communication can be thus classified and in so doing, better understood.

NEWS tells us something, but does not tell us how to do anything nor does it ask anything of us. NEWS is descriptive. It may be valid or invalid, true or false, biased or objective (if such a thing exists), valuable or worthless, entertaining or boring. Most communication is NEWS.

INSTRUCTION tells us how to do something. It teaches us but it does it does not ask us to do anything. INSTRUCTION may be accurate or flawed, appropriate or bizarre, easy or hard, straight-forward or distorted.

ENROLLMENT asks us to do something and we can do it (ENROLL) or not. There are three distinct types of enrollment: (1) invitation, (2) request, and (3) demand.

INVITATIONS ask, but they do not expect a response, and there is no negotiation if there is a response,and there is no consequence based upon the response. YES, NO, MAYBE, or even SILENCE are possible responses to an invitation.

REQUESTS ask and expect a response, and a specific response is desired. There is no consequence to the response, but YES or NO may precipitate NEGOTIATION if the response is other than the desired response. NEGOTIATION may comprise REQUESTS for further information (NEWS or INSTRUCTION), clarification of conditions (MORE NEWS), or COUNTEROFFERS. COUNTEROFFERS are REQUESTS as well.

DEMANDS ask and expect only one possible answer. There is a consequence if any answer other than the one answer is received. An overt DEMAND has a clear and overt consequence for failure to provide the proper response ( a covert DEMAND has a hidden consequence and is often disguised as a REQUEST or even as an INVITATION). A true DEMAND requires the position or authority to fulfill the consequence. Without this power, a DEMAND is a THREAT. Covert DEMANDS and THREATS are perversions of healthy communication. I mention them not as instruction in communication but as illustrations of unhealthy communication.

Frequently, REQUESTS and DEMANDS ask of us future actions and deeds and behavior. If the positive or negative ("will do" or "won't do") does not happen immediately, but will be fulfilled some time later, we offer a marker for the future compliance or completion. This "future marker" is called a PROMISE.

A PROMISE requires a TRUST. TRUST is the value that is ascribed to the PROMISE by the one holding it.

TRUST comes in three flavors: (1) blind, (2) transferred, and (3) earned.

BLIND TRUST is a gift that the holder gives to the promiser, based on nothing but faith. The holder has no reason to expect the promise to be kept, just a hope. If the promise is broken, then the promiser loses nothing, for they had nothing at stake. The holder loses faith.

TRANSFERRED TRUST is trust by association. An office or a profession may deserve transferred trust. A promise from a trusted source may recommend a transfer of trust. If the promise is broken, the office, profession, or trusted source loses the holders trust.

EARNED TRUST is accrued by fulfilling promises. Big promises successfully kept earn big trust, failures lose trust. The holder stores earned trust in the "trust bank". Profound betrayals may break the bank.

That is all for today class. Next week there will be a review and possibly a spot quiz! Be prepared!

"I am sorry" -- the technology of apology

2005-06-06T11:30:00.000-05:00

Communication skills are learned. Unfortunately, we all learn them from the world around us, where communication is far from careful or clean. We all end up as ineffective communicators.

Lesson One - Apology

An effective apology has three distinct elements:

(1) recognition of the damage
(2) expression of remorse
(3) repair of the damage

The first element is usually the easiest. If someone yelps, "ow!" then we know we something has occurred to cause pain. If we are told, "You hurt me!" then we should have a clue. Occasionally the hurt is more subtle and the damage is hidden or delayed. Our error may have been one of omission and it is later that we find, "Yesterday was our anniversary!" In any case, that light bulb moment occurs when we know that we are at cause in some disruption of the way things should be.

If we resist that moment or defend against it or deny our culpability, then the process cannot begin. The most difficult recognition is when we are held at fault, but we feel innocent as accused. It is still possible to RECOGNIZE that something occurred that has caused a breakdown or injury.

Step two belongs to our superego. Remorse should be natural. If we have caused a problem we, naturally. should feel bad. If we cause harm and do not feel remorse then we are wired wrong. If we are wired wrong then we have far greater problems than communication. The technology of step two is to EXPRESS our remorse. "I'm sorry" is the standard shorthand for "I hurt because I hurt you" or "I truly regret messing things up". Succinctly and effectively having communicating our actual remorse is the key.

Step three is two fold:

(a) cleaning up the mess
(b) preventing recurrences

After we have effectively communicated our sorrow for the problems we have caused, we must set out to repair or clean-up the the situation. Sometimes this is easy, other times it is difficult. It may be impossible to help if we are offering in the face of anger, "Haven't you done enough damage already??" Often the damage is irreparable. If unfixable, acknowledgment of that state is mandatory. If damage control or repair or clean-up is possible, jump in and do it, to the maximum of resources and abilities.

Whether or not repair is feasible, setting up systems or learning new methods or skills, or altering behaviors such that recurrences of the problem are eliminated or minimized is the last stage of apology. Ask, "What must be done so this won't happen again?" and then act upon the answer.

Reasonable and True (birthday blog)

2005-05-26T16:58:00.000-05:00

It is much easier to just not think about it. I often wish I could.

Thinking about it entails some attempt to understand it and to make sense out of it and to fit it into some sort of framework. Worse, thinking about it carries some sort of incentive or obligation to do something about it. Worst of all, thinking about it leads to some sort of sense of responsibility for it.

History is humbling. At least any attempt at honest history is so. There is no honest history, so an attempt is the best we can do. But since it is so deflating, perhaps it is the worst we can do.

The history of medicine is particularly damning for me, a physician. A mere century ago the truth was that all illness was caused by an imbalance of the vital humors. Today such beliefs are totally laughable. I know that all my truths of today will be totally discarded in the next century. But they are my truths, scientifically authenticated and verified, today.

Less pragmatic sciences, the "pure sciences" seek deeper truths and are more comfortable about discarding paradigms, for they are always seeking the best way to upset their current beliefs. Thus the history of science is also humorous in the truths that are embraced and then discarded, but less so because that is the game they intend to play.

More orthodox systems deal with the inevitability of change in more interesting ways.

Religion, the bastion of eternal truths, usually denies change. Instead, new truths (where DO they come from if not from Divine Inspiration?) engender new sects or new religions embodying the new REAL truths.

Politics, the bastion of the most ephemeral truths, also denies change. Politicians rewrite the past and rewrite the present: a most convenient way to handle the truth.

Politics and religion also kill off the opposition, thus silencing dissenting truths.

Leaving politics and religion, science and medicine aside, dealing only with day to day truths is still an impossibility. My truth is just not your truth. I do not believe you and you do not believe me. How could I believe you?.... you are WRONG! How could you ever believe ME?... I am SURELY wrong!

So I put aside truth and its physical manifestation -- reality (best definition: "a collective hunch").

What about "reason"? If truth is an illusion or delusion, then how can we be reasonable?

Deductive logic works just fine if we know the truth. True premises lead to true conclusions. The problem is in deriving those premises. Pesky unreliability of "truth"!

Inductive logic, always empirically based, is at best a statistical approximation of reality, at worst, an experiential guessing game.

So I muddle on... doing the best I can with the absolute knowledge that nothing is true or real. Life and death decisions are made on guesses and approximations. In the bigger world, wars are fought based on transiently truthful "facts". Ideologies battle and lives are spent for conflicting truths. In their respective recordings of history, the bearers of truth will tell their opposing tales.

Cerberus disguised as St. Peter

2005-05-03T12:01:00.000-05:00

This morning a patient described a familiar story. Her child has a minor need for special services from the school system. The social worker of the assessment team has informed her that services cannot be provided because her child's needs are below the cut-off level of severity. The mother's experience is that she is on the outside of the team caring for her child and cannot get in. She advocates for her child and is placed in an adversarial relationship with the team that is to provide the services her child needs.

She cannot get past THE GATEKEEPER.

I do not know when the metaphorical gatekeeper idea arose in our society. About fifteen years ago Managed Care turned the patients' best advocate (and best manager of care) into Cerberus guarding the gates of even mundane and routine care. Increasingly, it seems, those who we most trust to be on our side are actually those who deny us what we need. The restrictions are not for the better good of all, but for the financial protection of some system, be it the insurance company or the Board of Educaton budget.

I guess we get what we ask for. We allowed Managed Care to be the prevalent health care payment model. We vote down adequate school budgets. We ask for Cerberus when we want St. Peter.

Live like you are dying

2005-05-01T12:37:00.001-05:00

There is a popular song currently on the radio about a man who knows he is soon to die and explains how he lived his life once he knew that his time was short. Most of his response is about experiencing life: skydiving, mountain climbing, riding a bucking bull, and taking time to look at an eagle soaring in the sky. The rest is about loving, listening, and giving forgiveness that he had been withholding.

He does not really know EXACTLY when he is going to die, but he knows his time is limited.

Sounds a lot like ALL of us: we do not really know when we will die, but we know our time is limited.

His response makes for a popular song, but it bothers me a bit.

I have no problem with his loving/listening/forgiving. That is the juice of life.

I do have a problem with his adventures and peak experiences. I just do not think that is what life is about. I think those are the diversions from living life fully, not the meat of life.

The song I prefer is about the guy who, upon finding out he was going to die soon, goes back to work the next day and does the best he can do and continues to do that until the day he cannot go to work. If he realizes that the work he is doing is the WRONG work, then he could STOP it and START doing the RIGHT work.

People think I am a workaholic, but they are wrong. I can vacation and relax fully. I can take a diversion from life. But I hope to be Doctor Joe until I can no longer be. And if then I can do another JOB then I hope to do so. And then another until I die.

Ah! New Jersey!!!

2005-04-27T14:03:00.000-05:00

I have medical licenses in three states, New Jersey, North Carolina, and Pennsylvania. Every year I must renew my licenses. North Carolina and Pennsylvania send me a letter a few months in advance of the renewal date to remind me to go on line to renew. The renewal process is nearly identical for both of those state licenses: click to verify my demographics and answer a few dozen questions, enter credit card info and then I am done for the year.

For New Jersey I receive a pre-pre-application application in the mail which I must return in the mail. Months later I get the pre-application, asking more questions, which I return in the mail. A few days before the date of renewal, in years past, I would get the actual renewal application which was due back several weeks before it was mailed to me. I sent it back, every year, faithfully, with enclosed check. Like all other physicians in the state, I would actually have my renewed license months late. This, of course, wreaked havoc on all the institutions in which I practice, who require, by their bylaws, a prompt renewal of my license.

This year, after the pre-pre-application and the pre-application, today I received notice that this year we can renew ON LINE! The letter explaining this was difficult to understand, but I eventually figured it out.

Going to the website, I noticed that there was nowhere to click "online renewals" as instructed in the letter. I eventually found a renewal button to click. As soon as I did, there was a banner informing me that contrary to the letter's instructions, the website would not be available for another week.

Ah! Only in New Jersey!

Managing the mundane

2005-04-25T19:36:00.000-05:00

This is the BEGINNING of my primordial Medicare Rant.

Like many government programs, Medicare was started as a good idea. In the 60's the costs of medical care were slowly rising and the brunt of medical costs were for the care of hospitalized elderly. The government recognized the plight of the income-limited elderly and they created a safety net program to cover the excess costs of medical care.

From that good idea arose the nightmarish quagmire that exists today.

The first problem that arose was price inflation. To understand the impact that Medicare had upon the cost of medical care, we need first understand the prior impact that private insurance had on the cost of medical care.

Prior to the 50's medical insurance was rare. It became popular after WWII when the government, in an effort to support the economic growth in the post-war years made it advantageous (via tax breaks) for companies to offer health care insurance to the workers as part of their compensation package. Health care insurance became popular. It was called "Hospitalization insurance". It covered a percentage (about 80%) of the cost of hospitalization. For working men and their young families this usually came down to catastrophic illness and surgery. This led to the unregulated rise in the cost of hospitalization and medical procedures, almost exclusively surgical procedures. Despite the rise in the cost of hospitalization and surgery, medical care remained a reasonable expense and was not a burden on the individual and was no burden of the federal budget.

Medicare covered the hospitalization and the outpatient costs for the elderly. Here was a population that REALLY consumed medical resources. The think tanks that budgeted Medicare vastly underestimated the costs of this program. In the first years the actual expenditures were over 300% of what was planned. Every year they increased the budget to account for the previous years vast shortfalls, and still the cost rose at ballistic rates. Surgery and hospitalization was compensated, no matter the cost. Primary care was neglected. The gap in physician fees became vast, surgeons and hospital specialists earning ten to one hundred fold the fees of generalists and pediatricians.

Private insurance companies began to use the Medicare plan as a model.

To contain the costs the government added more and more controls. The controls became nonsensical. The private insurers followed suit.

The Medicare managed Care debacle and the Relative Value Scale disaster will be fodder for future blogs.

In time Medicare has risen to be the largest insurer of all time. It is managed by private companies on a regional basis. The rules dwarf the IRS code by over one hundred pages to one. The administrative costs of Medicare are now almost seventy five percent ( $0.75/dollar!) Medicare makes up one third of the Federal budget, and increases yearly. Since 1980 the cost of Medicare has exceeded the defense budget and is now nearly twice as large.

But remember, three-quarters of the Medicare budget is administrative.

With the regulations being so vast, no one on the planet understands them all. No one has ever actually READ them all. New regulations are promulgated every day, often revoking or altering regulations formulated just days or weeks before. I am blessed to receive e-mails with every change. I have received over one hundred such e-mails in the last six months, many with multiple notifications.

The Medicare rules do not dictate what can or cannot be done. They dictate what will be paid for what is done for what reason. And they dictate how one must submit the information to Medicare.

It is ESSENTIAL, apparently, that SOMEONE in the government needs to know exactly what the diagnosis is for every procedure done, and that it be coded according to the AMA's copyrighted code, the ICD-9. The ICD-9 is a markedly imperfect coding schema, essentially useless. This will be the subject of ANOTHER blog. The procedures performed must be coded according to another AMA copyrighted code , the CPT. Of course, everyone must pay the AMA for the use of these copyrighted codes. (Yes, the inspiration for yet another future blog!)

In any case, if the regulations allow a procedure for a certain diagnosis, then the government MAY pay for it. Anything done to KEEP one healthy or for early detection of occult disease is REJECTED, unless it is politically necessary for it to be reimbursed (like a flu shot, which is reimbursed at a fraction of its actual cost).

That's enough for today.... Stay tuned!

the needs of the one.....

2005-04-12T00:08:00.000-05:00

The current national buzz about "eminent domain abuse" has come to my little town.

legal dictionary:
eminent domain: the government act of converting privately owned land into public land, subject to reasonable compensation.

Eminent domain abuse occurs when the land is appropriated for one use and then used for another, OR if the land is appropriated for inappropriate non-public use, OR if the compensation is not just and reasonable.

My family were the victims of eminent domain abuse when my grandfather's farm was appropriated. It remains perhaps the deepest wound I carry with me. (Click on the harrysfarm.com link in My Links for all the details)

But we are NOT going to discuss eminent domain in this blog today. Nope. We are gonna talk about Star Trek philosophy!

In Star Trek III, The Search for Spock, the crew went back to the Genesis Planet to recover him. "Why?", asked the regenerated Spock.

"Because the needs of the one exceed the needs of the many!", enigmatically replied the captain.

I believe that that statement holds the key to the salvation of our race and the repair of the world and the restoration of the dignity of civilization.

Wow.

Here is how it works:

Each individual, each "one", is precious and special. Any grouping of individuals is
a "many". The many has an existence separate from the ones who comprise it, it is a conglomerate with its own needs and goals.

When the conglomerate acts counter the the needs of ANY one, then the needs of EVERY one are at risk and may be sacrificed at any time. If they MAY be sacrificed, in time, they WILL be sacrificed.

When individuals band together with a common goal, they create a many, a conglomerate. They give birth to an entity with a life of its own, independent of their individual lives. Unless designed with an utmost sanctity for the individual components, the conglomerate will eventually consume them.

The most benign of structures (like the United States, founded on "rugged individualism") or the most holy of purposes (those of organized religion) will eventually sacrifice individuals and eventually all its component members to the "needs of the many", UNLESS ....

Unless the "needs of the one" are sacrosanct and inviolable.

Alternative solutions to public dilemmas -- one less bridge, one less road, one less dam, one less mall, one less school -- may be necessary. One less soldier, a thousand less soldiers, no more wars..... may be possible. There will be less progress, less speed. There will be (get this!) less "entitlement" and more community.

If I lose my rights because of the perceived needs of the group, then we all lose our rights. If you lose your land because the community thinks it needs the land, we all lose our land. If the nation allows one individual to be lost then we are all lost.

If the many exist only to preserve the one, the ones, EVERY one, then we are saved.

my little town

2005-04-05T11:50:00.000-05:00

I love my little town. My parents grew up here. I grew up here. I returned here to live over twenty years ago. I moved my medical office here. It is a nice, sweet, gentle little town.

There are really high property taxes as there is no significant industry in the little town, and only one main street business district. Owning my home and my office means I get to pay a lot of taxes.

The current administration in town is working hard to improve it. There is a "Main Street USA" project and a "Business Improvement District". There are plans to spruce up the business district and make it classier.

Somehow, when the plans for the Business Improvement District, "the BID", were made, my office, a block off of main street in a residential area, was included. Later, a special tax was levied on businesses in "the BID".

When this became clear to me I made some inquiries as to what plans they actually had to improve my locale. I got no answer. As time went by I wondered if other professionals were included in "the BID" and the special taxation. I asked: I got no answer.

I have been more aggressive at asking the question of all the officials involved. The questions I ask are few and simple:

(1) If I am in the BID, what is in it for me?
(2) If there is nothing special for me, why am I in the BID?
(3) If there is nothing special for me, but there is some nebulous value meant to accrue to all professionals, why tax me and not all?

These questions seem simple. This is a small town. I love this town. Why can't they answer simple questions?

the anomaly of tenure

2005-04-02T20:30:00.000-05:00

I just read this article:

yaledailynews.com - NELC to suffer the loss of key language professors

In essence, The University of Delaware lured, from Yale University, with the promise of TENURE, a spectacularly successful teacher.

As far as I know, academia is the only "industry" that offers tenure. Other industries offered tenure-like job security in times recently past. Seniority was tantamount to tenure. Surely, if one worked well and reliably at a job then there was a tacit expectation of JOB SECURITY.

Now, with changes in societal mores and "corporate culture", no job is secure. Except the job of the tenured professor.

I have heard it said that "tenure" was invented to protect the venerable professor from expulsion from his job when, with the accumulation of knowledge and wisdom, he would take a stand that upset the status quo. Thus, tenure protected academic freedom.

I suspect this is apocryphal. Tenure more likely just gave job security to the aging member of the academic fraternity, awarded by the elders in the fraternity to their rising crony, and supported by the youngers with the expectation that they would get theirs in good time.

Would academia be better without this job lure? How would professors fair as "free agents"?

I understand that there is a glut of Ph.D.'s today. It seems it is becoming a "buyers market". Perhaps academia will soon follow suit and do away with this last bastion of job security.

Other industries COULD offer tenure to employees if they wished to do so... but they do not. Indeed, they have apparently abandoned all pretenses of commitment to employees in the current ethos. Would Corporate America be better if we tenured our most experienced workers?

I wonder if institutions that can be expected to stand by their employees would thrive in today's world. I wonder if the culture of today's world would change if that were so. Would the productivity and the very PRODUCTS change if the expectation of the role of the worker, from line-worker to cubicle-resident to ultimate leaders shifted to reliable commitment of the organization towards them?

beeps and boops and things that go bump in the night

2005-04-02T13:54:00.000-05:00

When I was a small boy and visited the hospital I was in awe of the gentle silence that prevailed. The signs on the street outside the hospital admonished "SSHHHHH!!! Quiet! Hospital Zone" The nurses glided silently down the halls in their crepe soled shoes. There was a gentle, restful, peaceful, quiet. The nurses smiled and talked in hushed tones. The very air felt quiet.

Around 1970 the BEEP was invented. Electronic devices were introduced into the medical world and have become ubiquitous. Every vital sign and activity is monitored and every variation is marked by a bleep, beep, boop, or incessant EEEEEEEEEEEEEEEEEEEEEEEEEEEEEE! It is often hard to tell what each noise means among the cacophony: is it the IV line that is malfunctioning and sounding the alarm... or the patient's heart?

The beeping is so everpresent that the nurses become immune and are likely to allow the beeping to continue for minutes or even hours before checking the cause and attending to the "alarming" situation. Savvy patients watch how the nurse silences a device's alarm and then they silence it before the nurse arrives and thus the averse situation is never noted.

But the beepbleepboops are not the only noise pollution in the modern hospital. The culture of quiet has gone, so doctors and nurses and hospital staff speak loudly and a lot. There is no more SSHHHHHHH!

But the most disturbing sounds are the sounds of construction. Thirty years or more ago, a decade would elapse before there would be a renovation or new construction in a hospital. Today, construction and renovation is continuous. There is no day that the jackhammers are not demolishing and the drills are not whining in some part of the hospital. Is progress (er... "progress") so swift today that the physical plant is always in a state of change and expansion?

I believe that quiet was better and that we have lost a valuable piece of the healing arts in our noisy hospital world.

Living wills and wonts

2005-03-31T20:06:00.000-05:00

Ms. Schiavo died today. May her soul rest in peace and her body be treated with respect.

I fear that a loud and highly opinionated orthodoxy (meaning only those who KNOW that theirs is the "right and true doctrine") have used Terri's family dysfunction as a platform from which to proclaim their agenda. And since powerful people (oh... like the president, for example) are in that right-righteous band, I fear that public policy will be shifted toward those beliefs and away from principles of ethics. I fear that it will become more difficult to enable dignity and grace in the end of life, and mandated to prolong needless and even horrid suffering.

I hope that advance directives and living wills become a routine part of life, a gift the robust and healthy living give to their families and to society, so that in the event that the circumstance arises that the living will is invoked, their wishes will be clear guidance.

Remember: a living will can instruct to "keep alive against all odds" as well as "remove support if the chance of quality life is small". Living wills are not a tool of the right nor left on this issue.

Perhaps....
A month of the senior high school curriculum in "health education" could be devoted to death and dying, and a project could be to create a living will to help clarify thoughts. By age eighteen, such a living will would be ethically binding. A horror to contemplate, but deicisions about teminally injured or ill teenagers need to be made every day.

Dignity. Autonomy. Freedom from pain. End to suffering. Peace in the hearts of our loved ones.

(note the Print LIVING WILL FORM on my "links")

life and death and the Big Mac

2005-03-30T14:19:00.000-05:00

The news media mouths (and thus the public) are stridently arguing (not debating, for a debate is formal and polite) the withholding of feedings of Terri Schiavo. The Pope just got a gastrostomy tube to feed him in his end-stage Parkinson's Disease. An American child dies of malnutrition every twenty minutes. Thousands around the world die of starvation every hour. McDonalds announces their new 750 calorie breakfast sandwich. Coca-Cola prohibits the sale of "small" size fountain drinks: just medium, large, and jumbo (thus redefing the middle as the smallest and emphasizing the largest as the best). (97% of the world's population recognizes the Coca-Cola logo.) Obesity is the number one "preventable" health problem in the "industrialized" nations, starvation the number one kller in the "third world".

$300 buys a breeding pair of llamas and pays for the education of a Guatemalan to raise, care for, and breed the llamas. The board meeting dinners cost $40 each for forty attendees, and the fare is mediocre yet extravagant and rapidly forgotten (most of it pushed aside on the plate, the eye appeal exceeding the palate appeal). Five Guatemalan families could have generations of lives changed for that same money. But won't.

The blog begins.....

2005-03-30T13:34:00.000-05:00

Welcome to my web log.

I am almost 53 years old. I am a family physician for a quarter of a century. I started this BLOG today to share my musings about life.

I was the most optimistic and idealistic of youths and I am now the most cynical of geezers. The youth that still lives within battles daily with the cynic who walks in my shoes. It has become difficult to be this contrary beast with two heads.

My everpresent sensation is that I see naked emperors all around me reveling in their fine new clothes. I have a compulsion to point out their nakedness, yet find myself mocked at best and attacked and ostracized at worst for indulging my compulsion. I wonder if I am delusional and that the emperor is actually clothed and it is my eyes that are defective.

My intention is to blog daily and to share my life and observations.