WH0 CAN I TRUST???

My mailbox reaches the flood stage each day, overflowing as waves of medical information from sources which I know to be reliable (i.e., The New England Journal of Medicine, the Medical Letter and a few others), and sources which have suddenly popped up and pass for authentic reliable information and advice (often with names including the words"institute" or "association") appear.

My problem is that most of what I receive comes from sources which do not disclose whether they represent vendors of drugs and equipment or are truly independent. How can I trust information which comes from cloudy sources which may be forwarding advertisers' hype?  Why are providers of medical information not required to fully disclose conflicts of interest to the people who write the prescriptions and orders for the products they are promoting?

Even more confusing are academic sources. How do I know whether a report from a well-known investigator or institution is truthful, is part of an effort to attract more and better paying patients, or part of a plan to attract more grant money to support a training or research program?

It would not be improper for patients to ask physicians for their evidence supporting medical diagnoses and physician recommendations for testing and treatment and then to further ask the physicians for hard information about the reliability of the source of that information. The patient may get some strange looks and responses to such questions, but the physician being questioned will be more careful with, and respectful of, the person who asks. And as a patient - that's what you deserve.

THE "RIGHT" APPROACH - BUT NO GUARANTEES

The recommendations for surgery were interesting, but I had treated a sufficient number of patients with this aggressive form of skin cancer, and chose to discuss a preliminary option with my physicians.  As described a recent blog post, the purpose in having a  medical test is to get information which will substantively affect patient care decision-making. And the PET scan ordered by my physician, which showed no activity outside the known location of metastatic melanoma, allowed me to accept my physicians' advice to have surgery.

Did this PET scan  offer me a guarantee? No - because no test is 100% accurate or complete (particularly when looking for a few malignant cells outside the known focus of 10,000,000,000 which a cubic centimeter of tumor  may contain). But having the test was rational, appropriate and medically indicated.  I had the surgery six days ago.

Pathology pending.  Further treatment plans pending. More to come.

The July Turnover Issue

I was fortunate to have my medical training at a time when the diagnosis of cardiac disease was dramatically improved by x-ray (angiographic) and   laboratory techniques (cardiac catheterization) and to have been exposed to superb clinicians, including Maimonides Hospital's (Brooklyn) extraordinary clinician, Dr. William Dressler, the cardiology staff, led by Drs. Harrison and Hancock, at Stanford Medical Center (Palo Alto) and Stanford's cardiac surgery team, led by Norman Shumway, M.D.  So, when I needed a cardiac diagnostic procedure and surgery I was faced with making a choice: a community cardiologist or a University Medical Center cardiologist. And then decide between a reputable community cardiac surgeon and team or surgery at the nearby University.

It was early July.  Having served as a  clinical faculty member myself at Stanford, Chief of Staff of a large local hospital and a member of a large hospital system board of trustees, I had enough experience and information to make the decision. I balanced the choice of a community hospital staffed by physicians and nurses who did complicated procedures well every day and the choice of  going to a university medical center where I would be facing experienced faculty and a new crop of interns, residents and fellows.  I stayed local and have never regretted that decision.

For information that might affect your decision in similar circumstances, see the Medline  article and its related article which provides even more information.   Be sure to discuss this issue with your trusted personal physician as you  make your decision.

Dementia-Impaired Physicians

Today I received confirmation that my chapter dealing with HIV-infected health care workers, in Thompson-Reuters' Health Law Guide (a near- encyclopedic publication for attorneys), has been forwarded to the publisher. In that chapter, I describe the low risk of blood borne  HIV infection transmission from health professional to patient, or from patient to health professional, but the unquantified risk of judgment deficiencies in AIDS-dementia affected health care professionals in practice. The term "unquantified" indicates that I have not been able to determine the number of professionals who have the condition, the measurable effect of that deficiency on that population's judgment, or its consequences for patients.

Today's New York Times features a thoughtful article about aging physicians with dementia, a troubling subject which deserves attention (not just for physicians, but for those in other professions, as well).  These demented physicians may go unnoticed and unreported by their colleagues and noticed, but not necessarily dealt-with by family members and others who are emotionally and economically related to them.

My only significant point of disagreement with the Times article is that periodic neuropsychological testing should be more frequently used by credentialing bodies to evaluate physicians' and other health (and non-health) professionals ability to practice safely.  Use of testing would protect not only patients, but the professionals whose judgments and learning capacities are impaired, and thus prevent calamities and tragedies for both groups.

As one who has had the experience of a quiet conversation with a professional, telling him(or her)  that the time has come to retire to protect patients and himself from deterioration in his judgment and skills, and then been thanked by the practitioner and (separately) his family for doing so, I know that it can be done. 

Doctors Groups Fail Because They Don't Understand Risk

The October 7, 2010 New England Journal of Medicine has two interesting articles, one by Harold S. Luft, Ph.D.  titled "Becoming Accountable - Opportunities and Obstacles for ACOs" and the other "The Effects of the Affordable Care Act on Workers' Heath Insurance Coverage" by Christine Eibner, Ph.D. and others. Like the Affordable Care Act, neither of the articles discusses an issue which my experience tells me has played a major role in the failure of a number of physicians' practices to survive managed care and other forms of contracted health care relationships.

Insurance companies understand risk: they hire skilled actuaries to analyze underwriting risk and to tell them about it and how to shuffle it off to others.  The Federal Government understands risk, and as one plows through the 900+ pages of the Affordable Care Act, there are many references to the requirement that highly sophisticated actuarial studies be done to guide future policies and actions  But individual doctors don't have the financial means to hire actuaries (or attorneys)  to tell them about the risks that they blithely assume, and even if they did, their fracturing into relatively small business entities makes the per-doctor cost of securing actuarial advice prohibitive.  And then there are antitrust issues when groups of physicians combine resources to strengthen their ability to negotiate with employers, government and insurers.  So insurers, government and business shift risk to physicians who bite off more than they can chew - and choke.

The current proposals for health reform is not going to solve that problem. As physicians learn that the emphasis on "efficiency" and driving down the cost of services leaves their bank accounts empty, I expect them to resort to their experience-tested means of generating income: see more patients, do more procedures, order more tests and ramp up the billing. In this era of "evidence-based care," ironically it is the physicians who lack evidence about the business risks they are asked to undertake by insurers, government and businesses.

Acountable care organizations will not survive in that environment.

First, Do No Wrong - Continued

In my blog of July 31, 2010 dealing with an experiment in which physicians' clinical notes are posted on the internet so that patients can read them (or possibly anyone whom the patient permits to see the notes can read them).  I mentioned patient and physician self-censorship with the comment that I would come back to the subject.

In my clinical experience, the most common situation in which patients withheld important information because of fear that it would be released to a third party, was spousal physical abuse about which California  physicians were (are) required to contact appropriate government agencies and patients did not want that report to be made. In spousal  physical abuse, there were telltale signs on examination which told the story even when patients' words did not. And I and other physicians would tell our doubly injured patients (physically and emotionally damaged) that we were required by law to report and that we would comply with the law. Should that information also  be recorded in a medical note to which the offending spouse might gain internet access even before the authorities intervened?

Less common patient censored information included sexual practices, sexually transmitted diseases, patient or familial mental disorders, childhood abuse,  alcohol and other substance abuse, and even the eating of food representing different ethnic practices which patients felt would lead to shame if disclosed to the physician or others. Physician inquiries about familial diseases were often responded-to with "I don't know" rather than the facts which (as time revealed) were well-known to these patients.

Physicians may censor information, which they know may lead to patient difficulties (i.e., advise patients to pay cash for certain tests because insurers might use the insurance-billing information, or information provided which might get back to an employer, in a way which might cause patients to lose insurance or their jobs) and make no mention of their advice or the conditions they were concerned about in their notes.

What do my readers think? For or against posting physician clinical notes on the internet? And why?

Framing The Health Care Reform Debate

When carpenters frame a new building's walls, the building takes a recognizable shape. Passers-by get a sense of structure, a release of anxiety, the assurance that the process is reasonable and guided by established principles of physics, mechanics, truth and responsibility.

Unfortunately for his investors, Bernard Madoff's framing process provided his investors with a sense of structure, freedom from anxiety, and assurance - echoed by respected financial experts - that his structure was reasonable, in accordance with the principles of the financial industry of which he was an noted executive, responsible and truthful. A Ponzi scheme is an exercise in framing for deceit.

Framing is not restricted to buildings and financial structures: it is also part of our daily political exposure. Arguments are carefully framed and discussed by health care "experts" representing entrenched vested personal and business financial interests in advocating or opposing health care reform. We hear the expert-of-the day on television proclaiming that he or she has a solution or a reason not to solve, our health care problems and we hear our Congresspeople in high dudgeon about the foolishness of some of the proposals.

What does the "frame" look like? How does it compare to the truth?

The Norman Rockwell painting showing a doctor by the bedside, indelibly etched into our psyche, is a good place to start. It is part of the mythology of American medicine: each person should have his or her own honest and competent personal physician who is completely dedicated to him or her, and can marshall all necessary care without any intervention by an outside force. Unfortunately, the physician that one sees when really sick is not likely to be the physician who might know you; the hospitalist may never have met you before admitting you to the hospital and probably will not know you after discharge. The specialists who undertake your care come and go, often unfamiliar faces appearing at odd hours. Medicine has changed from Rockwell's days when the doctor sat by the bedside, waiting for the patient to die because the doctor had no antibiotics, little technology, and scientific knowledge which was woefully deficient. And today's family practice physicians have the impossible task of being knowledgeable in many complex fields requiring their attention today.

Another myth grew from the non-profit operation of early health insurers such as Blue Cross and Blue Shield and non-profit HMOs, the latter established in response to Richard Nixon's actions supporting a new system of care. Insurers and HMOs have perpetuated an image of providing service and valuable expertise to health care, rather than acknowledging that they are essentially system integrators which primarily contract with networks of providers and themselves provide little or no health care, but lots of resource-draining bureaucratic intervention and political contributions.

Another frame issue is the concept that, as scientifically and technologically advanced Americans, we now provide high-quality and efficient health care to all who need it and that health care reform will exponentially increase health care expense. This is a dubious position: overflowing hospital emergency departments (many roadblocked by the uninsured) are many times more expensive than a doctor's office for providing episodic non-critical care. With health reform, why shouldn't we develop money and life-saving efficiency rather than perpetuating the wasteful system that perpetuates income flow to selected self-serving segments of the health care industry and poor quality inefficient care to many Americans?

Today's Lunch

Today's lunch, hosted by a drug company representative concerned about staying employed in this era of company consolidation with layoffs, was notable. A recently retired superb oncologist, with impeccable judgment, patient relationships, integrity, knowledge and skills told us that he had left practice because in his last year he lost $60,000 and could no longer afford to practice. Another excellent experienced highly competent physician, who needs to find new office space, observed that space comparable to his current $3 thousand a month space would cost him $8 thousand a month which he cannot afford.

These are solo physicians who have taken superb care of patients year in and year out. The corporatization of competing (but not equal quality) medical practice, and the inability of these physicians to negotiate successfully and competitively with payers and space/service providers because they are not part of a muscular network, has put them at risk of being forced out of practice.

The emphasis on computerized medical records is misplaced. Why throw high-quality current practicing doctors away while chasing the Computerized Medical Record windmill?

When A Banker, or Physician, Makes A Mistake

When a physician makes a mistake, whether it results in physical or economic injury to a patient, a lawsuit may be initiated (coupled with a complaint to the State Medical Board), the physician's malpractice insurer will assign defense attorneys and perhaps start its own investigation of the physician, the physician's hospital medical staff appoints an investigative committee which may result in disciplinary charges being filed and if upheld by a peer review committee and the hospital board of directors, in loss or limitation of medical staff membership. The state Medical Board may take disciplinary action, resulting in limitation or revocation of the physician's license to practice in that state. Other states in which the physician is licensed will pile on, adding similar discipline. If the physician loses the professional negligence lawsuit, he or she may face personal responsibility for losses above the policy limits. All of this is reported to the State government, which shares information with the Federal government, and the physician may lose her Medicare and Medicaid provider status. HMOs will dismiss the physician from their rosters. PPOs will remove the physician from their lists of participating physicians. Medical Societies will discipline the physician. The physician's life is ruined, often (as a Harvard study showed) because of a moment of inattention.

If a banker's deliberate and gross negligence costs shareholders, clients, the public or others their life savings, he or she may get to share in a two billion dollar year-end bonus. And if not that, at least in a federal bailout.

Is something wrong?

The Sunshine Enema

The sunshine enema is not something advertised in your spam email inbox. It's quite different. You may have already had one, without noticing.

I was introduced to the sunshine enema, early in my practice, when physicians would send newly diagnosed patients with cancer or leukemia (or sometimes walk down the hall with their arms around their shoulders) to introduce them to me. The physician usually said something like this: this is Dr. Kaplan who specializes in taking care of people with your illness. He will be taking good care of you and you will soon be feeling much better. You won't need to see me any more because he is now your doctor. If your family has any questions, have them call the good Dr. Kaplan.

Lest you think this was a complement to me, be assured, it wasn't. It was a way to avoid the truth, shift professional responsibility to someone else, and to deceive the patient and his/her family, giving them the illusion that their usual doctor was honest and open. In fact, the usual doctor often hadn't even told the patient the grim diagnosis.

No one talks about the potential for "pay for performance" to cause physicians and other health professionals to cherry pick their patients and to send many of them on to other professionals "who specialize in taking care of people with your illness" rather than bear the professional responsibility, potential financial risk, and likelihood of being labeled as less than expert under the new system. Particularly if you, or a family member, has a rare, difficult to treat, or potentially very serious illness you may find yourself cherry picked right of your customary doctors' offices and into the hands of a new set of professionals who represent the new dumping ground.

When our political candidates tell us that they have a fix for what is ailing the health system, and paint glowing pictures of the bright new world ahead, they are giving us all "the sunshine enema." And it doesn't cause us a moment's discomfort - yet.

McCain's Evocative Speech

Today, I listened hard to the McCain's nomination acceptance for a fleshed-out health policy, but it wasn't there. We heard about oil and other matters - not about the issue that affects the health and well-being of all Americans.

But it wasn't a complete bust. His talk of honor, duty, country and his experiences in and after Viet Nam, tied-in with a discussion earlier in the day during a chance meeting with an old colleague, a health care businessman. Each of us, independently, has noticed the lack of commitment of many young physicians to their profession. They are 9-5ers who check in at 9, leave at 5, have no ongoing responsibilities for patient care when they are off, and live like any hourly factory worker. He summed it up neatly: the older generation gets out of bed in the morning and go to bed at night, knowing that they are physicians; the newer generation are physicians when they put on their white coats from 9 through 5.

It's no accident that each of us has chosen the same community doctor as personal physician since this doctor is imbued with the spirit that we value. His sense of self-worth, professional honor, integrity commitment and duty have not been diminished by trivializing and unrealistic television programs, administrative bureaucracies, arrogant obstructive payers, and destructive political rhetoric. He is a professional.


So there's real American value in what McCain said tonight. His personal values resonate beyond his military service. His military family was overt in its respect for honor, duty and country. My father was a lawyer who patiently explained to me, when I was a youngster, that a commitment to a profession and clients (or patients) is different from any other role in society in terms of trust, integrity and duty. Perhaps it's time to remind our physicians of this difference and the reasons that they are given their license and franchise by society.

Who Will Provide Medical Care In A Disaster?

My wallet contains two unusual cards. One, which bears a picture of me at an earlier stage in my medical career, identifies me as a California Disaster Service Worker. The second, titled "Medical Volunteers for Disaster Response," identifies me as a physician specialising in internal medicine and hematology affiliated with the County of Santa Clara Public Health Department, Office of Disaster Medical Services.

It was in the context of the second card that I recently attended a three hour meeting of the Medical Volunteers. I learned that the system of federally recognized organized medical and public health professionals with which I am affiliated as a "sworn" volunteer is the 9th largest such emergency system in the nation, serves as daily population of about two million, covers more than 1300 square miles which includes 15 municipalities, and is headquartered in Silicon Valley. We are volunteering to respond to natural disasters and emergencies.

Santa Clara County's medical health system includes public and private elements, The County has 3 trauma centers, 11 emergency departments, 12 hospitals, a public health laboratory and disease outbreak teams. There are 12 fire service providers, 7 private ambulance service providers (with far more ambulances than the nearby City/County of San Francisco), and 14 public safety answering points. The medical health system is a major employer, with 1300 emergency medical technicians, 700 paramedics, 50 critical care transport nurses, 40 mobile intensive care nurses and more than 350 medical volunteers.

Medical health resources includes strategically placed chemical packs, elements of the strategic national stockpile, caches of personal protective equipment, stockpiled local pharmaceuticals, a biodetection system, environmental monitoring systems, hospital data systems, and field treatment site trailers. There is the capacity to electronically track patients, which experience in other catastrophes has proved to be essential.

Before an emergency, identification of the critical emergency players, facilities, equipment, resources, and system strengths and weaknesses, is essential. Santa Clara County has stepped up to the plate. In following blogs I will report my impressions of our readiness.