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Dampening Effect
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Physician's Offspring by Ted Bacharach MD (retired)
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PJ App for the iPhone
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Sound Familiar by Michael Gorback MD
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Lawsuit Angst
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Placebo Journal Update
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Career Counseling
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Let's Make A Deal
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Dog Smells Cancer
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Celebrity Endorsements
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Who Will Survive The Merge?
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Here's A Shocker
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Ridiculous Study of the Month: Coffee and Tea Lowers Diabetes Risk
1. Dampening Effect
The healthcare reform bill will probably include the Senate’s new tax on high-cost health plans. Taxing people is the major way to get some money to fund this behemoth. The problem is that this tax on "Cadillac" insurance plans could affect many union members (remember how good the unions did for Detroit?). The unions back the Democratic Party. Uh oh, something is amiss. Labor leaders are now pissed and are basically threatening NOT to back the party in the next elections. "Several key union leaders warned the bill’s final outlines could dampen their enthusiasm for the Democratic ticket in this year’s elections. " What will President Obama do? Will he stand by his principles or change his mind by compromising to the extortions made by union leaders? This is getting fun.
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2. Physician's Offspring by Ted Bacharach MD (retired)
Becoming a Physician
The medical profession was once a very desirable goal even for the offspring of physicians. I can testify to this because my father was a physician and the only conversation or topic discussed at home involved medical care. The physician back in those days was also a respected member of the community (it really was a long time ago.) Quite a few offsprings of physicians were interested in following in their father’s footsteps. Back in my father’s day the physician’s job was a 24 hour a day application and it would have been understandable why sons and daughters would opt for something less time consuming. The incomes of physicians has been a variable one. in the 20/s,30’s and early 40’s doctors did not earn very much, during the fifties, sixties and seventies incomes became quite good but in the nineties the drop had become noticeable especially for the family practice physicians and internists. Now that we have entered another decade, a gradual reduction has continued and the outlook for the future is also less attractive. The hours of work have been reduced but the method and practice of medicine has become increasingly restricted. Starting out in medicine has become quite simple, all that is required is a job and so far there are more jobs than physicians to fill them.
Is the desire of physician’s offsprings to follow in their father’s footsteps as great as it once was or have offspring been influenced in other directions? Back in the early days doctors often complained of the hours involved. Physician’s income was good and the doctor was a respected member of the community. Today and increasingly over the past decade complaints about how medicine must be practiced, how getting paid less and having to comply with everything the employer wants their physicians to do. Independent practice is a dead concept except for very few and involves insurmountable obstacles in many locations. While dealing with patients was once a problem, now dealing with insurance companies, government and employers has become more problematic.
Should physician’s offspring go into medicine? I think many are not attracted as much as in the past. The male offspring tend to be interested in a job in which he can be more independent. Female offspring are a little more attracted to medicine.
Evaluate your own children and see what you have inspired them to do.
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3. PJ APP for the iPHONE
Check it out here at Osler Mobile or go the iTunes store and search Placebo Journal. The price is only 99 cents!
Please forward the e-mail to friends and colleagues who might appreciate it. After all, a ton of docs have just gotten their first iPhone or iPod touch for the holidays and are looking for fun Apps to load onto it.
It is an easy way to show off your Placebo Journal to your friends.
4. Sound Familiar by Michael Gorback MD
I don't know how many of you have heard the new buzz about ACO's -
accountable cost organizations. If you have been following discussions
about Massachusetts health care you have seen this suggested.
ACOs are groups of doctors that receive a fixed amount of money and then
provide all of a patient's health care needs. I guess they figure they
can glue together a pediatrician, a heart surgeon, a dermatologist, etc
and make a cohesive group that provides one-stop shopping for all health
care needs. If the patient needs an MRI, the ACO pays for it. Hip
replacement, same thing. Labs, xrays, the whole deal. Kind of like an
insurance company, except now the doctors are the insurance company
without having any insurance company experience. We take in fixed
premiums and pay out benefits.
Does this sound like back to the future?This is basically capitation
revisited.
The geniuses in Washington, who think we are as corrupt as they are,
believe that instead of paying us to "do things" (which seems to be ok
for everybody but doctors) they can control costs this way. After all,
you'll think twice before you rip out that kid's tonsils if you have to
pay for it. Considering deliberately mismanaging someone's diabetes so
you can get $50,000 for a BKA? Not if it comes out of your own hide.
I think it will succeed, because if you stop paying people to "do
things" they will pretty much stop doing things. In my specialty the
general goal for most of us is to get a patient's pain under control
with minimal reliance on pain meds. Some of these modalities are
expensive. A spinal cord stimulator lead costs $1500, and the battery
about 10x that. An intrathecal pump is about $10,000. These are hardware
prices. they don't include O.R., anesthesia, etc.
So here I am in my new ACO office and a patient comes in with horrible
pain from failed back surgery that has been refractory to just about
everything.
* I know a stim could potentially help a lot.
* However, I also know that if I go around putting $15-20,000 worth of
hardware into people my partners are not going to be happy.
* I also know that writing a prescription is far easier and much better
for my health than spending an hour in front of a c-arm wearing a lead
apron under hot lights. And I will make MORE money that way. Plus, you can't surf the Internet while scrubbed.
So what's going to happen? They gave me an incentive to not do things
and I will accommodate them. Here's your methadone. It's cheap. Try not
to let your QT intervals get too long. If it makes you sick I'll call in
some Phenergan for you. No wait -- that might drop your WBC. That means
paying for lab tests. Try some flat ginger ale. That's what my mother
gave me for a tummy ache. Excuse me, time to check my email.
This didn't work when it was called capitation. I don't see how it will
work this time, and I can't imagine how they plan to get doctors to join
into diversified groups without killing each other. Maybe it will be
assigned seating like high school. Maybe they have figured out how to
herd cats. Maybe the CIA has secret pheromones that will make us
cooperate like ants and bees.
I want to know what will happen when a patient hates the group's
endocrinologist and wants to go "out-of-ACO". Can you do that, or do you
send the doctor and the patient to counseling to work it out? What if
the cardiologist you want is in another group?
What if you are a very popular or famous doctor, in big demand? Can you
threaten to go to another ACO if they don't give you more money? Will
there be a draft for doctors coming out of residency? When can you
become a free agent?
The ACO's are also supposed to help "coordinate care". This is the new
buzz word. The old buzz word, "preventive care", turned out to be not so
good after the data showed that it actually costs more to do tests on asymptomatic people. Not to mention that a PAP smear or colonoscopy is not preventive so much as early detection. Smallpox vaccine is preventive. Tetanus shots are preventive. Colonoscopies find what's already there. Anyway, it's not like we have any control over whether or not you eat a large pepperoni pizza every night, washed down with a 6-pack of beer, and then a few relaxing smokes. Nor can we prevent gallstones, broken ankles, cerebral aneurysms
or about 99% of the things that afflict people even if they all live like Dean Ornish in an isolation bubble. Healthy diet, a good night's sleep, exercise, don't smoke, watch your weight, and get lung cancer like non-smoker-vegetarian-yoga-enthusiast-transcendental-meditation-teacher-and-successful-actor/comedian Andy Kaufman, dead at age 35.
Do they think this will be like Boston Legal, where all the partners sit
around a conference table and discuss each case? How many of us call our
colleagues after every visit to discuss the patient? "I'm sorry, Dr.
Futznagle can't come to the phone to discuss Mrs. Balderdash. He's
already on the phone talking to Dr. Squigglemeyer and then he has to
return a call from Dr. Fussypants. Can he call you back next week after
he finishes returning last week's calls?"
Even the Europeans aren't that stupid. To really screw things up you
need the United States Congress, which seems to think that reinventing
the wheel by making a square wheel with a broken axle is the way to
decrease gas consumption.
Yes indeed, that's one way to do it.
5. Lawsuit Angst
Everyone should read the article written by JOAN SAVITSKY, M.D. at the NY Times. It was about a lawsuit that she never saw coming and that was riddled with false accusations and took years off her life. The lawsuit became a "noxious subtle film (that) had settled all around, making everything vaguely unfamiliar and unpleasant. I had become a little unfamiliar to myself". Dr. Savitsky retired before the case went to court. "I left my primary care practice after almost 30 years. I can’t say it was because of being sued, but I can’t say it was irrelevant either." To the doctor involved, the lawsuit was "deeply personal" and the "experience was devastating". The case never went to trial because evidently there NEVER was a case. The patient's lawyers tried to back out because it was unwinnable. The family wanted to continue. Eventually it was dropped - YEARS AFTER IT ALL STARTED. The big trend to allow doctors to say they are sorry to patients when things go wrong is gaining traction. Here is my question - where is the "I'm sorry" when the doctor is wrongfully sued? I am sure Dr. Savitsky would love to hear that as well.
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6. Placebo Journal Update
The next issue of the Placebo Journal is almost done. You only have until January 30th to make this issue.
If you are interested in subscribing to the only print medical journal that will make you laugh (on purpose) then just click below:
SUBSCRIBE
7. Career Counseling
I recently sat down with a former pre-med college student who is now leaning away from a career in medicine. This guy may end up being the valedictorian of his very big school. He was president of the "medical club" and was gung ho to be a doctor for his whole life. I am not sure what totally changed his mind. He did shadow a few physicians that I personally know (radiology, orthopedics) who are as dry as melba toast. Burnt to a crisp. Now this kid is thinking more bout going into surgical sales or another type of medical business. Sad. The worst part of his story is that the undergraduate advisor to his college (and liaison to the "medical club") told everyone that they shouldn't go into primary care as it doesn't pay enough. In fact, not one guest over the past four years has been a primary care doctor. Isn't that nice? The country is starving for primary care physicians and yet we are being disrespected by, well, everyone. My job can suck sometimes and yes, I would like to make more money, but I still think my job is better than this college advisor's job.
It is, right?
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8. Let's Make A Deal
- Special treatment for the construction industry in a way that benefits union members and contractors who use union labor
- A tax break for the Blue Cross and Blue Shield plan in Nebraska
- Medicare coverage for residents of Libby, Mont., sickened by a mineral mine
- Extra Medicaid money for Massachusetts, Nebraska and Vermont
- A special dispensation for a handful of doctor-owned hospitals
When it is all over I bet you will find tons of extra provisions (and pork). As Senator Harry Reid said, “There’s a hundred senators here, and I don’t know if there is a senator that doesn’t have something in this bill that was important to them. If they don’t have something in it important to them, then it doesn’t speak well of them. That’s what this legislation is all about. It’s the art of compromise.”
Or the art of extortion.
A dog owner in Australia was saved by her pet when he kept smelling her armpit. Turns out she had lymphoma. "Australian National Kennel Council vet Dr. Peter Higgins said it was time doctors used this remarkable ability by having dogs in their surgeries as early cancer detectors." Sounds interesting but would they get paid the same as some hem/onc docs I know? Er..that would be about $700K a year.
10. Celebrity Endorsements
From Jenny McCarthy to Suzanne Somers, we are constantly inundated with celebrities who play doctor by doling out medical advice. Most do this because they or a loved one are personally afflicted with a disease. The USA Today did a nice piece questioning whether they are crossing the line. I believe that having debate about these issues is a good thing but it can go overboard (i.e. autism and vaccines). I just wish some celebrities could come out about weird and exciting medical problems. I know we would all love to read about David Duchovney and Tiger Woods and the issue of sexual addiction. Heck, they could even start a Sex Addiction Charity (SAC) that we could all donate to. Their pitch line could be "Help Us Get Out of the SAC".
11. Who Will Survive The Merge?
Another great season of Survivor this year. What can I say? I am a huge fan. Russell got screwed, though, due to ego issues of the other tribe. In light of this I was thinking about the Senate and House healthcare reform bills. Who or what will survive that merge? There will be a lot of alliances made. There will be some blindsides. It should be fun. Remember, though, that this is all just for entertainment. The sponsors always win. Who are the sponsors? Let's just say that there is no coincidence that the insurance companies and pharmaceutical companies are doing really, really well on the stock exchanges right now.
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A survey showed that drinkers in the UK consume the equivalent of a bottle of wine per week more than they admit. They found that the difference between survey data and actual sales data reveals 225 million liters of alcohol go unaccounted for every year. Admittedly, the UK and the US are different but the overall concept is important. People block out "vices" in order to rationalize them. The same survey could and probably has been done here for food. We have lost perspective on what and how much we drink and eat (and yes, I am guilty as well) and this leads to more and more medical problems. No legislation will fix that except....prohibition. Wait a minute, we tried that once.
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13. Ridiculous Study of the Month: Coffee and Tea Lowers Diabetes Risk
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Until next time, keep smiling, keep laughing and keep out of the sample closet.
Doug
King of Medicine
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