I have not had time for an extensive Q&A, but this question deserves some ranting.

I would still be interested in your input regarding my earlier comment on your post on Quality Medical Care. Recent experiences of my own make me doubt that healthcare is even as rational as "rationed by ability to pay." I have excellent health insurance and the ability to pay out of pocket for what I need, but here in Boston it is virtually impossible to get a doctor's appointment with a GP or an obstetrician (forget about a specialist), even when I tell them I'm recovering from a pulmonary embolism that landed me in the hospital. Is there a doctor shortage? If so, money doesn't appear to move you to the front of the line. What is going on? No one seems to know, or at least want to discuss it.

Amazingly, I do think we have a doctor shortage. The shortage is subtle, but known to most practicing physicians. It differs among specialties.

I am often asked to help someone find a physician. Despite working in a major academic medical center, I find this a difficult task. Access seems no better in the private sector.

We need more first contact physicians - internists, family physicians, and obstetricians. Obstetricians are leaving practice secondary to malpractice costs. Internists and family physicians are leaving for the reasons that I state almost weekly. Overhead continues to increase while reimbursement is either flat or decreasing.

From the physician viewpoint, medical care does not work as a free market. Our patients get first preference of our time. Eventually you fill your practice and no longer take new patients.

I know that this does not make sense. It seems counterintuitive to me. We have often little incentive to accept an additional patient. Patient care is suffering - and ability to pay (while a factor) does not necessarily help one find a physician.

I expect some excellent comments from my physician readers.

Time for another edition of Q&A. Comments are flowing in, especially on the malpractice problem. We have some heated exchanges, which I will touch on. Keep those comments coming!!!

Yes, a lack of activity and a plethora of calories leads to unhealthy weight. This is a simple equation. However, I find that the articles I read on the subject of obesity in North American society consistantly oversimplify the issue. Okay, so teenagers are eating high calorie, low nutrition foods and are less active (as is the rest of the population). Well, why don't we ask the next logical question: "Why?"

With so many socio-economic factors contributing to this "epidemic of obesity," stating that a better diet and "get[ting] off our butts" is not going to make any difference in obesity rates. I acknowledge the importance of taking some personal responsibility for physical health, but when you dig deeper into obesity rates in America, you find a) a very strong link between poverty and obesity; and b) that our culture sends constant messages to consume. We have created an environment that produces obesity, and yet we seem confused when it occurs. Ignoring the social factors of obesity and placing the focus exclusively on a lack of personal responsibility only marginalizes an evergrowing portion of the population, when in fact they are simply a product of the society we've created.

This important comment highlights an important social and political issue. Should we blame society, and then sit back, waiting for society to fix the problem? Or rather should we acknowledge society's role, and offer solutions? I prefer the latter.

When dealing with individuals (which is my main role as a physician), I must focus on individual responsibility. We work to get patients more active and modifying their eating habits.

As a blogger, I have often highlighted efforts to positively impact society. We should support and demand changes to physical education programs in the schools. We should support and demand safe areas for outdoor exercise - running and bike paths for example. We should support programs to introduce more fruits and vegatables to poor areas (especially at reasonable prices).

While we strive to alter society, we still must give advice to individual patients. There we can only stress individual responsibility. If, through this blog, I convince one person to exercise and eat intelligently, then I have a success.

I am not so sure I would give the trial bar such an easy pass on their role in the crisis. They are the most significant force in the tort business, soliciting aggressively and portraying the filing of suits as an easy, cost-free, risk-free and consequence-free enterprise. That, of course, is a deception, and it successfully perverts and corrupts the public into believing there are no consequences to this kind of jackpot-seeking litigation. The fact is we all pay, and not just for medically-related litigation.

If a doctor operates unnecessarily or for inappropriate reasons, there are mechanisms that can stop that doctor: in hospitals, surgery centers, medical associations and state licensing boards. No, these mechanisms are not perfect. They can be resisted (by lawyers!) but they exist. Where is the similar mechanism for lawyers who abuse their professional privileges? When, short of criminal conviction, is it imposed? Our legislatures and much of our national political leadership is populated by attorneys. Is it any surprise the laws are lawyer-friendly?

This comment refers to a long rant from Friday. I focused on the tort laws rather than the lawyers. CHenry challenges me here, and specifically blames the lawyers.

This issue leaves me confused. One can almost make this a chicken and egg question. With proper tort reform, we would stymie the lawyers.

I argued that the lawyers see a way to make big bucks, and take advantage of the opportunity. While I would like to see lawyers consider the great societal good, I have a difficult time arguing that that is their responsibility.

As physicians we focus primarily on our individual patients. If our patient needs something, we are willing to have someone spend whatever it takes (AICD, IVIG, the latest greatest antiretroviral). While our patients advocacy may not aid the nation's health, we feel (appropriately) a moral obligation to advocate for our patient.

Thus, I have critiqued the tort system that allows lawyers to produce the current malpractice crisis. The tort system is the disease (admittedly one that lawyers produced). The individual lawyers see a financial opportunity and take it. They couch their client advocacy in flowery terms, but their goals seem financial. But we should not focus on changing them. They will only sue us if the laws allow. We must change our paradigm and educate everyone about the tort crisis and propose solutions which protect patients and the health care system.

"Most cases that actually go to trial are lost by the defendant" - true, because only the valid cases will ever go to trial. The others are dropped or settled. However, that doesn't mean that the frivolous attempts are cost-free - they aren't. Whether or not a case ever goes to trial, every attempt made at a lawsuit has to be investigated by the physician's insurance carrier. This takes time and money. Enough of these attempts and the physician's insurance premiums will go up, even if the physician is never actually sued.

This is an excellent comment from a fellow physician blogger - Feet First.

This is heartrending. And, unfortunately, not an unusual story by any means. I wish patients and their families could better understand what is meant by "extending their lives" most of the time.

Recently, a patient of mine with Alzheimer's deteriorated to the point that she was no longer eating because she could not remember how to swallow. The food merely sat in her mouth. I had multiple conversations with her granddaughter about placing a feeding tube. I made it clear that I did not recommend this procedure, that it would lengthen her life but that she would continue in the nursing home intensely demented and crippled by a stroke.

The granddaughter, of course, elected to have the tube placed. She's still with us today. Sometimes I think we ought to ask family members: "If YOU were in this situation, would you want your family to do this for you?" I think a sizable number of them would say no.

This is another post from Alice of Feet First. I have included it to highlight a problem, and suggest a solution. Alice's story happens frequently. We see these patients in the hospital and wonder - "what were they thinking".

Personally, as a ward attending, I have a rule about feeding tubes and PEG tubes (a PEG tube is a feeding tube which goes directly through the skin into the stomach). My rule - we should never place a feeding tube which does not have the probability of improving the patient's quality of life. When the patient can no longer participate in the decision making process, I do not feel an obligation to offer a feeding tube to a patient if he/she does not meet the above stated rule.

We are fortunate at our VA hospital to have an outstanding palliative care service. I often involve them in such decision making. Through many discussions, I have learned to only offer this option sparingly. I also resist this option with the argument that we would only prolong suffering (unless the patient meets the rule of the feeding tube improving the quality of life).

We (physicians) should become more paternalistic in these situations. Patient centered decision making works in most circumstances. This circumstance may require a more persuasive paternalistic approach.

At the end of the day all effective medical malpractice reform reduces to three options:

(1) Reduce the amount of compensation paid to the victims.

(2) Transfer the cost of the compensation from doctors to the taxpayer. Or spread the cost among all doctors equally so risky specialties such as obstetrics aren't hit especially hard.

(3) Make the practice of medicine less risky.

Option number three seems the obvious choice. I don't hear chiropracters complaining about their malpractice rates, because their practice has a smaller risk and their premiums are correspondingly less, despite having to face the same "greedy" trial lawyers. Now obviously making the practice of medicine less risky is easier said than done. But I think the real crisis in medicine is not the rising malpractice rates, it's the amount of risk in medical practice.

Bernie (of The Careless Hand) has posted often this week. We obviously see the world differently. He misses the point completely, especially in this post.

The costs of malpractice are spread. That is one of the problems! If I practice excellent medicine, and never get sued, my malpractice rates still skyrocket.

Please explain his third point to anyone (including me). Sick patients come to us hoping to improve. They would like a cure (and sometimes we can provide that). They want us to help them improve their quality of life (and often we can provide that).

As I have ranted often, each action we take to help the patient has a probability of success. It also has a probability of failure. It also has a probability of side effects. And the patient has a probability of getting another problem.

We can minimize risk only if we minimize the chance for benefit. We must work to balance risk and benefit, but ultimately we (the patient and the physician) must accept some risk to get some benefit.

If this makes my profession risky, then I accept that risk. We cannot make medicine less risky and more beneficial. These are the yin and yang of our work. Perhaps we need to do a better job of explaining this dilemma to society and to individual patients.

We get sued often because sometimes the risk materializes and the benefit does not occur. We may help 90 of 100 patients, but 10 patients have a poor outcome. We consider that a success. Lawyers consider that an opportunity. The 10 patients think we have failed. The 90 consider us wonderful.

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So ends another Q&A. As usual each Sunday I rant on those issues which strike me as controversial or otherwise interesting. I do read every comment, but do not always respond because of time pressures (I have this other job). Thnaks for writing and making the blog more interesting!

Time for some excellent questions and comments.

What study is your use of metoprolol in heart failure based upon and where did you get your information that Coreg 12.5 mg and metoprolol 25 mg are equivalent doses and where do you get a 25 mg tablet of metoprolol?

These are good questions, and I can only answer one for certain. The MERIT-HF study supported metoprolol for CHF - Fagerberg B, et al. Effect of metoprolol CR/XL in chronic heart failure: metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet June 12, 1999;353:2001-7.. I got the equivalent dose information from the COMET study - specifically this quote from theheart.org describing the COMET study -

They were randomized to carvedilol (target dose 25 mg twice daily) or metoprolol tartrate (target dose 50 mg twice daily). These doses were chosen because it was believed that they would give a comparable degree of beta blockade in both groups.

This comment comes from an earlier post, which is superceded by - COMET results previewed

The medical community has been working under market conditions that have applied to only a few other industries. There is of course the possibility of raising prices, but the buyers, in most cases insurers of patients and the government, have dictated reimbursement and effectively fixed prices, either by contract or by law. Only a few patients, very few, actually pay the charges at listed price. So there is not truly a free market in medical care. What there is is a sort of demand economy, where a few very large buyers, largely leveraged by the federal government and the reimbursement schedules paid by Medicare, fix the market prices, and where other payors usually follow suit. Of course, doctors are free to exclude insurers that pay poorly, the reason why so many refuse to accept Medicaid and Medicaid-like plans, lowball HMOs and plans that practice mendacious claims denials and downcoding.

It is a business of compromises. See enough patients that have plans that pay enough quickly enough so you can meet your bills and make a living for yourself that adequately compensates for your time, training and risks. Nothing is really different from other small businesses that way. As for patients, very few people have ever paid their full bill for their medical services as they might for other commerce where there is no third-party payor. This has been the case in the U.S. for more than a generation. Copayments, when they are due, are largely token payments and represent only a small proportion of the costs or the full payment expected. So patients usually are not rational participants in decisions about consuming medical care. There isn't exactly market transparency and those receiving care aren't the ones who pay the full bill and so don't feel the need to contain costs.

This is wisdom from CHenry. This echoes much that I have written over the past few months. Medical practice functions under a perverse system of fixed charges and increasing overhead. As Robert Prather argues, we need a true free market for medicine.

well...don't we all live in a society where we buy name brand items...from cars to clothes to the restaurants we eat....MD's sure are picky and I am sure their loved ones get the best medicine...the ones that are promoted

I beg to differ with this comment. Many physicians prefer generic drugs for their families, especially those who eschew free samples. I personally see no reason to spend more for an advertised trade name drug - when a generic will work just as well.

As a resident who has felt the changes of adapting to an 80 hour work week first-hand, I also have dealt with the difficulty of balancing the responsibilty of getting my interns out of the hospital on time with teaching them the importance of their responsiblity in appropriate patient transfer and care. I feel that this bill threatens at some level our clinical judgement by pressuring an already stressed out team to neatly wrap things up, often dumping a tremendous work load on either a busy on-call team or a day-float.

Even if they are allowed to leave, I want my intern's to at least intellectually.. want to stay. I want them to
learn to build relationships with their patients that makes the work not a burden or a time-clock slot but an opportunity to spend more time with someone who is suffering and in need of their help. Unfortunately relationships don't always come in a pre-packaged 12 hour time slots, they take time. If I can teach them that, then it doesn't matter how much time they spend at the hospital, they will have learned what it is to care for a patient, and that's all I want in my doctor.

First, I want to thank my former student for this insightful comment. It is exciting to receive comments from people I know!

Read this comment carefully. The resident makes some very important points. Rules (like the ACGME guidelines) can be dangerous. We really do not want physicians in training to develop a "punch the clock" mentality. We want them to care for their patients. Some days, weeks and months may require longer hours; some days, weeks and months may allow shorter hours. Arbitrary rules can negatively impact patient care and professionalism.

The ACGME has a laudable goal. I fear the unintended consequences of using rigid rules to legislate common sense. This July looms as an uncontrolled experiment in housestaff education and patient care. I will be there on the front lines with the new interns. I will report on our new system.

I have been diagnosed with eosinophilic fasciitis. Symptoms began in JANUARY. Swollen hands; carpal tunnel followed. By MARCH, Pale pink rash on knees and back of thighs, which became very painful, burning. Finally diagnosed 5/6/03 from biopsy of rash back of knee, which by then ws leathery. Now lungs are involved. Am on 40 mg. of prednisone (since 5/6/03) and 200 mg.of doxyciline. Wondering when I will get well. Please rant!

I wish I could answer questions like this one. We (physicians) often do not know when patients will improve. Often we try therapies, and then observe the response. This happens more often with less common diseases (like the one mentioned in this comment).

I wish I could give perfect medical advice to everyone who writes. Unfortunately, medicine remains part science, and part art. Sometimes, we do have to try therapies without out knowing how the patient will respond. In doing so, we try to balance risks and benefits.

I apologize for the long winded response. I cannot answer your question - and my frustration is minimal compared to the frustration that you must have concerning this problem.

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So this ends another Q&A. I hope everyone has had a great weekend. And remember that Father's Day is only 2 weeks away!!!
 

Late Sunday, time to clean out my comments and emails. Sorry for the delay.

I feel that ephedra is not forced upon the general public, by the companies that produce it. It is forced upon us by the media. I never knew what in the world ephedra was until the news took all of the dirt it could dig up on the herb and force fed it to me. Ephedra is no more dangerous than alchol. I have never heard of an ephedra user killing any innocent victims, I want the FDA to pretend like the people that are of age, to decide the future of our country, are capable of watching there weight or increasing energy what ever LEGAL way they want!

This comment on ephedra misses the point. Ephedra is a drug, not a food. I have several problems with the current way supplements are sold in general. Ephedra makes the point well.

We have no quality assurance mandated for supplements. Thus, the dose you take has much more randomness than the dose of any prescription (or even non-prescription) drug. When you think you are taking a specific dose of ephedra, you may or may not be taking that dose.

My other major problem with ephedra is the lack of appropriate warnings and caveats. It is possible that one could use ephedra responsibly with little danger (note that I say it is possible - that hypothesis would require testing). However, as currently marketed people take this drug without sufficient medical supervision. It can cause sudden death. Ephedra is dangerous, and therefore it should have the same regulations as any drug you might buy.

"If we had no efficacy requirement, drug companies would have the ability to assert claims without supporting data. The evidence based physician would not have the data necessary to make good decisions about drugs."

There is a difference between an unelected bureaucracy requiring some particular standard for an efficacy claim, and longstanding law forbidding fraud. You seem to have no faith in the latter.

If a pharm supplier made false claims of efficacy, they would be criminally liable for fraud, just as is anyone distributing anything that is not subject to FDA's particular requirements for efficacy.

I'd trust my physician's opinion on efficacy over a bureaucracy's any day. If I find my physician's opinions inaccurate, I can change physicians. If I find the FDA's pronouncements inaccurate, I can't change government bureaucracies.

I find this an interesting argument. As I consider it, I have two problems (and hope the writer will respond). First, proving liability for fraud would require that we engage our legal system. I do not believe that our legal system can answer these questions as well as scientists answer these questions. Second, as a physician, I do not trust my opinions on efficacy as much as I trust the FDA. I do not have the data, nor the time to analyze the data if I had it.

I believe that you do misunderstand the FDA. Their analyses include physicians and statisticians. These are not bureaucratic decisions, rather scientific decision (in my opinion). Thus, while I share your distrust of bureaucracy, in this specific case I believe we do have the right bureaucracy.

Would the patient have preferred the physician have not talked to him? Is the value of the visit only in the hands-on component? I agree that the case has to be made that the physician's time has value, whether it is spent listening, examining, performing procedures or talking. Lawyers, who do lots of talking, never seem to have to make this argument. Why is that? And for some reason--which does not seem to apply to our lawyer brethern--only the doctor's time spent with the patient is deemed to be compensable. Try telling a lawyer that you will only pay for the time spent is his presence. The patient needs to understand that listening and giving professional advice is a service. I think that retainer-based practice, which you have argued for here in the past, would help to fix this problem.

As usual C. Henry has made the point very well. This comment reinforces everything that I have stated about our current reimbursement system.

I agree in the importance of case taking and case taking skills. But good case taking isn't talking to the patient, it's listening to the patient. When people tell me that the doctor they saw was "no good", I ask why. The number one reason is, "He doesn't listen to what I have to say. The minute I give my complaint, out comes the prescription pad and he's writing the prescription."

Point well made!! If all we do is talk, then shame on us. We must listen and respond to the patient. Perhaps the key here is conversation rather than lecture.

Does anyone suffer from cancer of the stomach as a result of taking Proton Pump Inhibitors ?? I read that this is a known side effect to occur on trials of the drug on mice!

This theoretical consideration has no data to support it. We have many years of PPI use now, with no epidemiological evidence of a stomach cancer - PPI association.

I'm aware of the problem that lawyers sometimes make settlments in class action suits that enrich themeselves but provide little reward to the defendants. I would like to see the problem fixed as much as you do. However, to ignore the problem of adverse drug reactions, which is a leading cause of death and injury in America, and criticize lawyers pursing the issue on behalf of their clients is a perverse set of priorities. Why doesn't this issue get the attention it deserves from the medical profession?

Physicians worry about adverse drug reactions constantly. We are faced with a difficult situation. We must balance potential benefit against potential risk. Often patients can help with the decision making, however, many patients will not participate in the decision making process.

So we are damned if we do, and damned if we do not prescribe a specific medicine. Side effects occur. We do our best to minimize their impact, but sometimes we have an unavoidable risk.

How should we give this issue more attention? Who are you blaming - physicians, insurers, or the pharmaceutical industry?

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Thanks again for the comments and questions. I still have much to answer and comment. Hopefully I can find some time again tomorrow. Keep the comments coming, it certainly makes this blog a lot more interesting!!!

Back finally for a shortened version of Q&A. I have had too many trips recently, and Q&A needs quiet time at home. I will certainly get back to serious Q&A in 2 weeks.

How can I know in advance when a drug will be available as a generic? I saw a note at drugstore.com saying that Wellbutrin SR will be available as a generic soon but no date was given. I asked my pharmacist and she didn't know.

I have a love / hate relationship with the drug companies. I know they have a lot of costs to cover but if you look at the actual prices there's no way they're priced to market; they're priced to be sold to insurance companies. And the games they play with the patent system. It irritates me to no end.

The pharmacists are not much better. A couple of years ago I found out by chance -- in Time magazine of all places -- that an anxiety drug I was taking, Buspar, finally went generic after a bitter court battle. When I went for the refill she handed me the brand name and I asked for the generic. She was puzzled. There's only an $8 difference. I insisted she put the generic in and she gave in.

Several interesting concepts here. The first questions refers to how you know when a drug goes generic. I do not know a specific source for this information. Perhaps an astute reader does. I learn 'through the grapevine'.

Second, the reader comments on patent system games. He is correct. A down side of capitalism and government is that companies will always look for loopholes. They should from a pure financial viewpoint. But I can and should dislike their patent games.

What you don't mention is that pharmaceutical companies systematically manipulate how physicians practice medicine by:

1) not doing the studies that doctors would like performed.

2) publication bias - they don't report trials that are not favourable to selling their products.

3) many, many other ways.

The pharmaceutical companies have a goal - profits. Physicians generally (I will admit to some exceptions) have the joint goals of making money and helping their patients. Once one understands and accepts the pharmaceutical companies goals as a given, then one understands that they need not do studies unless they think those studies will result in a marketing edge. That is why I want a pharmaceutical tax which would fund the important studies.

Ok, I agree there are people in the drug industry who just want to do good.

But then there is.

The Journal of the American Medical Association on April 23 published the results of an incomplete clinical trial for a hypertension treatment developed by Pharmacia accompanied by a "scathing" editorial that criticizes the decision by the company to end the trial before its scheduled completion, the Los Angeles Times reports. In 1996, Pharmacia began to enroll participants in a clinical trial to compare the effectiveness of the hypertension treatment verapamil, marketed as Covera, to less-expensive diuretics and other treatments. About half the participants received Covera, and the other half received a diuretic or a short-term beta-blocker called atenolol. Pharmacia, which had spent about $50 million on the trial, decided to end the trial in 2000, two years early. Dr. Henry Black, dean of research at Rush-Presbyterian-St. Luke's Medical Center in Chicago and the lead researcher of the trial, said that Pharmacia officials decided to end the trial for "commercial reasons." Black said that Pharmacia ended the trial early because researchers could not determine the effectiveness of Covera compared to a diuretic (Maugh, Los Angeles Times, 4/23). According to the incomplete results of the trial, Covera proved no more effective than a diuretic in the prevention of heart attacks or stroke MacPherson, Newark Star-Ledger, 4/23).

This excellent comment needs no response. The sad thing about this episode is that no one is surprised.

I am schizophrenic with regards to the pharmaceutical industry as well. You're right, every rep tries to 'spin' the evidence so that their drug is the best, and your ACE inhibitor example is apt as every rep I talk to is now trying to echo the ALLHAT study (or whatever it was) that said that drug X prevented stroke better than other ACEs.

My favorite example pro-pharmaceutical companies is the vagotomy. As in, 'that surgery we used to do before H2 blockers and PPI's came along.' But when reps start pushing me to say their PPI is the best, I tell them, "You know, I like your drug, but I have to say I like all PPI's. I remember what it was like before we had these drugs and they're all miracle workers."

And I can't really play the outraged innocent, because I have been wined, dined and entertained at the expense of the industry many a time. That would actually make for a great rant. Do you accept such invitations, and what is your opinion of doctors who do?

Great comment, and I will respond to the last paragraph only. I have a $10 rule. I have decided that you cannot buy me for $10. Thus, I do eat drug company sponsored lunch at noon conference. I will not go to dinner a the drug companies expense. Nor will a play golf, or be a "consultant". I have done a few of these in the remote past, but as I thought through my peronal ethics I have decided on this personal costs. The pharmaceutical industry understands influence. They try to influence me, and I try very hard to use less biased sources of information.

Define healthy food.

Here's my problem, lowfat food almost always equal higher sugar food. If I switch my diet to a "healthy" diet I'll be taking more insulin and thus gain weight.

I'm a teacher and our cafeteria provides food that is very high in both fat and carbohydrate. Certainly not very healthy for the middle-aged adult.

We need to do some changes in food labeling. We need to call a serving of server. Look at your average sport bottle of Gatorade. (unhealthy drink for me) the nutrition label is misleading the serving size is in small case and is usually around 2 1/2 servings. Who drinks 2 1/2 servings of the sport bottle of Gatorade. They drink the sport bottle has one serving. Bet people would stay away from it if true servings were on the label.

Same thing goes for any other packaged food. Very few label's show true servings. And also would not hurt if restaurants started serving reasonable servings. Why is McDonald's selling two of things? And try to get them to give you one during those promotions.

I'll leave you with a funny... one of our assistant principals was eating candy, one of those large bags of cherry twists that are labeled a "no fat" food. It certainly wasn't a "no sugar" food.

Excellent comment! I will ask my daughter (who wrote the post referred to herein) for her response. I would say that the challenge of a food tax is arbitrating which foods deserve the tax, and which foods deserve the subsidy. Should we regulate taxes based on Atkins, or Walter Willett, or Dean Ornish? Each expert would probably stress a different list. While I like the proposal's concept, this comment does make us think about the potential problems.

That is it for this abbreviated Q&A. I hope everyone has a great week. Keep those comments coming - they certainly help focus my thinking and make this blog much better!!!

Here I am, back at the Q&A desk - sorting through the comments and questions. As always, the readers provide more material than I can use. Thanks to all who comment and question. Here are my highlights.

I enjoy your site, and noticed that you maintain a listing of "other medical blogs." I thought I'd point you towards my own site, the Ectopic Brain (http://pbrain.hypermart.net ), where I maintain a "What's New" page (http://pbrain.hypermart.net/blogger.html ) featuring news and information about the medical uses of Palm OS handhelds. Just FYI.

I had forgotten this email - but found it this morning. I have added the Ectopic Brain blog to the list on the left. For those who use Palm OS, this will be a valuable resource.

There is a reason why the real stuff will cost more and be more effective, there has been deep and serious research into it, using the best components to achieve the best possible results, generic medication may come from anywhere and the least expensive components will definetely be used. The molecules used in generic may vary just a little bit from the original, but the results will prove the difference between the two. Why pay less for your health? I'd rather buy something less this month and get what makes me feel great and healthy than saving a couple of dollars -or nothing at all -for something that makes me feel cheated and terrible. -Save in shoes, houses, etc, not in health.

This comment is wrong. Generic drugs have the same regulations from the FDA as trade drugs. The FDA maintains a site which provides information on generics - "http://www.fda.gov/cder/ob/default.htm">Electronic Orange Book. As one researches this issue one finds that often the same manufacturer makes both the generic and tradename preparation. I do not understand the disinformation concerning generics. They do work and they do save money.

Regarding your euthanasia position. Amen. But here's another place physicians should absolutely NOT be involved. Execution of the death penalty. How could any physician participate?

I do not think I could participate as a physician. The point is well made, and I believe that most physicians share this view.

I have read through the response from readers on omeprazole.  I find them interesting and strangely one-sided.  About 70% of omeprazole is being is dispensed as the generic, manufactured by Kremers Urban.  Given the millions of people switched to the generic (and many having been programmed to believe generics are of poor quality) I guess I shouldn't be surprised there are many who complain.

Having said that, I have two thoughts:

1) I have no respect for tactics used by the drug industry and wouldn't put it past them to have orchestrated some of these responses.  I worked for a state Medicaid agencies and frequently saw letters orchestrated by drug representatives (standard letter with different doc or patient name) opposing policy changes, and physician and patient letters complaining about generic failure.  Medicaid programs spend millions more for Clozaril (money desperately needed elsewhere), because prescribers demand the brand - all evidence to the contrary. This may sound paranoid, but with the $10+ billion involved in PPI sales, even those companies who hold patents will eventually see their market disappear to generic omeprazole.  PPIs represent a large share of many companies revenue.  Falling sales mean layoffs.  The drug industry is a master at controlling the message.  I have looked in chat rooms used by people with depression and seen drug industry reps pumping Lexapro as a wonder drug.  There must be a law against such action by a drug salesperson.

2) An aside, one of my colleagues complained when she switched to generic omeprazole, it didn't work as well as the Prilosec.  When I questioned her pattern of use, I discovered she took it with the breakfast meal.  When I told her to start taking the omeprazole 30 minutes before the morning meal, the problem resolved.  Many people don't know PPIs should be take 30 minutes or so before a meal.

3) If these are legitimate drug failures, prescribers should be encouraged to report them to the FDA.

Thanks for your rants on drugs like Nexium, Clarinex etc.  Many low income folks are duped by the drug industry and believe they must spend their limited discretionary income on these bogus drugs.   It appears all the ethics have gone out of the ethical drug industry.  Sad.

Often readers say things more elegantly than this ranter. This is such a case.

Well, I'd been dropping hints on my site for a week or so, and this week I made it official. I'm now one of Corante's tech bloggers - they needed someone to cover drug discovery and the like, and asked me if I'd like to come over. My site's been renamed from Lagniappe to "In the Pipeline," which at least gives folks some idea of what it's about.

The new URL is http://www.corante.com/pipeline. It looks a bit different from my old Blogspot site, but that's not necessarily a bad thing. Otherwise, nothing's changing - same topics and style as before. Same weird digressions, same lack of income, etc.

This commentary presented as a public service. I have changed the blogroll appropriately.

I have been switched to omeprazole 10 mg, but apart from slight mouth dryness I have had no other symptoms. On the contrary I am happy with the product; it has completely changed my life after the surgeon botched two hiatus hernia ops (and during the second one, accidentally tore my spleen!)

Anyway all my best wishes to fellow suffers - I know what its like!

By far the omeprazole rant has attracted the most attention of any single rant in this year of blogging. I included this positive comment, since it is in the minority.

I read your artical about patient autonomy. It was an excellent example of a physcian supporting the patient autonomy in the end stage of his life. Your approach to patient autonomy should be implemented as a routine practice.

We (medical school educators) generally are doing a much better job of teaching end of life issues. This education does include an understanding that our goal is to improve the patient's quality of life - as they define quality of life. I am personally impressed with how our students, interns and residents understand these concepts and apply them daily at the bedside.

Consider this: as these figures reflect declining compensation, our youngest graduates are entering the profession with the highest levels of educational debt in history, facing the highest prices for housing in many markets in a generation and have the greatest need to provide for their own retirements at a time of profound weakness in the investment markets. Practice costs have never been higher and the Medicare system is planning to cut reimbursements again next year, after a 5.4% gross cut last year. That 4.2% cut proposed cut will register against many doctors own incomes as double that amount given that other overhead will not be going down. Americans have blithely counted on the energy and durability of the private practice medical delivery system to see to the needs of our citizens. We don't have any real alternatives. Most patients really don't think of the effects of payment cuts except as it affects their copayments and deductibles. That luxury of ignorance may end abruptly and painfully.

This kind of information will travel quickly. College students trying to make decisions about going to medical school (vs. something else) won't ignore these reports, either. How can they? Finishing school with $200K of debt and without adequate compensation to repay the debt and to recover the opportunity costs of lengthy education and training isn't an option for anyone but the reckless and foolish. We want the best but don't want to pay for it, and will sue with abandon when we aren't satisfied. We are playing with fire with this. And we will very likely get burned.

I love C. Henry's rants. They are on target. We (society) are in trouble.

Hi, I was reading your Dec. 14, 2002 post about "Start Jogging" and you mentioned how you got shoes from a specialty shoe store. I haven't heard of any such stores around where I live, but how would you suggest I go about finding some? I've seen ads for a specialty shoe store that made custom inserts for shoes, but I'm looking for actual running shoes. Were your shoes custom made or did you just buy some popular brand like Adidas or Reebok?

We happen to have a specialty running store here in Birmingham. I friend at work suggested I go there. They sell regular brands, but helped me understand which type of shoe I needed. You might be able to figure that out yourself. This article from Runner's World should provide some valuable information - The Best Shoe for YOU! Let Runner's World help you find the right shoe for your running needs

What advice would you give to obese or overweight kids that try to diet or exercise but it never works?

Unfortunately, I am much better at identifying this problem than solving it. Exercise regimens do require self discipline. So does changing ones eating habits. Behavior changes challenge physicians so much that we start to avoid trying - because we get such a low success rate. The only advice that I can really give is to keep trying. Sometimes it takes multiple attempts until a change can really occur.

Was just switched over from Prilosec to the Generic Omeprazole and have been taking for 12 days now. I have had diarrhea and nausea for 10 of those days. Will be seeing the doctor about it soon! Does anyone know if the doctor has to say that the patient must have the Brand or the Generic version? This has been a bad experience!

While I doubt that the generic is the problem, I can answer your question about brand versus generic. Prescription pads give physicians the right to insist on brand name or allow substitution. If you want to pay for the brand name, it is your right to ask either the physician or the pharmacist.

====================

This ends todays session. Try as I might, I just cannot avoid the Prilosec/omeprazole controversy. Without this blog I would not even know there was such a controversy!

Thanks again for the comments and questions. It is nice to know that my ranting induces comments and emails. That is wonderful confirmation that this blog has some worth. Thanks!!!
 

Thanks for the many comments and questions. I pick for Sunday based on my assessment of reader interest, or my own interest.

I am troubled by your answer to one of yesterday's Q&A questions and further troubled given your rant today regarding "When doctors sell out."

Yesterday you indicated the current medical system is flawed in that doctors who make correct diagnoses are not rewarded, but rather are punished when something might go wrong (punished perhaps by being dragged into court). I assume you mean the satisfaction of a healthy patient is not a reward in and of itself, but rather there should be some financial incentive for physicians who make the right diagnosis. That is, because doctors might be "punished" by a malpractice claim, they should be equally rewarded for doing their job correctly. Should the same system be in place for a police officer who stops a crime, an air traffic controller who succesffuly allows planes to land without an accident, for the same pilot landing the plane, or countless other professionals whose only reward is a job well-done and the satisfaction of knowing they did their job well?

Compounding my frustration, is your comment in today's rant about doctors selling supplements when you said "While money is not necessarily the root of all evil, it certainly can cloud one's judgement." Is this the same "cloud" that you propose as a financial incentive for doctor's who perform their job correctly???

I have thought carefully about how to answer this question from a long time reader. He raises some very interesting points, which I will do my best to answer.

I probably did not make my first point clearly enough. In medicine, even when we do everything properly, patients can still have bad outcomes. Unfortunately, sometimes patients (or families if the patient has died) view the bad outcome as the physician's fault. This tendency increases in our "blame someone" culture. Thus, we may have penalties for bad outcomes, regardless of our actions.

In most professions, and indeed in most jobs one receives rewards for a job well done. Promotions occur in law enforcement; higher fees result in law; more business results for a restaurant. Physicians have no such "upside". All generalists that I know already have too many patients. Fees are fixed by the insurance companies. Overhead keeps increasing.

I hope that I have explained the frustration and imbalance here. A job well done does give great satifaction - but only when the outcome is a positive one. We do not need great rewards, but we do need a better system to avoid penalties - and being named in a malpractice suit, regardless of the outcome of the suit - is a huge penalty.

The second question really compares apples and oranges. Supplement selling probably clouds physician judgment. Once once has a financial interest in something one sells, one will tend to sell that thing. Rewards for good work represent a different financial incentive. Here the incentives are aligned with the patient and physician's best interest - the health of the patient. Perhaps my wording was a bit imprecise. The problem I see is when physicians receive a financial reward not for providing medical care, but rather for something which the sell (using their MD as a sales advantage).

While I agree that advertising can have its pitfalls, as a psychiatrist I am pleased that patients come in for
treatment-with me or with anyone else. It has been my experience that very few patients request medications that they have heard about on TV. What they do request is treatment for the condition that they learned they were suffering from when educated by the advertisement.

Currently, only 50% if depressives in this country receive a diagnosis, half of those receive treatment and only 8 per 100 patients with depression are currently treated to remission (the currently accepted standard of treatment).

If residency programs do not train physicians adequately in the recognition of mental illness, and as long as some doctors still refuse to diagnose or treat it, then the most effective way to assure treatment will be consumer-driven. I applaud those companies that continue to advertise antidepressants on TV and would also like to note that these companies are amazingly philanthropic in their willingness to provide free medication for the indigent. We also rely heavily on them to continue to put money back into research to further decrease the mental illness burden for future generations.

I posted this comment just for the alternate viewpoint! Psychiatry may represent the main area of benefit for these ads! As a generalist, I do not want to argue about Nexium or Celexa. I do understand this psychiatrists point - and it is well stated - but I do not find it generalizable to most medical conditions.

"it is our right and who is to decide you have to live in pain "

This comment refers to a post on euthanasia from last May! I personally cannot accept active euthanasia as an option. Passive euthanasia is perfectly acceptable. Let me try to clarify.

I care for terminally ill patients regularly in the VA hosptial. When we have such a patient, we make a complete assessment of their quality of life issues. We can do a good job of treating pain and other symptoms.

I would never give a patient a narcotic dose with the purpose of ending his/her life. However, I will give a patient enough narcotics so that they do not have pain, even if that dose could possible stop respirations. This line, in my mind, is very clear. It has to do with intent. I will allow a patient to die in peace; I will not purposely cause a patient to die.

I find the latter a slippery slope. Once we (physicians) cross the point so that we help patients die, we will always have difficulty defining acceptable criteria. How does one develop criteria to prevent physicians from using euthanasia too "loosely"?

Thus, I remain on the side of aggressive palliation - for those interested read this rant from last October - More on palliation .

Re: Statins and muscle pain

Should endurance athletes ( say a triathlete anticipating a 6-6.5 hour maximal effort in a half ironman race ) stop their statin prior to the race? If so, then for how long? Incidently, races of this length and longer can cause elevated CPKs and in some cases mild elevations in cardiac CPK levels. This data makes no mention about pre-race statin ingestion.

I wish I knew the answer to this question. Someone should perform a study, perhaps at first during a 10K. I suspect (having no data, just hypotheses) that most patients would have no problems. But I really do not know the answer.

Well, anecdotally (is there such a word?) speaking, I probably still won't volunteer. I get one mild cold once a year, and "walking pneumonia" about every fourth, but the worst was the last time I took the vaccine. I prefer the pneumonia.

Probably idiosyncratic, I do not discourage others from taking it.

This comment represents the problem physicians have in promoting prevention. Patients (and sometimes physicians) rely on anecdotes rather than data. This process is known as the availability heuristic . You can read more about the heuristic - Availability heuristic

Definition: A heuristic or "rule of thumb" strategy biased for estimating probabilities (of past or future events), based on how easily the related instances of that event come to mind.

Example: Although diseases kill many more people than accidents, it has been shown that people will judge accidents and diseases to be equally fatal. This is because accidents are more dramatic and are often written up in the paper or seen on the news on t.v., and are more available in memory than diseases.

Background: People use heuristics to solve problems or reduce the range of possible answers to questions. Although at times it can result in the correct solution, the availability heuristic can also result in erroneous solutions to problems/questions. In using this rule of thumb, people judge frequency based on a quick count of examples. The use of this strategy is very widespread, and is used in making both trivial and important judgements. People tend to overestimate the frequency of certain rare events if they are dramatic and sensational and underestimate those that are more frequent but occur in private, ordinary situations. This appears to be because the rare, dramatic and sensational events are more easily available in memory.

The reader is wrong. We have many studies which show clearly that flu vaccines do not cause illness. But I doubt that I can convince him.

SARS is a respiratory ailment. If a person is very fit, doing a lot of cardio to strengthen the heart and lungs, are they less likely to succumb to such a virus?

First, we really do not know enough epidemiology to fully answer this question. In general, with any viral infection, host factors have great importance. I suspect that being fit improves ones odds, but this virus does act very aggressively in a small percentage of patients.

As an RN who just recently recieved her MSN in nursing education and would like to go into teaching other nurses the profession, it is really hard to leave the bedside knowing that I will make less money. THere needs to be more incentive to get that higher degree. As far as replacing the number of nurses we need through enrollment, that will be a long process, but the problem took a long time to evolve, it may take a long time to solve also. The problem is going to get worse, and the more qualified nurses we do produce, the better care for patients and the society we live in. 

AMEN!!!

I am a Human Resources Staffing Specialist who also happens to be a college student. I'm doing a research project on the 80-hour workweek and I'm trying to get some additional information. Do you happen to know where I might find how hospitals are going to comply with this rule? At my hospital, a large academic medical center in Philadelphia, we are planning on utilizing nurse practitioners and physician's assistants to make up the difference. My project is going to focus on how hospitals are planning to make up the hours lost by the residents as well as a cost analysis. Obviously, this rule will have a major financial impact on hospitals, large and small.

Tip O'Neill (from Speaker of the House) once said - "All politics is local". I suspect that you will find a wide variety of solutions to the 80 hour workweek problem. You will find variations within the same hospital. Let me try to clarify a bit.

Most medicine and pediatric programs will make minor modifications, being fairly close to the 80 hour work week already. Radiology, anesthesiology and pathology should have no problems. Surgery programs will have the greatest problem, as they are currently the most frequent offender. I suspect that many programs have not really determined how they will address the new rules. And some will try to ignore these rules (see last week's Q&A for example). Good luck in your project!

Final comments

Thanks again for the many comments and questions this week. You, the readers, make me think, keep me honest, and make this blog much better. As usual I apologize for not answering all questions or highlighting all comments. I have decided to avoid the omeprazole controversy as I have nothing else to add at this time.

Now it looks like a beautful morning in Alabama - off to the golf course (I know that is a cliche for a physician - but I really do love golf)!

Sitting here, back at the Q&A desk. Today I will share both questions and comments. Receiving these comments provides a great reward - it tells me that some readers really care about my rants. And that is a wonderful feeling!

Reframe the discussion how ever you feel is convenient. The bottom line is state medical boards do a pretty lousy job of patrolling the profession for substandard care, based in large part on failure of professionals and health service organizations to self-report problem physicians, and budget and staffing support received from state legislatures. And responsibility for budget and staffing support limits, as well as limited grounds upon which to trigger an investigation or disciplinary action, can be placed at the feet of the provider interest groups.

This represents one of my excellent comments from the Bloviator (you should read his page regularly - just look over to the Medical Blog list). He forwards an interesting viewpoint on self-policing. I hope he is reading this rant - do lawyers do a good job of self-policing?

He points out that State Medical Boards do not receive adequate funding. Thus, they have difficulty becoming proactive in searching for "problem physicians". He has served as counsel to a State Board - so I would not dare challenge him on that point.

However, I believe this issue is indeed a side issue. Our problem stems from how our society defines and pays for malpractice. The entire concept of punitive damages is quite problematic. How can anyone adequately define those?

As I (and many readers) have said repeatedly, the problem with malpractice settlements should concern everyone. If malpractice premiums and rewards continue to rise, then no rationalization for the high rewards will matter. If physicians cannot afford to practice, then patients will really suffer. In some ways we are considering the penalties for errors of commission, and as a society ignoring the costs of paying those penalities.

I empathize with true malpractice victims. However, our current system works more like a lottery than a true check and balance.

Trial lawyers are the problem here. We need an alternate system for judging and paying for real malpractice. Our health care system really does an excellent job of caring for most patients. But we never get extra rewards for great care. When we make an important diagnosis or help a patient through a crisis, we receive the same fees as when we care for a more straightforward, simple diagnosis. If the patient has a bad outcome (even if we really did everything right), we just might get sued. That cannot make sense to anyone. Our system of judging malpractice is broken. The penalties for malpractice are broken. As a result, medical care actually suffers. The current malpractice system discourages improvements in health care.

I am a second year general surgery resident at a busy metropolitan academic center.  I enjoy reading your medrants whenever I can find the time.  Major kudos is due to you and your site.

You have written often about the 80-hour workweek issue.  I agree with most of what you have written.  I can tell you though, from my own experience and from talking to friends that I have in other surgical residencies around the country, that compliance by surgery programs will be very poor.  My program director has hatched a plan of pseudocompliance.  "You can go home 6 hours after you finish call if you want to, but everyone else is staying.  By the way, if you stay to work extra, its on your own time and you can't count it on your timesheets."

 This comment does not surprise me. I suspect many surgery programs will try such tactics, and some will get caught. Such programs will probably penalize residents who do not play their game. But if they fire those residents, the residents will likely sing.

Surgery programs have attitude (yes I know this is a generalization - but many colleagues around the country confirm that generalization). They truly believe they understand training better than any outside group. Some programs will comply; some programs will have the above attitude. We will have to follow the changes in July to see which specialities adapt well and which struggle.

An endoscopy the other day revealed "very mild" gastritis (probably from taking Advil on an empty stomach), also "very mild" esophogial irritation from a bout with heartburn that I had during a particularly stressful period several months ago. The doc, who is does a great job with the endoscopy, does not do such a good job with followup and simply gave my husband on the way out a script for Nexium, with little direction. I have so many questions! First of all, I have lowish platelets, around 100,000. Does Nexium, like Tagamet, interfere with platelet counts. Secondly, is this drug really necessary??? If both problems are "mild," and if I really don't even feel heartburn anymore, can't I a)change my behaviors and cure the gastritis and b)assume that the esophagial damage is from an old problem and that the esophagus will heal itself, given time? By the way, I am a 47-year-old woman who takes no scripts, who hates taking pharmaceuticals and likes to believe she can heal herself holistically -- until something life-threatening comes along, at which point I will be grateful for life-saving drugs. I don't see this situation as a life-threatening one. Thanks for listening and for whatever advice you can offer.

Thanks for the question. Giving advice on medical issues without actually talking with a patient and examining them and their medical record is a bad idea. Thus, I will couch my answer in generalities.

I am not aware of proton pump inhibitors (the class which includes Nexium) causing problems with thrombocytopenia. A quick search did not find any such problems. Tagamet is a histamine-2 blocker - a different drug class.

Not knowing your history of gastritis and esophagitis, I can make no comments on treatment. If you truly have endoscopic evidence of esophagitis, then I doubt holistic treatments will work. In general weight loss does help esophagitis.

If your gastroenterologist does not discuss your diagnosis well, you might try going back to your internist or family physicians. They should be able to sit down and discuss your management strategy. If you do not have a generalist, you need one (as I rant about regularly).

"We teach residents to consider a complete differential, but to concentrate on the four most common diagnoses - undiagnosed asthma, ACE inhibitor cough, post-nasal drainage, and gastroesophageal reflux disease (GERD)."

How about chronic bronchitis?

This comment came from a rant about cryptic cough. I did not make clear that I was talking about cryptic cough. Chronic bronchitis, in my experience, is rarely (if ever) cryptic). These patients have a productive cough and fit into a classic syndrome. If we take all cough presenstation, then chronic bronchitis is an important consideration.

I knew one attending whose favorite retort to the "natural" argument was to snap, "Well, poison ivy's natural
too!"

Well stated.

and what about the "natural course of an illness?" We all know that over 90% of common maladies like Otitis Media, Sinusitis, and Pharyngitis will resolve with NO intervention. Try saying THAT to the next patient with a runny nose who asks for a "natural cure."

While I do think we should prescribe antibiotics for bacterial otitis, sinusitis and pharyngitis, I agree that we are too quick to give patients antibiotics for viral infections. Why do we do this? It saves time and the patient expects it. I have always tried to avoid this behavior. Unfortunately, I see too many colleagues, residents and even students who start "a Z-pak" whenever they get a cold. We need to do a better job here!

A pre=emptive apology for this rant.

This is old news to the average otolaryngologist. OVERHWELMINGLY, patients who I see for chronic cough have underlying GERD. I'd guess that 80% have GERD, 10% have chronic sinusistis, and then there are about 10% "other." Most are not difficult to diagnose on history alone (not to sound facetious- most are easy to diagnose my simply LOOKING at them). Chronic sinusitis is easy to rule out- order a CT scan. The only problem you'll run into in that regard is that our radiology colleagues have a penchant for overreading these scans. (I would LOVE to see a blinded study of sinus CT scan interpretations by radiologists. I would wager that you'll get a substantially different interpretation by 5 out of 10 readers.)

I have a pet peeve: I IMPLORE my generalist colleagues (and others) to stop using the term "post-nasal drainage" so flippantly. I peer into pharynges every day of my working life (X 20 years) and I can tell you that it is RARE to actually spot any kind of discharge trailing down the posterior oropharyngeal wall. The only other time one sees this is as a subtle finding on endoscopic exam- a modality that is not available to the average generalist. I'm constantly astounded at how many patients come in telling me that their Primary care doctor "spotted drainage down my throat." Don't you find it odd that everyone and his cousin talks about "post-nasal" drainage" and yet this is not a term that is loosely used by the one specialist in human medicine who ought to know the most about it?

Sadly, most of my day is spent UNDIAGNOSING "sinusitis." These patients are almost always complaining of facial pain (shockingly, predominantly female, often depressed; usually with a background history of headache and other pain syndromes) i.e. "another sinus infection" and/or "post-nasal drainage" i.e. almost always symptoms of GERD. Is it any surprise that they don't get better with antibiotics? And the ones that do are often responding to a placebo effect.

There has been, and continues to be, a lot of gold to be minded treating "chronic sinusitis" surgically. Please spare your patients needless antibiotics and surgery. Concentrate on SYMPTOMS, not preconceived diagnoses. If you do, you'll almost always come upon the right assessment the first time.

Sometimes readers have better rants than DB. This is a great example. Thanks to Dr. Kranky for this post!

Do you know of a medical study on use of Singulair for people with chronic sinusitis? I do not have asthma but have had injections for years, had 2 sinus surgeries and suffered 10 years of infections every 3 months (average). I've slightly improved via acupuncture, but still need help. (It does not help living in the humid Washington, DC area) 

First, read the comment about. Second, do you have chronic sinusitis or allergic rhinitis, or both. If you have allergic rhinitis, then Singulair can help (but is not better than nasal steroids). You might benefit from a fresh look at your symptoms and treatment. Again, not talking with you and having access to all your records, I cannot completely answer your question.

One way to calculate the benefit is to measure the number of specialty referrals generated in a "shared" practice vs. the model that most of us feel is more beneficial- per given condition (or tentative diagnosis). AND factor in the number of visits to each primary care model BEFORE the referral was made.

It's been my experience as a consultant that too many conditions were turned into "chronic" or "complicated" this or that, simply because there were 3, 4 different primary care physicians (sometimes PA's of NP's) on the given patient's care.

Another excellent comment which complements (in my opinion) the point I tried to make. Continuity certainly has important benefits on satisfaction (for both patients and physicians). It also often leads to better care. I agree with the comment, although I do not know of a good study to confirm this observation.

...

Once again, thanks for the comments and questions.  
When there is no continuity in the thought process on a given patient's situation, is it any surprise that delay
and anxiety result?

How am I suppose to chose? Am I prepared to die on the operating table, NO. Do I want to die slowly by staying 362lbs, NO. So now what? I know most people think obese people should be able to just stop eating and the weight will come off, but it doesn't work that way for everyone. Me being one of those people. I have a 12 yr old son that I want to live for. I want this surgery but how can I say, as I'm being wheeling into surgery "see you soon" knowing that he may never see me again..all because I want to be healthy. I'm so confused!

This eloquent paragraph defines the problem of obesity. You know that your weight is a major problem, yet cannot succeed with conventional methods.

Most physicians and readers do have difficulty understanding your situation. Peronally, I have succeed in modifying my diet and enhancing my exercise program. That must not work for you.

So what are you to do? No one can make this difficult decision for you. When does one risk everything (albeit a low probability) to gain everything? I can tell you that on average having surgery will benefit you. But averages work for populations, not for individuals. Talk to some surgeons who specialize in this surgery. Interview them, and they might help you with your decision making. Good luck - we all hope you make the right decision for yourself.

I'm not a doctor... my wife has Atrial Flutter. She feels much better in Sinus Rhythm. So isn't it a good idea to have "rhythm" control just from a quality of life point of view?

And if she is in sinus, are the data clear that she should still be on warfarin? How about going back to warfarin if she should go into AF, but otherwise don't take it. She's been in sinus for several months now.

Thanks for this interesting question. Let me first describe the difference between atrial fibrillation and atrial flutter. Heart rhythm normal starts with the atria (the 2 smaller chambers) contracting, and very soon thereafter the ventricles (the larger chambers) contract. In normal hearts these contractions synchronize to maximize blood flow through the heart and out to the body.

Atrial fibrillation occurs when the atria no longer have coordinated contractions, rather they fibrillate (fibrillate refers to the act of fibrillation - muscular twitching involving individual muscle fibers acting without coordination). Thus, the atria "quiver" but do not send coordinated impulses to the ventricles. The ventricles receive irregular signals to contract. Thus, the rhythm becomes irregularly irregular.

One danger of atrial fibrillation comes from the "quivering" in the atria. Since they do not contract properly, the blood tends to pool, allowing coagulation to occur. (oops another medical term - coagulation means that clots can form). The clots are the problem. They can grow to a large enough size that they cause problems when they "break loose" from the atria. Thus, the risk of stroke in untreated atrial fibrillation.

Atrial flutter is a different rhythm. In this rhythm the atria do have coordinated contractions - usually at a very fast rate (think around 300 times per minute). This atrial rapid rate is usually modified by the electrical connection to the ventricles (what we call the AV node). The AV node handles the electrical impulses from the atria - passing on a signal to the ventricles to contract. A rate of 300 is too fast to pass on to the ventricles. Usually every other or every third signal gets through.

Because atrial flutter usually causes symptoms immediately, most patients receive treatment to restore sinus rhythm. The unusual patient with chronic atrial flutter does have some risk for thrombi and emboli (blood clot terms - thrombi when they form - emboli when they break off and flow elsewhere and cause problems).

When atrial flutter is succesfully treated, anticoagulation is generally not needed. If it became intermittent one might anticoagulate (especially if the patient alternated between atrial flutter and atrial fibrillation).

I hope this complex answer helps.

I just started taking Zetia after a muscle bout with Lipitor. What side effects will I have with Zetia? Hope to hear from you.

Having not yet treated any patients with Zetia, I have to look this one up. The FDA says stomach pain and tiredness can occur. FDA information on Zetia. I hope that helps.

Will the vaccine prevent other hpv like common warts and also when will it be available?

Great question, which I cannot answer! I suspect that the vaccine will prevent some warts - but will probably only work against a small subset of HPV strains (those which most commonly cause cervical cancer). I have no idea on the timetable for this vaccine.

Well, maybe. Services are services. But what about the consumer? I am facing 4 or 5 hours of work to sort out insurance problems caused either by the insurance company or by the doc's office. I've got a dentist who has filed 4 times for the same services (and was paid fully), and an internal medicine practice that just billed the insurance co. for services 8 months ago. Straightening this out will cost me 3 or 4 hours of weekend time. And no reimbursement! :) I have to go through this two or three times a year.

First, thanks for the comment, and I do understand your frustration. The object of your frustration is the insurance companies not the health care professionals. Why should we charge you for filling out forms? Because we are running a business and time is money! The forms that I imply are extra forms. Another comment states it well -

I am all for it. (Speaking as an MD.) Doctors spend huge amounts of time filling out these forms. I'm sure I don't have to convince *you*, but here is a partial list:
- Disability forms
- Jury duty forms
- health clearances for school, work, prospective adoptive parents
- Life insurance forms (death claims)
- Letters to health clubs allowing patients to get out of their memberships
 
It's unbelievable. It adds a significant amount of time to the time spent in the office. I think it's time to start charging.

And that is the point of the rant.

And is use of hormones also a placebo for those of us who have had hysterectomies with oophorectomies, or those twenty-somethings in premature menopause? Since we are lumped in with all other women and all conceivable forms of hormones are now too dangerous to use (and goodness knows there are no side effects or risks in the antidepressants, bone-density enhancers, statins, antihypertensives, false teeth, dried-up-eyeballs, and, let me not forget, copious helpings of KY to "treat" that vag atrophy that we'll be switching to), I can only guess not.

Gee, if hormones are that evil, maybe women should ALL have oophorectomies before menarche. Think of all the problems that would prevent!

Premature menopause and oophorectomies represent a totally different situation than the studies address. One difficulty in medicine is the balance between belief and data. I prefer data. We must criticize studies carefully, but then understand what they tell us. I would prescribe hormonal therapy to patients with oophorectomy or premature menopause until around 50 years.

With specific reference to vaginal atrophy, I understand that vaginal estrogen does help a great deal. Also, continued sexual activity seems to retard atrophy.

...

Thanks for the many excellent comments and questions. I hope some of these answers are helpful. And thanks for reading!!
 

First, let me apologize that this will be an abbreviated Q&A. I have many good questions sitting on my home computer. But, I am visiting friends in Richmond, Virginia, so I only have access to questions since Thursday. I will address a few questions today - and hopefully start catching up later this week.

hi, my husband cannot take statins of any kind due to the severe muscle symptoms, and the elevation of liver enzymes during a course, what are Zetia's side effects if this drug is taken alone. His cholesterol is 9.9. and has the inherited gene.

This is a very fair question. I did not know the answer to this question, but through the genius of Google I can provide a good reference. Zetia Side Effects

For what? These are grown men. They clearly know the risk. Their own friends and colleagues have died from this supplement, and yet they continue to take it. If we were to ban ephedra somehow, they'd just find something else to take, rather than perhaps cutting down the number of pancakes they have at breakfast. I'm all for education, but when your buddy dies from a drug that you yourself are taking, don't you think that'd be education enough?

This comment raises an interesting point. How far should we go to protect consumers? While I understand the reasoning behind her argument, I believe it to be an oversimplification.

We have many potential users of supplements. Athletes will find performance aids, legally or illegally - as Ron Dibble explains - On Steve Bechler's death . While one would think that athletes are "grown men", I doubt that they often act like them - but many would argue grown men may be an oxymoron. Can they really make informed decisions about supplements? I read where a baseball star argued against banning ephedra because "it is legally and OTC".

Even if I grant you that they should be able to take the risk, what about college athletes, or high school athletes, or just anyone trying to lose weight. And what other supplements are putting us at risk. We should all know about ephedra now, but I doubt that we do. The information on bottles is imprecise and uninformative.

So, I will stand by my previous rant. We need to revisit the dietary and supplement act of 1994. We should not allow marketting of dangerous ineffective supplements.

...

Well that is it for the abbreviated Q&A. I owe the readers more answers. I will catch up. I will catch up. I will catch up.

After travelling all day (LA to Birmingham), I finally sit down to a large number of excellent questions and comments. I may have to do a second Q&A later this week. Here are some highlights.

While this is an easy proposal to attempt to marginalize as impractical or unfavorable (or socialist), fortunately, this is not the only universal coverage proposal being discussed right now. Howard Dean and Dick Gephardt both offer universal coverage planks in their presidential platforms. To pull a quote from a Los Angeles Times article appearing today, "To me, what's exciting is that the universal coverage debate is back on the national agenda. That in itself is huge."

I respectfully disagree. I really do not think that universal coverage is really back on the national agenda. Yes, our health care system needs a boost, but this debate will not provide a constructive contribution (in my opinion).

Perhaps this type of thing must be allowed, but if the case is not proven to the satisfaction of both judge and jury some penalty should be exacted.

Alas, someone will eventually "win" a case on an emotional basis. If not against McD or other fast-food outlet, then against their suppliers or the ranchers and farmers.

The reader makes a powerful suggestion. What if these suits carried a penalty for losing? A losing suit does create costs to society and to the entity sued. Should there be a penalty for losing suits? Perhaps our friend the Bloviator can rant back on that one.

I appreciate your opportunistic jabs at the pharmaceutical industry--they are big business and thus an easy target. Historically speaking, any industry (US Steel, Microsoft, Standard Oil, etc. etc.) which turns a profit at greater rates than other businesses is made to feel that it is doing something wrong, either by the media, the government, or consumers that support it. It would prove to your readers that you truly are against the extravagances of the industry if you printed those stocks in your own 401K minus the dollar amounts) --I personally would be interested to see if pharma stock is absent or for that matter, any health care stock (particularly managed care stock). If you are like most doctors, most all of you benefit via retirement plans, annuities, ROTH's, etc from the profitabilty of an industry that you love to hang in effigy each and everyday. Most of you take great pride in claiming that you don't support the gifts, company incentives, and marketing ploys; however the purchase of stock in these companies makes your rage against them comical and nothing short of hypocritical. I have yet to meet a doctor who doesn't know what is going on with Pfizer, Merck or J&J stock. Why is that?

This is a fair critique. In the interest of full disclosure, I have no idea what stocks are in my 403(b) (working for a medical school I have a 403(b) rather than a 401(k)). My money goes into TIAA-CREF as mutual funds and bond funds. I do not know what stocks they buy. I have never bought a pharmaceutical stock, and believe that to do so would be personally unethical.

I was on Prilosec; harmacy gave me the generic - yep- Omeprazole! I had stomach aches for a week, and then had an "episode" with acid-the pain was so gut-wrenching, I was doubled over and in tears. To top it off, I gave the pills to my husband (who is on Prilosec too), and after one pill, he had a stomach ache three hours later! Who listens to these stories? How do we know the "right" people are hearing this AND can do something about it? I also want my money back!

As I have previously said, we do need a study of this issue. Knowing the chemical and the FDA rating, I remain skeptical. However, I continue to get many comments on this issue. I will remain vigilant for any news concerning generic omeprazole (brand name Prilosec).

Boxing is only dangerous when not played by professionals

Wrong! Boxing has as a goal creating brain damage (for that is what a knockout is). Amateur boxing is much safer than professional boxing. Nontheless, both should be banned (if I were the king of sports).

Did it ever occur to anyone that maybe the insurance companies should have a cap on their costs? Why should a patient who loses an arm, a leg, or worse have a cap put on the damages that they can collect? Oh, yes, I know, if we penalize the insurance industry it will jepordize our free enterprise system. Oh, heavens!! Far better to limint the awards those "little" people might collect for an incompetant doctor.

I do understand the desire to penalize the "incompetent doctor". Several problems exist in this response. The first is the assumption one makes of incompetence. Can a jury really judge medical competence? Sometimes yes, but not always. The next problem relates to the impact of large judgements. As a society we must balance the individual good with the societal good. Large malpractice awards penalize the innocent physicians and therefore their patients. The money must come from somewhere, and it is not coming from the physicians, even if he/she did commit malpractice.

The large damage awards and resulting high insurance costs may partially repay the public for the huge amount of time the doctors force us to waste. The money is just not distributed correctly.

Go into any doctor's waiting room and you find numbers of patients waiting, wasting time. A 2:00 o'clock appointment usually keeps you sitting for an hour or two in the waiting room, then half an hour or so in a small, sterile treatment room, finally about ten minutes with his eminence. This costs you a half days work. No wonder juries go against doctors. The jury members have been mistreated in this way too many times.

This comment uses gross generalizations and comes to illogical conclusions. First, most juries find in favor of the physician. Second, the reader is partially right - ideally we would rather not keep you waiting. Sometimes the exigencies of practice do cause these delays. Most physicians would like to see you on schedule, but we must "squeeze in" other sick patients, or have patients who need more time than we scheduled. I do understand you angst and hope you can find a physician more suited to your schedule.

...

More at a later date!

Back to questions and answers. I have several themes to discuss today. I hope to shed more light than heat - but you never know.

 DB, I fear your editorializing has overstepped your great capacity for logic. The plan does not require that insurance companies reform their rate-setting practices. Therefore, at best, it offers an extremely limited possibility of a solution.

But what do I know? I'm just an illogical lawyer. :)

First, thanks for providing the answer within your comment. Second, I do like the lawyerly technique of starting with flattering and then smashing me hard!

I admit to not being an expert on rate-setting practices. Lawyers seem to continually focus on this issue when malpractice rates are discussed. I assume that like political parties, someone gave all lawyers a set of "talking points" to use when the malpractice issue arises. Another comment on this rant shared this point.

In the state of Pennsylvania, for every $1 in premium collected, insurance companies have paid out $1.38. So they left the state. As long as legal expenses continue to rise, so will premiums.

Blaming the insurance companies is a smokescreen.

We obviously have a Mars/Venus thing going on here. I am certain that malpractice rates are having, and will have a negative effect on health care. If we do not develop a solution, we will have less physicians in many areas. It will impact the decision to enter medical school (remember it takes from 7 to 11 years after entering medical school before you start paying those rates). The malpractice crisis raises costs (defensive medicine) and damages the doctor patient relationship (from the doctor's side). We need lawyers to help us find a solution, but alas I see only talking points.

WOW...I thought it was my imagination about the generic. I unlike others am paying less for the generic, but then again, my insurance company isn't paying that much for the Prilosec so therefore, the generic in my case is far cheaper. I am also experiencing some major reflux symptoms when a friend swears that the generic has ALL the same ingredients, anyone else on my side???

I certainly get many of these comments and queries. Generic omeprazole is taking the blame for everything short of Saddam Hussein. I can find no studies of generic omeprazole. I refer to last week's research on the FDA web site. Someone should do a double blind crossover study. One problem occurs that everyone should consider - the placebo effect. In drug studies, placebos have many side effects. We tend to blame changes in how we feel to linked temporal events (like switching to generic omeprazole). It may or may not be the cause.

If one is really concerned, I suggest and N-of-1 trial. In such a trial, one would keep a notebook and go through periods on the trade name drug, alternating with the generic drug. The key here is blinding. Somehow, you must not know which one you are taking! That could prove to you whether the generic in some way caused your symptoms. I would bet against it - but then I am a betting man.

Spreading the pain around or one more deep pocket to pick? I generally am not sympathetic to HMOs as one who has too many times ended up with the short end of the stick in my dealings with them. All the same, this seems like a judgment that is a lawyers' relief act, making open season on a class of defendants that are particularly unsympathetic (which the trial lawyers will like) and which until now have escaped civil accountability under arcane federal law loopholes. That being said, nothing comes without a price. I expect that the underwriters for the HMOs will be busy recalculating their premium schedules to account for their newly affirmed exposure. So raise the premiums. And expect new HMO contracts to contain stiff arbitration agreements, hold-harmless clauses and other terms that place doctors who do business with them at risk for the HMOs' acts. One more reason not to do business with them, if you ask me. How will this pass as the Bush administration tries to tie prescription drug benefits to managed care contract enrollment?

Well said, and it spurs a few comments. I, like many physicians, have felt great frustration with HMO decisions about medical care. They could make seemingly arbitrary decisions about what I could or could not prescribe or what test I could order. This decision makes them accountable and balances the scales a bit.

I agree that not doing business with managed care organizations makes a lot of sense. Given today's health care climate, I suspect increasing numbers of physicians are taking that step. I see the reign of HMOs on the wane. It does raise significant questins about a prescription drug benefit plan.

It is about time there were some teeth put into the resident workweek limits. As one whose surgical internship year had quite a few 120+ -hour weeks, I couldn't recommend that experience to anyone as something beneficial. Setting aside the usual self-denying surgical machismo that wants to shout "wimp" at complaining co-residents, the hard truth is that not much extra learning takes place for that 50% increase in the workweek (over the 100% increase from the rest of the world!). And it isn't safe, not least for the patient. At the time of my residency, a decade ago, the only specialty organization to have done a legitimate study on resident performance and workweek and shift length was anaesthesiology. Their study prompted them to limit shifts to 24 hours. No other specialty wanted to repeat a similar study for their residents, perhaps for fear of knowing the truth. It also isn't safe for the resident, chronically in sleep debt. I know of my own microsleep episodes driving at speed on the freeway home, and the automobile accidents of my internship classmates (thankfully, none injured). These were responsible, hard-working people pushed beyond their limits of safe endurance, who unfortunately worked for an employer--in this case, the United States Navy--that just didn't want to know the truth.

Not much to add here. We have had the goal of an 80 hour work week in internal medicine for the past 5-6 years. It does help. Watching how residencies deal with change this summer should be very interesting. Hopefully, it will improve the personalities of many residents.

The MSNBC article said "DEPRESSION WILL affect about 10 percent of women and five percent of men sometime during their lives." These numbers seem low to me (no pun intended). Perhaps a Sunday Q and A re: this? 

Ask and ye shall receive. I believe these numbers for clinical depression are fairly accurate.

I glanced at Alex's site at one point concerning this topic and appreciate the different point of view. I don't know how it is for other people, but for me, antidepressants have literally been a life saver. I've been on them for years and every time I have tried to stop them, I end up in the same frame of mind. Merely reducing the dose causes a relapse. Clearly they don't work for everyone. I'm glad they work for me.

This comment reflects my clinical experience. I do not have access to the entire Lancet article, but I did find the summary. Their summary makes sense.

Antidepressants reduce the risk of relapse in depressive disorder, and continued treatment with antidepressants would benefit many patients with recurrent depressive disorder. The treatment benefit for an individual patient will depend on their absolute risk of relapse with greater absolute benefits in those at higher risk. Further trials are needed to establish the optimum length of therapy and should include patients who were not well represented in these trials, including those at low risk of relapse.

Well that is it for this week. Next Sunday's Q&A will appear late (travelling most of the day from California). Keep those excellent comments and questions coming!!
 

You keep posting great comments and questions. Some comments deserve this stage and I will have little to add.

This, I think, is the area most neglected by physicians in their practice. I have personally experienced, and been told of experiences, in which the patient or the patient's family were treated as troublesome, stupid, interfering nuisances who dared to question, disagree, discuss or otherwise impune the 'wisdom' of the white coat.

While waiting in the closed door, windowless examining room, I have felt that I am in an assembly line. When I have waited more than 20 minutes, and dare to query staff on this delay, I am treated as if I spoke against a GREAT SPIRIT and am seldom given any relevant information about the delay.

I have been seen by specialists who seem to forget that the body part or function in which they are interested is part of a whole person. I have had my 'story' ignored, while the physician rushes through her or his mental list of rule-outs, data sets, and hypothesis checks. Yet, often, it has been the 'story' that contains the reason(s) for the problem.

Advances in medical technology, basic sciences, and other arenas provide wonderful tools and treatments. But, there always is a complex, integrated, mind-body person who comes seeking a partner in finding health.

This comment beautifully should remind us about doctoring. Doctoring is not just knowing a lot. It is not just making diagnoses or prescribing medications. Doctoring requires engaging the patient to develop an approach to diagnosis and treatment. Patients recognize good doctoring. Payors do not.

Maybe. Then again, it is possible that another scenario will prevail: large groups that use not medical doctors but nurse practitioners and physician assistants as the principal providers, with smaller numbers of doctors acting as supervisors and consultants.

Several reasons lead me to see this as one way things will go: the model has been tried in institutional settings for several years--the military, for one-- and nurse practitioners have already obtained considerable practice latitude and independence, even forming practice groups independent of doctors. Cost controls will be a relentless requirement, and even if the sway of graduate training interest again turns more favorably toward generalist physician training, there still has to be a way of paying for that kind of primary care. More likely there will be a greater split between high and low option services, with primary care services provided by well-paid internists enjoying a less stressful practice schedule being available only to those able and willing to pay for that quality of service.

The definition of primary care holds the key to this problem. What is primary care? Can physician extenders provide it? If primary care means 'simple care', i.e., care for minor episodic illness, hypertension control and preventive examinations, then the comment makes sense. If one uses the original Institute of Medicine definition - "accessible, comprehensive, coordinated and continual care", then I do not believe that physician extenders will suffice. Once the patient has multiple diseases, then physicians make a major difference. Take our average VA patient with diabetes mellitus, hyperlipidemia, coronary artery disease and worsening renal function. This patient needs a good generalist.

I do believe the pendulum will shift, and I do not think that we can or should replace physicians.

As the Pima study indicates (if not proves) exercise and diet will cut down on obesity. But as it also shows, some are not much helped even by that.

Should we patients try diet/exercise/lifestyle changes? Certainly! For many it not only works, but can be satisfying in itself.

Even if there were a med that would magically take off weight, losing that weight - in any manner - might encourage lifestyle changes as well.

Let me make few comments about this well stated comment. First, we should not fear research into the genetic bases of weight control. Some people seemingly have no difficulty with weight control, while others have a life long battle. Understanding the genetic bases will allow us to better treat those with a genetic predisposition to obesity. I suspect that we will see increasing research and results in this area.

Even when we succeed with genetic understanding, we will still have diet and exercise as important subjects. Many can not blame their weight on genetics. When I become a couch potato, I can easily become a size 38. With diet and exercise, I am a size 35 (and hopefully soon a size 34). My genetics have not changed, my attention to lifestyle has. Almost everyone improves their health (or at least odds at good health) when they eat smart and exercise. I believe that genetic understanding will help those people with major genetic influences (like the Pima Indians) to succeed with normal efforts. Remember, a fit overweight person does much better than a deconditioned overweight person.

Alas, Dr Centor .. you miss the point. Canada spends a fraction of what we spend on healthcare as a percentage of GNP. Their current problems stem from their decisions to limit healthcare spending in this way ... not from the structure of their system.

Their system - with a structure to rationally make decisions about healthcare spending (rationing?) nearly eliminates the ~25% administrative overhead that we have in this country. We spend 25 cents of every healthcare dollar on administration. They spend 4 cents. They insure the whole country with that extra 21 cents .. and they STILL spend much less per capita than we do.

Health plan administrators make an average of $175,000 .. and insurance company investors bring home their dividends ... These are clearly $$ that flow INTO the thealthcare system .. yet go out in a form that has rather little to do with the provision of healthcare. In Canada, since there are no such beasts .. the $$ that go IN .. are devoted to providing the services.

Today I saw 22 patients. 4 of them had no insurance. While Canadians may wait .. at least they can get care. Last week, I cared for an uninsured patient with a kidney stone in the office. Our system requires me to reach right into my own pocket and provide services, medications, etc .. for our patients without the means to pay for it themselves. Sure .. I can do this once in a while .. But I can't do it too often . or I won't be able to pay the nurses or the rent or pay for my kids braces.

No .. I dont' drive a Mercedes. I drive a 1993 Saturn. We're not in this business to make lots of money .. but should we really support a system that puts us (and our patients) in this uncomfortable position?

A combination fo the Canadian style STRUCTURE .. with the funding levels that we currently dedicate to healthcare could significantly improve the quality of care for all Americans.

This comment comes from a blogger - Family Medicine Notes. I do respect the passion of the argument, but I still cannot agree with the conclusion. If we have a universal health care plan, the government will play a role. They will ultimately determine the budget. Congress always controls the budget. And that scares me a lot. I see the decisions made in the VA system. I see the decisions made concerning Medicare. The Canadian system has continual struggles. The British system has serious problems.

We do need to develop a better plan for treating the uninsured. I just fear more governmental control.

The answer to this question brings a moment of truth. If doctors leave because of hostile practice climates, then all in the affected community will bear the consequences, including those with no vote and hence no voice in the debate. We aren't just talking about local bond issues for road expansions and other typical issues of local governance. Poor specialist coverage may mean some people will die who might otherwise not in better-served communities, given the same circumstances. Are we prepared to accept these consequences? Personally, I think it is morally and economically bankrupt of any society to allow the ruinous, selfish, greed-driven litigation industry such as we have, to squander the human capital in our medical system. Remember, when you drive off the doctors you have, you won't necessarily get replacements.

I agree with this comment. For context, I ranted about an editorial urging state experimentation with differing malpractice reforms. I am in favor of a national solution. This is a national crisis, thus it requires a national solution. If legislators in one state make bad choices, what will that mean for the health care of their citizens. And when will some enterprising lawyer sue the legislators for decreased access to medical care, caused by increasing malpractice premiums. If the legislators (and Governor) of that state do not 'solve the problem', are they not responsible to citizens having decreased access to care.

This is a major national issue. Lawyers do not seem to understand, perhaps because their business follows capitalistic rules. Our 'business' has controlled pricing (or at least reimbursement) and uncontrolled costs (nice combination). We have no method of passing increased insurance costs on to patients (unlike most businesses who pass their increased costs on to consumers). Hopefully, Dr. Frist will lead the charge here. Will the Democrats filibuster on this issue?

This is very relevant to my job in CCU. As patients get sicker and sicker, more and more specialists are brought
on the case, until the 'generalist' who actually admitted the patient in the first place can barely keep up with what the other 5 are doing.

I've lost count of how many times the pulmonologist has ordered or dc'd antibiotics without telling the I.D. MD, who then comes in at 8pm and rants at the nurses for not notifying them of the change. I'm not sure what a good solution would be. We need both generalists and specialists, but the missing link is communication... and common
sense (Why consult ID if you're not going to abide by their recommendations, or even chat with them about concerns before just blatantly dc'ing their orders? Oh yeah.. because the surgeon consulted ID... not pulmonology....Does pulmonolgy even know that ID's on the case?). That's just one example. Sometimes it seems like people feel as though they've had their toes stepped on.

This wonderful comment comes from Geena at code blog - tales of a nurse . She understands. Fortunately I am rarely called a gatekeeper anymore. I have always preferred the concept of the generalist as the conductor. I must understand all the parts, especially when several consultants become involved. Someone has to direct traffic and decide amongst competing recommendations. The generalist has great value, even in the ICU. And he (or she) is probably the least financially compensated.

Thanks again for all the comments and questions. I apologize if I ever insult anyone. I like the banter, the arguing and listening to all sides of an argument. I hope you do too.

It is Sunday, the evil virus has subsided (I was able to make rounds this morning), and it is time for Q&A. I have collected the comments from this past week. Some comments are not exactly questions, nonetheless, I can still rant. So here goes my selection of interesting topics.

Every year millions of men go in for a psa for the prostate. Almost without exception the Dr will say come in in a couple weeks so we can go over your test. I just had mine and it was 2.1 I told the nurse this is what is helping to run the medical costs up.As long as their is not a problem a simple phone call would suffice and probably save my insurance co $50.

I had blood work done and had to go to the Drs.office for him to tell me everything is perfect.Once again a phone call would take care of it.

So,everything is perfect.I want to see you in 3 months.For what?To ask me if everything is alright. Another $50. I left the office saying to myself Doc you will see me when I have a medical problem. If we were trying to treat something that would be different.I could see coming back.Don't ask patients to come back for no reason. If everyone would use a little common sense medical costs could be lowered considerably. Enough of that.

This is a long comment, but very relevant. When should we see patients back in the office. When does a phone call suffice? How about email of results?

While this seems straightforward and easy, let me suggest the following complications. First, phone calls are not simple. They take physician time (and unlike lawyers we do not bill for our time, just visits). Moreover, the patient does not always answer and you may start a game of telephone tag.

Sometimes the visit helps reinforce a treatment plan. Sometimes the news is 'bad' and we do not feel comfortable having the discussion over the phone.

All that being said, the comment has validity. We need a system of contacting patients and communicating other than the office visit. If we had a modest retainer fee from each patient (paying for the time necessary for all the calls and email) then perhaps we would embrace these alternate methods. The system is not running smoothly.

Well stated! I'm happy to see that at least one doctor shares my viewpoint, that the biggest issue here is the way creationists reject science.

I like flattery. I also like her post - Loxosceles on evolution

I too was asked to switch to Omeprazole instead of Prilosec. I fear that it will not be as effective. Does anyone have similar negative experiences with omeprazole?

This question appears in many forms. I have done some research. According to the FDA there should not be any problems. Omeprazole ratings - omeprazole generic gets and AB rating - which means "(2) actual or potential bioequivalence problems have been resolved with adequate in vivo and/or in vitro evidence supporting bioequivalence. These are designated AB." For those interested in checking any generic - Electronic Orange Book

Referring to herbal remedies - If you want the view from the other side read this.
Understand, I'm not saying you're wrong, but sometimes just being right isn't enough.

This is an interesting read. I have the following problems with herbal intake. First, there are no controls on potency. While many herbal preparations seem harmless, who knows. We do not really know what we are taking. Second, the championing of herbal preparations does somtimes delay prompt medical care. If you are not really sick, then I have no problem, but if you are sick, you need a diagnosis. The person behind the counter at the health food store is unlikely to make an accurate diagnosis. Third, herbal preparations can have adverse reactions including interactions with prescribed drugs.

I understand why patients gravitate towards herbals, but I will and must rant against them.

Love your blog - it's nice to see someone in the medical field unafraid to throw out such strong opinions :) Congratulations on the 10 pounds gone!

What is your take on the Food Pyramid? Opponents say that it's too heavily loaded with sugars and carbohydrates and is nothing more than marketing materials. My nutritionist gave it to me and basically told me to treat it as a bible (which I don't do).

I have written about the pyramids recently and clearly favor the Willett pyramid. Check these two rants and associated links - Sorting out the pyramids and What to eat?

Will there be a vaccine developed to prevent men from contracting HPV?

Great question! I have had several related to this question., HPV is not just a problem for women. I have seen proposed strategies for immunizing all adolescents. Once a vaccine becomes available, I would bet that both sexually active men and women should get vaccinated.

Very interesting. This makes me feel better about having fired the general surgeon who was originally scheduled to treat my hyperparathyroidism. I asked him how many times he had done this operation. He said about fifty. I figured that he probably inflated the figurte by a factor of two or so, and I had the adenoma removed by a surgeon who specialized in endocrine surgery.

I can only say amen! Patients needing complex or unusual surgery should find a expert who does the procedure often. As the initial rant stated, practice generally helps. This is actually especially true for parathyroid surgery!

Speaking of colonoscopy - This was the most painful test that I have ever had. I will NEVER have this done again.Colonoscopy should not cause pain in 2003. Most gastroenterologist use sufficient medications so that you have amnesia for the event and have sufficient pain control. I wonder whether the reader had a sigmoidoscopy without sufficient pain medications. I have sent many patients for colonoscopy. They only complain about the prep, not the procedure. I have had my own colonoscopy, and do not remember a minute of the procedure. It may have hurt, but I do not know that.

I have been on Zocor for about two years. Also, I have been doing weight machine exercises on a regular basis for about the same length of time. I have gained some strength but my muscles remain flabby. Could Zocor be the cause? My age is 73. This is a difficult question, because I do not know what flabby means. I have researched this question on Medline and can find no relevant reference. I suspect that Zocor is not 'the problem'. If you are gaining strength at 73 you are to be commended. This is important for you overall health. I cannot speak to the aesthetics.

Drink some fluids and get some rest. I hope you feel better in the morning.

I did and I do!

I have a few more comments that may turn into rants this week. Please keep the questions and comments coming. I love the interaction and love the challenges to my rants! For now, I will plan to do these Q&A rants each Sunday.
 
 

Thanks to you - the readers of this blog. I have noted increased readership recently. I also have noted an increasing number of comments. While I write this blog primarily for the self discipline and what I learn, knowing that I am reaching an interested audience means much. As I view the readership numbers and read the comments, I am receiving positive feedback. This feedback suggests that I am stimulating thinking.

What do I get from writing this blog? Daily I consider medical care and new develoments in medicine. This discipline, and the striving to express those thoughts concisely and coherently, is a major personal reward. I know when I have done a good job, and when I have not thought clearly enough. Your participation adds an external reward to that internal reward, and for that I thank you! Please keep commenting, and if you do not choose to comment, consider scrolling back to rants that strike your interest to see if others comment. The comments often add greatly to my thought process and hopefu

If you read yesterday's post, and want to read further, please read Syndey Smith's comment (she of Medpundit). Also check out this complimentary explication from RangelMD - Generalists and Specialists. I love the collegial atmosphere of the blogosphere!

Medicine has an ongoing tension. What is the value of the generalist; what is the value of the specialist? How do we balance their skills? Which patients need a specialist? When can the generalist provide the best care?

I find this an interesting debate (albeit an implicit one). The pendulum swung in the early 90s towards 'primary care'. Specialists apparently felt threatened. They began to publish studies which showed that they could provide better care for their particular condition than could a geneeralist.

I find these results interesting but uninformative. These studies, e.g. do cardiologists specializing in heart failure do a better job of caring for heart failure than generalists, or do rheumatologists do a 'better' job of caring for rheumatoid arthritis, are asking the wrong question! We are taught early in medical school that the 'unit of importance' is the patient, not the disease. Good physicians care for patients, not diseases.

So what is the value of the generalist? The generalist should excel in diagnosing and managing the 'undifferentiated' patient. When the patient comes to the office or hospital with complaints (rather than after being diagnosed with a specific disease), the generalist should be able to consider the breadth of the complaints, physical findings and laboratory data to lead to the diagnoses. Generalists should have open minds, considering all possibilities. Unfortunately, when the only tool a carpenter owns is a hammer, everything looks like a nail. Many specialists view the world through specialty colored glasses.

Generalists tend to excel in prevention. We are more comfortable with appropriate uncertainty. We understand time as a diagnostic test and therapeutic option.

Specialists excel in various aspects of medicine. Many specialities have associated diagnostic and therapeutic procedures. They often can help with either the unusual diagnosis (e.g., a patient with new restrictive lung disease) or an unusual presentation of a common disease. Specialists become more comfortable treating the less common disease of their specialty, e.g. Crohn's disease, SLE, or using complex treatments like interferon and ribavirin for hepatitis C. Many specialists excel in caring for a specific chronic disease.

The challenge in medicine is to find the best physician for the patient. I would argue that we need more specialoids. What is a specialoid? When a generalists cares for large numbers of a disease, they become a specialoid. Many generalists are specialoids in HIV care. The key to being a specialoid is volume and interest (manifested by extra reading and perhaps conferences). One could become a diabetes specialoid.

Now the crux of my argument. Once the patient has several problems, a generalist should provide better care for the patient. Having one physician who can balance the diseases and their treatments must be superior to having 3 or more specialists each caring for a separate organ system. None of us really wants care by committee.

Even with one chronic disease, I would argue that a specialoid (a generalist with a special interest which does not dominate their entire practice) will do a better job on the problems not related to the chronic disease. I woud refer you to the following editorials from Clinical Cardiology - Cardiovascular Diabetology and Cardiovascular Diabetology - Two Years Later. Let me quote from the original editorial -

Cardiologists know a little bit about endocrine diseases and endocrinologists know a little bit about cardiovascular medicine. Diabetes may be the disease that allows both disciplines to develop a combined strategy to prevent or modify the serious complications of this disease.
Epidemiologic studies from Framingham have long ago shown that diabetes mellitus is a potent independent risk factor for cardiovascular disease.
Of all patients with diabetes, approximately 80% die of cardiovascular disease. Diabetes can affect the heart in many ways, including premature and extensive coronary artery disease, neuropathies, cardiomyopathy, and disease of the microcirculation. Two excellent review articles, one by Butler et al. and one by O'Keefe et al.,provide the reader with a solid background for understanding the complicated nature of diabetes mellitus and its relationship to cardiovascular disease.

...

Endocrinologists (diabetologists) need to educate the cardiologist, and vice versa, if we wish to optimize therapy of the diabetic patient with cardiovascular disease. Joint conferences would be a good start.

In my world, the patient with coronary artery disease and diabetes (who probably also is hyperlipidemic and hypertensive) needs a generalist. That patient needs comprehensive care, not fragmented care. What if the patient develops depression? Who will remember to screen for colon cancer?

The world needs specialists. I consult them and value their advice and help. The world also needs generalists. We must understand the value each brings to the health care table. Insurers should understand the skill and time involved in caring for these complex patients. Researchers should ask the question, how can we best care for the complex patient? I believe this is the true role of the well trained generalist.

Since I started this blog, no issue has captured commentary as passionate and thoughtful as Oregon's Measure 23 - On Oregon's measure 23. I urge you to go back and read the original post and the subsequent comments.

Thanks to the many comments, I have focused on this issue. In the car returning from my golf trip, I discussed these issues with 2 good friends (not physicians). Several issues have crystallized as I have pondered this measure.

Our health care system is broken. While we provide the best specialty care in the world, we have too many holes in the safety net. Most Americans can get bypass surgery almost on demand, while others cannot afford their blood pressure medications. Thus, one must ask, whether the trade-off for excellence is a system of winners and losers.

Many would argue that this trade off defines capitalism, and why should medical care be any different. We rarely decry inequality in housing, transportation, clothing or food, why is medical care different? One could imagine that once one socializes medical care, one starts down a slippery slope.

We should, however, be able to afford a reasonable (defining reasonable may be impossible) base of care for all. Our current system makes that very difficult. However, would we accept the cure? Read Brian Gray's comments written earlier today

My brother in law just died in England. He was 65. He has been waiting months for a quadruple by-pass operation. He rose to be number 10 on the waiting list then he died. My friend Tom Kennedy age 71 in England needed a hip replacement. Waiting time, 4 years. He flew to the USA and paid to have it done here. Waiting time One day. I lived for 36 years in Britain before moving to the USA and saw the abuse in the system there. Everyone feels they should go to the doctor for the slightest thing. Got a cold? Go to the doctor. Want time off work? Go to the doctor and tell him your back hurts. Britain has now introduced private medical insurance. There's a clue. The Scandinavian countries are having an even worse time with their Government run health plans. Having lived with both systems I can say that the existing American model is light years ahead of the European welfare state. The proposed Oregan plan is far more extreme than the money losing European ones. Taxes will go through the roof. Treatment will be limited to save money. Doctors will leave the State, just as doctors and dentists leave Britain. Deductibles and co-payments control abuse of the system. How many people leave the USA and go to Britain or Cuba or Russia or Germany for medical treatment? NONE, but thousands of their citizens come to America in order to receive the best treatment in the world. There is no free lunch.

Please read that again. Our system works in its own way. We are the envy of the world. That does not mean that we could not improve our system.

I would like to see several improvements, but I do understand the political realities. We would need the Democrats to show courage against the trial lawyers and the Republicans to show courage against the large pharmaceutical firms and the HMOs. I doubt this will happen.

We need an intelligent system of 'first contact' care. I hesitate to use the term primary care because most readers will not read that phrase as I mean it. I consider primary care's most important attributes as comprehensiveness and continuity. A good primary care physician works to aid the patient through the health care maze. This includes advising the patient on how to improve their health (diet, exercise, seat belts, immunizations, screening), evaluating for risk factors, and treating those risk factors. The good primary care physician can diagnose and treat most complaints, and when the patient needs referral, then pick the appropriate subspecialist. Many patients will then consult that primary care physician about the proposed plan of action (should the patient have an operation, or take chemotherapy).

Alas, my concept of primary care differs from the picture painted by too many subspecialists and by the insurance companies. My concept of primary care is not hurried, the patient and physician have time to spend together to plan an approach to health or an approach to treating either a risk factor or an illness. One cannot do that in 15 minutes. One cannot do that for $39 when the overhead costs $50.

Unfortunately, my concept of primary care is not accepted in most of the US or Canada or Europe. If we could support this concept, we would not have as many holes in the safety net. Supporting such a solution does not have enough flare for politicians. I fear that few understand the implications of such a solution. Most primary care physicians understand, but despair at even dreaming of that solution.

So where does that leave us with Measure 23? This measure has good intentions. We would like to provide health care to all. I wonder if our society will ever be willing to pay for that luxury. Measure 23 has major flaws, from the financing structure, to the naive assumptions. It should fail for those flaws. Hopefully, it will fail on a close vote, and the debate will continue. I only hope that those in favor approach the debate in a rational way. They must develop a better solution than Canada or England, because those systems are not worth emulating.

As I get back off my soapbox, I would like to thank all the commenters on this issue. You make important points which we should all consider seriously. As in many political issues, there are no right or wrong answers. Our challenge is to anticipate the unintended consequences. In this case, I believe those consequences would negatively impact health care in Oregon.

Many physicians suffer burnout. We often are better at caring for others than caring for ourselves. Many characteristics that help us achieve medical school acceptance and success can lead to problems later in life. Surviving (and even enjoying) medicine

Hands up if you recognise any of the following psychological traits: perfectionist, overly conscientious, tendency to seek approval ("people pleasing") and need to control others, great sense of responsibility, chronic self doubt, uncomfortable with praise, and ability to delay gratification. It's a given that most people who enter medicine will hold many of these characteristics.

It's not something that happens to us at medical school---although a lot of what happens there does account for later problems---it's what we medics tend to bring with us. It's what attracts us to medicine in the first place. Acknowledging this helps. Acknowledging it early enough, and adopting self caring practices, will help to ensure that we do not burn out and that we remain safe and competent at our jobs, and we may even reverse the trend of seeking early retirement. Most doctors suffer from an episode of depression at some point in their career, and every medical school should include lectures on "burnout prevention" alongside those on anatomy and physiology. According to a recent US conference on physicians' health in South Carolina, organised by the American and the Canadian Medical Associations, we doctors are sitting ducks for becoming burnt out. With thanks to some of the conference speakers, here are five practical tips on how to survive, succeed, and sustain interest in a career in medicine.

Five ways to survive as a doctor

• Make sure you do things other than work
• Create your dream work schedule
• Learn to say no, without feeling guilty
• If you need help, ask for it
• Seek peer support

I have seen too many physicians burnout during my career. I have tried to follow these points - and work on doing so continuously. Striking the balance is the first in a series of articles about protecting ourselves. You can find more from this author at - the doctorscoach website!. I submit that these concepts are important for ourselves and for many of our patients. If you are burnt out, think about starting to improve today. You owe it to yourself, your family and friends and your patients.

Two years ago, the HOPE trial expanded the indications for ACE inhibition - Effects of an Angiotensin-Converting–Enzyme Inhibitor, Ramipril, on Cardiovascular Events in High-Risk Patients (subscription to NEJM required). This week I will review this important study and discuss its implications.

The first thing I do when reading such a study is to study the patient population. I want to know who the investigators studied, and see if the data will fit my patient population.

A total of 9297 high-risk patients (55 years of age or older) who had evidence of vascular disease or diabetes plus one other cardiovascular risk factor and who were not known to have a low ejection fraction or heart failure were randomly assigned to receive ramipril (10 mg once per day orally) or matching placebo for a mean of five years. The primary outcome was a composite of myocardial infarction, stroke, or death from cardiovascular causes.

The patients in that study were at least 55 years old. They either had known vascular disease or THE EQUIVALENT (diabetes plus another risk factor). They did not have another clear indication for ACE inhibition. This study population seems general enough to cover many patients that I see.

The intervention was simple, ramipril versus placebo. The study design was appropriate - a randomized controlled trial.

The reduction in the risk of the composite outcome with ramipril therapy was evident within one year after randomization (169 patients reached the end point in the ramipril group, as compared with 198 in the placebo group; relative risk, 0.85; 95 percent confidence interval, 0.70 to 1.05) and was significant at two years (326 vs. 398 patients; relative risk, 0.82; 95 percent confidence interval, 0.70 to 0.94). The relative risk was 0.78 in the second year, 0.73 in the third year, and 0.74 in the fourth year, when the data on patients who were still alive at the end of the preceding year were analyzed.

Ramipril helped patients in a variety of subgroups - both men and women, diabetics and nondiabetics, above and below 65. The results impressed me when I first read the article in 2000; they impress me today. Given the previous information that we had on ACE inhibitor benefits (all classes of CHF, slowing the protection of diabetic nephropathy, preventing CHF after myocardial infarction) these data fit into a pattern.

So what do I do in 2002. I work hard to place all patients with known vascular disease on ACE inhibitors. Most diabetic patients that we see are also hypertensive, in those patients we use ACE inhibitors as first line therapy. In the patient with adult onset diabetes who is normotensive but has another risk factor (hypercholestemia, family history, 55 yo man or 65 yo woman) I generally start an ACE for protection based on the HOPE trial. Even though the study required patients to be at least 55 years old, I will extrapolate the data and make the same decisions in younger patients.

For two good reviews of this study - The HOPE Trial: Implications for Primary Care and An ACE inhibitor in the hole for cardiovascular prevention

2 years ago I was asked to address the new first year students at their white coat ceremony.

The White Coat Ceremony is a rite of passage for first-year medical students that symbolizes a psychological contract in which the student strives to become a competent and caring professional. The activities of the ceremony are designed to emphasize the importance of both scientific excellence and compassionate care for the patient.

The White Coat Ceremony, as conducted at medical schools across America, is the result of a vision by Arnold P. Gold, M.D., a professor of surgery at the College of Physicians and Surgeons at Columbia University. Dr. Gold believes that medical students should be introduced to the white coat and what it represents as they enter medical school rather than as they exit, which had been the case historically.

I recently reviewed my comments and feel that they hold up well. I hope you find them interesting.

25 Years Of Medicine – Advances in Science and Art

Recently I went to Richmond, Virginia to attend my 25th Medical School reunion. As I anticipated that reunion, I reflected on how medicine has changed during my quarter of a century as a physician. I shared some of these thoughts with students and residents here at UAB. In verbalizing my thoughts, I began to appreciate in amazement these medical advances.

These reflections remind me very explicitly why I love being a physician. My excitement over advances in science, technology and the art in medicine over these 25 years clarified my sense of the privilege of my chosen profession.

My remarks will feature some advances in our knowledge of science, technology and how the art of medicine has progressed. I hope that these reflections will stimulate you to have as much excitement about medicine as I continue to have to this day.

In 1975, when I started my internship, the most common surgery in this country was ulcer surgery. At that time we were convinced that ulcers were caused by stress and acid. In the 80’s a lone voice started trying to convince everyone that bacteria caused ulcers. This was initially greeted with derision but over time, with persistence, the case for a bacteria causing ulcers grew and grew. We now know that ulcers are caused by the bacteria helicobacter pylori.

Several things happened prior to that discovery. First, we learned that we could control acid with a class of drugs called H-2 Blockers. Everyone in the audience is familiar with H-2 blockers because they are advertised widely on TV; these include Tagamet, Zantac, and Pepcid. These drugs while not perfect at inhibiting acid in the stomach do an excellent job and replaced the need for ulcer surgery in most patients. However, ulcers would recur if patients did not stay on these medications indefinitely. In the year 2000, when someone is diagnosed with an ulcer we demonstrate that they are infected, we then treat them with antibiotics and cure their ulcer. To take this in context of living in 1975, would have seemed like science fiction.

Severe congestive heart failure is a disease with a horrible prognosis. In 1975 when we diagnosed someone with severe congestive heart failure, the average life expectancy was six months. Over the course of the past 25 years we have had a variety of studies which have taught us how to better care for these patients and extend their useful life. Life expectancy has increased dramatically for this disease despite the fact that many people who develop congestive heart failure are elderly and have many complicating medical diseases. We also do much now to prevent congestive heart failure in patients.

If you came to the emergency room in 1975 with a heart attack we would put you in intensive care, put you to rest, give you some medicine to try to decrease the chance that you would have sudden death and then see what happens. We talked about, but were unable, to decrease the amount of heart muscle damage. We really didn’t really understand the details of why heart attacks occurred or how to prevent future heart attacks or at least decrease the chance of future heart attacks.

If you have a heart attack today, and you come in early enough you get thrombolytic therapy (therapy to break up blood clots). You’ve seen and heard about patients getting such therapy. We have a variety of medications that are given in the acute phase of a heart attack, you’ve seen advertisements of the importance of aspirin for heart attacks and those are accurate advertisements. We treat people with a class of drugs called beta-blockers, which were not released when I started my internship.

Moreover, we do a much better job of secondary prevention. That is prevention of the progression of the underlying of coronary artery disease that causes heart attacks. We can do an excellent job of treating with medications the elevated cholesterol a major risk factor for heart attacks. We are much better at helping people stop smoking. We have a variety of other medications that lead to increased life expectancy as well as quality of life.

In 1975 if you had gallstones and needed surgery, you were out for 6 weeks. There was a large incision under your ribs in the right upper side of the abdomen. The surgery was successful but was short term debilitating. We now know that people get laporoscopic cholecytectomy and return to work in a week or so. This laporoscope can be used for a variety of other surgeries. This technology has revolutionized surgery so that complications are decreased and recovery time is greatly decreased.

The mid 1970’s started coronary artery bypass-grafting era. This operation is so common now as to be one that we are all familiar with. At that time that was really the only treatment of blockages of the coronary arteries. Over the next decade we learned about balloon angioplasty, where physicians put a catheter into the coronary artery and open the artery up. This was followed by a variety other procedures and the current often used procedure to put a stent into the artery to keep it open. This management of coronary artery disease compliments all of the things that we are doing to treat heart attack patients aggressively with medications.

The diagnostic technology of medicine advances rapidly. My career has seen the introduction of ultrasound, CT scanning and MRI. It is rare to watch ESPN Sports Center and not hear that someone has an injury in a sporting event that will require an MRI in the morning. This is a common part of our language and we all understand that the MRI does a wonderful job of showing us damage to soft tissues and even cartilege.

But MRI was not even introduced until the 1980's. Our ability to diagnosis a variety of disease is greatly enhanced by these radiological techniques.

When a football player injuries his knee, we see on Sports Center that he is going to have his MRI. The next day we hear that the MRI showed disc damage and he is scheduled for surgery the next day. Within ten days he is playing football again. In the 1970's, knee surgery was always major and reconstructive and was months of rehabilitation. Now athletes often are back on the field shortly.

These scientific advances are exciting and noteworthy. I have only briefly described the extent of the scientific advances that I have seen thus far in my career. Just as interesting in many ways is the evolution of doctor patient relationship.

The art of medicine has advanced greatly as has the science. Over the past 25 years we have seen the growth of the hospice movement - the understanding that the dying patient deserves dignity and respect is much more explicit than it was in 1975.

Most medicine was paternalistic in the 1970’s. What do I mean by paternalistic? Paternalistic refers to the physician telling the patient what to do and the patient saying yes sir. In my class less than 10% of the students were women. Today we balance paternalism with a desire for patient autonomy. Patients are much more involved in deciding about their care and gaining knowledge of their care. The Internet has given patients the opportunity to research their illnesses. We now offer our patients a great deal of individualism in how they choose to care for themselves.

We have championed informed consent and now very much want our patients to understand the decisions they are making, why they are making the decisions and what the various options are. These changes occur slowly, but when one reflects they do represent major advances in the doctor patient relationship. Even the idea of discussing the doctor patient relationship as an important relationship is new to the last two decades. This concept was rarely discussed during my training and really became popularized in the 80’s and 90’s.

So what does all this mean? Are these just the ramblings of an OLD MAN, I don’t think so. I don’t think that there is anything different about my 25 years in medicine than your first 25 years in medicine or my teachers first 25 years in medicine. For me medicine remains the most exciting profession. I wake up every morning and I am grateful that I am allowed to be a physician in this country during this era.

Medicine remains exciting, it remains vital because of the advances in science & technology, because of our ability to better care for our patients every year then we could the previous year. Medicine grows with times, the act of being a physician and interacting with patients changes constantly so that one need not ever get bored of doing exactly the same thing day after day.

The greatest gift is the doctor side of the doctor patient relationship. When you first enter the room, the patient assumes you to be a good person. The patient respects you and starts out liking you. Patients in this country expect the best from their physicians and generally get it. The pleasure of the doctor’s side of the doctor-patient relationship is a pleasure and privilege, which you will soon understand. We are very fortunate to be physicians, we are very excited that you will join our profession, and I personally hope that your first 25 years as a physician will be as exciting as my first 25 years as a physician.

I find being a physician a great privilege. As a physician, I strive daily to help patients, either directly while they are under my care, or in the future by studying, teaching medical students and residents, or doing research. My profession challenges me intellectually, and often rewards me on a personal level. Most times when I enter a room and meet a patient for the first time, he/she looks at me kindly, with trust, and assumes that I care. Patients like their physicians.

While our jobs are usually challenging, yet pleasing, sometimes we must deliver bad news. I would like to present a couple of patient scenarios for your consideration, then refer you to a well written article about bad news.

Once, in the 1990s, I got a call from the pathology lab. The pathologist called and said she wanted to discuss a laboratory result on one of my patients. The patient was newly HIV positive. The problem was I did not recognize the patient's name. So I called my secretary and asked if the patient was scheduled to see me. In fact he was scheduled the next week as a new patient. So I asked who referred him, and found out that a general surgeon had made the referral. "Call the surgeon," I thought. Our discussion revealed that this 29 year old man had come to him for evaluation of posterior cervical adenopathy. The surgeon biopsied the nodes with the pathology suggesting AIDS. He sent off an HIV test and referred the patient.

I thought about the situation, and decided that I could probably do a better job breaking the bad news to the patient than could the surgeon (knowing his style, and the circumstances of the referral). I remember telling the patient the diagnosis, and having a productive long discussion with him that day. He did well during the 2 years that I followed him, eventually referring him to an HIV specialty clinic.

Recently, a 61 year old man was referred to our inpatient service to 'confirm his non-Hodgkin's lymphoma'. The patient had become sick a couple months previously. After a month of routine outpatient antibiotics and symptomatic treatments, a chest X-ray showed bilateral hilar adenopathy. A CT of the chest and abdomen showed many nodes and splenomegaly. The patient had a hemolytic anemia and thrombocytopenia. We had pulmonary and oncology consults, both of who suspected lymphoma, both of whom wanted a definitive diagnosis.

At the other hospital, he had had a peripheral node biopsy which showed reactive lymph tissue. A bone marrow biopsy was 'abnormal, but non-specific'. The referring physician had told the patient and his wife that he had lymphoma, and that she was referring him to us to confirm the diagnosis.

We sat down with the patient and his wife to understand their comprehension, their fears and try to understand their interactive style. As the data mounted, it became more likely that the patient did no have a lymphoma. Several days into the hospitalization, we sat down (I as the attending did most of the talking, but the resident, interns and students were present in the room) to discuss what we knew and what we did not know. Our previous discussion had made it clear that the wife especially was not ready for uncertain news. She did not want to know that he probably had lymphoma; she wanted a more certain diagnosis. The bad news (on incomplete data) had shocked the patient, his wife, and the children.

Our evaluation proceed slowly. After peripheral biopsies, another bone marrow biopsy, a mediastinoscopy with biopsies, a bronchoscopy with biopsies and many serologies we determined that in fact he did not have lymphoma. We believe that he has a rheumatologic diagnosis (in fact the precise diagnosis remains a bit uncertain). He has responded beautifully to oral prednisone. We did not discuss his presumed diagnosis until we had successfully eliminated lymphoma from our differential diagnosis.

What principles do I derive from these two patients? First, breaking bad news is a primary responsibility of generalist physicians (whether family physician, pediatrician, internist or hospitalists). We probably have more opportunities, and therefore we must learn how to help patients work through these difficult situations. Second, we should not break bad news until we are certain of the bad news. My patient with the hilar adenopathy is not unique. A colleague had a similar patient with a large lung mass and brain mass recently, which turned out to be an infection despite everyone thinking cancer. Prior to shepherding the patient through an emotional rollercoaster, we must have as much certainty as one can get in medicine.

I always have to emotionally prepare for these conversations. I usually decompress by discussing the conversation with the housestaff and students. This decompression helps and supports my feelings, and hopefully provides some role modeling for their future encounters.

Browsing the web today, I found this article - Breaking Bad News. I highly recommend reading this nicely written exposition on the skills of breaking bad news. I plan to hand the article out to my housestaff and students, and then discuss the details. Hopefully, by focusing on this issue, we can improve, to the benefit of our patients and their families.

Ten years ago I was sitting in my office seeing patients. The nurse asked me if I could squeeze in AA - he had just shown up at the front desk and wanted to see me. I agreed, and he and his wife came to the room.

AA was 15 months from what we thought was successful surgery for lung cancer. He had presented with an acute bronchitic attack and something made me get a chest X-ray. That X-ray showed an early lung cancer. I referred him to Thoracic Surgery. He was a good surgical candidate and we thought he was cured.

His thoracic surgeon saw him every 3 months, getting repeat X-rays. His most recent X-ray had shown recurrence. The surgeon told him that she could not operate on him again, and referred him to an oncologist. The oncologist give him a choice between chemotherapy and supportive care. The patient choose supportive care, and in the patient's opinion, the oncologist seemed to lose interest. He came to my office that day to tell me the story (no one had kept me informed).

He actually started with a most unusual request, 'Will you be my doctor?' The question astonished me. As I quickly told him, I am your doctor, and will remain your doctor.

AA had started seeing me about 5 years prior to that incident. He was a prominent person in town, now aged 77. He had had a good full life. We talked for some time at that first visit.

While I cannot remember the precise details, I do remember the gist of our planning. AA wanted dignity until the end. He wanted to remain lucid as long as possible. He did not want any heroic measures. At that visit, he cried and I consoled. We discussed advance directives and made plans. I scheduled him to return in 3 weeks.

Over the remaining 4 months of his life I probably saw him 6 times. We had long visits and just talked about 'stuff'. He was a most interesting man, and loved to tell his stories. His first project was to produce an autobiographical audio tape for friends and family. He achieved that within the first month.

His wife and daughter (from a previous wife) gave him outstanding support and strength. One incident sticks in my mind.

During this time I was being recruited by 2 medical schools. I finally decided to move to my current school that spring. I took a trip here one week for 2 days (making plans to start). The next day I was in my academic office handling the details of severing my relationship with my former institution. Given the whirlwind of my interviewing, visits, and pending move, I forgot my beeper at home. That afternoon I got a telephone call that AA was in the hospital.

I went to visit him to find out what was wrong. Apparently, he started feeling poorly, tried to call me, finding me out of town then called the surgeon. She admitted him and let her resident and intern care for him. He had a rapid heartbeat (due to a superventricular tachycardia), so the surgical housestaff called the electrophysiology service. They gave him some medication to slow his heart rate, and put a monitor in his room. The monitor beeped incessantly.

Now he was in a special section of the hospital known as the 'Pavilion'. He had two rooms - so the family had a sitting room. I go in and everyone is crying. The family explains that he is frustrated because he does not want a monitor or IV fluids. I go to see the patient.

He quickly explains his frustration. He tells me that he is ready to die, but he does not want to die with an IV or a monitor. He wants to die at home with his loved ones around him.

As I assess the situation, I note that while he might die that night, he might stabilize, regardless of our therapy. Fortunately, he had no pain or other discomfort.

I quickly took over the situation to the relief of the patient, family and nurses. I wrote orders discontinuing the IVs and monitors. I wrote a long note in the chart explaining what I had done, and making clear that I would accept the patient on my service if thoracic surgery desired such. It was 6 p.m

At 7:30 p.m. I was starting dinner, when I received a page to the hospital. Answering I found the surgical intern on the phone. He seemed frantic and nervous. His resident had apparently told him to call me. He said 'My resident said that if we can't do anything for the patient, we would have to transfer him to your service'. I was astonished because my note stated clearly that I would willingly accept that patient. But even more, I knew that I was doing much for the patient. I wanted to teach the intern and resident, but knew by the intern's tone that they were not ready for this important lesson. I told him that I was glad to take responsibility for the patient (my note had made that clear). I discharged AA the next morning to the relief of all.

AA lived another 2 months. He started to deteriorate soon thereafter. Fortunately excellent hospice care made his final days fit his dream. I remember the last time I saw him. I visited his house, and talked to his wife. He was already stuporous, but comfortable. I did not have anything medical to offer, yet my visit helped the family and helped me. He died 3 days after I moved.

Later that month I received a wonderful and cherished note from his daughter. She thanked me for the dignity with which his death occurred. She thanked me for caring about his humanity more than his disease.

That was 1993, and I knew little about palliative care. I am now exposed to excellent palliative care daily, as we have one of the superior programs in the country. In reflecting about AA, I probably could have made him even more comfortable if I had known more.

The Center to Advance Palliative Care (CAPC) is a resource to hospitals and other healthcare settings interested in developing palliative care programs. CAPC is a national initiative supported by The Robert Wood Johnson Foundation with direction and technical assistance provided by Mount Sinai School of Medicine. We are fortunate to have an active aggressive palliative care program at our VA hospital. My housestaff and I are exposed to these principles daily.

This brings me to the ethical dilemma that I suggest in the title of this rant. Given a patient with no reasonable chance for recovery, is paternalism acceptable? How do we provide humane compassionate care when we as physicians understand the risks and benefits of treatments in a more complete way than the patient does? A recent patient on my service may illustrate this point.

Mr. S. is a 74 year old gentleman with advanced dementia. He has contractures and does not communicate at all. He came from his nursing home because of a volvulus, which the GI fellow reduced in the ER. The nursing home had him scheduled for a PEG tube placement that week. For those who are not familar a PEG tube is a feeding tube that goes directly into the stomach through the abdominal wall. I have a visceral reaction to the general concept of PEG tubes, understanding that they are worthwhile in selected circumstance.

His 99 yo mother had verbally agreed to the PEG tube, because the nursing home had asked. We (my resident, interns and I) did not agree. We involved the palliative care physician and evaluated the patient carefully. He (with my resident) called the mother and had a long conversation about the patient. He directed her towards comfort and minimizing suffering. He acted paternalistically with these woman who clearly wanted direction. We discharged him to hospice care the next day without a feeding tube, either nasogastric or PEG. We expected him to die within the week.

Many situations call for some degree of paternalism. I would argue that palliation must combine patient autonomy with paternalism. We must understand the patient's goals and desires even if he (she) can no longer communicate them. We generally guide the patient's family towards comfort. In many ways, achieving comfort represents the ultimate medical achievement. We want our patients to die with the same dignity that they want. If that requires paternalism, then we should choose it.

Thank you AA, for you taught me much. I try to bring your lessons to every dying patient. You live in my memories.

How long should the average generalist patient visit last? While this certainly varies with the visit reason, we all understand that the visit should last long enough. Most adults require appropriate time to do a variety of tasks. I have read, but cannot find the reference, that the average visit length with an internist is currently around 21-22 minutes. As we ask our generalists to do more each visit, and hold them responsible, can patients possibly receive adequate care?

Imagine a 50 year old woman with Type II diabetes, hypertension, obesity (BMI of 31), and depression. She smokes 1 pack per day for the past 30 years. She says she cannot exercise because of knee pain. We can imagine the agendas at the visit.

First, we must address her diabetes. We review her medications. We then go through the FLECKS (my mneumonic for diabetes care). Check her feet for lesions, and for early peripheral neuropathy. Review her lipid profile (remember to treat hyperlipidemia aggressively in type II diabetes. Consider her eyes by reviewing her record to see if she has visited the opthalmologist. If we have no record then ask her who she saw - and request their consultation report. Ask her about her blood sugar control, and review her HgbA1c value. Again review her labs for evidence of early kidney disease, or check to see how much proteinuria she has on treatment - considering whether to increase her ACE inhibitor or ARB (or add one). Review her shot history - is she uptodate on her immunizations (especially pneumovax and influenza vaccine). Ask her an open ended question about diabetes complications and medication adherence. That handles her diabetes.

We then review her hypertension history, her medications, her blood pressures (especially if she checks them at home or at the fire station or at the pharmacist. Ask her about medication side effects again. Reassess her regimen and adjust as is appropriate.

Review her depression, evaluate any medications for side effects. Ask about sleep, crying, her social situation. Reassess that treatment and try to understand her satisfaction and needs with the management of this problem.

She is 50 so we need to consider prevention. Have we screened her for colon cancer? If not, we take time to discuss her options (this is not usually a quick discussion). We review her breast cancer screening and gynecologic screening history. At 50 we start to check on symptoms of impending menopause.

Now we get to the cigarette smoking. We have counseled her in the past, but we must try again. We try logic, we try emotional appeals, we try anything that we can imagine.

We discuss exercise and diet. She states that she cannot exercise because her knees hurt. This new complaint takes several minutes to assess. While one's initial thought is osteoarthritis secondary to a BMI of 31, one must be thorough - occasionally it is something else.

We finish with an open ended discussion allowing her agenda to come forth. Anything could happen at the end of the visit. We sometimes joke in teaching clinic that we hate hearing (at the end of the visit) the phrase, 'Doc, by the way'. Often that phrase does not occur until you are getting ready to leave the office.

The direct patient encounter has finished (probably 20-25 minutes if one is very efficient), but the true visit time continues. If any prescriptions have expired, or we changed medications we write new prescriptions. We order appropriate laboratory tests, and determine when to see that patient back. One must then dictate the visit. This will probably take around 5 minutes - documentation is important for the next visit, but we must dictate even more to satisfy the bureaucrats and the lawyers. Our notes are longer and include redundant information than is necessary. Nonetheless, in 2002 we must dictate a fairly complete note.

So we can assume 20 minutes with the patient (and that was very efficient), and 5 minutes after the visit dictating. But time continues. The next day or so, our laboratory data returns. We must review the results in the context of the patient. We might decide to alter her medication regimen based on her lipid profile, or change her diabetes medicines because her HgbA1c has increased. Or we find increased proteinuria and consider that regimen. Often we need to talk to the patient on the phone (another 2-3 minutes). I will assume 2 minutes on average for laboratory and test review.

If we dictate our notes, they come back soon, and we need to proof the dictation and sign it (hopefully just 1 minute). Between visits, the patient likely will call the office with an issue (add another minute to answer the question). Have you kept track? I would estimate that the true time of the visit is 30 minutes.

How many hours should a generalist work each day? How many days a week? Should physicians also have a life?

We will assume that one can see 90 such patients each week (hoping for few 'no shows'). If my time assumptions hold, that represents a 45 hour week in the office (with extra time for 'keeping up'). If one restricts the practice to outpatient medicine, we must add time for telephone calls with specialists, hospitalists, emergency rooms and pharmacies. Give me another 5 hours.

What is a fair salary for that physicians? I would argue that $150,000 seems reasonable (remember 4 years of college, 4 years of medical school and 3 years of residency - leaving > $100,000 debt). The physician first generates income at age 30 (if he or she goes straight through schooling and residency). Assume a 50 week year (2 weeks for much need vacation), that comes to $3,000 per week. Divide by 90 patients each week and you need $33 per patient visit after overhead (rent, supplies, nurse salaries, clerical salaries, and malpractice insurance). Overhead generally runs around 50-60% for such a practice. Assume 50% overhead, then the physician would need to charge and receive $66 per patient visit. If you assume that $100,000 is a large enough income, then we could lower our estimates to $45 per visit (assuming we could really decrease overhead costs - a very debatable point).

Many readers are now thinking that I am whining about physician income (damn rich doctors). The problem is that the generalist should be the key to one's ongoing best health. Only the generalist will consider the array of issues that the patient has. Every specialist makes more than the generalist. With current reimbursement, the generalist has difficulty making the $100,000. Medical students and residents know this - and they choose more lucrative fields in medicine. Specialization follow money.

If we assume the $100,000 income (and 2500 hours per year), we get $40 per hour for a highly trained physician to attend to your health. You pay more for car repair, or a plummer, or an electrician. Our health care system has undervalued your generalist. We have a decreasing number of physicians practicing general medicine (either family medicine or general internal medicine). Health care costs will increase because prevention will decrease. Concientious medical care requires time. In our current system, time is not on your side.

20 Questions for President George W. Bush: A Running Conversation . Many readers know that the current issue of Runner's World features President Bush. Maureen Dowd criticizes the President today about this interview and contrasts it with her perception of what he is not telling us about Iraq - Treadmills of His Mind. While I will not comment on the President and Iraq, I am impressed with his role modelling on exercise. We need more stress on healthy lifestyles. If the President helps a few people get off the couch and workout (and he probably will) then he has done well.

I will quote some of his answers and comment .

What’s your response to people who say they are too busy to have enough time to exercise?
I say they don’t have their priorities straight. These are the same people who say they don’t have enough time for their families. I don’t take that as an acceptable answer. I believe anyone can make time. As a matter of fact, I don’t believe it—I know it. If the President of the United States can make time, they can make time

Exercise is so important that corporate America should help their employees make time. Offer flex time. There should be flex time for families and there should be flex time for exercise. A healthy work force is a more productive work force. We have got to do a better job of encouraging that in America.

As I have said often, one should plan one's exercise week consistently. Stephen Covey's book - 7 Habits of Highly Effective People - encouraged me to consider this philosophy. I like his book and was struck by the 7th Habit . A summary of the Habits - Summary of Stephen R. Covey's
The 7 Habits of Highly Effective People. They summarize the 7th habit thus

Habit 7: Sharpen the Saw
Take time out from production to build production capacity through personal renewal of the physical, mental, social/emotional, and spiritual dimensions. Maintain a balance among these dimensions.

I subscribe to maintaining balance in my life, and espouse that philosophy to my residents, medical students and faculty. All work and no play makes Jack a dull boy. It also leads to burnout. The President's exercise philosophy does not just strengthen the body, it also helps the mind. Exercising gives me a time to sort out ideas. It provides respite from the hassles of the day. After exercising, I have more energy to attack problems.

Finally, what do you view as the greatest health issue facing our nation?
Tobacco, bad food and lack of exercise. A lot of disease can be prevented. And I think you’ll see the health-care systems will evolve toward encouraging prevention. Wise business insurers will work with physical fitness folks to encourage reasonable exercise. Statistic after statistic is beginning to sink into the consciousness of the American people that exercise is one of the keys to a healthy lifestyle.

One of my jobs as President is to set examples. I have an opportunity to send the message to the American people that I’m serious about exercising—and you should be too.

Bravo, clap hands, the President has it right. He does understand that the choices we each make about our lifestyle have profound effects on our longetivity and quality of life. I wish that smoking cessation was just a matter of will.

Physicians understand this message. On the VA inpatient wards, I estimate that over half the patients have serious diseases as a result of lifestyle choices - smoking, lack of exercise, obesity, alcohol abuse and former IV drug experimentation. These "choices" all effect insurance rates and contribute to the high cost of health care.

Can we make a difference? Certainly, we can influence one person at a time. We must discuss lifestyle choices regularly with our patients, our friends and our family. We must understand that our challenge never ends. We must search for the buttons to push that will allow people to make healthier choices. We must start by being role models - like the President.

Sometimes Medpundit and I gravitate to the same issue. Today is such a day. The NY Times article is a must read . - Decade After Health Care Crisis, Soaring Costs Bring New Strains. I will excerpt from this long article and provide my own commentary. Then read Medpundit's view.

If the cost of coverage keeps going up, experts warn, even more Americans will join the ranks of the uninsured because they will be priced out of the market. Many health care analysts, their faith shaken in managed care, see no easy fixes.

Politicians in both parties are beginning to respond, but they are profoundly divided on the issue, a deadlock underscored last month by the Senate's inability to pass a prescription drug benefit for Medicare. As a result, the issue is expected to bubble throughout the fall elections.

The last decade saw a squeezing of health care costs. Every drop of easy decrease was accomplished. The next cuts will require a major change in thinking. Politics cannot solve this problem, because politicians do not address issues, they address constituencies.

The soaring costs are driven, in part, by the biomedical revolution of the past decade, which has produced an array of expensive new treatments for an aging population, from drugs to fight osteoporosis to high-tech heart pumps. The result is a health care system filled with great promise and inequity — such as wonder drugs that many of the nation's elderly must struggle to afford.

Dr. Janelle Walhout sees the paradox every day at the community clinic in Seattle where she works. "I've been thinking lately about the mismatch," Dr. Walhout said, "between how very high-tech medicine has become, with all these genetic tests for everything, mixing your medications like fine cocktails, and our patients, who can't afford them, can't understand it, can't get interpreters to explain it and are just not accessing those things."

These paragraphs outline the problem well. We can do so much more than we could. And we will be able to do even more. What is this progress worth? Should we set limits on health care expenditures? No one has good answers to these questions. Our society accepts inequities in legal care, automobiles, housing, but wants to deny those inequities in health care. If health care is special, if it is a right, then society must pay. If it is not a right, then we cannot be hypocritical about that decision. Declare it, and accept a multi-tiered system. But I do not think we really want to do that.

Spending on health care rose faster in 2000 than at any time since 1993, federal researchers reported this year. Spending on prescription drugs and hospital stays grew particularly fast, largely because of advances in technology and "the retreat from tightly managed care," said Paul Ginsberg, president of the Center for Studying Health System Change, a research organization.

That quote about retreating from tightly managed care really bothers me. The cost problems come from our ability to do more, with drugs and with procedures. No one was happy with tightly managed care - and medical care was worse.

Not surprisingly, doctors disagree. Dr. Richard Corlin, a former president of the American Medical Association, cited "advancing technology and an aging population," along with the rapid increases in the cost of malpractice insurance, as the primary reasons for the rising cost of care. The A.M.A. also notes that insurance companies are reaping higher profits.

And the AMA is correct. Physicians are making less money and health care costs are increasing. We have increased regulations (all of which cost much money), increased malpractice, more expensive drugs, more excellent technological advances - it has to cost more money.

Many health policy experts argue that tackling health care inflation will require a fundamental cultural shift in the American approach to medicine. They say doctors and patients must begin taking cost into account when making treatment decisions. They say Americans must limit themselves to treatments that are proven to work and accept the premise that more care does not necessarily mean better care.

"As a society, sooner or later we will have to determine whether there are some benefits that are too plain small to justify the cost," said David Eddy, an independent analyst who advises health care organizations, including the managed care industry. Americans, he said, "have an enormous tendency to use treatments if we think they work or if we hope work, even if there is no evidence that they do work."

In the 1990's, for instance, bone marrow transplants were widely used to treat aggressive breast cancer. Then studies showed it was no better than standard therapy. Hormone replacement therapy, prescribed to millions of American women, has now been discredited as a way to prevent heart disease and stroke.

Dr. Eddy says he believes a new government agency should be set up to take this kind of scientific literature into account, and then make recommendations about whether new treatments are worth the cost. But while health experts agree there is a critical need for independent evaluations of new technologies, they doubt such an agency will ever come into existence.

"It would be killed by all the lobbying groups," said Uwe Reinhardt, a health economist at Princeton University.

First, we have a such an agency - the Agency for Health Care and Quality (AHRQ), which receives a meager budget (relative to NIH), and which cannot do the studies needed because of lobbying groups. We do need more efficacy studies of many treatments. I have previously called for device manufacturers and pharmaceutical companies to fund these studies but not have any control over their design or execution . Such studies such be the litmus test for adoption of new treatments or diagnostic tests. We can do the studies. Unlike Medpundit I think we will have to involve subspecialists to do the studies properly. However, each study panel should have a heavy representation from generalists. Patients will only take cost into consideration when they share in the costs. Our health insurance system makes health care an entitlement. If it is - then let's pay, if it isn't let the patient participate in the costs.

Finally, let me suggest that the doctor patient relationship might actually help here. Physicians who have the appropriate amount of time with patients can take a more complete history, provide better prevention, more carefully select diagnostic tests, refer more appropriately. Our system has evolved over the past 10 years to shorter visits - and I believe the visit length leads to more expenses. We need to test this hypothesis. The system is trying to save money in the wrong places. The generalists should not be squeezed. They control much care, many expenses and can do a great job if given the tools and the time. This topic will recur often. And I will probably sound like a broken record.

Today's entry is my 300th. That accomplishment tells me that I look forward to blogging about medicine each day. As a medicine blogger, I do not expect to run out of topics. As a physician I never run out of wonder.

While I understand the frustration that many physicians have with the current health non-system, I am still very happy that I decided to become a physician (and would do it again were I in college). I will rant daily about the problems we face - politically, legally, and socially. Nonetheless, we have a wonderful profession.

As I consider being a doctor, I marvel in the balance between the science of medicine and the art of medicine. Let me first comment on the science.

As an intellectually curious human being, I desire knowledge. As knowledge advances, we can often use that knowledge to help our patients. An example picked from my 30 years since starting medical school will illustrate my thoughts.

As a medical student we were taught about the acid hypothesis for ulcer disease. We treated patients with frequent small feedings and antacids. The most common surgery in the country was a Bilroth II (a vagotomy and gastrojejeunostomy). Over the next decade, the histamine 2 receptor was discovered and blockers developed. The introduction of cimetidine (Tagamet) had a marked impact, decreasing dramatically the need for ulcer surgery. After a few more years, the first proton pump inhibitor (omeprazole - Prilosec) was introduced, advancing our care even more. Meanwhile, a renegade researcher, Barry Marshall began pushing the hypothesis that a bacteria caused most ulcer disease. We now treat ulcer disease with an antibiotics concoction. The story all makes sense now, but who could have imagined it when I started medical school.

That story is not an isolated example. As I teach internal medicine on the wards, I draw from new findings daily. Medicine brings intellectual excitement daily.

Medicine also brings an emotional high. The art of medicine is fascinating. Although I have not done other jobs, I cannot imagine any other vocation where you meet someone (the patient) and they respect you and will tell you almost anything. Patients like physicians and physicians like patients. Our job is difficult, including delivering bad news, discussing end of life issues, and trying to steer patients to help themselves. The challenge of combining our need to maintain our knowledge base with the opportunity to effect patients in the manner we talk to them makes what I do a constant wonder. As I reflect on this past ward month, I remember several patient discussions about end of life care and dignity. The patients (and their families) showed such gratitude that we cared to insure their humanity, even when their medical condition was trying to rob them of that same humanity. We had to deliver the news of undesirable diagnoses. We saw the ravages of severe dpression, and learned how our caring and understanding allows the patient to start climbing out of the abyss. And we were fortunate enough to deliver some good news. This art of medicine makes our profession special.

The politicians will never understand. The insurers look at our patients as numbers not humans. The lawyers see the unfortunate as opportunities to sue (and gain contingency fees). But I see patients and want to help them. Sometimes my knowledge of science can make a dramatic difference. Sometimes I can use technology to make a diagnosis and get the right specialist to help the patient. But regardless, I can help the patient by bringing my humanity to the bedside and respecting the patient's humanity at all times. I really love my profession and feel fortunate that I found this way those many years ago.

This week Jane Galt and I have had a stimulating discussion - Discourse with Jane Galt. Many interesting issues have arisen, and today I would like to focus on knowledge.

The chief of Cardiology discussed Congestive Heart Failure (CHF) at this week's Medical Grand Rounds. During his presentation, he discussed a variety of medical devices available for managing severe CHF. He made an important observation when he pointed out the the device manufacturers had no interest in funding studies which carefully delineate which patients should benefit from a particular expensive device. They would rather show efficacy, and do not apparently mind if physicians implant excess devices (two examples include automatic implantable cardioverter defibrillators (AICD) and atrial synchronous biventricular pacing (ASBP)). Each of these treatments cost approximately $30,000 per patient. We know that in carefully designed studies and carefully selected patients these devices work, improve quantity and often quality of life. We do not know the proper indications for the devices. For ASBP in particular, data suggest that not all patients benefit. Cardiologist would benefit from studies which examine predictors of efficacy. The device manufacturer will not fund these studies, and given our current regulations they have no such obligation. Economic advisors would tell them not to limit the potential market, and the right efficacy study would limit their market. Thus, the economic incentives for society (use these expensive devices only in those patients likely to benefit) clash with the economic incentives for the device manufacturer (sell as many devices as feasible).

A naive response comes to mind. Let the NIH fund the study. But the NIH (actually in this case the NHLBI) will probably not fund that study, stating that they have higher priorities for their research dollars. Medicare rarely funds such studies - their bureaucracy does not seem to understand the importance of efficacy studies.

Let me switch to a pharmaceutical example. Adult onset diabetes mellitus causes more kidney failure than any other disease in the United States (and probably the world). We have learned much about the onset and progression of kidney disease in diabetic patients. We know that very small amounts of protein in the urine predict eventual kidney failure. We have learned that we can both decrease the amount of protein in the urine (without treatment these small amounts become grams of protein) and delay or even prevent the onset of kidney failure.

Recently published studies (for those interested, I have a slide series available from a talk I gave on this subject last year - Update in Nephrology) have documented both a decrease in urine protein and delayed progression of kidney disease. The studies that I cite in that talk all used a class of antihypertensives called angiotensin receptor blockers (ARBs). Of interest, earlier research in patients with childhood type diabetes used angiotensin converting enzyme inhibitors (ACE-Is). The firms that produce ARBs funded the recent studies. They have not, and likely will not fund studies to compare ARBs and ACE-Is. The ACE-I manufacturers will not fund any studies, because those drugs are nearing their patent expiration (at least 2 of that class have available generics, and that number will increase soon). One would expect that the ACE-Is should work as well as the ARBs, but how can we find out? One could easily design that study, but such studies are very expensive. No manufacturer has a financial incentive to fund the desired study, and the NIH apparently will not fund such a study.

We need a new mechanism to insure that we fund important clinical studies. The current system works only when it benefits the manufacture or the issue is so large that the NIH funds the work.

Therefore, I make this modest proposal. We should charge a research fee to device manufacturers and pharmaceutical manufacturers. I have not worked out whether a fee or a research tax makes more sense. We would then have moneys to fund efficacy studies. An expert clinical panel would prioritize proposed studies, and fund them in order until that year's moneys expire. This would allow us to do the right studies.

I suppose that this idea has many flaws. It seems too simple to work. What do you think? How important are efficacy studies? Can we fund the right ones?

This Sunday I will focus on three phrases that, in my opinion, should mean something different than administrators and subspecialists think. To do this, I must go against the Dictionary.

Primary Care -The medical care a patient receives upon first contact with the health care system, before referral elsewhere within the system.

Managed Care - Any arrangement for health care in which an organization, such as an HMO, another type of doctor-hospital network, or an insurance company, acts an intermediate between the person seeking care and the physician.

Productivity 1. The quality of being productive. 2. Economics. The rate at which goods or services are produced especially output per unit of labor.

I like the first definition as it could refer to medical practice. I hate the economic definition. When I think of a productive physicians, I must consider quality. Has the patient had questions asked and answered? Are all pertinent issues addressed? Is prevention up to date? Is the patient receiving high quality care? The second definition just counts our patient visits, much like making widgets. But we aren't making widgets. I understand the drive to see more patients per session. It comes from how we are paid. Lawyers learned long ago to charge for their actual time. Maybe that would be a better model for medicine. Given the middlemen (the insurance companies), we probably won't see that revolution. Maybe that is why I keep wondering if retainer medicine may be a superior model.

We are overweight. We aren't in good cardiovascular shape. Our most endemic disease is the metabolic syndrome - diabetes mellitus, hypertension, hyperlipidemia and all the consequences of that syndrome. While our genetics vary, and some (at the extreme the Pima Indians) have a greater tendency to these problems, I venture that all our diverse peoples suffer with the syndrome.

Why are we overweight and obese? The simple answer probably reflects reality - we eat more calories than we burn. We eat the wrong foods, although we can't easily obtain general agreement on our ideal diet. Few of us exercise enough, either aerobic exercise or strength conditioning. Too many become "coach potatoes", minimizing their caloric expenditure, allowing their natural muscles to atrophy slowly, while eating empty calories. I know, I've been there.

Thirty pounds ago I wore size 38 pants. I had frequent heartburn. My energy level decreased monthly. One day I looked at myself in the mirror, and wondered how it had happened. I've been an athlete my entire life - not a great one - just a dedicated recreational athlete. I played basketball (full court) until around age 45. Basketball kept me in shape. Nonetheless, I still struggled a bit with my weight.

When I stopped playing basketball, I didn't have an exercise plan. I played golf regularly, but I didn't fool myself. Riding in a golf cart doesn't represent exercise. Golf is a great game which benefits from ones physical conditioning, but it doesn't create the level of exercise that I needed.

So 3 years ago, I made a commitment to myself. A commitment to get in shape! Being relatively naive, I started with cardiovascular conditioning. That was a very reasonable place to start. I bought an expensive treadmill (I now know that when you use the treadmill regularly it isn't really expensive, it just costs some money). At first I walked at 4 MPH for 20 minutes. I was sweating, and tachycardic. I started dieting (not a very healthy diet, just worked on decreasing calories). The treadmill was my challenge. Running became my goal. Each day on the treadmill I would increase my speed a little. One day I could job at 5 MPH. While not very fast, this success excited me.

Over time I could actually run on the treadmill - as fast as a 9 minute mile or even better. At that time, my progress stalled. I needed more information on diet, and probably needed some strength training. I got to strength training through golf. One day I'm talking to one of my golfing buddies, and asked him if he knew anyone who specialized in golf training. He does a weekly golf radio show, and had a sponsor who had such a program. 11 months ago I walked in and started.

The first month we mostly stretched and learned balance, but over time my program has evolved to strength training and body shaping. My trainers (I've worked with several) have exposed me to nutrition and muscle. Being inquisitive, I began to read medical journal articles about nutrition and the importance of muscle mass. Readers of this blog know that I do focus on such articles often. This past February, we developed some goals. I had a complete evaluation of strength, flexibility, measurements, and body fat (using calipers). My July evaluation (5 months later) showed dramatic results. I've lost no more weight, yet my body fat percentage decreased from 23 to 18. As you can imagine, my proportions are changing.

My road thus far has been a long one; one which has become a central activity.

So what does my personal journey tell me about working with the average patient? I'll suggest some principles, without demanding a randomized controlled trial.

• Incorporating fitness into one's lifestyle is the goal - if one does - the weight generally takes care of itself
• We have an excess of dietary theories - but I'm certain that we shouldn't eat excess fats or "unrefined" carbohydrates. Calories matter, but so does the composition of the diet.
• Cardiovascular fitness and muscle fitness complement each other
• One should contemplate each week with a plan - when will I workout - how will I balance my diet
• As a country we must encourage studies which evaluate methods for making fitness easier and a greater priority for Joe and Jill six-pack

I hope that this ride on db's soapbox and personal journey was acceptable. The obesity battle requires hard work but that hard work is worthwhile. As physicians we should constantly encourage our patients to modify their lifestyle. Our research industry (especially the NIH) should fund research so that we can give our patients better information. And I will continue to cite articles that address this general topic.

The past decade has seen remarkable advances in our ability to prevent disease or disease progresion. We can decrease the probability of coronary artery disease, congestive heart failure, diabetes mellitus, colon cancer, skin cancer, etc. We can treat patients with those diseases and retard progression. Yet we only do a mediocre job. As I consider various posts since starting this blog, several common themes relate to prevention:

• The cost of preventive medications


• Conflicting data on whether a preventive measure works


• Physician's inconsistency in prescribing preventive measure


• Patient's reluctance to accept screening tests


• Risk benefit ratios change as new studies are published

Physician time pressures have negative effects on patient care. Prevention often takes time. One cannot just write a prescription for exercise or diet, and expect excellent results. These issues take exploration, reinforcement, and questioning. Physicians don't have the time to do this right. We aren't trained that well in behavioral modification, and generally don't develop those skills. Our time pressures also decrease our ability to remember the increasing list of prevention issues. If you only have 15-20 minutes per patient, some issues cannot have full exploration.

Finally, we have conflicting recommendations. Specialty societies often develop guidelines based on their beliefs, rather than objective data. When independent groups develop alternate guidelines, physician confusion reigns. At what age should I start ordering mammograms, or PSAs? Is an annual rectal examination worthwhile? Which patients with hypercholesterolemia deserve treatment?

I hope medical leaders will address these issues. Interesting that most things generally boil down to time and money. Regardless, continue to consider prevention. Try to develop your system to maximize your patient's future health.

The ACGME report on the new standards for resident work hours raises many interesting questions. We must examine ourselves as a profession. Attendings should consider themselves role models, and reflect on that role. How should a physician balance work and life outside work? How do we keep our moral contract with patients, while maintain our humanity and our personal lives?

I believe that many programs and attendings have lost their way. They mean well, but they haven't considered carefully how changes in health care should change our residencies. My cohort remembers working every third night. When residents work every fourth they assume it is easier. We often forget the many changes which have occurred on the inpatient wards - all make residency more challenging.

The average length of stay during my residency was longer than a week. We admitted less patients per night, and the patients were not as sick. Occasionally we would "get slammed" and get 6 or more admissions, but at least in my program that was unusual. We had time to develop a management plan, and to view the outcome of that plan.

Attending physicians made teaching rounds during the week, but the resident was king (or queen). The attending taught, but didn't direct care. Soon after I first became an attending, we had to start writing very brief notes. As the documentation requirements have increased, so has the attending input on rounds. The challenge we face today is that of balance - how do balance our clinical documentation responsibility with our teaching function. Attendings differ in their approach, not all taking the resident's circumstances into their equation.

Much of the distress in housestaff training comes from how their attendings treat them. As an attending I have to balance the resident's situation and patient care. Teaching becomes secondary to the situation. Or at least it should. We should rethink how we do rounds, when we teach, and how we transmit our expectations. Neverending rounds aren't consistent with housestaff mental health. At the risk of becoming pedantic let me make some modest suggestions:

• Daily rounds need an announced ending time. The housestaff have much to do, as an attending I should give them the certainty of when they can do their work. If I drone on and on, I selfishly impinge on their time.
• Post-call rounds should take into consideration how difficult the night call treated the housestaff. If you come in and they look haggard and tired, then adjust. I call such rounds - "survival rounds". On those days we have minimal teaching, and no longer have complete presentations on each patient. I may have to spend a little extra time after rounds, but the housestaff need time to stabilize the service.
• We should be role models of healthy lives. Let the housestaff know that you have hobbies. Discuss your life with them. Get to know them - what they enjoy - what they do on their days off. I've seen too many physicians burn out; I hope that I can prevent a few from that self-destructive life style.
Be their advocates, not their enemies.

Given the relative dearth of news on Sunday, I've decided to pick an issue each Sunday and share my thoughts. These past 2 weeks the key issue comes from the ACGME and the AMA. First the ACGME published their proposed new guidelines on resident work hours Click on ' ACGME Approves New Common Requirements for Resident Duty Hours'. Later in the week the AMA endorsed those limits AMA endorses limit on residents' hours . Let's revisit the proposed new requirements and try to understand their impact.

All these requirements work on 4 week averages.

• 80 hour limit per week


• 1 full day off each week


• No more than 24 hours on call with up to 6 additional hours to insure patient care continuity


• Call no more frequent than every 3rd night


• Complex moonlighting recommendations

Now let's assume an every 4th day cycle. We have 7 call days in our 4 weeks. Thus, we have 210 hours for those 14 days (7 on call/post call combos) - with 110 hours remaining on the remaining 10 days (assuming 4 full days off). This allows for 11 hour days. In our program, weekend days often take no more than 5 -6 hours.

Putting this into perspective, the residents will have to become more time efficient and more willing to give tasks to the on call team (because they will have to leave at a reasonable time). This requires a culture change amongst many residents. Residents have their own macho culture of taking care of everything prior to leaving. We will now have to force this culture change.

So these rules will put some pressure on residents. Likewise attendings will have pressure to reconsider postcall rounds. At our institution many of us have learned that post call rounds are often "survival rounds". We come in at 7:00 a.m. post call to make certain that significant patient care issues have attending input very early in the day. I've learned that post call days cannot involve extensive teaching (unless it happens to follow a very light call day). Attendings will have to make adjustments for the residents.

Are these rules good or necessary? I'm not certain that these are the right limits. As I referenced on Tuesday, Sleep Won May Come at a Price. Sometimes patient care does require longer hours. Most residents know this and respond appropriately. By strictly limiting hours to 80, sometimes patient care could suffer. Residency training now enters a major transition. Residents and attendings will have to work hard together to make these limits work both for education and patient care.

Now that I've framed the problem, it's time to examine the movement. I'll assert that, ignoring the money, patients will prefer retainer medicine. Under this system, patients have greater access and more attention from their physician. This system meets patient desires.

Most internists would relish a retainer practice. The system removes our concerns about time. We can provide comprehensive care, both inpatient and outpatient. We have time to talk to patients, in the office and on the phone. When a consult is needed, we can discuss the patient with the consultant both before and after the consultation visit. One can view the X-rays and discuss them with the radiologist. In short, one need not take short cuts to providing complete care.

If not for the money, this would seem perfect. Even without the money though, we would have problems. The numbers don't work. We don't have enough primary care physicians for all the patients. If I decrease my practice from 2000 or even 3000 patients, to only 600 or perhaps 1000 patients, who will care for the remaining patients?

The pros of retainer medicine are obvious. Patients love the attention, and may even get better care (although we have no data to support that claim). Doctors also love the pace and comprehensiveness. Most internists would prefer a mix of inpatient and outpatient medicine, and retainer medicine allows for that mix. Caring for 600 (or even 1000 patients) allows a better quality of life for the physician. The doctor-patient relationship strengthens which gladdens both doctor and patient. Finally, if we adopted a more widespread retainer model, more physicians would choose general internal medicine and family medicine. The retainer model makes the finances work. This model pays for the time and effort to think through each patient, rewarding the physician's intellectual tasks. Seems wonderful.

Opponents raise several interesting points. First, if I downsize from 2000 patients to 600 patients, what happens to the 1400 patients. Have I abandoned those patients? And do they have another physician to choose .. probably not in today's financial climate. Second, will we create a multi-tiered system. They argue that health care is a fundamental right, and no one should be able to pay for First Class care different from any other patient's care. Third, following that argument, increased adoption of retainer medicine would leave increasing numbers of patients without access to good primary care.

I'll take the side of the retainer movement, admittedly understanding the objections. However, when I chose internal medicine, I didn't chose financial suicide, I chose good patient care. I argue that the system, insurers and the government have forced this movement. If I want to practice ideal medicine, Marcus Whelby medicine, then this may be my only option. If health care is a fundamental right, then the insurers and government (Medicare) especially should reimburse general internists and family physicians a reasonable fee, while limiting costly bureaucratic rules. Individual physicians can't just act altruistically, they have responsibilities to their own health and quality of life. The current system is brutalizing those physicians. Growth of the retainer model will help focus the debate to the true antecedants. We have a health care reimbursement system that is tragically flawed. Critique retainer medicine, deride "concierge medicine", but please think. We need good internists and family physicians. If we don't address the root causes, then we will have less access. You cannot force physicians to choose to practice in the current system. And you shouldn't.

Whenever a new idea arises, whenever a new movement starts, one benefits from a clear understanding of the root antecedents. What atmosphere in the medical climate led to the idea and the growing adoption of that idea? Those that blindly criticize the concept miss the point. This idea couldn't arise in a vacuum. As Steven Covey says, 'Seek first to understand, then be understood'.

Let me first define my understanding of retainer medicine (I choose to use this term rather than the term concierge medicine which, in my opinion, immediately labels the concept). The patient contracts with a physician for comprehensive care, and 24 hour access. If the patient needs to see the doctor that day, the doctor can and will comply. The doctor cares for the patient in the hospital, in the office, at the patient's house or on the phone.

Patients want continuity, comprehensiveness, and access. None of my golf buddies are physicians. They want access at their convenience. Often they'll call me in the morning and want a problem addressed that day. I try to help them, when I can, but the current system generally lacks that responsiveness. Last year my 25 year old daughter called me on a Sunday night complaining of an acute illness. I was fairly certain that she had influenza and would benefit from medication. I told her to call her internist the next morning to either get a prescription called in or be seen. Her internist's office said she couldn't be seen until Tuesday. My understanding of the anti-influenza medications says that those 24 hours were very important - she remained ill for approximately a week.

Patients want time with their physician. One physician that works in my division has a great clinical reputation. Her patients commonly tell me that she spends enough time with them and 'really listens'. Unfortunately, you don't often hear physicians described like that.

So we have the first phase of understanding. Patients have difficulty satisfying their needs of continuity, comprehensiveness and access. From the patient viewpoint, I believe that the current system has worsened all these needs over that past 10 years.

General internists are the less satisfied physicians in the United States. When asked they complain about many things, but most complaints center on time and money. Let's address the time issue first. In order to achieve adequate gross income, an internist must see approximately 3 patients an hour, an average of 20 minutes per patient. While some visits really require 10 or 15 minutes, some visits should take 30 or 45 minutes. And the physician doesn't know until the visit starts. What is the internist trying to do? First, one must address any new complaints. Sometimes these come in a long list, often handwritten or typed. Often, the patient has read something on the internet, and wants you to comment. Second, one must address ongoing problems. Each medical problem requires some thought as to how treatment is going, or whether new tests are indicated. One should reconsider each medication, is the dose correct, are there any potential side-effects, could any combination of medications cause an interaction. Third, one considers prevention. Are all prevent issues on schedule? Is it time for new testing? Fourth, one screens for disease. As discussed earlier this week, one should screen regularly for depression. There may be other screening issues related to the patient's underlying diseases. Fifth, one should offer lifestyle counseling and advice. Most patients need dietary and exercise encouragement. Internists rarely invest in show advice, both due to lack of training but more important the lack of time. Yet such lifestyle advice can successfully reduce the risk of diabetes in many of our patients (Prevention of Type 2 Diabetes Mellitus by Changes in Lifestyle among Subjects with Impaired Glucose Tolerance - N Engl J Med 2001; 344:1343-1350). Sixth, one often needs to spend a short time listening to the patient's concerns or eliciting feelings and responding. This ideal visit cannot often occur in 20 minutes.

How much does Medicare pay for that visit? $39!!!!! And the office cost more than that to keep open - assuming the physician were independently wealthy and didn't deserve a salary. Thinking, talking, interacting and caring isn't reimbursed in our current system. This angers internists. Internists have wonderful training, handle medical and psychosocial complexity, can provide care for inpatients and outpatients, yet the payors seem to not value what we do. They value a lab test, or a radiologic procedure, or a surgical procedure, but they don't value careful thought. And remember that the time spent is greater than the patient's visit. The internist reviews laboratory data, radiologic data, and gets back to the patient about the tests (at least in an ideal world). The internist responds to phone and email inquiries (no charge). His office receives approximately 2 calls for each actual visit. Someone has to answer those calls, triage the questions, and often the physician either responds or crafts a response. $39!!!!!!!!! Are they serious?

Just to add fuel to the fire, over the past 10 years, governmental bureaucracy makes things even worse. We can no longer charge for looking at a urine sample, or a gram stain, or do a few lab tests (CLIA standards). Our documentation requirements skyrocket each year both for inpatient and outpatient visits. Each insurance company has differing requirements, leading to a plethora of business staff for this office that gets peanuts per visits. ARRRRRRGGGGGGGHHHHHHHHHHH!

From these concerns arose a new concept - retainer medicine. For a fixed fee, the patient has the doctor's total attention. He/she can reach the physician 24 hours a day. The physician cares for the patient in the hospital, in the office, in the home when appropriate, by phone, or by email. If the patient needs a visit today, he/she gets that visit. Such care costs more than insurers pay. Thus, a retainer is required. A sound business concept which allows the physician to practice a more ideal medicine, a more satisfying medicine, a more thoughtful medicine, a more comprehensive medicine. A sound business concept which gives the patient what he/she desires - access, comprehensiveness and continuity.

So what's the problem, why does anyone criticize this concept? I'll try to address that later today. Now off to hospital rounds!