In view of the recent hooraw over whether or not testing for and treating prostate cancer saves lives, I feel I should re-visit this subject, which I first discussed in my blog of May 15, 2009. I want to begin by emphasizing once again, speaking as a trained scientist, that in any given field what counts is what we can show to be true by experiment, and not what we can deduce or think should be true (with Einstein's Theory of General Relativity being a notable exception, but even that theory was based upon an experimental result, namely the equivalence of inertial and gravitational mess, as first shown by Galileo). It also doesn't matter what we would like to be true, because Mother Nature's rules are independent of our beliefs.
Some of the examples of medical facts and treatments that we thought should be true or benefit patients but were shown to be false or harmful or not proven when subjected to clinical testing are:
1) If a patient has calcium oxalate kidney stones then the proper treatment is toDEcrease the amount of calcium in the diet.
2) Beta-blockers should never be used in a patient who is in heart failure.
3) Everyone needs 8 glasses of water or fluid a day for good health.
4) Everyone needs at least one bowel movement a day.
5) If a patient is ill, bleeding with leeches will generally make him/her better.
6) An hour of sleep before midnight is worth two hours after.
7) If you go swimming right after eating you will develop an abdominal cramp and drown.
8) Vitamin E, because of its anti-oxidant properties, prevents heart attacks.
9) Beta-carotene, because of its anti-oxidant properties, protects smokers from lung cancer.
10) Mammograms taken between the ages of 40 and 50 saves lives.
11) The optimum time interval between complete physical exams is one year.
12) The optimum time interval between colonoscopies is 10 years.
13) The optimum time interval between mammograms is one year.
14) A drink of alcohol a day cannot possibly be good for you.
15) Daily doses of saw palmetto help treat an enlarged prostsate.
16) Daily doses of gingko balboa help prevent Alzheimer's Disease.
I could easily add another 10 to 20 pseudofacts to the above list. Now let us look at the question of PSA testing as well as the treatment of prostate cancer. Before asking whether or not measuring the PSA saves lives, we first have to determine if treating prostate cancer saves lives. As of today, there is absolutely no evidence that it does. It may seem counterintuitive that this is so, but the fact is that the majority of men die WITH prostate cancer, and not OF prostate cancer. Roughly speaking, the percentage of men who have prostate cancer at autopsy is equal to their age at death: 70% of men at age 70 have microfoci of prostate cancer, etc. Much as we would like to believe that detecting prostate cancer early and treating it will save lives, there is absolutely no evidence that this is so.
There have been many review articles coming to this conclusion, and you can check PubMed, the abstract archive of the National Institutes of Health for references. So why do people do the PSA, or take treatment if a prostate biopsy shows prostate cancer? The answers are many and varied, and all are ultimately the result of individual decisions by individual patients. Some of the reasons are:
1) Some people cannot tolerate the thought of having cancer within their bodies.
2) Some wives cannot tolerate the thought that their husband is walking around with cancer.
3) Some men believe that treatment of prostate cancer will save their lives.
Very few men are told that most prostate cancers detected on biopsy will not spread and kill them. Very few men are told of the possible lingering (6 months to 2 years) or permanent symptoms of radiation proctitis that can result (chronic bloody or non-bloody diarrhea). Many men don't fully understand the implications of the fact that 30% of treated men will develop urinary incontinence (and need to wear a diaper) or be unable to mount or maintain and erection (even with the help of Viagra), or both.
Since a physician's first duty to his/her patient is to "do no harm", I lay out all the above info to my patients, and if asked, I tell them that I never have taken a PSA test and would never treat prostate cancer in myself. However, if a patient decides on treatment, I urge him to consult with both a urologic surgeon and a radiation oncologist to listen to the pros and cons of each procedure, and then to consult with a medical oncologist for an overall view. I also suggest that he not discuss his decision with any friends who have been treated in order to avoid impassioned but not dispassionate arguments and lectures. And then I remind him that it is his body, that he is the patient and must make the final decision, and not to do any treatment or non-treatment that he does not fully agree with.
Tuesday, October 11, 2011
Sunday, October 9, 2011
Why You Can't Get The Medicines You Need, Especially Generics at a Reasonable Price
The capitalist profit system usually works, except in a few cases. The courts have held, for instance, that you cannot charge an outrageous price for a drink of water for a man dying of thirst or for a crust of bread for a starving man. Similarly, there are laws against ticket scalping, and no matter what the underlying economic theory (communist, capitalist, libertarian) there are always subsidies given to farmers to avoid a famine, which subsidies are NEVER provided for or explained in the original theory, but is rather based upon thousands of years of experience with farmers, food crops and famines. That is probably why there has never been a killing famine in a democracy---the voters would never stand for it.
When it comes to drug prices, however, the economic and politico-legal landscape becomes murkier. About 10 years ago, Lilly and Lederle got so tired of being sued by parents who claimed that their children were permanently damaged by the MMR (measles, mumps, rubella) vaccine, that Lilly threatened to institute the default position that only Lederle of Canada would manufacture the MMR vaccine, and it would never be sold in the USA so as to avoid tort claims of damage in the US courts. The US government, faced with this possibility, passed a law that the government would reimburse any parents who sued and could prove a case.
Similarly, the morning sickness of pregnancy with horrendous vomiting and secondary severe dehydration can prove fatal, as it did to the novelist Charlotte Bronte, sister of Emily. Merrill-Dow had a drug that treated and reduced the severity of morning sickness, called Bendectin. Now historically one out of 2500 children born has some sort of birth defect. One year, seven of the parents of such children sued Merrill-Dow, claiming that the Bendectin the pregnant mothers had taken had caused the birth defect. Merrill-Dow won all seven cases, but the legal fees far exceeded their profit from making Bendectin, so they ceased production. Their final words on the subject were: "If you are pregnant and suffer from morning sickness, call a malpractice lawyer".
Now we come to generic drugs. When a new drug is patented, there are virtually no limits on the price that the manufacturing pharmaceutical company can charge, and it is impossible to calculate what a "fair" price should be, after you try to amortize the years of studies needed to produce the drug as well as those drugs that were tested and never made it to market. It's somewhat similar to the fact that most movies never show a "net" profit, so a smart actor/producer takes a percentage of the gross, which is readily measured. If I am not mistaken, the film company that produced "The Producers" claimed that there was no net profit, and Mel Brooks had to sue them for his share of the net profits. (Caveat: if it was not "The Producers", it was a similarly successful film that generated huge grosses.) In order to encourage the production of a generic substitute, the US government will grant a six month exclusive license to the first generic company to bring a generic product to market when the patent on the brand name wears off.
Now what do the brand name drug manufacturers do when the patent for the parent, patented drug nears an end? The simplest practice was done by Roche, who put a hollow "v" in their brand name Valium, so patients could complain to their doctors that the generic valium tablet looked different, which it had to, by law. Similarly, the makers of Ativan converted the basic shape to a pentagon, again uniquely and memorably different in appearance from the generic lorazepam. Another solution is to take Prilosec, which is a mixture of right-handed and left-handed molecules (and there IS a difference in their chemical action) and start to make only (purple) Nexium, which is the isolated right-handed form of the basic patent and therefore is entitled to a new patent. Similarly Floxin is the brand name for ofloxacin, which is also a 50-50 mixture of right and left-handed molecules, and the company went on to patent and market only the L-form , called Levaquin, heavily and successfully. A final chemical "trick" was done with the anti-histamine Seldane, which was patented as the first non-sedating anti-histamine. This pro-drug was converted into its active form Allegra, in the liver. As Seldane neared the end of its patent life, the company merely stopped producing it and started to produce the newly patented and tested Allegra. None of these practices is illegal or dangerous to the patient. It just increases the cost of medicine to the patient and the profits of the drug company.
Now, however, things get a little murkier. Let us say that the generic maker "first on the scene" stands to make a profit of $200,000,000 in the first 6 months of sole production of the generic drug. The brand name producer makes $4,000,000,000 in the same six months, or 20 times the profit. The brand name company simply offers the generic company $400,000,000 free and clear,if the generic company does NOT make the generic drug, i.e. buys up their six-month rights, so the generic company makes double the profit without tying up their production lines, and the brand name company makes an additional $4B, and the consumers pay more. Just good old free enterprise in action. Or, the brand name company can (and this has happened) buy up all the basic chemical from which Xanax is made, so the generic manufacturers have to buy their base
product from them.
But the most egregious, albeit legal events have occurred in generic drugs that treat breast and other common cancers such as the drug adriamycin. Generic drugs yield the least profit, so few companies want to manufacture them or devote a lot of their production line to them, For this reason there has been a severe shortage of many cancer-treating drugs, and many patients have to wait to start their treatment. A few even had to halt their weekly treatment in the middle. A weekly bulletin of the drug shortages can be found at the FDA web site. There is at present absolutely no legal method whereby the federal government can compel any generic manufacturer to make any drug, whether the drug is used to treat cancer, heart failure, or warts, and there seem no solutions on the horizon.
When it comes to drug prices, however, the economic and politico-legal landscape becomes murkier. About 10 years ago, Lilly and Lederle got so tired of being sued by parents who claimed that their children were permanently damaged by the MMR (measles, mumps, rubella) vaccine, that Lilly threatened to institute the default position that only Lederle of Canada would manufacture the MMR vaccine, and it would never be sold in the USA so as to avoid tort claims of damage in the US courts. The US government, faced with this possibility, passed a law that the government would reimburse any parents who sued and could prove a case.
Similarly, the morning sickness of pregnancy with horrendous vomiting and secondary severe dehydration can prove fatal, as it did to the novelist Charlotte Bronte, sister of Emily. Merrill-Dow had a drug that treated and reduced the severity of morning sickness, called Bendectin. Now historically one out of 2500 children born has some sort of birth defect. One year, seven of the parents of such children sued Merrill-Dow, claiming that the Bendectin the pregnant mothers had taken had caused the birth defect. Merrill-Dow won all seven cases, but the legal fees far exceeded their profit from making Bendectin, so they ceased production. Their final words on the subject were: "If you are pregnant and suffer from morning sickness, call a malpractice lawyer".
Now we come to generic drugs. When a new drug is patented, there are virtually no limits on the price that the manufacturing pharmaceutical company can charge, and it is impossible to calculate what a "fair" price should be, after you try to amortize the years of studies needed to produce the drug as well as those drugs that were tested and never made it to market. It's somewhat similar to the fact that most movies never show a "net" profit, so a smart actor/producer takes a percentage of the gross, which is readily measured. If I am not mistaken, the film company that produced "The Producers" claimed that there was no net profit, and Mel Brooks had to sue them for his share of the net profits. (Caveat: if it was not "The Producers", it was a similarly successful film that generated huge grosses.) In order to encourage the production of a generic substitute, the US government will grant a six month exclusive license to the first generic company to bring a generic product to market when the patent on the brand name wears off.
Now what do the brand name drug manufacturers do when the patent for the parent, patented drug nears an end? The simplest practice was done by Roche, who put a hollow "v" in their brand name Valium, so patients could complain to their doctors that the generic valium tablet looked different, which it had to, by law. Similarly, the makers of Ativan converted the basic shape to a pentagon, again uniquely and memorably different in appearance from the generic lorazepam. Another solution is to take Prilosec, which is a mixture of right-handed and left-handed molecules (and there IS a difference in their chemical action) and start to make only (purple) Nexium, which is the isolated right-handed form of the basic patent and therefore is entitled to a new patent. Similarly Floxin is the brand name for ofloxacin, which is also a 50-50 mixture of right and left-handed molecules, and the company went on to patent and market only the L-form , called Levaquin, heavily and successfully. A final chemical "trick" was done with the anti-histamine Seldane, which was patented as the first non-sedating anti-histamine. This pro-drug was converted into its active form Allegra, in the liver. As Seldane neared the end of its patent life, the company merely stopped producing it and started to produce the newly patented and tested Allegra. None of these practices is illegal or dangerous to the patient. It just increases the cost of medicine to the patient and the profits of the drug company.
Now, however, things get a little murkier. Let us say that the generic maker "first on the scene" stands to make a profit of $200,000,000 in the first 6 months of sole production of the generic drug. The brand name producer makes $4,000,000,000 in the same six months, or 20 times the profit. The brand name company simply offers the generic company $400,000,000 free and clear,if the generic company does NOT make the generic drug, i.e. buys up their six-month rights, so the generic company makes double the profit without tying up their production lines, and the brand name company makes an additional $4B, and the consumers pay more. Just good old free enterprise in action. Or, the brand name company can (and this has happened) buy up all the basic chemical from which Xanax is made, so the generic manufacturers have to buy their base
product from them.
But the most egregious, albeit legal events have occurred in generic drugs that treat breast and other common cancers such as the drug adriamycin. Generic drugs yield the least profit, so few companies want to manufacture them or devote a lot of their production line to them, For this reason there has been a severe shortage of many cancer-treating drugs, and many patients have to wait to start their treatment. A few even had to halt their weekly treatment in the middle. A weekly bulletin of the drug shortages can be found at the FDA web site. There is at present absolutely no legal method whereby the federal government can compel any generic manufacturer to make any drug, whether the drug is used to treat cancer, heart failure, or warts, and there seem no solutions on the horizon.
Monday, October 3, 2011
New Medical Device = Guinea Pig Patient
By now almost all of my readers have probably read about the horrific results that have developed and will continue to develop in some patients whose artificial hip is the new one of metal-on-metal rather than the old one of metal-on-plastic.The old artificial hip used a metal rod with an attached metal ball to replace the upper half of the femur, and installed a plastic cup into the acetabulum, or that part of the pelvis with which the femoral head fitted and subsequently pivoted, rotated and articulated , just as in the old hip joint. The new artificial hip used a metal cup instead of plastic so there was constant grinding of metal-on-metal.
Unbeknownst to anyone, this constant grinding of metal on metal created thousands if not millions of tiny metal splinters and released them around the joint space. The white blood cells engulfed and tried to destroy them as if they were foreign invaders (which is why an unattended splinter in your finger turns red and the surrounding area gets tender). The subsequent release of inflammatory chemicals generated by the white blood cells apparently caused chronic pain and also damaged some of the leg muscles around the joint, necessitating the replacement of the new metal-on-metal joint with the older metal-on-plastic one.
I mention this not to criticize the inventor of the new artificial joint, but to illustrate the dangers inherent in replacing a " tried-and-true" device with a new one that has theoretical advantages. There is no experimental way to mimic the effect of inserting a medical device into a human being for five minutes, let alone five years. In my opinion unless a medical device immediately provides a tangible benefit that no previous device did, you should let someone else be the guinea pig and have it inserted in them for the first six months to five years of the release of the new device. BTW, did you know that the salesman for the new orthopedic device often accompanies the surgeon into the OR to verbally instruct in the insertion of the device? You certainly have the right to (a) ask the surgeon how many of these devices he/she has personally installed, and (b) ask that only doctors, nurses, etc. be allowed into the OR while they are operating on you, or that you be told who besides the surgeon will be present.
The FDA clearance of a device does not imply verification of its "duty cycle" This is an engineering term. A light switch has a (tested) duty cycle of, say 10,000, meaning that it can be turned on and off at least 10,000 times before it fails to work., A light bulb has a defined duty cycle based on how often it is turned on and off, and for how long it is kept lit each time. A soldier's rifle has a tested duty cycle, as does your car's ignition and your electric garage door opener. (For a wonderful movie about the vibration duty cycle of the tail of an airplane, I heartily recommend "No Island in the Sky", based on the novel of the same name by Nevil Shute, and starring James Stewart as the airplane designer and co-starring Marlene Dietrich and Glynis Johns.) But the duty cycle of any device inserted into a human being is NEVER tested under true operating conditions. Thus we have had some heart valves that shattered, or some that clotted in an unacceptable way. We have had new materials inserted into human bodies that were subsequently rejected by the body and had to be removed. If any doctor wants to insert a new material into you (and to me "new" means being on the market for less than 5 years), I would think carefully before agreeing. The same would apply, for different reasons, if a new drug has been out for less than six months, unless no other drug does what it does, e.g. oral Dabigatgran. And remember also that you may be able to tolerate a brand-name drug, but be allergic to the products that are use to constitute the tablet that contains the generic drug.
What this means is that any new product implanted in your body is a potential time bomb, similar to the cardiac (heart) permanent pacemaker wires that broke inside the body after months of use, or the use of Xrays to treat childhood acne which greatly increased their risk of developing thyroid cancer, or the rush of men to treat their prostate cancer with external beam radiation rather than surgery in the belief that this treatment lessened their chance of becoming impotent which has been shown not to be the case. When it comes to surgery, newer is not necessarily better, and we should not confuse the French work "neuf" with the French word "nouveau".Remember that the purpose of all advertising, including the advertising of medical services and products, is an effort to convince you to buy or insist on using the advertiser's product, just as in the 1920's tapeworm eggs were advertised and sold to women as a guaranteed method of weight loss.
Finally, remember that the government always has its own agenda, and you might not know what it is truly looking for. To mention some of the more egregious government-sanctioned medical "experiments" on unwitting human guinea pigs (and Wikipedia can give you further information on each indicent) we have had (1) The Tuskegee experiment where Negro men in the USA were infected with syphilis without being told what was being done, and with treatment then being withheld so the doctors could study the "natural" course of the disease, (2) The infecting of Guatemalan natives with gonorrhea, again without telling them what was being done to them, or offering any treatment (3) the testing of the efficacy of Birth Control Pills on females in Puerto Rico who were told that they were getting a free pill to prevent pregnancy, but 50% of the women received sugar placebos instead without being told of the substitution. I won't even mention the escape of nerve gas from the U.S.Army Proving Ground in Dugway, Utah that killed over 6,000 sheep, or the CIA putting LSD into the drinks of unsuspecting drinkers at bars in the 60's to study the effects of LSD on unsuspecting users.
And be very careful about announcing that the (government) agent is wearing no clothes. In 1947 or so, a noted atomic physicist, Lewis Branscomb, was appointed head of the National Bureau of Standards, In the course of his government-directed studies, he conclusively demonstrated that an advertised additive did not extend the useful life of a car battery. He was subsequently hounded and persecuted by the Senator from the state in which the additive was manufactured.
Unbeknownst to anyone, this constant grinding of metal on metal created thousands if not millions of tiny metal splinters and released them around the joint space. The white blood cells engulfed and tried to destroy them as if they were foreign invaders (which is why an unattended splinter in your finger turns red and the surrounding area gets tender). The subsequent release of inflammatory chemicals generated by the white blood cells apparently caused chronic pain and also damaged some of the leg muscles around the joint, necessitating the replacement of the new metal-on-metal joint with the older metal-on-plastic one.
I mention this not to criticize the inventor of the new artificial joint, but to illustrate the dangers inherent in replacing a " tried-and-true" device with a new one that has theoretical advantages. There is no experimental way to mimic the effect of inserting a medical device into a human being for five minutes, let alone five years. In my opinion unless a medical device immediately provides a tangible benefit that no previous device did, you should let someone else be the guinea pig and have it inserted in them for the first six months to five years of the release of the new device. BTW, did you know that the salesman for the new orthopedic device often accompanies the surgeon into the OR to verbally instruct in the insertion of the device? You certainly have the right to (a) ask the surgeon how many of these devices he/she has personally installed, and (b) ask that only doctors, nurses, etc. be allowed into the OR while they are operating on you, or that you be told who besides the surgeon will be present.
The FDA clearance of a device does not imply verification of its "duty cycle" This is an engineering term. A light switch has a (tested) duty cycle of, say 10,000, meaning that it can be turned on and off at least 10,000 times before it fails to work., A light bulb has a defined duty cycle based on how often it is turned on and off, and for how long it is kept lit each time. A soldier's rifle has a tested duty cycle, as does your car's ignition and your electric garage door opener. (For a wonderful movie about the vibration duty cycle of the tail of an airplane, I heartily recommend "No Island in the Sky", based on the novel of the same name by Nevil Shute, and starring James Stewart as the airplane designer and co-starring Marlene Dietrich and Glynis Johns.) But the duty cycle of any device inserted into a human being is NEVER tested under true operating conditions. Thus we have had some heart valves that shattered, or some that clotted in an unacceptable way. We have had new materials inserted into human bodies that were subsequently rejected by the body and had to be removed. If any doctor wants to insert a new material into you (and to me "new" means being on the market for less than 5 years), I would think carefully before agreeing. The same would apply, for different reasons, if a new drug has been out for less than six months, unless no other drug does what it does, e.g. oral Dabigatgran. And remember also that you may be able to tolerate a brand-name drug, but be allergic to the products that are use to constitute the tablet that contains the generic drug.
What this means is that any new product implanted in your body is a potential time bomb, similar to the cardiac (heart) permanent pacemaker wires that broke inside the body after months of use, or the use of Xrays to treat childhood acne which greatly increased their risk of developing thyroid cancer, or the rush of men to treat their prostate cancer with external beam radiation rather than surgery in the belief that this treatment lessened their chance of becoming impotent which has been shown not to be the case. When it comes to surgery, newer is not necessarily better, and we should not confuse the French work "neuf" with the French word "nouveau".Remember that the purpose of all advertising, including the advertising of medical services and products, is an effort to convince you to buy or insist on using the advertiser's product, just as in the 1920's tapeworm eggs were advertised and sold to women as a guaranteed method of weight loss.
Finally, remember that the government always has its own agenda, and you might not know what it is truly looking for. To mention some of the more egregious government-sanctioned medical "experiments" on unwitting human guinea pigs (and Wikipedia can give you further information on each indicent) we have had (1) The Tuskegee experiment where Negro men in the USA were infected with syphilis without being told what was being done, and with treatment then being withheld so the doctors could study the "natural" course of the disease, (2) The infecting of Guatemalan natives with gonorrhea, again without telling them what was being done to them, or offering any treatment (3) the testing of the efficacy of Birth Control Pills on females in Puerto Rico who were told that they were getting a free pill to prevent pregnancy, but 50% of the women received sugar placebos instead without being told of the substitution. I won't even mention the escape of nerve gas from the U.S.Army Proving Ground in Dugway, Utah that killed over 6,000 sheep, or the CIA putting LSD into the drinks of unsuspecting drinkers at bars in the 60's to study the effects of LSD on unsuspecting users.
And be very careful about announcing that the (government) agent is wearing no clothes. In 1947 or so, a noted atomic physicist, Lewis Branscomb, was appointed head of the National Bureau of Standards, In the course of his government-directed studies, he conclusively demonstrated that an advertised additive did not extend the useful life of a car battery. He was subsequently hounded and persecuted by the Senator from the state in which the additive was manufactured.
Sunday, September 18, 2011
What I Covered in a Patient's Medical History by Dr. Robin Motz
I am continually surprised at the lack of depth and detail in many medical histories that I read that were in the charts of new patients. Of course I was trained at Columbia Presbyterian Medical Center in the late 1970's, and we were taught to allow at least a full hour for the complete history and physical of a new patient. I also have to mention that the last medical patient I admitted as an intern in June 1976 to ward 9W was a 19 year old female with new onset diabetes presenting as DKA secondary to an unknown infection. I examined her down in the ER, brought her up to the ward, and broke her DKA 20 minutes after I extracted a tampon I found on pelvic exam that she had forgotten she had inserted the previous month and was the source of her infection.
We were also taught to come out and greet the patient in the waiting room and escort the patient back to our consulting room, rather than have the PA put the patient directly into the exam room.
I would like to list here some of the questions that I find are often not asked of a patient on the initial exam by the new physician. This of course pertains to the office exam, and not to the ER exam. In the ER as I would tell my residents, the two main considerations are: (1) does this patient need a hospital admission, and (2) what disease or process can the patient have than can kill him/her before I come in to make my morning attending rounds (and, in the case of females, ALWAYS do a pregnancy test). The following list is not exhaustive, but I believe that if the questions are not asked, the patient is not going to get the best possible medical treatment.
The order of the questions is usually unimportant, and their place on the list need not correspond to their importance.
1) Are you allergic to any prescription drugs? What was the reaction? (Important)
2) Are you allergic to any over-the-counter-drugs or vitamins or health foods? What was the reaction?
3) Were you ever hospitalized for any allergic reaction and did you have to be intubated?
4) What prescription drugs do you take and what are their doses? What was the last one added?
5) Are you on birth control pills (many women do not think of this as a prescription)?
6) What daily vitamin and food supplements do you take?----dosage and frequency. ?Daily aspirin dose?
7) Have you ever donated blood? To the blood bank or prophylactally pre-surgery.
8) Have you ever received a blood transfusion? After an accident? or surgery? or childbirth?
9) Do you still have your gallbladder, appendix and tonsils? Any recovery problems or excessive bleeding?
10) Last TB skin test and AIDS test.
11) Last tetanus, pneumonia , and flu vaccine. .Vaccinated against hepatitis A,B; or HPV? MMR? one or two?
12) Have you ever had unprotected sex? More than once? What were the circumstances?
13) When you were a child, did an adult of either sex ever make inappropriate advances to you?
14) Any broken bones, or damages in a motor vehicle accident?
15) Any surgeries or transplants. If yes, any anesthesia reaction?
16) Date of last mammogram, pap smear, colonoscopy, chest x-ray, EKG, stress-test, bone density test.
17) Date of last eye exam. Can you read street signs at night? Are you fearful of night driving?
18) Where were you born, where did you live and go to elementary school, high school, and any college or further education. Any serious illnesses or fractures or sprains while growing up?
19) Have you ever been pregnant? How many times and how many births? Medical pregnancy problems---elevated sugar, elevated blood pressure, C-section. Current method of birth control.
20) How many siblings.
21) Illnesses that run in family. Causes of death and ages at death of parents and any first degree relatives.
22) Excessive bleeding after dental work or tooth extraction or minor surgical procedure.
23) Do you look forward to your S.O. coming home, or to coming home to your S.O.?
24) When was your last vacation?
25) Do you look forward to going to work?
26) Do you have ongoing problems with your parents or inlaws?
27) With your children?
28) If dog in the house, does dog get monthly protective treatment against Lyme ticks? What other pets, and are they sick?
29) When was the last time you had sex with your S.O.,? Did you both enjoy it? When was the last time before that?
30) Do you have trouble falling asleep or staying asleep?
31) Have you ever consulted a psychiatrist or other mental health worker? Any prescriptions given?
32) Have you ever thought of committing suicide? If yes, have you ever actually made plans.?
33) If you have a health care proxy, who is the named person? If not your S.O., what is the difference of opinion that caused that?
34) Where do you see yourself 5 years from now? 10 years from now?
35) Is there anything you would like to tell me that I haven't covered, or ask me?
36) Have you ever traveled outside the continental U.S. If yes, did you get sick on your travels? If you traveled to a malarious area did you take the prescribed anti-malaria medicine and for how long?
37) Have you ever fainted or passed out? What tests were done if you did?
38) How many times a week do you exercise?
39) What was your weight at high school graduation? College graduation? Before first pregnancy?
40) Do you think you drink too much?
We were also taught to come out and greet the patient in the waiting room and escort the patient back to our consulting room, rather than have the PA put the patient directly into the exam room.
I would like to list here some of the questions that I find are often not asked of a patient on the initial exam by the new physician. This of course pertains to the office exam, and not to the ER exam. In the ER as I would tell my residents, the two main considerations are: (1) does this patient need a hospital admission, and (2) what disease or process can the patient have than can kill him/her before I come in to make my morning attending rounds (and, in the case of females, ALWAYS do a pregnancy test). The following list is not exhaustive, but I believe that if the questions are not asked, the patient is not going to get the best possible medical treatment.
The order of the questions is usually unimportant, and their place on the list need not correspond to their importance.
1) Are you allergic to any prescription drugs? What was the reaction? (Important)
2) Are you allergic to any over-the-counter-drugs or vitamins or health foods? What was the reaction?
3) Were you ever hospitalized for any allergic reaction and did you have to be intubated?
4) What prescription drugs do you take and what are their doses? What was the last one added?
5) Are you on birth control pills (many women do not think of this as a prescription)?
6) What daily vitamin and food supplements do you take?----dosage and frequency. ?Daily aspirin dose?
7) Have you ever donated blood? To the blood bank or prophylactally pre-surgery.
8) Have you ever received a blood transfusion? After an accident? or surgery? or childbirth?
9) Do you still have your gallbladder, appendix and tonsils? Any recovery problems or excessive bleeding?
10) Last TB skin test and AIDS test.
11) Last tetanus, pneumonia , and flu vaccine. .Vaccinated against hepatitis A,B; or HPV? MMR? one or two?
12) Have you ever had unprotected sex? More than once? What were the circumstances?
13) When you were a child, did an adult of either sex ever make inappropriate advances to you?
14) Any broken bones, or damages in a motor vehicle accident?
15) Any surgeries or transplants. If yes, any anesthesia reaction?
16) Date of last mammogram, pap smear, colonoscopy, chest x-ray, EKG, stress-test, bone density test.
17) Date of last eye exam. Can you read street signs at night? Are you fearful of night driving?
18) Where were you born, where did you live and go to elementary school, high school, and any college or further education. Any serious illnesses or fractures or sprains while growing up?
19) Have you ever been pregnant? How many times and how many births? Medical pregnancy problems---elevated sugar, elevated blood pressure, C-section. Current method of birth control.
20) How many siblings.
21) Illnesses that run in family. Causes of death and ages at death of parents and any first degree relatives.
22) Excessive bleeding after dental work or tooth extraction or minor surgical procedure.
23) Do you look forward to your S.O. coming home, or to coming home to your S.O.?
24) When was your last vacation?
25) Do you look forward to going to work?
26) Do you have ongoing problems with your parents or inlaws?
27) With your children?
28) If dog in the house, does dog get monthly protective treatment against Lyme ticks? What other pets, and are they sick?
29) When was the last time you had sex with your S.O.,? Did you both enjoy it? When was the last time before that?
30) Do you have trouble falling asleep or staying asleep?
31) Have you ever consulted a psychiatrist or other mental health worker? Any prescriptions given?
32) Have you ever thought of committing suicide? If yes, have you ever actually made plans.?
33) If you have a health care proxy, who is the named person? If not your S.O., what is the difference of opinion that caused that?
34) Where do you see yourself 5 years from now? 10 years from now?
35) Is there anything you would like to tell me that I haven't covered, or ask me?
36) Have you ever traveled outside the continental U.S. If yes, did you get sick on your travels? If you traveled to a malarious area did you take the prescribed anti-malaria medicine and for how long?
37) Have you ever fainted or passed out? What tests were done if you did?
38) How many times a week do you exercise?
39) What was your weight at high school graduation? College graduation? Before first pregnancy?
40) Do you think you drink too much?
Saturday, September 17, 2011
Dr. George Thomas is pen name for Dr. Robin O. Motz
Hello All,
Because I started this blog when I was actively practicing internal medicine, I used the pen name of Dr. George Thomas. All case reports and stories of my training and attending are true. I attended Columbia University College of Physicians and Surgeons from 1971-1975, graduating as valedictorian, and was a resident in internal medicine at Columbia-Presbyterian Medical Center from 1975-1978. Upon finishing training I was immediately offered the position of Assistant Professor of Clinical Medicine at Columbia University as well as Assistant Attending in Medicine at Columbia-Presbyterian Medical Center. I am now retired from the direct practice of medicine, and am an Emeritus Assistant Professor at Columbia University.
My home page, which contains my CV, is at www.DrRMotz.com
I am now engaged in Stress Reduction,Life Coaching, Tutoring in Math and Physics, and dealing with Relationship Problems, as well as doing volunteer work at Gilda's Club of Northern New Jersey, which exists to help those patients who have cancer as well as their families, and is staffed almost entirely by volunteers. I also write a monthly column on medicine for Inner Realm, and am the Director of the Stress Reduction Center of New Jersey, LLC.
You can reach me at:
200 Grand Ave., Suite 201
Englewood, N.J. 07631-4363
Tel: 201-569-0040
Fax 201-569-3244
rom1@columbia.edu
Robin O. Motz, M.S., M.D., Ph.D. (Physics)
Because I started this blog when I was actively practicing internal medicine, I used the pen name of Dr. George Thomas. All case reports and stories of my training and attending are true. I attended Columbia University College of Physicians and Surgeons from 1971-1975, graduating as valedictorian, and was a resident in internal medicine at Columbia-Presbyterian Medical Center from 1975-1978. Upon finishing training I was immediately offered the position of Assistant Professor of Clinical Medicine at Columbia University as well as Assistant Attending in Medicine at Columbia-Presbyterian Medical Center. I am now retired from the direct practice of medicine, and am an Emeritus Assistant Professor at Columbia University.
My home page, which contains my CV, is at www.DrRMotz.com
I am now engaged in Stress Reduction,Life Coaching, Tutoring in Math and Physics, and dealing with Relationship Problems, as well as doing volunteer work at Gilda's Club of Northern New Jersey, which exists to help those patients who have cancer as well as their families, and is staffed almost entirely by volunteers. I also write a monthly column on medicine for Inner Realm, and am the Director of the Stress Reduction Center of New Jersey, LLC.
You can reach me at:
200 Grand Ave., Suite 201
Englewood, N.J. 07631-4363
Tel: 201-569-0040
Fax 201-569-3244
rom1@columbia.edu
Robin O. Motz, M.S., M.D., Ph.D. (Physics)
Monday, September 5, 2011
The Death of Professionalism in (Internal) Medicine
I have been in the practice of internal medicine for 30 years, starting with my internal medicine residency for 3 years in a big city medical school hospital and then 27 years of the solo practice of internal medicine. I was taught to go into the waiting room to greet each individual patient, escort him/her into my office to discuss the presenting problem(s), then take the patient into the exam room and have the chaperone help the patient into an exam gown. During the exam, I would ask additional questions. I would then tell the patient to get dressed and come back into my consulting room so we could discuss my diagnosis and possible treatments. During all of my training and practice I was always aware that medicine was a mixture of art and science, as well as a gestalt of the patient's medical belief system. One develops a "feel" for illnesses of various types, for the presence of stress, for histories that don't quite match the physical, for the inconsistencies in the way that the patient answers certain questions, and how to recognize when the patient resists (consciously or unconsciously) when I steered the post-exam conversation in the direction of certain diagnoses and treatments. All of this and more is contained in the professional practice of medicine, which is a mixture of medical knowledge, science, art, psychology, and empathy.
The concept of professionalism encompasses respect for your patients, respect for yourself, a desire for the respect of your peers, a feeling of collegiality with your fellow physicians, and, I personally believe, always placing the patient's needs first, without appearing shocked at anything the patient says. Too often we doctors forget that we define what is "normal" for the patient. (The old saying that an alcoholic is any patient who has two drinks a day more than the doctor does still holds.) You should also feel personal disappointment if you do not give the patient as much time as the patient needs (within reason), or if you ever make the same mistake twice.
You should also be able to spend the majority of your time in direct patient contact and care, rather than filling out forms, calling HMO's and drug plans, and writing letters to Medicare. And if you find that you are getting angry during your work day or telling your personal or professional problems to your patients, you should either take a vacation or change your profession.
When I started practice I felt proud of my practice and my professionalism. I charged more than most physicians in exchange for which I gave my patients much more time than they did, and all my patients were happy with this arrangement. I also treated poor people for free in my office(I allowed an hour for the initial visit, and didn't charge extra if more time was needed), I ordered the blood tests and Xrays that I determined that the patient needed and also made referrals to other doctors that I thought was indicated. I also made house calls and charged my patients my usual fee for the time I spend at their house, plus $25 for making the house call,. I generally was following 8 to 10 patients at home, who I saw at intervals varying from weekly to monthly. I also had patients in 2 different nursing homes.
Then along came Medicare, and managed care (HMO's) and drug payment plans. Suddenly I could no longer take the best possible care of my patients. Medicare began by not permitting me the $25 house call surcharge to patients, so I stopped house calls and explained why. Then I had the problem of an Oxford patient needing shoulder surgery when the best shoulder surgeon I knew was part of Cigna. Then one of my two admitting hospitals had a payment argument with Blue Cross so that my BC patients could not be admitted to that hospital. Then I had to spend time explaining to a drug plan that although Nexium was their preferred PPI to suppress stomach acid, Nexium did not work on my patient and only Prevacid did. Then Medicare asked me why I did more of a certain procedure to test for cancer than other internists did. When I wrote them back asking why more internists didn't look for cancer, I never heard from them again on that subject. The final straw was when Medicare D, which pays for drugs, decided it would only pay for generic and not brand name drugs. In some of my patients, generic Ativan, or Prozac or Wellbutrin, for instance do not work. I have now dropped all HMO's and insurance plans as well as Medicare. I still have to argue with drug plans, but that is all. It is a problem for my HMO patients, because they had to find another primary care doctor for referral to specialists, but I also got tired of telling patients that I could not recommend any surgeon in their HMO. As a final note, if I saw two Medicare patients the same day in a nursing home then Medicare paid me less for seeing the second patient and even less for the third, so I stopped seeing nursing home patients.
I could no longer take care of my patients in the manner in which I was trained, and so I was forced to switch to an all cash billing system. This had immediate advantages. Since I no longer submitted any bills except to the patients, I did not need an electronic billing system. And one of my staff no longer had to spend half of her workday on the telephone with drug companies and HMO's.
But to return to the problem of the death of professionalism in medicine. The insurance companies feel that all doctors are fungible and interchangeable. Anyone would agree that the best doctor (plumber, lawyer accountant) should be allowed to charge more, but no one knows how to measure them. All admissions to hospitals have to match a computer diagnosis, so I can no longer say:"This patient looks so sick that immediate hospital admission is needed". Medicare patients whom I see still have Medicare paying for their lab tests. I cannot say that " in my experience I think this patient needs a particular blood test", but rather I have to invent a diagnosis to justify ordering the test. The Joint Hospital Committee invented a rule that all patients with pneumonia in the ER must get antibiotics within 4 hours of ER admission or else the hospital would be sanctioned. I got used to writing in the ER chart that the patient refused antibiotics at the 4 hour mark after I told the patient that I was unsure of the proper antibiotic at that time. I resented the fact that I had to "game" the system to obtain what I thought was the best possible care for my patients.
In line with the anti-professionalism trend I know of two large internal medicine practices which have installed a 900 number for after-hours and weekend telephone calls. The recorded message tells callers to either go directly to the ER, or to stay on the line where they will receive a bill for each minute they spend on the phone. This has generated some additional income and cut down a lot on after-hours phone calls.
I cannot help but feel that patients are not as well served if doctors cannot afford to spend a lot of time with them, even if there is not a negative result in the mortality statistics. It takes much less time to order a test when a patient has a complaint than to take the time to take a proper history, but the doctor makes more money the former way. And I detest the practice of the PA going into the exam room to obtain a history and take the blood pressure.
There is something wrong with the practice of medicine when the most competitive residency is dermatology, since dermatologists can charge whatever the practice will bear since neither insurance companies nor Medicare pays for cosmetic dermatology. At a typical teaching hospital, the top grossing dermatologist takes in almost twice the fees that the top cardiac surgeon does. Plus we have the old saying that one advantage of dermatology is that (barring cancer) "the patient never dies, never gets well, and never calls you in the middle of the night".
The concept of professionalism encompasses respect for your patients, respect for yourself, a desire for the respect of your peers, a feeling of collegiality with your fellow physicians, and, I personally believe, always placing the patient's needs first, without appearing shocked at anything the patient says. Too often we doctors forget that we define what is "normal" for the patient. (The old saying that an alcoholic is any patient who has two drinks a day more than the doctor does still holds.) You should also feel personal disappointment if you do not give the patient as much time as the patient needs (within reason), or if you ever make the same mistake twice.
You should also be able to spend the majority of your time in direct patient contact and care, rather than filling out forms, calling HMO's and drug plans, and writing letters to Medicare. And if you find that you are getting angry during your work day or telling your personal or professional problems to your patients, you should either take a vacation or change your profession.
When I started practice I felt proud of my practice and my professionalism. I charged more than most physicians in exchange for which I gave my patients much more time than they did, and all my patients were happy with this arrangement. I also treated poor people for free in my office(I allowed an hour for the initial visit, and didn't charge extra if more time was needed), I ordered the blood tests and Xrays that I determined that the patient needed and also made referrals to other doctors that I thought was indicated. I also made house calls and charged my patients my usual fee for the time I spend at their house, plus $25 for making the house call,. I generally was following 8 to 10 patients at home, who I saw at intervals varying from weekly to monthly. I also had patients in 2 different nursing homes.
Then along came Medicare, and managed care (HMO's) and drug payment plans. Suddenly I could no longer take the best possible care of my patients. Medicare began by not permitting me the $25 house call surcharge to patients, so I stopped house calls and explained why. Then I had the problem of an Oxford patient needing shoulder surgery when the best shoulder surgeon I knew was part of Cigna. Then one of my two admitting hospitals had a payment argument with Blue Cross so that my BC patients could not be admitted to that hospital. Then I had to spend time explaining to a drug plan that although Nexium was their preferred PPI to suppress stomach acid, Nexium did not work on my patient and only Prevacid did. Then Medicare asked me why I did more of a certain procedure to test for cancer than other internists did. When I wrote them back asking why more internists didn't look for cancer, I never heard from them again on that subject. The final straw was when Medicare D, which pays for drugs, decided it would only pay for generic and not brand name drugs. In some of my patients, generic Ativan, or Prozac or Wellbutrin, for instance do not work. I have now dropped all HMO's and insurance plans as well as Medicare. I still have to argue with drug plans, but that is all. It is a problem for my HMO patients, because they had to find another primary care doctor for referral to specialists, but I also got tired of telling patients that I could not recommend any surgeon in their HMO. As a final note, if I saw two Medicare patients the same day in a nursing home then Medicare paid me less for seeing the second patient and even less for the third, so I stopped seeing nursing home patients.
I could no longer take care of my patients in the manner in which I was trained, and so I was forced to switch to an all cash billing system. This had immediate advantages. Since I no longer submitted any bills except to the patients, I did not need an electronic billing system. And one of my staff no longer had to spend half of her workday on the telephone with drug companies and HMO's.
But to return to the problem of the death of professionalism in medicine. The insurance companies feel that all doctors are fungible and interchangeable. Anyone would agree that the best doctor (plumber, lawyer accountant) should be allowed to charge more, but no one knows how to measure them. All admissions to hospitals have to match a computer diagnosis, so I can no longer say:"This patient looks so sick that immediate hospital admission is needed". Medicare patients whom I see still have Medicare paying for their lab tests. I cannot say that " in my experience I think this patient needs a particular blood test", but rather I have to invent a diagnosis to justify ordering the test. The Joint Hospital Committee invented a rule that all patients with pneumonia in the ER must get antibiotics within 4 hours of ER admission or else the hospital would be sanctioned. I got used to writing in the ER chart that the patient refused antibiotics at the 4 hour mark after I told the patient that I was unsure of the proper antibiotic at that time. I resented the fact that I had to "game" the system to obtain what I thought was the best possible care for my patients.
In line with the anti-professionalism trend I know of two large internal medicine practices which have installed a 900 number for after-hours and weekend telephone calls. The recorded message tells callers to either go directly to the ER, or to stay on the line where they will receive a bill for each minute they spend on the phone. This has generated some additional income and cut down a lot on after-hours phone calls.
I cannot help but feel that patients are not as well served if doctors cannot afford to spend a lot of time with them, even if there is not a negative result in the mortality statistics. It takes much less time to order a test when a patient has a complaint than to take the time to take a proper history, but the doctor makes more money the former way. And I detest the practice of the PA going into the exam room to obtain a history and take the blood pressure.
There is something wrong with the practice of medicine when the most competitive residency is dermatology, since dermatologists can charge whatever the practice will bear since neither insurance companies nor Medicare pays for cosmetic dermatology. At a typical teaching hospital, the top grossing dermatologist takes in almost twice the fees that the top cardiac surgeon does. Plus we have the old saying that one advantage of dermatology is that (barring cancer) "the patient never dies, never gets well, and never calls you in the middle of the night".
Wednesday, August 24, 2011
Medical Economics
All the talk about the overall cost of medicine is really Macroeconomics. But man is an economic animal, or so the capitalists believe, so an individual doctor's behavior must be considered from a Microeconomic point of view. Of course, in addition to making money, a doctor practices altruism, works for the good of his individual patient (which does not necessarily correspond to the good of society), spends a lot of uncompensated time (ever try arguing with an insurance company about drug coverage?), values the respect of his peers, values himself as an ethical professional, and wants to avoid being sued for malpractice (which is not the same as practicing responsible medicine---see my previous blog on how doctors can avoid malpractice suits). Then we have the insurance company and government interference when both groups say they will only pay for "indicated and necessary" tests and procedures, and then ,make doctors jump through all sorts of hoops to justify the tests and procedures (which again may not benefit the patient), but which they think will save money. Rather than writing a discursive article, I will just list the many circumstances, events, and laws, some of which are based on flawed and/;or unproven assumptions, that circumscribe the actions of doctors. Some of it may be unbelievable, but I can assure you it is all true, as even a cursory search of the internet will show.
1) Medicare (henceforth MCR) decreed that in order to save money, if a dermatologist biopsied two lesions at the same visit, he would be paid less for the second biopsy, since the patient was there already. Dermatologists immediately started telling their patients to come back in two weeks for the second biopsy, so they could collect a full fee for the second biopsy.
2) I used to have four to six of my patients in a nursing home at any one time, following them there after hospital discharge, until they were well enough to go home. I would see these patients every week, two weeks, or four weeks, as I thought the medical situation warranted. (And the state requires that the admitting doctor see each nursing home patient at least once in every 30 day period, which is very reasonable.) If I saw three patients in a nursing home the same day, then MCR paid me less for the second and third patient, saying that I was already there to see the first. Strangely enough they do not apply this payment process when I have three patients in the hospital and see them all the same day. So I have to make six visits to the nursing home in one month to see my six patients which is a grossly inefficient use of my time. Then if I see a patient more often than once every 30 days, if I do not have them sign a statement saying that they acknowledge that MCR might not pay for a doctor's visit more than once every 30 days, then I can't bill the patient or MCR. I finally stopped seeing any nursing home patients. They were not medically abandoned, since by law every nursing home must have an attached doctor who will admit and follow medically any patient who does not have a personal admitting doctor.
3) An orthopedic surgeon is paid a fee for surgery that includes all the follow-up visits and care in the hospital. He does NOT get paid extra money for a patient's extra days in the hospital. MCR rules were that a patient could go home when he/she could walk 100 feet unaided. Now 65 year old Mr. Jones was much stronger than 95 year old Mrs. Smith, and recovered faster. So the surgeon would send Mr. Jones home at the 100 foot mark, but would tell the physical therapist not to record Mrs. Smith's walking 100 unaided feet until two weeks after the surgery.
4) NY State started keeping a report card of the patient death rates of hospitals and individual cardiac surgeons. The immediate result is that cardiac surgeons stopped doing difficult cardiac cases where the estimated mortality was greater than 20%. As a result fewer open heart procedures were done in NYC teaching hospitals than were done before the report cards were issued.
5) The most competitive residency is dermatology, because of the enormous amount of elective plastic surgery that they do, such as Botox and Restalen injections. In NYC, one Botox injection costs the patient about $500, and has to be repeated every 3 months. Doctors can charge whatever the traffic will bear: since neither MCR nor insurance companies pay for the procedure, their fees are uncapped.
6) All doctors memorize the diagnosis codes necessary so MCR will pay for a blood test that is "indicated" for the diagnosed condition. If a patient looks pale and has orthostatic drops in blood pressure as well as a rapid pulse,
there is no computer code for "in my experience, this patient is anemic". But if I ask him if he/she has ever been tired in the past 20 years, and I get a "yes" answer, then the code 780.79 (fatigue) will let MCR pay for the blood count (CBC). We do this all the time, since there is no fuzzy logic in computer diagnoses, any more than I can say "this patient looks sick and needs hospital admission".
In the same vein, hyperthyroidism is one of the treatable causes of high blood pressure. Until a few years ago, a diagnosis of 401.9, hypertension, was a justifiable diagnosis for MCR to pay for a thyroid test. Then they stopped allowing this diagnosis. Thank God at every autopsy every patient has at least one minute thyroid nodule, so we can put down "goiter" as a diagnosis in order to measure the thyroid hormone of a newly hypertensive patient without breaking the law.
7) All hospitals are paid for an admission by DRG's, or Diagnosis Related Groups. That is if I admit a 65 year old male insulin-dependent diabetic with an anterior wall heart attack, then the insurance company or MCR will pay for X days of hospital treatment. If the patient is sent home before X days, the hospital makes extra money on the admission. If the patient stays longer than X days, then the hospital loses money. The hospital puts pressure on the ward attendings who pressure the residents who pressure the interns into discharging their patients home as rapidly as possible. Every patient has a "problem list",or a list of his/her medical problems in descending order of importance: (1) heart attack, (2) insulin-dependent diabetes, (3) non-suicidal depression secondary to #1, etc. Now the common saying is: "Problem #1---discharge plans".
8) As an aside, there is a perfectly good reason why doctors are not supposed to treat their families: insufficient emotional distance, and a chance of making a medical decision for partly non-medical reasons. But now all the states require family members to decide when to "pull the plug" on a family member, a decision they are neither emotionally equipped to do nor have any emotional distance from. So according to the state, it is right and proper for a person to end the life of a family member, but not proper for a doctor to write a prescription for a family member. And let's not forget that the doctor probably knows his/her patients true feelings about death and life better than does the family, We all have families in our practice where the spouse is not given this decision-making power because the children are trusted to make the patient;s wishes come true, and not the spouse.
9) Until recently, MCR said that a patient needed two units of blood or no transfusion at all, and sanctioned doctors who gave only one unit. Guess what the doctors started doing with all their MCR patients if they felt they needed a transfusion of one unit of blood?
10) Medicare is going to reward doctors who prescribe electronically and financially penalize doctors who do not, without any pilot study showing that electronic prescribing either saves money or is safer for the patient. The same Johns Hopkins pediatric hospital that showed the numerous errors resulting from in-hospital written orders instituted an electronic ordering system. A follow-up 2-year study showed no decrease (and a statistically insignificant increase) in medication errors.
11) Finally MCR pays non-linearly. A lawyer or plumber charges a fixed amount per hour, broken down into 10 minute segments or whatever. But MCR will pay me much more to see 2 patients in 20 minutes than 1 patient in 20 minutes, even if the single patient gets better care and a more precise diagnosis from the extra 10 minutes of my . So if a doctor wants to make more money, he will see one patient every 10 minutes and order a test and tell the patient to come back, rather than one every 20 minutes. And let's not forget that psychiatrists get paid 2/3 of what an internist gets paid for the same amount of time, probably because the government feels that if you are a little crazy it won't kill you!
1) Medicare (henceforth MCR) decreed that in order to save money, if a dermatologist biopsied two lesions at the same visit, he would be paid less for the second biopsy, since the patient was there already. Dermatologists immediately started telling their patients to come back in two weeks for the second biopsy, so they could collect a full fee for the second biopsy.
2) I used to have four to six of my patients in a nursing home at any one time, following them there after hospital discharge, until they were well enough to go home. I would see these patients every week, two weeks, or four weeks, as I thought the medical situation warranted. (And the state requires that the admitting doctor see each nursing home patient at least once in every 30 day period, which is very reasonable.) If I saw three patients in a nursing home the same day, then MCR paid me less for the second and third patient, saying that I was already there to see the first. Strangely enough they do not apply this payment process when I have three patients in the hospital and see them all the same day. So I have to make six visits to the nursing home in one month to see my six patients which is a grossly inefficient use of my time. Then if I see a patient more often than once every 30 days, if I do not have them sign a statement saying that they acknowledge that MCR might not pay for a doctor's visit more than once every 30 days, then I can't bill the patient or MCR. I finally stopped seeing any nursing home patients. They were not medically abandoned, since by law every nursing home must have an attached doctor who will admit and follow medically any patient who does not have a personal admitting doctor.
3) An orthopedic surgeon is paid a fee for surgery that includes all the follow-up visits and care in the hospital. He does NOT get paid extra money for a patient's extra days in the hospital. MCR rules were that a patient could go home when he/she could walk 100 feet unaided. Now 65 year old Mr. Jones was much stronger than 95 year old Mrs. Smith, and recovered faster. So the surgeon would send Mr. Jones home at the 100 foot mark, but would tell the physical therapist not to record Mrs. Smith's walking 100 unaided feet until two weeks after the surgery.
4) NY State started keeping a report card of the patient death rates of hospitals and individual cardiac surgeons. The immediate result is that cardiac surgeons stopped doing difficult cardiac cases where the estimated mortality was greater than 20%. As a result fewer open heart procedures were done in NYC teaching hospitals than were done before the report cards were issued.
5) The most competitive residency is dermatology, because of the enormous amount of elective plastic surgery that they do, such as Botox and Restalen injections. In NYC, one Botox injection costs the patient about $500, and has to be repeated every 3 months. Doctors can charge whatever the traffic will bear: since neither MCR nor insurance companies pay for the procedure, their fees are uncapped.
6) All doctors memorize the diagnosis codes necessary so MCR will pay for a blood test that is "indicated" for the diagnosed condition. If a patient looks pale and has orthostatic drops in blood pressure as well as a rapid pulse,
there is no computer code for "in my experience, this patient is anemic". But if I ask him if he/she has ever been tired in the past 20 years, and I get a "yes" answer, then the code 780.79 (fatigue) will let MCR pay for the blood count (CBC). We do this all the time, since there is no fuzzy logic in computer diagnoses, any more than I can say "this patient looks sick and needs hospital admission".
In the same vein, hyperthyroidism is one of the treatable causes of high blood pressure. Until a few years ago, a diagnosis of 401.9, hypertension, was a justifiable diagnosis for MCR to pay for a thyroid test. Then they stopped allowing this diagnosis. Thank God at every autopsy every patient has at least one minute thyroid nodule, so we can put down "goiter" as a diagnosis in order to measure the thyroid hormone of a newly hypertensive patient without breaking the law.
7) All hospitals are paid for an admission by DRG's, or Diagnosis Related Groups. That is if I admit a 65 year old male insulin-dependent diabetic with an anterior wall heart attack, then the insurance company or MCR will pay for X days of hospital treatment. If the patient is sent home before X days, the hospital makes extra money on the admission. If the patient stays longer than X days, then the hospital loses money. The hospital puts pressure on the ward attendings who pressure the residents who pressure the interns into discharging their patients home as rapidly as possible. Every patient has a "problem list",or a list of his/her medical problems in descending order of importance: (1) heart attack, (2) insulin-dependent diabetes, (3) non-suicidal depression secondary to #1, etc. Now the common saying is: "Problem #1---discharge plans".
8) As an aside, there is a perfectly good reason why doctors are not supposed to treat their families: insufficient emotional distance, and a chance of making a medical decision for partly non-medical reasons. But now all the states require family members to decide when to "pull the plug" on a family member, a decision they are neither emotionally equipped to do nor have any emotional distance from. So according to the state, it is right and proper for a person to end the life of a family member, but not proper for a doctor to write a prescription for a family member. And let's not forget that the doctor probably knows his/her patients true feelings about death and life better than does the family, We all have families in our practice where the spouse is not given this decision-making power because the children are trusted to make the patient;s wishes come true, and not the spouse.
9) Until recently, MCR said that a patient needed two units of blood or no transfusion at all, and sanctioned doctors who gave only one unit. Guess what the doctors started doing with all their MCR patients if they felt they needed a transfusion of one unit of blood?
10) Medicare is going to reward doctors who prescribe electronically and financially penalize doctors who do not, without any pilot study showing that electronic prescribing either saves money or is safer for the patient. The same Johns Hopkins pediatric hospital that showed the numerous errors resulting from in-hospital written orders instituted an electronic ordering system. A follow-up 2-year study showed no decrease (and a statistically insignificant increase) in medication errors.
11) Finally MCR pays non-linearly. A lawyer or plumber charges a fixed amount per hour, broken down into 10 minute segments or whatever. But MCR will pay me much more to see 2 patients in 20 minutes than 1 patient in 20 minutes, even if the single patient gets better care and a more precise diagnosis from the extra 10 minutes of my . So if a doctor wants to make more money, he will see one patient every 10 minutes and order a test and tell the patient to come back, rather than one every 20 minutes. And let's not forget that psychiatrists get paid 2/3 of what an internist gets paid for the same amount of time, probably because the government feels that if you are a little crazy it won't kill you!
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