1.       Placebo Television

2.       SCHIP Away, Medicaid, and Making Things Free

3.       Placebo Journal Update

4.       Gorback’s Thoughts by Michael Gorback MD

5.       It’s Still Not Hip

6.       Functional Syndromes

7.       Joke of the Month

8.       Ridiculous Study of the Month

9.       Bacharach’s Beliefs by Ted Bacharach MD, retired

10.    Sorry, Chalie

11.    Sarita’s Stuff by Sarita Salzberg MD

12.    Tidbits

13.    Feedback About The Placebo Gazette

1.  Placebo Television

If you are interested in supporting an organization that truly believes laughter is the best medicine, click below for a subscription:

SUBSCRIBE

4. Gorback’s Thoughts by Michael Gorback MD

Whose pocket is Senator Kay Bailey Hutchison (R-TX) in?  Let's find out. I wrote to Senator Hutchison recently about Medicare fees. This my short note:

"Once again, I am facing a cut in my Medicare fees.  Meanwhile, CMS pays a 12% PREMIUM to Medicare Advantage plans. This is just plain disgusting. It's time to fix the SGR mess instead of giving doctors a stay of execution every year.

Physician fees have been static for several years, although inflation has not. The net effect is a loss of income for me seeing Medicare patients. I am rapidly approaching the point where new Medicare patients will be unwelcome in my practice.”

What I received back was a long spiel about the history of Medicare HMOs (see full text below) and the usual noncommittal garbage that I am used to seeing from senator Hutchison, who has never given me a straight answer on the issues. 

Dear Dr. Gorback:

Thank you for contacting me regarding the Medicare Advantage program.  I appreciate your thoughts and comments on this issue.

 I supported the creation of the Medicare+Choice (M+C) program in 1997, under the Balanced Budget Act, in order to provide a wider range of health plans for Medicare beneficiaries. Unfortunately, the M+C programs discontinued their coverage as a result of insufficient reimbursement. The Medicare Prescription Drug, Improvement and Modernization Act of 2003 made many changes to the M+C program, now called Medicare Advantage (MA). Under MA, private health plans agree to provide Medicare covered benefits to beneficiaries who enroll in their plans. MA plans are paid a per capita monthly fee for providing all

required Part A and Part B services to each plan enrollee, regardless of the amount of services used. To ensure the financial viability of MA, this legislation increased payment rates, created a competition program and regional plans beginning in 2006, and would begin in 2010 a six-year comparative cost adjustment program that enhances  competition between MA plans and requires traditional Medicare to compete with MA plans.

 Over seven million Medicare beneficiaries have enrolled in MA plans. We must ensure that senior citizens have meaningful choices with their health care, whether they choose traditional fee-for-service program or MA. Medicare health care programs upon which senior citizens depend should receive adequate reimbursements and should not be overly burdened by unnecessary regulations. Should legislation come before the Senate regarding this issue, you may be certain that I will keep your views in mind.

I appreciate hearing from you and hope you will not hesitate to keep in touch on any issue of concern to you.

Sincerely,

Kay Bailey Hutchison

What really caught my eye was this sentence:

 "Medicare health care programs upon which senior citizens depend should receive adequate reimbursements and should not be overly burdened by unnecessary regulations."

My reply:

What a nice sentiment. Maybe you should try extending this concept to doctors too. I am NOT getting adequate reimbursement, and I am drowning in regulations.

I wrote to you about the SGR formula and I get back this canned crap defending insurance companies. Obviously you are in their pocket. Although I have been a life-long Republican I will not vote for you, and I will be sure to contribute to whomever opposes you in any election.

Earlier this month, the NY Times did a nice piece on the hard work the medical system does to keep as much information out of the hands of their patients’ relatives.  This is just one more consequence of the burdensome HIPAA rule.

In the old days, doctors used to get into trouble when they used monikers like the “heart failure patient in room 2”, “the yellow man in the ER (jaundice)” and so on.  Though it is still politically incorrect, it does work for HIPAA.  Here are some examples offered in the NY Times article:

• Birthday parties in nursing homes in New York and Arizona have been canceled for fear that revealing a resident’s date of birth could be a violation.
• Patients were assigned code names in doctor’s waiting rooms — say, “Zebra” for a child in Newton, Mass., or “Elvis” for an adult in Kansas City, Mo. — so they could be summoned without identification.
• Nurses in an emergency room refused to telephone parents of ailing students themselves, insisting a friend do it, for fear of passing out confidential information.
• State health departments throughout the country have been slowed in their efforts to create immunization registries for children because information from doctors no longer flows freely.

The bottom line is that though the intention behind HIPAA was probably good, it really can go too far.  It causes too much red tape, gives more administrators a reason to have a job, and leaves us medical folk out in the dark. 

Here is my latest dilemma. I have a patient with a multiple personality disorder.  I am afraid to give him his medical information for fear that he may tell the other personalities which may put me in violation of HIPAA. 

I just read the most idiotic piece of reporting.  The title was Functional syndromes elude medical diagnosis.  It came from the St. Louis Dispatch.  The story got so chopped up in my local paper that it didn’t make sense.  The full article was even less clear. 

The following is from our first issue of the Placebo Journal in 2001.  I think our study will clear everything up:

A Landmark Case Study of SLS by Cornelius Parody MD and Aristotle Jones PhD

Below is a case study which reveals a new but common syndrome plaguing many medical offices around the country.  SLS is endemic and Drs. Parody and Jones use their unique style to address this disorder and give some recommendations for treatment.

HPI:  A 38 year old WF presents to the office as a new patient with multiple complaints.  She has had an eighteen-month history of fatigue as well migrating myalgias and fleeting arthralgias.  She is currently on workers compensation and looking for disability for worsening back pain that occurred while lifting a patient on the job as a certified nurse assistant.  She has been seen by multiple specialists for her ills including a neurosurgeon, rheumatologist, physiatrist, psychiatrist, gastroenterologist, gynecologist, internist, two chiropractors and a shaman.  Their diagnoses consisted of reflex sympathetic dystrophy, fibromyalgia, myofascial pain syndrome, major depression, irritable bowel syndrome, premenstrual dysphoric disorder, chronic fatigue syndrome, atlanto-axial misalignment and “animal spirit disunity” respectively.

ROS: all positive including 21 normal TSH tests; also has multiple  normal sleep studies, CT scans and MRIs

PMH: As per HPI as well migraines, PTSD, overweight, fibroids, insomnia, fibrocystic breast disease and chronic abdominal pain

SH: Single mother with three children at home, ages 4, 5, 6.  She has another child, age 9, who is currently incarcerated but she states “I am not sure he’s mine”.  The six year old has been diagnosed with ADD and had been suspended from the school and its buses for behavioral outbursts such as lighting them all on fire.  The youngest two children are being seen by a child psychiatrist for depression and probable oppositional defiant disorder.  The patient smokes three packs per day, in the house, and has failed cessation treatment on multiple occasions because “no medicine will work on me!”  The patient drinks over 14 cups of coffee before noon and states she only eats eleven or twelve calories a day yet “keeps gaining weight!”  Her alcohol use is defined as minimal.  Patient does not exercise but gets offended when questioned and responds by stating “I get enough exercise watching these crazy kids”.  Education includes GED and local night college for her certified nurse assistant certificate.

MEDS:  Valium 5 mg prn, Zoloft 100 mg a day, and trazedone 100 mg qhs, Imitrex 50 mg prn migraine (average 15 per month).  OTC meds include Metabolife 356 for energy and weight loss.

ALL: PCN, all macrolides, sulfa and quinolones. 

FH: Depression and alcoholism throughout her family including siblings and parents.  Mother also has chronic fatigue and fibromyalgia. Father has PTSD from being married to her mother.

SxHx:  T&A as a child for chronic sore throats.  Tympanostomy tubes as a child for chronic ear infections (parents smoked in the house as now does she).  TAH-BSO for fibroids and dysfunctional uterine bleeding.  Multiple benign breast biopsies for fibrocystic breast disease.

PE:

VSS; wt 243, ht 5 “1

Gen - Patient switches from crying jags to out and out aggressive or defensive demeanor.

Neck – no thyromegaly

CV- RRR no murmer

Lungs – clear

Abdomen – obese; diffuse pain throughout with no rebound or Murphy sign

Skin – multiple tattoos; no rash or dysplastic lesions

Back- no spasms but exquisite pain with palpation, percussion or even observation

Musculoskeletal – pain with palpation of every muscle

Neuro – grossly intact, negative straight leg raises, normal reflexes

Workup: Full review of patients old records (over 640 pages) show that all possible testing has been done including Pet-Scans, dexamethasone suppression tests, Schilling tests, tilt table testing, EEG, allergy RAST testing, pan-endoscopies and even a PSA for some reason.  All studies normal.

Diagnosis: SLS (classical type)

Discussion:  Just as described by Edward B. Foote MD in 1896 in his infamous book Plain Home Talk: Medical Common Sense, the above patient symbolizes a syndrome that is very real to physicians yet surreal in its etiology, work-up and treatment.  Similar to Foote’s “neurasthenia with a notion of chronic withering” it becomes more obvious that with this patient there really is less here than meets the eye.

Like an onion, the layers of fibromyalgia, chronic fatigue, IBS, etc. continue to be peeled off until the final syndrome is truly defined.  SLS or “Shitty Life Syndrome” is a constellation of ailments not unlike an enigma wrapped in a riddle whose only common thread to reality is social dysfunction.  These patients, like our lady described above, present to the medical community and are subsequently medicalized, surgerized, and psychoanalyzed only to have the true cause escape all.  The reason these patients have these symptoms is quite simple.  To them their life totally sucks and for this there is no medical cure.

Although there is no hard data to support our conclusions or anything else we say for that matter, the authors justify the existence of SLS in order to maintain their own sanity.   Because SLS is contagious, it is the physician who may come away from the visit with medical problems such as GERD, abdominal pain and depression.  Therefore treatment for this syndrome is not so much for the patient but for the poor doctor who must endure the torture of frustration.

SLS is very common and the differential is very large.  Such syndromes as irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, gastroparesis, migraines, myofascial pain syndrome, stress, depression, anxiety, cystitis, RSD, chronic pain and PTSD only reveal the tip of the iceberg whose base is comprised of one big piece of SLS. 

Treatment is usually unsuccessful as the medical dollars are burned yet the patient’s symptoms worsen or change.  Anti-depressants help briefly but the doctor soon has to realize he or she can’t rely on taking these medications forever.  He or she must go back to work and stare the patient in the face with an SLS eating grin and let the SLS hit the fan. Since it is the patient who believes that their life sucks then it is only the patient who can wipe themselves clean of SLS.

In conclusion, the authors believe in their hearts that SLS or “Shitty Life Syndrome” not only exists but is actually pervasive.  Like kryptonite, physicians are powerless against this disorder.   If one is not careful, one may step into a big pile of SLS without ever knowing it.

7. Joke of the Week

A guy falls asleep on the beach for several hours and gets a horrible sunburn.

He goes to the hospital and is promptly admitted after being diagnosed with second degree burns. He was already starting to blister and in agony.  The doctor prescribed continuous intravenous feeding with saline and electrolytes, a sedative, and a Viagra pill every four hours.

The nurse, rather astounded, said, "What good will Viagra do him?"

The doctor replied, "It'll keep the sheets off his legs."

8. Ridiculous Study of the Month

The issue of diet colas and obesity is being Vlogged on Placebo Television below:

 http://youtube.com/watch?v=VgAtBcLvVaA

9. Bacharach’s Beliefs by Ted Bacharach MD, retired

Known for American industrial potentials and accomplishments it was not too
surprising that sooner or later the same principles that applied to industry would
be applied to medical care. Efficiency, productivity and profit are primary
considerations. Old fashioned care, sensitivity, compassion and a one to one
relationship that characterized the practice of medicine cannot be measured and
are not a source of profit. More in line with industrialization several changes were
made. Depersonalizing the patient was accomplished by designating him a
“consumer”. The physicians once called doctors were designated “providers”.
Differentiating physicians from other healthcare providers was no longer possible
since both are accepted as being “providers”.

The result of this industrialization of medical care has been demonstrably dismal. Costs climbed as the delivery of services declined. A new industry that has been quite profitable emerged. This healthcare industry consists of HMOs, managed care companies, health insurance companies and hospitals. The designation “not for profit” has been applied to some of these entities. If you really believe in the “not for profit” designation I believe your gullibility is indeed great. Multimillion dollar salaries are common in all of them and add little to the delivery or quality of medical care.

The provider once known as a physician has become a “sacrificial lamb”. Portrayed as overpaid and greedy, no one came to their defense. The first step in
harnessing physician power was to make them more productive. This
accomplished two things. By increasing the number of consumers the doctor could see, the physician would be able to charge less per patient and still maintain his or her income. Once upon a time many family physicians saw 15 patients a day. After all of the time saving productivity was instituted, he or she was obliged to see 30 patients or more a day. The time consuming process of having a consumer take off his or her clothes had to be eliminated to the point where very few primary care providers know whether the patient has a large tattoo on his back or a scar from previous bypass surgery. The idea that the primary care provider would follow a patient if they were sent to the hospital was also untenable. This type of wasteful activity would decrease consumer output and decrease efficiency.

For most hospitalizations a “complete physical and history” is required. Communication between the primary care provider and the surgeon, cardiologist or hospitalist is generally limited. This limitation was augmented by HIPAA which safeguarded the patient’s medical history and physical from prying eyes, it has also interfered with the interchange of information between providers.

The need for compensation results in many short cuts. The history once extracted with patience and discernment was replaced by a patient questionnaire. The physical was abbreviated by what is done and lengthened by canned data. In the case of my wife, her history and physical noted an appendectomy as well as a hysterectomy. She had had neither but the information was copied to at least three “History and Physicals” during hospitalization. Three different doctors utilized and copied this information.

Efficiency and honesty are not always good companions. The present dissatisfaction with the delivery of medical care has resulted in many
suggestions. Improvements are certainly needed but simple solutions will not fix a situation that has drifted as far off course as medical care. The easiest course to fix the problem that has been suggested has been to adopt a system of “socialized medicine”. The expertise shown by governmental agencies as well as their ability to control costs both by privatization as well as creating government agencies has been well documented and found lacking. Going backwards is also untenable. I would suggest that, regardless of what is proposed, that physicians who are familiar with the practice of medicine on a first hand basis be included in the design and implementation of any changes that are under consideration. The lack of good practical advice on most of the changes that have been instituted in the past clearly demonstrate that the primary people involved should be included in assessing and implementing changes in any proposed system.

Letting the fox design the hen house has not worked too well so far.

One of the coaches I truly admire lost his lawsuit against his doctors recently.  Charlie Weiss, former coach of the New England Patriots, claimed they botched his care after he had gastric bypass surgery five years ago.  The jury deliberated almost three hours before finding Massachusetts General Hospital surgeons Charles Ferguson and Richard Hodin were not negligent.  These two docs have stellar reputations and did not want to settle.  They felt that internal bleeding was a well-known complication of the stomach stapling surgery and it is.  In fact, there are a lot of complications to this supposed quit fix; all of which, I am sure, Weiss was told about when he signed his consent form.  I feel bad that this happened to Charlie as I bet the surgeons did.  Bad things do happen.  Doctors are not gods.  If they can’t be protected by a consent form even when the patient was educated about the risks, then surgeons would stop doing any risky procedure at all.  The right team won this time.

11.  Sarita’s Stuff by Sarita Salzberg MD

 

The most recent American Family Physician had a piece called Answers to Medical Student Questions about Family Medicine.  Essentially through innovations such as group visits, the EMR, patient-centered care, and advanced access scheduling...blah, blah, blah...family medicine will become the future of medicine.  It will be like "Back to the Future" with Michael J. Fox and Jim-from-Taxi.  The Dad will finally get the respect he deserves and not go ballistic on David Letterman, but with better computers and a medical home and...well, I kind of zoned out thinking what choices I could have made in the 80's and early 90's that may have led me to an entirely different future.   And the Back To The Future ride is formally closing at Universal Studios on August 2^nd.

Anyway, medical students stand on the brink of these choices and they don't have a fancy time travel car with side-opening doors to drive back and fix what the heck happened.  Don't they deserve some real answers?

So how about some responses from some real family physicians who can say what is really going on?

For starters, here are my advantages:

1. You can always tell a family member or friend or acquaintance that you are not a specialist in this area -  after they question what happened in a medical adventure or misadventure.  This is a biggie. 

2. You attend CME programs entitled "Don't Kill Your Patient" This really  builds your confidence as a Family Physician.  Not that anyone’s noncompliance, or diet balanced with equal visits to Carl's Jr, White Castle, Captain D's or KFC had anything to do with a bad outcome (and in court, it won't either) so attend the conference.

3. Shortest residency in length of time.  It only seems longer because of the knowledge that all the procedures you log won't help you at all when you get out.  You can look at the procedure logs years later and realize where your life went, but that's pretty much it. Patients will ask you, "Did you really do surgeries?"; "Did you really deliver babies?"  And when you say "Yes" you can see the "Yeah, right...." look on the patient's face.  And you'd really rather forget the whole experience but can't for the first several years.  Eventually you realize to answer "No, I just filled out the paperwork",  and the patient will feel a better sense of order in the world. 

4. You can know that your generalist office can be the true intersection of all socio-economic problems in our world.  Sometimes you can see all the socioeconomic troubles in the world combine on one person and you can be ultimately responsible for everything.  You can try to accomplish this as the patient questions why they should have to come back for regular visits when all they really need is a specialist. In infectious disease, you can order a Pan-Culture.  We can order the Pan-Specialist-Consult.

5. Family Doctors "Specialize in You".  Kind of like "Have it Your Way" at Burger King.  Burger King specializes in you and how you want your burgers cooked and dressed.  You can frequent Burger King before and after your more humane 24-hour shifts in your candy-coated 80-hour-work-week-reform-residencies.  Burger King probably won't be around to pay for your liposuction, but you can know they cared or at least remember how great it felt to talk to the kind person at a counter  (the one person in your day who wasn't angry about not getting their specialist consult soon enough).

6. You can ponder the following after reading the AFP article:  Who is actually doing group visits?  Is anyone really doing this?  And, if they were, wouldn't HIPAA just go medieval on their sorry asses? 

I could only thing of 6.  Can the other family docs out there please pitch in for the guidance of our future colleagues?  Obviously, however, they didn't get very good advice to begin with or they wouldn't be in Medical School. We can only do so much without that DeLorean!

• I highly recommend you check out the Wall Street Journal article about an organization called Medical Justice.  They work with doctors in high risk fields to protect them from frivolous lawsuits.  They go after “expert” witnesses who commit ethical violations.  They push for patient-physician contracts.  And they fight back.  They have brought down the lawsuit rate for their members to just 2% a year (where it is normal 8-12%)
• Speaking of which, a Kaiser Family Foundation analysis found that payments on medical malpractice claims approached $4 billion last year.
• Tease Lindsay Lohan all you want but this person has a real addiction and a death wish.  She probably needs tough love, like doing some jail time.  Does anyone else think that this recent crop of stars is trying to compete for the best looking mug shot?

13. Feedback About The Placebo Gazette

I WANT TO KNOW WHAT YOU THINK.  Please go below and post your thoughts under the WRITE A REVIEW section.  You can also see some one of these articles on our blog:

Until next time, keep smiling, keep laughing and keep out of the sample closet.

Doug

King of Medicine