Ideal Medical Practices

Letter to the Editor - ethical case for health reform now

Today, my local newspaper posted an editorial about why we should delay health care reform for at least another year. Here is my response:

To the Editor:

The four pillars of medical ethics are beneficence (provide good care), non-maleficence (do no harm), respect for autonomy and social justice. While the first two seem to get a lot of attention in medical schools and the press, the last two, and particularly the pillar of social justice, are rarely mentioned. Estimates are that each year nearly 20,000 Americans die from not being able to have access to health care. Health care costs are the number one cause for personal bankruptcy and are therefore the most common factor in keeping people in poverty.  Every passing day pushes more citizens into financial crises and forces more to silently but tragically die an unnecessary death.

Every passing day also allows those who reap financial treasure through the status quo to continue to pump fear and doubt into anyone who will listen. Their tactic, which has worked quite well over the past five decades of inaction, seems to be working again as support for health care reform has started to wane even though no alternative legislation has been suggested. The longer health care reform is put off, the less likely it will be to pass.  

So why rush to push reform through? We cannot and should not continue to wait for the perfect piece of healthcare legislation to magically appear when people are dying. Waiting turns our back on the pillar of social justice and is therefore simply unethical.

John Brady

AMA past president letter is both bizarre and helpful

Three past presidents of the AMA penned an interesting letter to the Washington Times on 7/23. 

The past presidents start with a series of indefensible statements like:

"We have the best health care system in the world." [Unless you count being last or near last on the list of quality of care, affordability, percent of people with chronic conditions who can't take medications as prescribed due to costs.  See Commonwealth Fund reports.]

"...the vast majority of [Americans] are satisfied with the coverage they have..." [Only if you fail to ask a representative sample of Americans about affordability, limits placed on choice, ubiquitous waits & delays, and more. Better look at those reports again.]

They parrot talking points that seem to have come right out of the boardrooms of the insurance industry and their PR firms bent on maintaining the status quo at all costs.

What I find quite odd is discovering that I agree with the authors on the three key points they want from Congress:

First, we should expand the choices of types of plan and access to primary and specialized care.  [Yay!  A public option that adds choice and access!  I agree!]

Second, every American should have the opportunity and the responsibility to choose and own the insurance plan that meets their needs and those of their family, with the periodic right to change if dissatisfied with the previous choice. Because the beneficiary owns the coverage, it is totally portable and not locked to specific employment.   [Not locked to specific employment, plans that meet individual and family needs - that's what the President has been describing.  We agree again!]

Third, whoever puts up a subsidy (defined contribution) for the purchase of the insurance should put up the same subsidy, no matter what choice the person makes. [Sounds like an argument for a defined set of basic benefits that doesn't vary by insurer/employer/prior condition - I love it!]

If they want these things then they - like I - believe the status quo is not so good.  Bravo!  I can support these points.  I'm glad to find that they are included in the bills working their way through Congress right now. 

Odd that the letter is in opposition to the bill, but I suppose that could be corrected if these past AMA presidents sit down with folks in Congress and engage in a discussion on what we can do to change the status quo.

Remember who wins the status-quo game. 
Not our patients. 
Not all the small and large businesses swamped with health care premiums or unable to afford any health coverage for their employees.
Not the American taxpayer. 
Not the 45 million Americans with no health coverage. 
Not the 26 million additional Americans with health coverage they can't afford to use. 
Not the 50 percent of people who file for personal bankruptcy because of medical debt (75% of whom had insurance at the time)
Certainly not those of us on the front lines of health care struggling to survive in this oh-so-wonderful status quo environment.

I don't know what the future will bring, but the status quo holds no charms for me. 
The status quo is broken.

I am thrilled to be part of a small but growing community of health care professionals who have chosen to risk much in pursuit of the care our patients want and need and the careers we thought we would have when we entered medical school.

Effective primary care is the heart of any high performing health system.
Our contribution to framing reform helps make that reform better.
No solution will be perfect, but any solution would benefit from our involvement and diminished by our absence.
We should continue pushing back against this messy non-system, but we have a chance to also work within the system to change it. 
That chance may be slim and the risks may be great, but to deny ourselves even the slimmest chance would be a shame.

I'm willing to speak out against reform that stifles innovation, choice, freedom, care, outcomes, but I'm also willing to speak up for our patients, to speak for reform that inspires and supports innovation, choice, freedom, care, outcomes.

I'm glad the past presidents of the AMA articulate the key changes they want to see.  The status quo does not serve us or our patients.  It is time for change. 

L Gordon Moore

IMPcamp09 blogging contest with Sermo support

To all current and potential 2009 IMP Camp attendees:

How would you like to get paid to go to IMP Camp? In collaboration with Sermo, an online physician forum, we are looking for some intrepid soul with the fortitude and gumption to take on the arduous role of "Official IMP Camp Blogger" for the upcoming IMP Camp in Seattle, WA from August 14-15th.

Here's the deal:
1. Contest is only open to physicians who will be attending IMP Camp 2009 in Seattle.
2. To enter, submit an article on the general topic, "My Ideal Medical Practice". It can be about the practice that you've always dreamed of but don't know how to achieve, the practice that you already have and how you want to improve it, why you are going to IMP Camp, why you gave up a promising career as an American Idol to become a doctor, or some other interesting angle. We value creativity here.
3. All entries may be posted on the Ideal Medical Practices blog, and may be edited for grammar, spelling and editorial discretion.
4. The winning entry will be selected by Gordon Moore, MD.
5. The winner would become the "Official IMP Camp Blogger" and post 4 to 6 daily updates while attending IMP Camp that will then be published on Sermo. You can either bring your laptop to camp or we will provide you with Internet access. You need to be comfortable using e-mail and be willing to work with a Sermo representative who will give advice/coaching. Obviously, you would need to join Sermo which is free.
6. After IMP Camp is over, you would be expected to check in at Sermo over the next 7 days for follow up and feedback about your experiences.
7. In return for all your talent and hard work, you will receive a $200 Honorarium courtesy of Sermo and eternal fame throughout the blogosphere.
8. E-mail your entry to: glseto (at)mac.com.
9. Entry deadline is midnight, July 31st, 2009.
10. So break out your keyboards and fountain pens and start writing. Good luck!

Gary Seto
South Pasadena, CA

Another Example of Our Broken System

While we were on vacation last week, my wife and I had the pleasure of meeting up with one of her high school friends and his wife. Conversation flowed easily as my wife and Jack (not his real name) talked about lost high school aquaintances and teachers, but soon it took on a much more serious tone as Jack revealed that last year he suffered a ruptured brain aneurysm. As I listened to his story, I was at the same time appalled at the care he received and completely understanding of how so many things could go wrong. Here are the highlights:

Jack awoke at 11 pm to find his CPAP machine mask broken. He got up and rumaged around in the closet tring to find an old mask. When he bent down, he felt a searing pain in his head which was the "worst headache" of his life. He took 2 motrin, and laid back down. The next morning, he still felt bad, so he called in to work and took a sick day so he could get an appointment with his doctor. His wife went to work but called him numerous times because she said he was just acting a little different. He did get an appointment with his doctor who evaluated him and said he was concerned Jack might have meningitis. Jack was told to go to the ER for full evaluation. Jack's wife was called to come pick him up (as he was now in no condition to drive). By the time she arrived at the doctor's office 10 minutes later, she found him slumped over in a chair in the waiting room holding some papers (apparently his lab results). No one else was around. Apparently, the doctor had left to go to another office and the staff went out to lunch. She stated that when she saw Jack she knew something was really wrong as he was as pale as a ghost and his blue eyes were completely black (from pupillary dilation). She managed to get him to the car and drive to the ER 12 minutes away. Once there, they were told to have a seat in the waiting room even though Jack could barely talk and was leaning dangerously forward. After becoming more emotional than she wanted, Jack's wife convinced the ER triage staff to bring him to the back. Once there, the doc quickly evaluated him and he got a CT scan which showed a brain hemorrhage. Neurosurgery was called. Even though they have an office across the street, a Physician Assistant who apparently does their consults was called in from another hospital to see him. It took hours for him to arrive. When the evaluation was finally complete, the PA felt that Jack would benefit from being transferred to a different hospital. When Jack arrived at the other hospital, it was decided that he should have an angiogram. Unfortunately, it was now after hours on a holiday weekend and no interventional radiologists could be found to do the test. After toying with the idea of transferring him to a third hospital to get the test, someone finally convinced one of the radiologists to come in. The angiogram showed that the bleed had spontaneously stopped. Jack spent 9 days in the ICU and additional time on the ward which included:

1) Not being fed even though he is a diabetic

2) Being left on the toilet for 5 hours as the nursing staff ignored his call light (he was too weak to get up himself)

3) Being told through the door of the bathroom (the same day) by the PA doing the rounds he was going to be discharged

4) Being given a prescription which cost $1500/month without any warning of the cost or discussing other options

5) Being discharged with no follow-up or home health even though Jack could not walk by himself.

After getting home, his wife figured out how to set up PT, and thankfully they helped him regain most of his lost function. He did receive a bill from his primary care doctor, and when Jack protested, the doc admitted he had no knowledge of anything which transpired after Jack left the examining room. 

The amazing thing about this story is that it is crystal clear example of what is wrong. Harried doctors, burned out staff, lack of communication and lack of coordination all leading to a system which is unempathetic and dangerous. The only reason Jack is still alive is that his body decided to heal itself instead of waiting for our medical system to do the right thing. Talk about a scary thought.

John

Who speaks for physicians? Not the AMA please! We need another voice.

Dr. David Palestrant - the founder and CEO of Sermo - is stirring up his 107K+ physician community by calling out the AMA.  He points out that the AMA's membership numbers appear to be inflated by counting medical students, trainees, retirees and doctors who merely subscribe to JAMA. 

This is an important issue since policy folks who want physicians input on health issues turn to the AMA as representing physicians, but the AMA consistently works against reform.  As Dr. Palestrant points out, the AMA represents only a fraction of physicians and appears to have a significant conflict of interest due to the bulk of its revenue coming from industry relationships and not the physicians.

Dr. Palestrant polled Sermo physician members, 89% of whom (myself among them) said that the AMA does not speak for them.

This begs the question - who does speak for physicians?  I suggest we create a voice specific to primary care.

At this point one of the biggest problems in US health care is the structural incapacity of primary care.  This is NOT due to lack of intellect, energy, professionalism or caring on the part of the primary care work force.  This IS due to policy and payment that directly impede the work of effective primary care.  To solve the quality/cost problems in US health care we must address these structural issues.

If we had adequately funded primary care that lived up to the four cornerstone principles, we'd have better health care outcomes at much reduced costs.

Engaging in the full scope of effective primary care requires getting off the "visit" hamster wheel (pushing patients through our offices like cattle, if you'll pardon the mixed metaphor), learning new processes and skills and using new tools that improve population health outcome.  Every one of these interventions pushes primary care further into financial ruin in the current payment paradigm.

We can step up to the full scope of work only when there is a legitimate course of action that includes resources adequate to the work.  This includes adequate funding for the work as well as eliminating the crushing burden of administrative trivia dictated by the insurance industry. 

Some fully integrated delivery systems are able and willing to increase their primary care funding internally and achieve improved results, but we're leaving the majority of Americans and primary care clinicians out in the cold if all Congress does is suggest that everyone join integrated delivery systems.

To achieve improved population health, improved experience of care, and dramatically cut the total costs of health care we need three things:

1. Primary care must learn to engage in the full scope of work of effective primary care
2. Primary care must have resources that adequately fund this work (tools, team, time)
3. We must eliminate the patient-harming mind-numbing administrative trivial pursuits

I suggest that at this point we need a voice for primary care.  This voice should be inclusive - including specialists and others who support effective primary care.  Let's start here and build a primary care voice that supports the ethical practice of medicine, one that moves us from glorified billing clerks back to the professionals we imagined when we entered the field.

Join me in creating a voice that speaks of the dignity and caring that are the bedrock of our profession.

L Gordon Moore MD

Inspiring residency graduation speech

When I read this I had a few reactions
Like  oh come on are you kidding me?
 She probably thinks we should hug  patients too.
Doesn't this woman understand??
Health care  is a mess  Patients won't trust us  despite our years of toil and education We  carry tremendous responsibility working long hours carrying delayed gratification for years- who is this young person, what does   she know about  the real business of staying afloat? Malpractice is a nightmare, there are global codes to deal with  and tugs from the practice manager and the staff who want raises and my kid who needs me at a soccer game. I have to run faster and  buy more gadgets to keep  my income. Of course we care about patients. This young woman will soon hit   a wall of  harsh reality .
Washington needs to fix alot of things. Flowers in the waiting room won'to help.
Patients do not remember anything I say . If only they would follow directions. Naivete is good , I thought ,but this young doctor is going to hit a wall

Then I remembered what I did yesterday.
I too am a family doc
I used to think patient centered care meant hugs  and fresh muffins in the waiting room. Yuck.
  Yesterday i saw S whose first husband beat her  and whose her current husband was the love of her life but now  weighs 400 lbs and cannot leave the house and  she  feels guilty so cares for a mentally ill sister who hits her  and had S arrested last week after  she picked a fight with S . I dx'd S with  cancer of the vulva a few days ago .She has no car to get to the oncologist  2 hrs away. She is  poor, a diabetic and has severe  pain.
Then G came in. G's husband was getting  joint injecions for pain .But wasn't xray'd  Had a  metastatic lesion.Many weeks, pain, and tests later he got the egd that found the primary. G got ascending cholangitis while she was visiting him .Both in the hospital at the same time. He is now in hospice and she says I will take him home the first second I am strong enough!
ANd i sawC who had  a egd for a Schaitzi's ring .And was ruptured But I had a perfect  record this 91 yr old said to me yesterday. Lived alone  with Mulligan her dog and took no meds. Drove. So after the esophageal rupture she was in Icu, the floor, ICu, then two intermediate facilties a few times .Yesterday she went home- home.
 I remembered I see everyone the day they call for  at least 30min and i am on call 24/7 for 4 yrs now even on my one vacation to Mexico. but  I cannot save for retirement. Specialists seem to be impatient with me .
But now i see that   patients don;t trust becasue no one listens to them
Patient centered care is about sharing my skills and education with a person who has some   questions and symptoms, and coming to a place where the dx and treatment make sense for them
 I am deeply seething angry most days that I  both have the honor to  work as a doc  but cannot pay  my bills  and have patients  i cannot get transportation for to see a critical doctor   who may not communicate well but will be so burnt out he  will scream "but I am trying" without  knowing anymore what trying could mean . I cannot change others but I can  keep talking to my colleagues one at a time and I can stand behind my patietns and use every colleague i know  every program i can get my hands on, every skill I have to get people  what they need 
I wish this young doctor well -she IS up agianst alot .I understand. MAy there  be more like her.

Inspiring residency graduation speech - getting compassion back into care

here is the speech i gave at residency graduation.

it contains NO STATISTICS a miracle!

...

people often ask me what my intentions are, since i'm taking a career track that's different from most of ours.

i'm planning to work by myself as a primary doctor, without any nurse or other staff, and i'm going to just give my patients my cell phone number so they can call me directly, and i'm going to try to minimize my interactions with the insurance industry as much as possible, to maximize the interactions with patients directly.
i hope you don't mind if i take 5 minutes, to explain why i'm doing this.

i'm starting a practice in a university town in oregon that is less than one-quarter the size of the wisconsin city we live in now. it has about 140 thousand people.
i chose it because it has very progressive politics, including around health and spirituality, and because it's nestled in between two mountain ranges, and is only an hour away from the pacific ocean.
and there are a lot of vineyards nearby.
i thought it seemed like a friendly place to start trying to live out my vision.

a long time ago, i kind of became that one person you might go to for advice - if you didn't have health insurance - when you broke out in a weird rash, or got pregnant, or twisted your ankle.
it worked out that way basically because i was pretty fearless, and not easily grossed out, and i liked to buy old science books from the used book store.
my kids were young, and i had a couple of teenage baby sitters who would come over and hang around sometimes.
i was living in a place with a really great kitchen table.

so we'd sit at the kitchen table, and i'd tell them about birth control, and ask them about their self-esteem, and tell them what an immune system is, and why it's so cool.
and they would bring their teenage friends over, to talk about birth control and self-esteem and immune systems some more.
and i started thinking, maybe i could be more effective if i had some teachers.
so i went to college for the first time when i was 30.
but i kept having these conversations at the kitchen table, about health and self-esteem and science, because they were really fun and interesting, and plus, i had this really great kitchen table.
and that's one reason why i want to have my own practice. i want it to be kind of like that.

then when i was in medical school, i had this great teacher, who was this crazy neurology guy at the VA.
he was very funny. he wrote a book called "extreme clinic," that you should read.
anyway, when i told him i wanted to be a family doc, he said, "that's not medicine, that's a cult! you're too smart for that! you should do REAL medicine!"

and i didn't know what to say to that.
but later i thought... wait a minute!
what's wrong with having a cult?
i think i'd be a great cult leader!
so it's possible that that's another reason i want to start my own practice.
i'm pretty comfortable running my own show, and i'm pretty comfortable taking responsibility.

then last year, i had one of those days that just really illuminated what i DIDN'T want to do.

i had a fifteen-minute appointment scheduled with this one patient.
they'd been waiting in the exam room for a long time, because i was late.
they were very anxious about coming to the doctor.
they had some chronic illnesses that were pretty bad, and it looked like they probably weren't really taking their meds.
and it turned out there had been some domestic violence in the picture, and that alcohol was involved in some way.
so, not sure what to do, i played the efficiency-expert doctor card of asking, "which of all these things is the most important to you today?"
and they said, that, more than anything else, they wanted some advice for how to lose weight.
and they really did badly need to lose weight!
but by this time, most of my fifteen minutes were used up.

and i thought, i never want to say that to a patient again.
i never want to demand again, that a patient make a little priority list for me, of everything that's wrong with them, so i can pick one to pay attention to, all because i have to see 35 patients a day, if i'm going to pay my overhead - if i'm going to be able to pay my nurse and my receptionist and my medical assistant and my biller and my scheduler and my answering service and the rent for the building big enough to hold all these people, etc., etc....

but that patient is the whole reason i'm here!
and that person is NOT a walking priority list, of diseases and disasters.
they're a *person* who's having a particular set of experiences, body and soul, and their whole story matters.
we all say that, and we all believe it.
but we often aren't able to practice it.
and it *really* bugs us.
and that's another reason i need to have my own practice.

now, over the last 3 years, i've had a recurring dream about being a family doctor.

i'm walking down a road, going to a patient's house, and i feel a little ashamed and nervous, because i don't have any equipment with me, not even a stethoscope.
i'm empty handed.
sometimes i'm not even wearing any shoes - you know how dreams are.

but i go up to the house, because that's my real patient.
in the dream, my patient is the home, and everything, and everybody, in it.
so we start going through the closets and bedrooms, and the kitchen cupboards, taking stock of everything, and making a plan for how to to make things easier, and more efficient, and healthier for them.
this usually involves a speech about getting rid of the chips and sodas at some point.

and in my dream, i always start feeling excited and happy, when i finally realize, hey! i can do this!
i don't need to wait until i know everything and am always right.
these are my neighbors!
i can see it their way, and THAT'S my most important skill.
everything else is just a bunch of science classes.

so that's my vision: a kitchen-table cult, of long appointments, figuring out what matters, in a context of neighborliness.
so that's what i'm going to do.

thanks for listening.
thank you for being my teachers, and thank you for helping me get here.

...

my teachers are all very excited because they've never known anybody that started this kind of thing straight out of residency.

leigh saint-louis
drleigh.org

"Health Insurance" does not mean what people think it means

I first want to point out again my commitment to health care for all but point out my growing concern with the conflation of health insurance and health care.

Most folks think that if they have health insurance they're covered if bad medical things happen.  A friend - Tina Lehmann - suggests that we need to think more clearly about what we're buying and what it means.  She suggests we are really buying Sickness Insurance, and says health care is another thing entirely.

I think she's hit the nail on the head.  Too many people believe that health insurance = health care.  Congress certainly seems to hold to this belief.  Perpetuating this myth is a problem.  Yet another article in the New York Times describes the financial ruin of Lawrence Yurdin & his wife when Mr. Yurdin was hospitalized in Texas.   Mr. Yurdin had insurance.  The brochure said it covered up to $150,000 per year. 

Too bad about that small print.

Too bad that state regulations vary widely and insurers are able to drop people when they start to eat into corporate profits.

Too bad about another personal bankruptcy - 50% are due to medical expenses, and three quarters of those people had "health insurance."

Premiums have skyrocketed and employers are passing the costs on to their employees and dressing this pig up as "consumer directed health plans" and the like.  The real meaning translates to 45 million Americans without "health insurance" and another 25 million with "health insurance" they can't really use because of the outrageous out-of-pocket costs.  And the rest of us are one major sickness or medical disaster away from financial ruin.

Too bad that "health reform" seems to mean "everyone has to buy health insurance."  The pilot project in Massachusetts is running into very predictable trouble.

The health care status quo in the US is broken.
We need serious reform.
Making everyone buy health insurance will certainly please the health insurnace industry (and since they donate so much money to Congress we can totally understand why this proposal is most favored in Washington).
I'm just wondering how long it will take for most of America to wake up to see that they're funnelling money into a broken system and getting almost nothing in return.

Real health reform starts with fixing the broken system.

We must join the ranks of all other developed nations in the world and provide health care to all.

Let's buy eveyone Sickness Insurance.

Then let's get everyone health care too.

L. Gordon Moore