WHAT DOES DR. DINK THINK?

A CHANGE THAT MAKES (AND SAVES) CENTS, PART 1

2010-02-16T07:25:00.002-12:00

I think we all know by now, the Obama health care overhaul went nowhere. Despite being well intentioned, it was ill conceived and overreaching.

The quality and innovation of the American health care system needs to stay intact. The cost to people to utilize the system needs to come down. This should be done through free market principles not socialist ones.

The government’s role should be that of an oversight agency to prevent the abuses that have been allowed to occur to the benefit of a few and the detriment of many. (Wall Street anyone?) The government should not be competing with private entities.

The three main sources of the health care problems are the malpractice lawyers, the doctors themselves and the insurance companies. The list is in ascending order of culpability with the first two causing <5%> 95%.

Over the next several weeks I will address what those three groups need to do to correct things. The motivation for this will not come from within, but must come from the government and the people who elect them.

RIGHT (NOT) TO WORK

2007-09-27T07:33:00.000-12:00

I think that Indiana is making it hard to be a small business owner. Everyone is aware of the outrageous property taxes. These affect the business owner twice, as he is likely a homeowner also. Most people don't know how ridiculously the administrative law judge for the Indiana Department of Workforce Development for Henry County applies the law.

Indiana has an "at will" employment statute. This theoretically means that an employee can quit an employer at any time without penalty and an employer can hire and fire employees at any time. An exception exists that prevents the firing to be based on an act of discrimination such as for race, ethnicity, or religion.

Indiana has gone beyond that to allow unemployment benefits to be awarded to a worker who is not terminated for "just cause". To establish just cause the employer must prove: (1) there was a rule; (2) the rule was reasonable; (3) the rule was uniformly enforced; (4) the claimant knew of the rule; and (5) the claimant knowingly violated the rule.

This all seems very reasonable as it protects the employee from the financial difficulties from being arbitrarily fired without warning or reason. An employer can still terminate someone at will, but that person is entitled to unemployment benefits.

The problem arises when the people involved in this decision making process are biased towards one side or the other or interpret the law in a matter that defies logic or even common sense. Such is the situation for Henry County.

The administrative law judge, Ann Carnes, has taken a very biased and liberal view on who deserves unemployment benefits. The most egregious example of which is where a policeman in New Castle, who was terminated for and admitted to taking a bribe, was granted unemployment benefits. The reasoning was that since the city couldn't prove that every past and current policeman had never taken a bribe, the policy wasn't being uniformly enforced. It didn't matter that all policeman caught taking a bribe were fired.

My own experiences involved an employee being awarded benefits who admitted to having violated a company policy against using cell phones at work. There was one involving an employee who was proven to have violated a company policy against using work computers for personal e-mails. And there is a pending one involving an employee who was fired for being rude to patients and causing them to transfer care to other doctors.

I lost the first two cases. I also fully expect to lose the third as well despite overwhelming evidence in my favor.

The problem this poses for the employer are multi-fold. They involve direct and indirect effects.

Directly, when an ex-employee is granted unemployment benefits, the employers unemployment tax rate goes up. This adds another straw on the small business owner's back.

Indirectly, the employer is less likely to hire full-time employees. Indiana does not grant unemployment benefits to part-time workers. There are therefore less full-time jobs available and therefore less health care benefits available to workers.

Unemployment benefits were created by the federal government in 1935 to form as a social welfare benefit to assist employees who lost their jobs through no fault of their own, e.g. through lay-offs. The requirements were that the worker would continue to actively seek other employment during the 26 week benefit period.

The problem with Indiana's system is that the system permits basically a 26 week partially paid vacation. There is an inappropriate granting of benefits and an inadequate monitoring of people who are receiving unemployment benefits. Many times these people 1) do not report having obtained a job, 2) take a job while being paid under the table, or 3) do not bother to look for a job at all until the benefits period expires.

Indiana would do well to encourage small business owners in these difficult economic times. Those people who abuse the unemployment system as well as those who ignore the problem with it should be aware that if there are fewer employers left in Indiana, there will be fewer opportunities for Hoosiers to obtain full time jobs.

WORKING FOR A LIVING

2007-08-21T11:24:00.000-12:00

I think that the system for medical disability is a mess. Too often I see patients who should be granted disability unable to get it and too often I see patients who should not have been granted disability get it.

A big part of the reason that the disability system is a mess is because it's run by lawyers and the government. Nothing good comes to mind when you mix the two together.

Disability is of course a legal term. It is determined by the court system. A doctor never determines if a patient is disabled or not. Disability is very subjective which explains why two patients with the same condition may have one labeled as disabled but not the other one.

The doctor determines a patient's impairment rating which is based upon objective exam findings. There exists a published guideline to allow a concise number to be obtained which is called an impairment rating. This rating is a percentage with the maximum being 100%, say if someone is completely impaired from quadriplegia, and can range to less than 1%, say in the case of the loss of a little toe.

While one could argue the validity of the relative percentages assigned to different physical limitations, the important point is that these numbers have great reliability amongst different examining physicians. Consistency is a hallmark in impairment ratings but not so in disability ratings.

The disability rating, which is determined by the legal/government system, takes into account the impairment rating along with the patient's age, education level, ability to continue in his chosen profession and other factors. For example, a construction worker and a computer programmer would have the same impairment rating from the loss of a leg, but the former would have a much greater disability based on their ongoing ability to perform their current jobs.

Unfortunately, anyone can apply for disability at anytime. This process sets off a time consuming and expensive cascade of events that may involve an application, a review of same, a request for medical records, a review of same, a physical examination by a physician, a referral for additional diagnostic tests, a referral to a specialist, and finally a review of all the preceding information. The taxpayer pays for all these services regardless of how legitimate the claim for disability is.

The government pays a pittance for the amount of work required by a physician to review the records and perform a history and physical examination on the patient who is applying for disability. Thus, these exams are often performed by under trained and underpaid physicians who don't have the ability or communication skills to provide better employment opportunities.

A good rule of thumb is that everyone gets denied disability when they first apply. I have personally never heard of anyone receiving disability without retaining the services of an attorney first. I suppose this deters to some degree the people who shouldn't be applying in the first place, but not until the previously listed process is gone through. It does however also deter many deserving patients of this determination.

There is a reason you see ads on television for lawyers who specialize in disability claims. There is money to be made from people that deserve disability but cannot get it without an attorney's intervention on their behalf.

Too often a patient will come in and request disability papers be filled out and not be interested in nor having had pursued any treatment for the perceived disability. These patients, much like those that are in the process of suing someone over an accident, are not motivated, some consciously some subconsciously, to get better.

The rare but unfortunate case is the patient who has a condition that can be successfully treated and wants to be treated, but cannot afford the care required to treat and sometimes cure their disability. Once disability benefits, including health insurance, are granted, this patient will aggressively pursue treatment. The more frequent case is that of the patient who would rather maintain the disability, receive benefits, and eschew treatment.

Just like the welfare system used to reward mothers for having children out of wedlock and penalize women who married, so too does the disability system reward people for not working and penalize those who do try to work.

We are all aware of the patient who is on disability for a physical condition, but can golf, Jet Ski, and do any number of physical activities except work for a living. I remember a fellow resident who talked to first grade class about careers. He asked the students what they wanted to do when they grow up and one child said he wanted to be on disability, just like his dad. Sad, but true.

People should not be able to self-refer for a disability evaluation. Only doctors should have that right. And once a patient is referred the process should be streamlined and not require the patient to hire a lawyer to get disability benefits. If the evaluating physician thinks that an impairment and subsequent disability exists, then a lawyer should not be necessary. If the evaluating physician thinks that an impairment doesn't exist or doesn't merit disability, then a lawyer and court should not be allowed to overrule.

Although certain conditions are diseases and are disabling, they are also completely preventable. No one should be permitted to receive disability payments for obesity, alcoholism, or drug abuse.

If disability is granted, it should be determined whether it will persist despite treatment, it will persist only if treatments are discontinued, or it will not persist once a finite treatment is provided. This triage system would allow an appropriate and cost effective approach.

An example of the first case would be a person with quadriplegia. Although treatment can prevent complications from developing, the underlying problem of paralysis will not change. This person would require medical benefits and living expenses. All patients in this class should be re-evaluated annually to determine if any new treatments are available that could improve their underlying disability.

A patient in the second group would include someone with seizures. This person would require medical treatment to control his disability and should be provided medical benefits only once the seizures are controlled to the point where employment would be viable. An annual re-evaluation would determine whether medical benefits needed to be continued, or if the patient could now coped with his ongoing medical expenses on his own or through private insurance.

The people in the last class would include someone with severe hip arthritis. This condition is curable through surgery and medical benefits should end once that person has fully recovered and is able to return to full active work activities.

If someone has an impairment that prevents certain work, then they should be expected to work at a job that can perform with their disability. If this causes an income discrepancy from their pre-morbid state, then the difference can be provided. This makes much more sense than not allowing a partially disabled person to work full time if able.

When it comes to determining medical disability, the lawyers should be removed from the process. The government's role should be limited in the process. Disability benefits should be available on an "as needed basis" for an "as long as needed basis" as determined by a physician.

COLOSSIANS 3:16

2007-07-24T02:51:00.000-12:00

I think that too many people today do not have any sense of gratitude. While certainly gratitude is not a trait that is promoted by the popular culture, it is one that any mature, responsible adult should exhibit. When one doesn't display gratitude, it raises serious questions about one's upbringing and suggests inadequate parenting.

Gratitude is an expression of thankfulness towards someone who has done you a favor especially when they were not obligated to do so and more so when it comes at some cost to the giver. In Christian terms, gratitude towards God is one of the central themes of the Bible.

Research shows that feelings of gratitude improve one's emotional well being. Studies show that people who are more grateful also are happier, more helpful and forgiving, and less depressed than those who profess lesser degrees of gratitude.

A lack of gratitude is not limited to patients and doctors. It is also evident in workers and bosses, children and parents, as well as Christians and God.

In medicine, as in other areas of life, gratitude is not due someone just because they are performing a service that they are being paid for. It should more correctly be considered thankfulness when a patient expresses their happiness to the doctor when receiving good care that they paid for.

Gratitude is due when the doctor goes beyond his obligation to the patient. Three areas in which a doctor, at an expense to him, may give the patient a free service includes providing medication samples, completing insurance and disability forms, and checking blood pressures.

When free samples of medicine are provided, the patient is getting something beyond what they are paying for and the doctor, who has no direct monetary cost for this service, is taking his and his staff's time to meet with the drug reps to receive the samples, using time and space to store the samples, taking time to prepare the samples, and spending time to answer phone calls for patients' who request them. When a patient receives them, gratitude is due.

Doctors often will fill out the cumbersome paperwork involved with insurance, work release forms, and patient assistance forms. The doctor is only obligated to complete insurance forms if they are a member of that particular plan. Filling out FMLA papers and other disability forms required by a patients' employer are not included in the office visit charge. The exception being with workers' compensation claims. The patient assistance forms required by drug companies to provide patients with free samples are especially burdensome and time consuming.

Many offices charge for these forms to be completed. Indeed the AMA and other professional organizations consider it acceptable and ethical to charge separately for this extra work. When it is done at no charge to the patient, gratitude is due.

Even blood pressure checks performed by an office nurse can ethically and legally be charged to the patient. The doctor is paying for his nurse's time and for the equipment and the facility with which and where the service is rendered. There exists an insurance code to charge for this service and many offices do so. When such a service is provided at no charge, gratitude is due.

Unfortunately it seems that the more gratitude that is due, the less that is shown.

Patients all too frequently stop in for their free samples only to complain when the staff doesn't stop every other task to immediately devote all their energy to getting the samples ready. And heaven help the poor receptionist who has to tell the irate patient that the office is out of the particular samples that he is requesting (demanding).

Multi-page forms are often expected to be completed on the spot despite a waiting room full of sick people who need cared for. At other times, a form is dropped off with the patient telling the receptionist that they need it completed that afternoon.

Having to wait too long for their free blood pressure check (often while getting their free blood pressure medicine) is a frequent complaint of some patients. It gets worse when they have to wait to for the doctor to review the result when it is too high.

By logical extension, the most grateful patient should be the one who is given the most services at the least cost. This includes patients who are provided free care and most Medicaid patients. The difference in the attitudes between these two groups is often quite dramatic.

The former group does not have a sense of entitlement. They realize that they are not due anything from the doctor. When a doctor chooses to see a patient pro bono, he does so out of generosity at a significant expense to himself. Because of this and knowing that this free service could be rightly revoked at any time, these patients tend to be very grateful.

The latter group will often display a sense of entitlement. That comes from an unfortunate system in which otherwise healthy people are only entitled to free medical care if they don't work or they work in a job with substandard pay and benefits. These patients don't realize that doctors who treat Medicaid patients do so out of a sense of obligation knowing that that the money they receive is less than the cost of providing the service.

Talk to your emergency room physicians about some of the Medicaid patients. You will here stories about ungrateful, impatient, entitled individuals who come in for chronic or trivial complaints because it is convenient for them without giving any thought to what it costs to the taxpayers to provide this service for them.

At its root is that sense of entitlement. If someone thinks that they deserve something, they will not be grateful, and usually not even thankful for it. Remember this when you hear a politician suggest that people should be "entitled" to free health care. Anything that is not paid for in some manner, not necessarily monetarily, is soon taken for granted, not valued, and therefore soon to be abused.

WHO'S YOUR DADDY?

2007-07-03T05:21:00.000-12:00

I think too many people in health care are paternalistic when it comes to providing information to patients. This group includes many, if not most, doctors and hospital administrators both locally and nationally.

There exists an inevitable movement to provide people information on doctors and hospitals. The information includes prices as well as quality measures. Having previously discussed prices on my blog, I will now focus on the effort to make quality information available to patients.

In the past, patients had to assume doctors and hospital were qualified based on third party reports. There was no direct to consumer information readily available to the average patient. There was no way to determine which doctor or hospital provided a higher quality of service.

It was assumed that if a doctor was board certified, he must have received the appropriate training in his specialty and passed an examination. Nowadays, to remain board certified, a physician must maintain continuing medical education credits through seminars or self-study courses and possibly, depending on the specialty, be required to pass the accreditation exam every few years. A failure would result in a loss of board certification, but not of the license to practice medicine.

Medicare would require hospitals to pay a third party to audit themselves every few years to assure the quality of care, and more importantly to the inspectors, and that the paperwork was up to date. Again, no information was available to patients other than whether the hospital passed or failed an inspection. A failure would result in the hospital no longer being allowed to bill for Medicare services. This would effectively shut a hospital down.

As patients are becoming much more sophisticated about their own health and the health care system in general, a demand has developed for more information. People want to be able to compare doctors and hospitals just like they compare car makes and models before making a decision on where to spend their health care dollars.

There are several inherent problems with trying to compare doctors or hospitals. A car make or model has a well defined service record and resale value. People don't. A patient might not get better compared to another one because of a multitude of reasons with the quality of the health care provided being merely one.

A doctor might have more elderly patients, more acutely ill or injured patients, or other demographic differences based on the location and type of practice, even within the same specialty. The socioeconomic condition of the patients might impact the compliance and ability to afford medications.

Comparing hospitals will have similar problems. Even after accounting for the difference in the size and location, considerable, confounding variables will exist making it difficult to fairly compare one hospital against another.

Another difficulty to be overcome will be the motivation of the reviewing organization. Unfortunately there is no Consumer Reports for health care. Health care quality cannot be tested in a controlled laboratory setting. Some groups do not divulge what information the assessment is derived from, but will provide that, for a nice fee, to the doctor or hospital so they can work on "improving" their rank with that specific group.

Who will be watching the watchmen is a question that should be asked of these self-appointed raters. There is tremendous opportunity to slant results for political or financial gain.

The upside will be that too much and conflicting information is better than the current situation of too little information. Most people will be able to sort out and compare information from different organizations to draw their own conclusions on the quality of different doctors and hospitals. Indeed they do so now based on a far lower quality and quantity of information, largely word of mouth.

Certainly some people will draw the wrong conclusions from the information given, but the American Way has always been for people to have the right to make poor choices. And a poor choice is less likely if it is also an informed choice.

NKDA Q.E.D.

2007-06-27T09:13:00.000-12:00

I think that most patients do not understand medication allergies very well. Wrongly thinking that you are allergic to certain medications can limit the choices your doctor has in deciding which the best medicine for your current condition is. You could be given a costlier or less effective medication if you incorrectly state that you are allergic to a particular drug.

It is important to know the difference between an allergic reaction to a medicine and a side-effect from a medication. Some patients have been erroneously told by their doctors that a medicine caused an allergic rash when in reality the rash was caused by the underlying illness that the medication was prescribed for. Your doctor should know about any medicine that you have had an allergic reaction to or a side-effect from and should be able to differentiate between the two.

An allergic reaction to a medication occurs when your body's immune system reacts to a drug. The symptoms can include itching and a generalized rash. In severe cases an anaphylaxis allergic reaction occurs which can lead to life-threatening breathing and circulatory troubles.

The allergic reaction can occur even with medications that have been used without problems in the past. Once it occurs the medication will always cause reactions in the future, oftentimes escalating in the severity, unless an allergist desensitizes you to that particular drug by giving you tiny incremental amounts over several months. It will recur with medicines in the same class and sometimes with closely related medications. Just because a family member had an allergic reaction to a certain medication, doesn't mean that you will.

A side effect is not based on your immune system's response to a medication. It most commonly includes nausea, headaches, and drowsiness but can include many other symptoms such as dizziness and taste disturbance. These side-effects are annoying but seldom dangerous.

The side effect might improve with a dose adjustment or just over time with continued use of the same dose. It will usually recur if the same medicine is given in the future. It will sometimes occur with similar medicines but often is specific to a certain drug.

A common mistake a patient will make involves refusing to take a certain medication because of concerns of either allergic reactions or side effects. Unfortunately our pharmacist friends provide written handouts that are often misleading when it comes to warning patients against taking a particular drug if a prior reaction occurred with a similar but different medication. Three common situations are detailed below.

If you had an allergic reaction to penicillin in the past you are still able to safely take some, if not all, cephalosporins (Keflex, Ceclor, etc.). You and your doctor do need to be extra careful however if your allergic reaction to penicillin in the past was an anaphylactic one.

Many patients say they are allergic to codeine. That almost always means that they have a side effect of nausea and/or vomiting when they take codeine. That does not exclude you from taking hydrocodone for pain or a cough, if it is indicated. While you could coincidentally have a gastrointestinal side-effect from that, it is much less likely.

There is a difference between sulfa and sulfates/sulfites. The former is used as an antibiotic while the latter are included in many medications such as morphine and some diabetes pills. Many patients develop a rash with the antibiotic (much more so than with penicillin in my experience), but very few, if any, of them will have any reaction to the other medications.

You should tell your doctor which medications have given you which symptoms and let him decide if it was an allergic reaction or a side-effect. Only by doing this can you assure yourself of allowing your doctor to choose the most beneficial and cost-effective treatment for your condition.

THIS IS NOT BURGER KING

2007-06-19T11:25:00.000-12:00

I think that some patients confuse a doctor's office with a supermarket. They come in with a written or mental list of what they want and are not happy unless they receive what's on that list. I will explain what a visit to a physician is and isn't.

A patient is paying for an evaluation and treatment of a medical condition. It would be a mistake to take your car to a mechanic and tell them you need a new water pump. If they replace it and the car still has the same problem, you would be upset. You should tell your mechanic that your car is overheating and let the expert determine if the problem is the water pump, the thermostat, the radiator or something altogether different. Certainly a car owner with a lot of knowledge about cars can provide thoughts as to what the problem is, but the diagnosis should be left up to the mechanic.

So too should the patient avoid going to the doctor and tell him that you need Nexium for your hiatal hernia. If you are just given the prescription without a proper evaluation and then have a heart attack, you would be upset. You should tell the doctor that you are having indigestion and let the expert determine if the problem is a hiatal hernia, ulcers, angina, or something altogether different. Certainly a patient with a lot of knowledge about health can provide thoughts as to what the problem is, but the diagnosis and treatment options should be left up to the doctor.

The above is not a perfect analogy as diagnosing medical conditions is often an art and not an exact science. If the diagnosis turns out to be incorrect or incomplete on several occasions, you should find a new expert.

The two areas that often bring out the worst in patients are for prescriptions of antibiotics and pain medications. These are the two most frequent situations in which some patients insist on particular medications and will refuse others.

With antibiotics some patients insist on getting one even if they have a condition in which there is no benefit from it. I do not know why someone would expose themselves to the risk of allergic reactions, unnecessary side-effects, and the build-up of resistant bacteria in their system if antibiotics are not going to help them recover from their illness faster.

Other patients insist that they are immune to certain ones. It is often difficult to convince these people that while some bacteria are resistant to certain antibiotics, people are not. An antibiotic that might not have worked for a particular infection in one instance may very well be the best choice for a different infection.

It can be helpful for a patient to notify the doctor if they have had side-effects, allergies, good success, or bad success with a certain antibiotic for a similar infection in the past. The ultimate choice however, should be left up to the expert.

With pain medication, it is one thing to let your doctor know your past experience and results with particular drugs. It is quite another to insist on only one particular medication for your pain. You run the risk of being thought of as a drug-seeker if you are unwilling to try any medication other than strong narcotics.

Just as there are many different types of pain so are there different types of pain medications. One kind may be good for one pain while another might be better for another pain. Your doctor is in the best position to diagnose the cause of your pain and offer the most effective and appropriate medications for the situation at hand.

With any medication that your doctor prescribes, there is a chance that it will cause side-effects or might not be fully effective. That does not mean that the wrong medication was chosen. But your physician needs to be available to adjust a dose or change a prescription if the results are not satisfactory.

While a doctor patient relationship is a partnership, it is not an equal one. They each have their roles and responsibilities to achieve optimal results. The doctor should listen, examine, and advise. The patient should ask questions, choose among reasonable treatment options, and comply with the recommendations. Patients receive better care when they work with instead of trying to be their doctor.

MAKE HASTE...SLOWLY

2007-06-12T06:17:00.000-12:00

I think that patients need to have more patience. Some people rush to the Emergency Room for conditions that can safely wait to be evaluated by a physician in 24 to 48 hours. This waiting strategy can save you both time (if you have ever gone to the E.R. on a Saturday night with a non-life threatening problem you know what I mean) and money (if you have ever received a bill from the E.R. you also know what I mean).

As the summer is upon us, I will discuss several common conditions that patients often seek immediate care for but that can safely wait a period of time. These include sprains, cuts, and insect bites or stings.

Most people with an injury to a bone or joint are concerned whether or not there is a fracture. This is a reasonable concern as an untreated fracture or one not treated in a timely fashion can lead to long-term impairment or prolonged recovery.

Despite rumors to the contrary, being able to move a body part does not guarantee that there is no fracture. Many patients have walked into a doctor's office with a broken foot or ankle. An obvious deformity can make finding a fracture more likely, but unless you are Superman, you need an x-ray to detect a non-displaced fracture.

Fractures that require immediate attention include open fractures in which a bone is protruding through the skin and displaced fractures that compromise circulation. The former condition is readily apparent even to the untrained observer. The latter condition is detected when there is a decrease in pulse, coolness to touch, or pallor distal to the site of injury.

The vast majority of fractures can be managed with the use of rest, ice, compression, elevation, and over the counter pain medications until an office evaluation can be performed. Ideally this should be no later than 2 or 3 days after the injury.

Cuts require immediate attention if bleeding cannot be stopped with direct pressure. Otherwise relatively clean cuts can be sutured up to 19 hours after the injury. A longer delay increases the chances for infection.

A tetanus booster should be given within the first 24 hours of the wound if one is needed. A patient with a dirty or deep wound should receive this if more than 5 years have elapsed since the last booster while a patient with a clean or shallow wound only needs a booster if over 10 years have elapsed since the last booster.

Patients who step on a rusty nail should be seen immediately as these wounds should be anesthetized and thoroughly cleansed due to their extreme risk of infection. This prompt attention is even more important if the patient has a compromised immune system from diabetes or other chronic illness.

A bite from a mosquito or tick will take several days to cause symptoms if a disease has been spread. There is no known benefit from prophylactic antibiotics with these. If a fever or rash develops in the week or so following the bite, evaluation should be sought within a day or so.

A sting from an insect should prompt immediate medical attention if the patient has a history of severe allergic reactions to them in the past or if the patient develops hives or any breathing difficulties. Otherwise ice and oral benedryl can be utilized. If significant swelling or itching at the site of the bite occurs despite these measures, a physician can be consulted in a day or two.

While many common conditions are painful and frightening, the above guidelines can help the patient determine which ones require immediate attention from a doctor and which ones can be safely treated hours or days later. This knowledge will help avoid unnecessary trips to the emergency room after doctors' offices and urgent care centers are closed. The patient's patience can result in dramatic time and cost savings.

LOCUM TERRORS

2007-06-01T06:07:00.000-12:00

I think that it's better to temporarily provide no service rather than poor service. That is why the Spiceland Pike Medical Center will be closed Sunday, June 3rd and not reopen until Sunday, June 10th. This will mark the first time in our 10+ years of business that we will be closed for more than 2 days in a row.

I pride myself on being the hardest working doctor in New Castle. I work more days a week, more days a month, and more days a year every year than any other area doctor. I do this because I love my work and I care for my patients and want them to have access to my services as much as possible.

In the past few years, I have opted to hire a "locum tenens" doctor. That is a doctor provided by a temporary agency. Unfortunately, that has been a disaster to varying degrees all three years. Despite the agencies assurances of the quality of the doctors, the locum agencies universally committed a cardinal sin of business by over promising and under delivering.

I explained to the agencies in great detail the type of practice I have and the skills and speed that are required of a physician to perform a competent job. The companies would then fax me resumes of "qualified", available doctors. I was then permitted to review the credentials of the doctors and have a phone interview with them ahead of time to directly and explicitly explain what was required of them. This only proved to me that anyone can talk a good game, but actions speak louder than words.

The first year we hired a physician who showed up late on his first day, worked incredibly slow, and took breaks to eat during the day despite a waiting room full of people that needed medical attention. His work quality at least was satisfactory.

When I talked with the locum agency upon my return, I was given a sympathetic ear. I was asked what I would like done to rectify the situation, I stated that I would like to be reimbursed for the time he spent eating instead of seeing patients and that I would like to leave a letter in his file to inform future clients of my concerns. Not surprisingly, while both requests were accepted, only the former was acted upon.

The second time I used a locum agency was worse. I was told a week before my scheduled vacation that the original doctor had backed out. But I was not to worry because they would find a new one in time. They had no answer for my questions of what would happen if they didn't and what would happen if this replacement was unacceptable to me.

A new physician was found and I was assured that the company would stand by her fully since they had used her before and received good reviews from her past employers. Well, this didn't turn out to be exactly true.

While she did exercise some questionable medical judgment at times and was incredibly slow, she did manage to work when she was supposed to instead of eating.
The bigger problem was that she failed to dictate on the office visits for many patients.

This creates two problems. I cannot submit insurance claims for patients if I have no record of what transpired during the visit and I cannot adequately address problems a patient might still be having if I don't know what was diagnosed and how that was determined.

The doctor blamed the equipment and initially refused to write out or re dictate the findings from the office visit. The locum agency was largely antagonistic and unhelpful in resolving this issue. Only after I refused to pay for her uncompleted services was the work done.

When I asked the company's representative whether there had been any other hiring physicians' complaints against her, they admitted that she had never worked for them before despite assurances to the contrary made earlier. I was transferred to their lawyer when I requested to speak with a supervisor. The lawyer made it clear that the agency had no interest in retaining me as a customer and did not care that I was unhappy with their last minute replacement physician.

The third time was going to be different. I was using a different agency and I was paying extra to hire a physician who could handle the sometimes hectic pace of a walk-in clinic.

What a relief when they sent me a resume of a doctor who already worked for them extensively as an urgent care physician. The best part was that the doctor had worked over the past month filling in at a local walk-in clinic.

Not wanting to take any chances, we called the local clinic and received glowing reviews on his speed and conduct. I had him stop into the office to personally talk with him and show him we ran things. The third time seemed like it would be the charm.

Not quite. He turned out to be the most unprofessional and irresponsible of the three. He would answer his cell phone to take personal calls while in rooms with patients. He would take frequent breaks to eat instead of seeing patients. He would dictate in front of patients about their "deviant lifestyles" if they were homosexual or had what he considered to be inappropriate or too many piercings. He would not treat anyone with a sexually transmitted disease. The list goes on.

When I voiced my concerns to the locum agency's representative I was told that if I was unhappy with his services I should have dismissed him. I asked them if they would have provided an immediate replacement. "We would have tried," was the response.

When I balked at paying the higher rate for a physician who could handle an urgent care volume I was told that he was an urgent care doctor because he stated that he was one. But calling a Nova a Cadillac doesn't make it so. After much arguing, the representative admitted that they had no obligation other than providing a warm body with a medical license. They were sorry that he had performed unprofessionally and unethically, but that was all.

I threatened not to pay the full amount. They threatened to sue. I retained an attorney and received a small discount. They still call back several times a year to ask if I want to use their services again. I think not.

So three strikes and I am out. These locum firms are interested in money, not customer satisfaction. They excuse the conduct of their physicians and do not properly screen them to provide suitable candidates for doctors like myself who are trying to provide continuous satisfactory care for patients.

I apologize for the inconvenience, but this year no physician will be available for one week. For your convenience however, a nurse will be available from 12:30 p.m. until 3:00 p.m. from Monday through Friday to answer questions, provide medical advice and provide refills when indicated. Thank you for your understanding of this difficult decision.

THE "F" WORD

2007-05-29T08:58:00.000-12:00

I think that fibromyalgia is a diagnosis that is used too freely by both physicians and patients. It is often used when no other etiology for a person's symptoms of fatigue with diffuse aches and pains can be found after a physical exam is performed and laboratory studies are obtained.

The purpose of a diagnosis is several fold. For the doctor, it defines an array of effective treatments and anticipated outcomes. For the patient, it provides reassurance that they have a known, definable condition with predictable long term expectations.

The problem arises for a doctor when a diagnosis is assigned to a patient prematurely or incorrectly. The problem arises for a patient when a diagnosis is misconstrued, resulting in unwarranted feelings of helplessness and hopelessness.

Not so long ago, many patients were given a diagnosis of hypoglycemia or chronic Epstein-Barr virus infection to explain a constellation of vague symptoms that did not appear to have any clear medical explanation. These diagnoses allowed the doctor to have an explanation to the give the patient for their condition and avoid the need for additional studies or referrals. The patient could be told that they just have to live with it as there were no effective treatments.

The diagnosis allowed the patient to be assured that no dire, life-threatening condition existed. Although no treatment would help, a variety of symptoms could now be safely ignored whenever the patient's particular condition flared up.

The diagnosis that serves this function now is fibromyalgia. While there is no confirmatory blood test or x-ray that can establish this condition with certainty, there exists a defined list of symptoms and subjective exam findings to support it. More often than not, the diagnosis is loosely and frequently applied.

My professional opinion is that a patient with this condition has an abnormally low pain threshold. Everybody has aches and pains daily. Most people are either too busy to notice them or they minimize those that they do notice and accept that they occur without allowing them to limit their activities or become the focus of their lives. Oftentimes the fibromyalgia patient will obsess over every minor symptom.

I believe that people with fibromyalgia have true symptoms and real pain. I do not believe that a physician is doing those patients any favors by enabling them to view themselves as disabled or invalids because of the condition. I have seen many patients on disability and on chronic narcotics because of fibromyalgia.

A patient is better served by having a doctor treat the symptoms of this condition with medications that are safe to use long-term such as anti-depressants, sleep-aids, muscle relaxers, and non-addictive pain medications. The doctor needs to encourage the patient to try and live a fully-functional life and not support the patient's erroneous belief that their condition should dominate their day to day existence.

Some patients with fibromyalgia will doctor shop and prescription shop in a futile attempt to become symptom free. The doctor needs to make it very clear to the patient that the above scenario is not realistic. Rather the emphasis should be on safe, long-term symptom control to allow the patient to participate in as much work and recreational activity as is feasible.

If the patient, and especially their doctor, sows a future of misery and limitations, that is what is learned and that is what is reaped. The power of positive (and realistic) thinking is important and genuine.

CAVEAT EMPTOR

2007-05-23T09:22:00.000-12:00

I think people should think long and hard about how important their health is to them before deciding to order medications from Canada or over the Internet. Saving a little (or sometimes even a lot) can be very costly.

Now I understand, as should all primary care physicians, that the cost of prescriptions can impose an extreme financial burden on a patient. But I also understand that proper medications can improve life's quality and prolong its length.

Unfortunately, some doctors just assume a patient has insurance coverage for medications and so prescribe without concern for cost. A physician should always inquire about a patient's ability to afford an expensive medicine before prescribing it.

For almost all medical conditions there are several different drugs that can be used for treatment. The choice should be based on effectiveness, side effects, and cost. A doctor is not doing the patients any favors by prescribing the most marvelous medicine in the world if it is unaffordable by them.

If a patient has good prescription insurance coverage, or is independently wealthy, a doctor has it made. Any medication can be used. The challenge comes when the choices are limited.

The cash paying patient obviously has limitations on what is affordable. The patient with insurance who has a high deductible or very restrictive formulary might have very similar if not identical limitations. Options for these individuals include samples, generics, pharmacy discounted medications, and patient assistance programs.

My office, thanks to the generosity of some pharmaceutical companies, is often able to provide the patient with samples of medications, often for months at a time. The advantage includes no cost to the patient while the disadvantages include inconvenience in the patient having to call and come by the office monthly or more often to pick up the medicine. The medicine might need to be changed depending on sample selection which might require additional office visits or lab studies.

Generic drugs are an attractive choice for many patients without insurance and required by formulary rules for many with insurance. The pharmacies like them since the profit margin is often greater from a generic prescription than from a brand name one.

All medications eventually become generic as the patents expire and so these are always older agents. They may require several doses a day and require more frequent monitoring for a higher rate of side effects, as well as not be as beneficial in treating certain diseases as compared to newer, branded drugs.

A few medications for blood thinning, thyroid troubles and heart problems should not be given generically since the amount of active drug in one generic may be a little higher than in the branded medication but a little lower in a different generic. You may receive a different company's generic pill every month. This can result in too much fluctuation in a medicine that needs to be kept in a narrow therapeutic range to be safe and effective.

Within the past year, starting with Wal-Mart, some pharmacies have been offering certain generic medications for free or for a very low set price. While this clearly benefits the patient, I suspect it also benefits the store as people will tend to shop and buy other products while waiting for their prescriptions to be filled. The lists tend to be fairly inclusive by including several options for many common conditions like infections, diabetes, and hypertension.

Most pharmaceutical companies offer a patient assistance program for people that require a particular branded drug but do not have insurance to cover it or cannot afford it. This should be a last resort as the paperwork required is usually quite burdensome to both the patient and the doctor. The patient is required to send in proof of income and the doctor is required to complete pages of information and repeat the process up to every three months depending on the particular company.

People who choose to try to save money by ordering medication through Canadian pharmacies or over the Internet are making a mistake and their doctor should not condone or assist them in this endeavor. The reason for the price disparity in the cost of the same branded medication in different countries is muti-factorial and will not be delved into in this particular essay. The cost savings does not justify the risks involved for either the patient or the physician.

It is still illegal for a patient to directly receive prescriptions from foreign countries in the United States. You may not agree with this, but not agreeing with the law does not justify breaking it in this case. Your doctor is also breaking the law if he assists you in this endeavor. I suspect the medications received from reputable Canadian mail-in pharmacies are probably genuine and safe.

It is a crapshoot when you get medications from elsewhere outside this country or over the Internet. There are countless examples of counterfeit branded medications being sold for everything from erectile dysfunction to cancer chemotherapy. Contrary to the popular dictum of the worst medication a doctor can give a patient is one that cannot be afforded, the really worst medication a doctor can give a patient is one that is different from what is prescribed.

The doctor must be sure a patient can afford the prescribed medications. The patient must be sure the doctor is aware if a particular medication is unaffordable. Only then can the above listed measures be utilized effectively to provide the optimal health care for an individual. Only then can both parties avoid illegal activities and be sure that the medication being prescribed is the medication being taken.

DOCTOR KNOWS BEST

2007-05-15T06:28:00.000-12:00

I think a little bit of knowledge can be a dangerous thing, especially when it involves your health. In days of yore, the only readily available health information was from your family doctor. Today, there is a cesspool of health information easily accessible.

Information can be accurate or inaccurate. It can be appropriately or inappropriately applied. Good information taken out of context can be just as harmful as bad information.

The best source of information for health care information is your family doctor. Other reliable sources include websites from respectable organizations such as the American Academy of Family Physicians.

Poor sources of information that may not be accurate can include well meaning family and friends, disreputable web sites, as well as ads placed in newspapers or on television by lawyers. Information from these sources should either be ignored or viewed with a very jaundiced eye.

Medicine is increasingly complex and what might have been true in the past might not be true in the present. I will often see older patients who request a penicillin shot to cure their infection. This is what always worked when they were a kid I am told. Unfortunately, most bacteria have developed resistance to this antibiotic and unless they have strep throat or syphilis, penicillin isn't likely to get the job done.

One can find a web site to support any crackpot medical idea. They often quote so-called "professionals" with questionable credentials and have dubious testimonials. They usually attempt to dupe the reader into purchasing a cure-all snake oil product or self-help book.

Lawyer sponsored ads attempt to scare anybody that has been on a particular medication to call even if there are no past or current health problems related to that drug. They obviously have a tremendous financial interest in convincing you that had, are having, or might someday have a significant health problem from just being on a certain medication regardless of how briefly that it was used. It is interesting to note which T.V. shows tend to run these ads (Jerry Springer, et. al.).

Poor sources of information that are accurate can include the Physicians' Desk Reference (PDR), the pharmacy's handout that is provided with your prescription, the television, and newspaper health advice columns.

The PDR is a book that functions best as a c.y.a. vehicle for pharmaceutical companies. It does have useful information, but this is a needle amidst a haystack of useless information. Among other things, it lists every side effect ever reported by anyone taking the drug during the trial phases. This does not mean that the drug caused the side effect. Thus you might find insomnia listed as a side effect of sleeping pills and headache as a side effect of migraine medicines.

The pharmacy provides a written handout that consolidates the information from the P.D.R. and translates it into lay language for the patient. It is almost always from a software program purchased from a national vendor and is intended to be a c.y.a. vehicle for the pharmacist. It also contains useful information, but this is not distinguished from the useless information. A medicine might be listed as causing contradictory side effects like drowsiness and sleeplessness.

Unfortunately, the patients that are the most likely to obsessively read the handout and look up the drug in the P.D.R. are the same folks who are very suggestible. It is well known that medical and nursing students often become convinced that they have the various diseases that they are currently studying.

The television reports a sensationalized version of health care news. This news is often reported before the information can undergo a peer review process in which other doctors analyze the study and data to determine its relevance and validity. You will have heard the information as soon as or before your doctor has making it very difficult for him to know how that new information can best be applied to individual patients.

The syndicated columnist is attempting to diagnose patients by information that is presented to the writer. This is precarious at best since there is no exam, no review of tests, and no ability to ask for additional information. Because of these factors, the columnist offers several possibilities and then almost invariably advises the patient to see a specialist.

A plethora of sources are available for health care information with widely differing quality and pertinence. But there is no substitute for your family physician when it comes to receiving personalized, accurate, and useful health related information.

HEY LOLLY, LOLLY

2007-05-09T09:27:00.000-12:00

I think that having your doctor treat you over the phone for a new medical problem is very problematic. It is even more worrisome if the doctor you are dealing with is a physician who is covering for your regular doctor.

There are many reasons that patients try to get diagnosed and treated over the phone. There are also many reasons that your physician may choose to treat you over the phone. Seldom are these good reasons.

A patient might not want to take the time to come in for an office visit or the doctor might not have an appointment available when the patient needs to be seen. To me, a primary care doctor has a duty to see a patient who needs evaluated regardless of how full the schedule might be.

Problems might arise outside of the doctor's office hours. To me, a patient who is evaluated over the phone for a new problem should either be triaged to see a doctor soon (through the E.R., an urgent care or at their own doctor's office) or be advised to try an over the counter product and seek face to face medical attention if the symptoms worsen or do not resolve. Unfortunately, some patients have been known to intentionally wait to call until after hours in an attempt to get treated over the phone and avoid an office visit.

A patient and/or doctor might be trying to avoid the expense of an office visit. With some health insurance plans (i.e. HMOs), the doctor gets a set amount of money every month for each patient whether or not they are seen in the office. This creates an inherent conflict of interest in that the doctor makes more money by treating a sick HMO patient over the phone and reserving appointment slots for those who pay for each visit.

I don't blame the patient for trying to get medical advice over the phone. Locally it seems to be a readily accepted practice of both doctors and patients. The patient feels they are getting all the benefits of an office visit, evaluation and treatment, with none of the downside, time and expense. The doctor should be the one that knows better.

It is well documented in the medical literature that patients' ability to accurately self-diagnose their ailment is very poor. So, for example when a woman calls and states that she has a yeast infection or a urinary tract infection, she is more often than not, incorrect. While gas pain is could be just indigestion, sometimes it is a heart attack and while a fever and stiff neck could be strep throat, it is also sometimes meningitis.

A proper diagnosis is often difficult even during an office visit. It is often impossible to do over the phone. These misdiagnoses may just be a nuisance and involve inappropriate and ineffective treatment, or it could result in a catastrophic delay in a proper hands-on evaluation by a physician with potentially life saving timely treatment.

An incorrect phone diagnosis of an acute illness is an avoidable and indefensible liability. A patient and physician might benefit when things go right, but when things go wrong, only the lawyers benefit.

THE LONG AND WINDING ROAD

2007-05-03T04:19:00.000-12:00

I think that Josh Estelle, of the Pfenninger insurance agency, and Kim Cronk, of the County council, should be congratulated. They came up with an idea to increase the health care options for city and county employees while decreasing total health care costs.

The city and county are self-insured. In simplified terms, this means that the more health care expenses the employees incur, the more the city and county (i.e. the taxpayers) must pay. As the eighth and fifth largest employers respectively, this amounts to a large sum of money.

A significant expense involves emergency room visits. Unfortunately, after 5 p.m. (or earlier depending on the doctor) during the week and not at all on weekends, the employees' physicians are not available to see patients. So, while a medical problem may not be a life or limb threatening emergency, it may be a condition that could become one if not appropriately treated for 2 or 3 days.

After-hours or on weekends, phone advise from your doctor may be helpful, but it does not take the place of a hands-on evaluation from a physician. Previously, the employee's only option locally was to go the emergency room and have the city or county (i.e. taxpayer) pay a large bill or to come to the Spiceland Pike Medical Center.

The problem with the latter choice was the requirement to pay up front and the patient might not get reimbursed from their insurance company. Many people would rather wait for long periods in the emergency room for care that can be provided more efficiently and inexpensively in a doctor's office if it means no immediate expense and the co-pay for the E.R. visit will be about the same as the cost of an office visit. The taxpayer's cost however will be vastly different.

Mr. Estelle and Mr. Cronk were both aware, as are the regular readers of my compositions, that for a variety of reasons, I am loathe to join any health insurance plan. But, their idea addressed my concerns about charging different people different amounts for the same service, loss of autonomy in medical decision making and administrative hassles.

As of 4-15-07 the Spiceland Pike Medical Center now will see patients with city and county health insurance and charge only the co-pay at the time of service. My understanding is that the co-pay will be less than the employees have to pay at any other doctor's office.

This was made possible because I am allowed to keep my already low fee schedule intact and not have to arbitrarily provide a percent discount. My charges sans discount are lower than those "discounted" prices of other providers so the city and county save money.

Another key component was the elimination of my loss of medical decision making autonomy. I refer to specialists and for additional testing as I, and not some insurance pencil pusher, sees fit.

The last selling point to me was the lack of administrative hassles. I can bill the insurance company and receive reimbursement quickly and efficiently and can therefore keep my prices the same due to not incurring any additional overhead expense. My contract with the insurance company is one page. For comparison the one I was offered from another insurance company recently was over 40 pages and did not even include a fee schedule, as per the norm.

This agreement benefits all those involved. Patients have more options, the county and city (taxpayers) save money, the emergency department can devote its resources to true emergencies, and I have the opportunity to help more people while maintaining my ability to practice medicine without compromising my autonomy.

Of note, I do not know why other insurance companies do not do likewise. I suppose it's because they do not want the hassle of changing the status quo for a single doctor. It would be nice if those purchasing the policies were thought of first and provided with more choices as it would not cost the insurance companies any extra money.

I did offer this same proposition to the local hospital when I first opened. The administration at that time would not discuss this unless I joined their health network which I was not about to do. There is no good reason that the self-insured local county owned hospital, as the third largest employer in Henry County, shouldn't try and save taxpayer dollars by entering into a similar agreement with myself for the benefit of its employees and the taxpayers.

NOT IN OUR STARS

2007-04-23T09:46:00.000-12:00

I think we need to take responsibility for our actions. Somewhere along the way, blaming others for our mistakes or even for our bad luck has become the norm. Anytime something bad happens, it seems that someone else must be blamed.

A good part of this societal attitude change has to do with our legal system. One gets rewarded financially if personal responsibility can be minimized and victimization maximized.

We were all outraged by the story of the lawsuit by the lady at McDonalds who won millions by claiming the coffee was too hot that she spilled on herself. We all shake our heads in disbelief when we read about the burglar who hurts himself breaking into a residence and then sues the property owner.

Locally the students from Knightstown High School received a large settlement ordered by the court which ruled that the children's freedom of speech was being violated by their expulsion for the creation of a DVD that demeaned and threatened a teacher. Since the students were reinstated, wouldn't it have sent a wonderful message about responsibility if those families had donated their lawsuit proceeds back to the school or community?

You cannot watch television or read a newspaper without seeing an ad by a lawyer who wants you to sue someone just because you used a product even if you never suffered any ill effects. The only people who make any significant amount of money from class-action lawsuits are the lawyers but we all sign on in an attempt to get money for nothing.

Lawsuits are justified if a company knowingly allows an unsafe product to be available to consumers without informing people of the risks. If the risks are obvious then no financial recourse should be available if harm occurs.

You should not be allowed to sue a fast-food restaurant just because you became obese by eating their product. Your family should not be allowed to sue the hair dryer manufacturer if you get electrocuted using it while in the bathtub regardless of whether or not there is a warning sticker on the product.

There are many examples of lawyers and patients becoming millionaires from lawsuits which are based on bad luck, bad science, and bad lifestyle choices of patients.

John Edwards, one of the democratic presidential candidates, made his fortune as a lawyer by suing doctors over cases in which babies were born with cerebral palsy or other birth defects. From studies on placentas, science clearly shows us that the vast majority of infants afflicted had the damage occur during the earlier trimesters and that the bad outcome was predetermined before the onset of labor and delivery. That didn't stop the blaming of the delivery room doctors in many cases.

The Dow chemical company went bankrupt defending lawsuits over claims of illness arising over the use of silicon breast implants. Despite multiple studies without a single one showing any link between the implants and any disease in the women receiving them, lawyers and patients got rich. The medical and scientific facts didn't seem to enter into the jury decisions. Science eventually won out over the hysteria and the products are again available.

A generation or two of underground coal miners in Kentucky and West Virginia, and of course their lawyers, profited from the black-lung myth. While black-lung disease can show changes on x-rays, it only rarely causes any type of disability. The symptoms these patients had been almost exclusively from smoking. Studies found that the more time a miner spent underground, the less respiratory problems they had despite worse looking x-rays. The reason was they weren't allowed to smoke while in the mines and therefore had less tobacco exposure than those who worked above ground.

This brings to mind the case of the cigarette companies. It is abundantly documented that the adverse health effects of cigarettes were well known to the manufacturers many years before they were known to the health care community. Since this information was hidden from consumers, patients did not have all the facts needed to make fully informed choices on the use of tobacco products. The recent multi-state attorney generals' lawsuit was appropriate in this case.

In medicine, not all bad outcomes are someone's fault. It clearly can be, such as the incident with the wrong dose of heparin given to the babies at Methodist. But just as sometimes a bad outcome occurs despite good care, so too sometimes good outcomes occur despite suboptimal care. As long as physicians are human, mistakes will be made. The majority of which fortunately do not harm anyone.

If you are obese and smoke with poorly controlled diabetes and hypertension, don't blame the doctor or the drug company if you have a heart attack or stroke. If you exercise regularly and have a healthy diet and lifestyle, you have more of a right to look for other factors that may have led to a heart attack or stroke. Responsibility must always lie first with the individual.

To automatically assume that a poor outcome was the fault of someone else is naive and pompous. God heals and God calls people home. In our society, the tendency to place blame on someone every time a patient is stricken by or doesn't fully recover from a disease or illness, is as harmful as it is popular.

WAFER THIN MINT

2007-04-17T06:24:00.000-12:00

I think that weight loss is simple. Note that I did not say it was easy. There's a big difference. It is important because of the increased incidence of arthritis, certain cancers, heart disease, gallbladder disease, diabetes, hypertension, and elevated cholesterol in obese individuals.

At the most basic level, ones change in weight is based on the amount of calories coming in and the amount of calories being burned off. With the exception of fluid retention, you will only gain weight if your caloric intake exceeds the number of calories you are burning off. Conversely, you will only lose weight if you burn off more calories than you take in.

There are 3500 calories per pound. Therefore to lose a pound you must burn off 3500 more calories than you are consuming. To achieve a one pound per week weight loss will require an average of eating 500 fewer calories per day, burning off an average of 500 more calories per day, or some combination of the two.

To lose 2 pounds of fat per week by diet alone would require a decrease of 1000 calories per day. This would be very difficult for most people and any faster rate of weight loss is unrealistic. More profound rapid weight loss claims usually are the result of temporary fluid loss and dehydration.

Looking at this long term is not as discouraging. Up to a 50 pound weight loss over the course of year can be targeted. It took a good while to get overweight and a year or more is not an unrealistic time frame to meet a target weight depending on the degree of obesity present.

Patients often complain that they can't lose weight even though they have a very low caloric intake. They need to learn that it is very difficult to lose weight with calorie restrictions alone. It seems that the body tries to conserve energy and if a significant decrease in calories is detected, the natural tendency is for the body to try and conserve energy by expending fewer calories.

Patients also complain that they are gaining weight year to year despite no change in diet and exercise habits. Unfortunately, as we age our metabolism slows down and we will gain weight unless an active effort is made to eat less and/or exercise more.

It is abundantly clear that genetics plays a large factor in determining one's weight. Not all of it is learned behavior creating poor eating habits. Everyone knows people that are couch potatoes and who eat an incredible amount of calories and are rail thin. We also know people who can seemingly gain weight just by looking at food. This is as unfair as it is undeniable.

A successful long-term weight loss plan involves lifestyle modification. Do not buy unhealthy food to tempt you in a moment of weakness. Nobody ever got fat eating carrots and celery sticks. Do not eat when bored or stressed. Ideally, eat only when hungry and not to the point of being full. Do not eat out of multi-serving cartons or bags.

Exercise aerobically daily. It is very enlightening to see how much walking or running is required to burn off the calories from one candy bar. Eat what you like, but eat less of it. Fad diets are by definition unlikely to be sustainable over the long run.

Weigh yourself weekly when trying to lose weight. A daily weight just leads to frustrations from the normal variations in hydration status.

Weigh yourself daily when trying to maintain your weight. Too much weight can be put on over the course of a bad week to not try and identify this earlier. If the weight is up 1-2 pounds over a day or two, be extra careful on the caloric intake until the weight has returned to baseline.

Of the two ways to lose weight, all medicines work by decreasing caloric intake. There is no medication that will increase your metabolism and allow you to lose weight without a change in your diet or exercise pattern.

In our society, it is harder than ever not to be overweight. A sedentary lifestyle is encouraged by the seemingly infinite channels on television as well as DVDs, computers and video games. Unhealthy fast food is heavily advertised, cheap, and tasty. Time constraints make it difficult to exercise and to shop and prepare healthy meals on a regular basis.

Progressive communities and lawmakers have recently attempted to tackle this issue in a variety of ways. Methods have included outlawing the use of unhealthy cooking fats, requiring caloric counts to be printed on restaurant menus, and banning the sale of soft drinks in public schools. I applaud all of these measures and wish that our locally elected officials had the intestinal fortitude to adopt these ideas.

Other more heavy handed measures that have been proposed include having a junk food tax and banning certain commercials. I am less comfortable with these options for a variety of reasons having more to do with my philosophy on the roll of government than on the desired results. I think I would be in favor of a mandatory showing of "Super Size Me" in high school health classes though.

But, as is typical of the American way of thinking, easy solutions are sought out. These often involve wishful thinking that the latest over the counter diet pill or weight loss diet will be the answer. For those with the means, surgery with liposuction or gastric banding is a tempting answer, but long term efficacy and safety issues remain.

Ultimately, the long term solution still involves eating less and exercising more. Weight loss can be simple as sugar and easy as (turning down a slice of) pie.

NOBODY GETS OUT ALIVE

2007-04-09T11:14:00.000-12:00

I think that life is like Bob Dylan sang "he not busy being born is busy dying". When patients complain that they are getting old I remind them that the only alternative is not so great.

Hospice care can provide spiritual and physical comfort to the dying. It is for patients who have a terminal condition and are believed to have 6 months or less of life left. Enrollment requires that the patient not be seeking curative therapy for their condition. A large focus is on pain control.

Some doctors are hesitant to enroll a patient because of not wanting to guarantee that the patient will expire within the six month period. There is no penalty to the patient or the physician if the patient lives longer.

The hospice company employs social workers, chaplains, nurses, nurse aids, and a medical director to facilitate the transition of the patient to the afterlife. They can provide assistance to the patient as well as the family in their own home or in an extended care facility.

Elisabeth Kubler-Ross, in her seminal book "On Death and Dying", taught us the five stages of dying. They are denial, anger, bargaining, depression, and acceptance.

Clearly, a patient in the fifth stage is ready for and can benefit from hospice care. The problem sometimes occurs in the other stages and that is where it is critical to know the policies and philosophies of the individual hospice company and its medical director.

Most patients in hospice choose to have their personal physician remain in charge of their overall care. Some doctors choose to relinquish complete care over to the hospice's medical director. Some request that the medical director take care of pain and comfort issues only while other doctors use the hospice physician for consultations only if difficulties arise.

Some medical directors take a more aggressive, hands-on approach and will overrule the patient's doctor treatment decisions if a disagreement exists on how to best treat a specific problem. This is only appropriate when a patient is not receiving adequate symptom relief and the personal physician is unwilling to modify the current treatment.

While the patient has the right to withdraw from hospice at any time for any reason, the hospice has the right to withdraw from the patient's care for certain reasons. Some reasons are required by regulations and others are company specific.

All hospices will revoke a patient's care if curative care for the terminal condition is sought. Services can be restored should the patient later on abandon these efforts.

Some hospices will revoke a patient's care if the patient chooses to go the hospital for any reason. I strongly disagree with this position. There is no reason not to aggressively treat an unrelated condition if it will improve or prolong the quality of someone's life.

For example, if a patient has terminal brain cancer and is having a good quality of life, there is no reason not to consider hospitalization to manage unrelated conditions such as pneumonias or heart problems. Even surgery might be appropriate in certain circumstances.

Some hospices require a patient sign a statement that they do not want to be intubated, on a ventilator or have CPR performed on them. I strongly disagree with this position as well. Part of the service of hospice is to assist the patient in the dying process.

Not all patients are in the stage of acceptance when hospice services are appropriate. Hopefully, with counseling and time a patient can be moved through all the stages before death occurs. But to deny hospice care to someone because they are not ready to formerly sign a "Do Not Resuscitate" order seems almost cold-hearted.

Patients in the earlier stages of dying often need the spiritual and physical help that hospice can provide more than those in the later stages. A hospice should assist patients in the process of accepting a DNR order. This process may take weeks or months and in some patients it may never occur.

If you or a loved one is a potential hospice candidate, consult with the patient's doctor. If hospice is deemed appropriate, consult with several hospice providers to find the one that best meets your needs and is in sync with your philosophy on caring for the terminally ill.

WALK ON

2007-04-02T06:55:00.000-12:00

I think that companies that advertise motorized scooters for Medicare recipients are intrusive and detrimental to the doctor/patient relationship. All marketing at its most basic level is about creating a need and then filling it. These companies try to create a need which doesn't necessarily already exist.

Now I understand that in America a company has the right to advertise its product in an attempt to create consumer demand. The situation is different however when the product being promoted requires the authorization of a third party, a physician.

This is similar to the direct consumer ads from pharmaceutical companies. They fall into two broad categories. The first is aimed at making the consumer aware of disease and that treatment exist while the second is aimed at getting the patient to pester his doctor for a specific brand of medicine.

When these ads educate the public about treatments that are available for embarrassing or seldom discussed health problems like overactive bladder, peripheral arterial disease, or restless leg syndrome, the chance for dialog is created. The patient might not have been aware of treatments available for certain conditions and has an opportunity brought up symptoms that a busy physician might not have the time to inquire about without prompting.

What I don't care for are the pharmaceutical ads that merely promote products for well recognized conditions like allergies and erectile dysfunction in an attempt to have a patient badger their doctor into prescribing a particular brand for a condition in which multiple medication options are available. The scooter ads fall into this category as everyone that's been to any grocery store or Wal-Mart knows that these devices exist.

The scooters are promised to be available at no out-of-pocket expense to patients, suggesting that only a cold-hearted physician would deny this marvelous device to his kind, frail patients. This creates ill will should the physician not acquiesce to the demands of the patient and the scooter company.

The companies hawking these devices are preying on patients' sense of entitlement. After all, the viewer who has Medicare has paid into the system his whole life. He deserves whatever products are available at no charge to Medicare patients whether or not it's needed be it scooters, diabetic shoes, hospital beds or a host of other medical products promoted to the elderly.

Most patients, even those that frail and elderly, need to be as active as possible. Use it or lose it certainly applies to ones mobility. Walk if you can, use crutches or a walker to assist if needed, and even a wheelchair that you self-propel as a healthier alternative than a motorized scooter. Some patients who have suffered catastrophic injuries or strokes are not ever going to ambulate again and are clearly going to benefit from the latter.

Most patients want one because it is difficult or painful for them to walk. While physicians strive to alleviate pain and suffering when it is associated with illness or injury, life is inherently painful. From birth onwards, pain is inevitable. Doctors should not attempt to completely eliminate pain from life. Limit it to manageable levels absolutely, but not at the expense of the patients' autonomy and overall health.

Patients should report their difficulties with walking to their doctors. Their doctors should evaluate them and cure what can be cured and treat to alleviate symptoms of those problems that cannot be cured. It is better to walk with some pain than to never walk without pain. The motorized scooter should be an option of last resort for those patients who would not otherwise be physically able to get around in any other way because the less you walk; the less you're going to walk.

IN THE BEGINNING

2007-03-23T05:47:00.000-12:00

The following article that I wrote was published in Medical Economics a few years ago. For those readers who feel that I am too critical of Henry County Memorial Hospital, this explains the foundation of my viewpoint. I have since found out about more shenannigans that the current and past administrations have been a part of as well as also personally being the subject of prejudicial treatment by my tax supported county hospital. More details to folow.

“Wish I didn’t know now what I didn’t know then.” Bob Seger 1980.

Thirty five years ago I believed in Santa Claus. Twenty-five years ago I believed in U.F.O.s. Fifteen years ago I believed that only bad doctors get sued.

Ten years ago I believed the following:

A community hospital is there to benefit the community, to serve the health care needs of those citizens, and to facilitate the access of patients to the community resources which best meet their health care needs.

I no longer believe any of those things.

In March, 1993 I arrived in New Castle, Indiana. I was recruited during my
residency by the community hospital to provide family physician services in their
community. I could join an existing group or the administration would use their financial and practice management assistance in setting me up in solo practice. It didn’t matter to them. The community needed more family physicians.

Those were exciting times. I chose to join the group and I was finally a real doctor in a real town taking care of real people. There were frustrations to be sure but overall it was a nice start to a rewarding career as a small town family doctor.

Not being a partner, I guess I shouldn’t have been surprised to find out through the grapevine that negotiations were under way for the hospital to buy out the practice in early 1996. Apparently the practice was not fiscally sound and was not going to be able to meet an upcoming financial obligation.

The hospital administration realized the importance of keeping family physicians in the community. They negotiated to buy the practice with the four partners working off their debt in a matter similar to the loan repayment program that the hospital had provided me.

My original contract was worded that as long as I remained a practicing physician in the community, the loan would continue to be repaid. My family liked the town, and I liked practicing medicine there. I had learned over the prior three years that I preferred autonomy and didn’t particularly play well with others.

Here was an opportunity, thrust upon me as it were, to start a solo practice. I already had an established practice and colleagues to help with coverage. All I needed was some financial assistance and practice management know-how to get started.

I figured I need look no further than the hospital. Just three short years ago the administration aggressively recruited me to help the community with the physician shortage which still existed. Surely a community hospital would do all it could to retain a Family Physician that wanted to remain in the community providing healthcare to citizens of the community. No problem.

Problem. I was given the option of signing a multi-year contract to work for the hospital or..... nothing. There was no other option. Staying with the group for six months while I made arrangements to secure my financial and practice management assistance elsewhere was not an option according to the administration.

Well, I wasn’t going to sign on a long term contract with the hospital and I wanted to stay in this town. I didn’t have any savings to live off of while I started a solo practice from scratch, so I became a moonlighter. I commuted out of town to an E.R., three urgent care centers, and served as a company physician.

I did this for nine long months while I educated myself in practice management, while I went to six different banks to finally get approved for a loan, and that only after jointly applying through the Small Business Administration, and while I tried to convince myself that my community was worth this stress. One lender was honest enough to tell me that since his bank did business with the hospital, they wouldn’t loan me the money for fear of alienating the community hospital.

Despite knowing of my plans, the hospital owned group would tell my previous patients that I had just up and left town and that they should see one of the groups other doctors. A four week wait wasn’t all that long to see a doctor for a problem, was it?

I opened in April of 1997. A solo family practice doctor with walk-in availability open seven days a week 1 to 7 p.m.. Letting bygones be bygones, I invited the hospital administration to the open house. No one came.

I still admit patients to the hospital, I still see patients at the nursing homes, I still serve as the doctor for the county jail. I still try to do what’s best for my patients which happen to live in my community which happens to have a hospital which happens to be a non-profit, community funded hospital.

Over the last six plus years I have re-learned the definition of a community
hospital is a hospital that is located in a community it is not a hospital that exists for the community.

DO NOT PASS GO

2007-03-11T02:57:00.000-12:00

I think that monopolies in the health care industry are bad for patients. They are bad when they involve health insurance companies. They are bad when they involve physicians. And they are bad when they involve hospitals. They are bad on a national level. They are bad on a regional level. And they are bad on a local level.

Now I am not referring to monopolies in a legal sense as those are already outlawed. I am referring to monopolies in a practical sense; those that drastically limit patients' choices.

When there are fewer choices, prices go up and service goes down. Competition is necessary and good for customers. It is well documented that when banks consolidate, their fees to customers increase. I will let you be the judge of what sort of service you feel the Bureau of Motor Vehicles provides as an example of a business with a monopoly.

In health care, when a market is controlled by few insurance companies, these same trends occur when it comes to prices and services. Not only does this limit options for the patient, it limits doctors' ability to get a fair shake from the insurance company. If one company insures most of the patients in a geographic area, a physician risks losing all those patients unless he capitulates to the demands of the insurer.

Because it is illegal for independent doctors to collectively bargain as a group with the insurance companies, these insurers have enormous leverage in contracting with physicians. This is one of the main reasons doctors are forming larger and larger groups. The balance of power can be restored if most doctors in one area are part of a single group. The insurance company needs to provide its subscribers with area physicians as much as the area physicians need to be able to accept the patients' insurance. It is easy for an insurer to leave a single physician out of its network. It is much more problematic to do so to a large group of doctors.

The doctors benefit financially from these larger groups as they can negotiate a higher reimbursement from the insurance companies. The patient is left with fewer choices and higher prices. This is clearly happening on a regional level as evidenced by specialists such as cardiologists and orthopedists continue to consolidate into larger and fewer groups.

Unfortunately, this is also happening on a local level. Twelve years ago, the New Castle Clinic was the largest group in town with four internists and two general surgeons. The next largest group was New Castle Family Physicians with five doctors. All the other doctors in town were either solo practitioners or in with a single partner.

Ten years ago Henry County Memorial Hospital bought out New Castle Family Physicians and made those doctors employees. All except for one independent, intrepid individual who went on to successfully start his own practice on Spiceland Pike.

Since then, like a cancer that is inevitably spreading, the hospital has taken over almost all other doctors' practices in New Castle. First were the family practitioners, then the OB/Gyns, the orthopedists, the pediatricians, and finally the internists and general surgeons. Currently there are only three full time doctors with offices in town that are not hospital employees.

As inpatient revenues declined, the hospital looked for other areas to increase cash flow. Henry County Memorial Hospital delved first into the visiting nurse market, then the hospice market, the pharmacy market, the assisted living facility market, and finally the urgent care market.

While ensuring a captive market, a free market has largely disappeared. This translates into less freedom for the patient. Although the same doctors are still available and most patients may not be able to discern any difference from when the doctors were self-employed to now that they are hospital employees, differences do exist. Some are subtle, some are not.

There exists certainly the appearance of a conflict of interest when your hospital employed physician directs you to a physical therapist, a pharmacist, a visiting nurse, or a hospice. Is the referral based solely on the needs of the patient? Or is it influenced overtly or subtly by what's in the best financial interest of the doctor's employer.

Now most of the doctors that are employed by the hospital are honorable people, but to believe that a referral is not influenced by that relationship is naive. Only by the doctor not having any vested interest in any of these health care entities can the patient be assured that said referral is based solely on what is in their best interest.

There is also a distinct lack of competitive pricing when the majority of physician offices are run by the hospital. As I discussed elsewhere, this matters little to the patient with insurance but to the cash paying patient there is less ability to negotiate a fair price for a service. To a large entity like a hospital there is a lack of incentive to provide accommodations as an individual patient is less valuable.

Just as the doctor is an employee, so too are the staff at the offices. There is less accountability to the physician from the staff as opposed to the situation in a doctor owned office. In any business there exists the inevitable bureaucracy and lack of efficiency as the highest levels of management becomes further and further removed from the finished product. The patient bears the brunt of this in trying to get health care and billing questions answered as well as trying to deal directly with people who are empowered to make the decisions necessary to address unique situations and problems. Customer service becomes such a monumental problem that outside consultants are paid to teach basic skills to employees and to provide self-congratulatory press releases based on bogus surveys.

Locally, the analogy with Wal-Mart comes to mind. While Wal-Mart does not buy out competitors, it does eliminate them and reduces local shopping options to customers; options not just for department store items but also for groceries and pharmaceuticals. But at least with Wal-Mart you get low prices.

JUST ANOTHER WORD FOR NOTHING LEFT TO LOSE

2007-02-24T06:31:00.000-12:00

I think freedom is critical in optimizing people's health care. For patients to be able to choose their own pharmacist, their own hospital and their own physician is as important as it is rare.

Unfortunately by relying so heavily on health insurance and the inflated prices related to that, most patients are financially pressured into using a mail-order pharmacy service. From personal experience I can tell you, many of the operators for these places lie.

When I called to check on the status of a prescription I mailed in for my son I was told that I had not received it because they had called the doctor's office and the doctor personally canceled it. I was never given an answer on how that was possible since I was the ordering doctor and didn't remember that phone call.

My office has been called by these mail order pharmacies on several occasions to notify me that a patient specifically requested that I change a medication to one which would save the patient (and more importantly, the pharmacy) a lot of money. When my nurse would call the patient to confirm this, the patient would not be able to remember that phone call.

Either both I and my patients have extremely poor memories or these mail order pharmacy employees could give lawyers a run for the money ethically. If you have an insurance that provides prescription benefits, you should be able to use those discounts at the pharmacy of your choice.

A local pharmacist can be an important member of a patient's health care team. They establish a relationship with their customers and can provide important advice on appropriate over the counter products to take with an individual's prescription drugs, they can advise your physician on possible drug interactions, and they can provide education on the best and safest ways to use the medications.

Only having one local hospital, the choice of hospitals is not a large issue for most of the residents of Henry County. It can come into play when your doctor needs to transfer you from Henry County Memorial Hospital to one in Indianapolis. Due to the large expenses incurred from a hospitalization, a patient that is not independently wealthy will go to a hospital where the insurance will cover the expense.

Your primary care doctor may have a preferred hospital to send you to based on where he trained or based on previous good experiences. Overall I do not see this as a big problem as my experience has been good in dealing with doctors at all the major hospitals in Indianapolis.

The biggest obstacle to optimal health care is the restrictions placed by insurance companies on which doctor the patient is allowed to see. In the "good old days" this decision was left entirely up to the patient and it worked well from everyone's perspective. That is until the insurance companies realized they could make more money by changing the status quo.

The health insurance companies reasoned that since they paid the bills, they could control which doctors the patients went to see. Just as they do with pharmacies, the choices are based almost entirely on the cost to the insurance companies. The doctors who were willing to discount their prices were "preferred providers" to them. Quality of care didn't enter into it. This meant that instead of allowing the patient complete freedom to choose their doctor, choosing a "non-preferred" doctor was now a more expensive option than a "preferred one.

While with most insurance the customer has certain rights in choosing who repairs their car or house after an insurance claim, not so with health insurance. The insurance company can elect to not pay anything if you exercise your freedom in choosing a pharmacist, or hospital, or even a doctor who is not a "preferred provider".

Some might argue that such is the prerogative of the health insurer since they are paying the bill. I would suggest that health care is different, that there is an intimate relationship between a patient and a doctor and that to be able to receive optimal health care it is necessary to have a trusting, ongoing relationship with a "patient preferred" physician.

I believe that health insurance policies should of necessity be required to offer the same benefits and services to whomever the patient prefers in regards to their choice of pharmacy, hospital and especially physician. The patient's freedom in choosing their health care providers should supersede the insurance company's right to dictate who they will provide benefits to on behalf of the patient.

COMMON SENSE ISN'T

2007-02-16T11:13:00.000-12:00

I think that common sense isn't anymore. Maybe it never was. Everyday I see examples of behaviors that seem like it should be self-evident to be irresponsible, disrespectful, or rude. Three common examples that are related to health care come to mind.

It should be common sense when you are driving to pull over when an ambulance with sirens and flashers going is within view. It seems to me that in New Castle, the only time people consistently pull off to the side of the road is when there is a funeral procession in progress. I suppose that it is comforting to the patient in the ambulance knowing that if he dies because of a delay in getting to the hospital caused by drivers not pulling over, he will at least get that courtesy in a few days during his funeral procession.

It should be common sense to treat authority figures with respect. If you are in a professional setting, you should address professionals by their titles regardless of whether or not you know them socially. You wouldn't (or rather shouldn't) call a judge by his first name in court, or a pastor by his first name in church, or a policeman by his first name when he's in uniform and you shouldn't call your doctor by his name in his office or the hospital.

Some doctors don't mind having their patients address them by their first name. Certainly that is their prerogative, but it just further erodes the status of physicians in society. The lawyers and media are doing a good enough job on their own of this and don't need the extra help.

Now I'm not an uppity guy by any means, but I like to be shown the respect I've earned by being addressed as a professional. I'm even OK with "doc", just ask my wife. So if you see me at Wal-Mart and want to say "Hey Keith, how are you?" that's fine, but in the office or hospital keep it professional.

It should be common sense to turn off your cell phone when you are in a doctor's office. While most people will turn them off in a movie theater or during a church service, I would argue that these same people do not see anything wrong with leaving their cell phone on during the entire time that they are in the doctor's office.

Too often people are talking on a cell phone why a nurse is checking vital signs or asking them questions about their health. This creates an unacceptable and avoidable chance for errors as well as causing a delay in making the chart ready for the doctor to evaluate the patient. A person talking on the phone when the doctor enters the room or who answers a cell phone while the doctor is present is telling his physician the type of patient he is going to be. Self-absorbed and non-compliant are some of the unappealing words that come to mind.

Now most people have voice mail and there is no good reason to leave a cell phone on during a doctor visit. Very, very few situations exist where a phone call can't be returned half an hour later or longer. Believe it or not, 15 years ago when most people didn't have cell phones, not many lives were lost by patients not being immediately accessible by cell phones during an office visit. If you are waiting on a phone call that is of such importance that you are willing to interrupt your evaluation by your physician, I would suggest you need to reschedule your visit.

While it is debatable that good manners are a thing of the past, it is clear to me that things that should go without saying (like pulling over for ambulances, calling a doctor by his title, and turning off cell phones during office visits) can't. So at the risk of alienating people, I am saying what needs to be said (or more accurately writing what needs to be written (and you are reading what needs to be read)).

YOU'RE IN GOD'S HANDS

2007-02-10T08:26:00.000-12:00

I think people need to rethink health insurance. Like most insurance, it should be to help pay for unmanageable expenses which in health care include surgeries, hospitalizations, and unfortunately even emergency room visits. Somewhere along the way however, many people became spoiled and became used to health insurance paying for office visits and medications as well as the catastrophic expenses.

There are a host of reasons health insurance costs as much as it does, (the CEO of Anthems $42 million dollar bonus last year comes to mind). The bottom line is that the more any insurance covers and the lower its deductible, the more it will cost. Just think for a moment what would happen to your auto insurance premium if it had to cover oil changes, tune-ups, and repairs.

It is very natural for people to want to get the most for their money (looking at people eat at a buffet should illustrate this nicely). If you feel you have paid greatly for your health insurance, you want to be able to use it freely. You want to be seen for even minor complaints, you want the most modern tests, and you want to see the specialist. I would too.

That is why the medical savings account (MSA) makes the most sense for most people. You put money in just like you pay for traditional health insurance premiums and money is paid out to cover routine expenses with the insurance company covering catastrophic expenses. If you have few health care expenses from good lifestyle choice, good genes, or just flat out good luck, the majority of the money stays as yours.

Your health insurance is a contract between you and your insurance company. If a doctor has signed a contract with the insurance company they become a participating provider and agree to abide by all the insurance companies rules when it comes to referring patients to other doctors, prescribing medications, and obtaining prior authorization to order expensive imaging tests like an MRI or CT scan. Your doctor no longer works just for you; he also works for the insurance company.

By not being a participating provider with any insurance company I am able to be a complete advocate for my patients. I have no inherent conflict of interest when it comes to referring patients, prescribing medications, or authorizing needed tests. I also greatly limit my overhead cost by not having to hiring additional personnel to constantly be on the phone with the insurance company, by not having a delay in reimbursement from the insurance company, and by not having extra paperwork that being a participating provider entails.

These cost savings are why I can charge so little compared to other doctors. The majority of simple visits cost less than most patients' monthly cell phone or cable/satellite television bill. In many cases it is very close to patients' office co-pay charge. If you have a $30 co-pay you are $30 out every time you visit the doctor. If your insurance reimburses you 50% on doctor visits that are not participating providers, you are out $21 of a $42 office visit charge. The only drawback, which is necessary for me to make this work, is that you need to pay the $42 at the time of service and wait for you insurance company to send the portion they pay back to you.

Obviously this relatively small expense can be a burden to some. Generally the people with health insurance have good jobs and can afford an office visit. The people without health insurance are punished when they incur large expenses and when they are forced to pay the inflated charges at most doctors' offices as I explained in a previous article. This can work if physicians do their part and charge a reasonable and fair amount for an office visit.

For health insurance to become affordable we will need to rethink its role, especially in primary care. Health insurance is clearly indispensable when it comes to covering the expense of catastrophic illnesses and injuries. It should not be expected to cover smaller, manageable office visit expenses. If you think it should, then you should not complain about the cost of health insurance.

THE PRICE IS RIGHT

2007-01-29T12:51:00.000-12:00

I think it is the right thing for doctors to post their prices for all to see. I am posting my prices for the most common procedures that I do. You can call my office if you need additional prices for things like x-rays, lab tests, mole removals, etc.. I challenge other area doctors and the hospital to do likewise. Medicare and Medicaid are unique in that the government largely mandates those prices for everyone, with little to no difference among doctors, and so I won't be listing those prices here.

To make sure you are comparing apples to apples and oranges to oranges you need to know that all doctors use Current Procedural Terminology (CPT) codes to bill insurance and patients. Every billable thing a doctor does has a procedure code, even office visits. You can compare prices if you know the codes. I'm listing some of the most common codes I use. The most used ones are the office visit codes which get charged for virtually every visit.

The CPT code is followed by the procedure description and then my charge for 2007.
99212 office visit brief $42
99213 office visit expanded $54
99214 office visit detailed $85
90718 tetanus shot $38
73140 finger x-ray $46
80061 lipid profile $16
84703 blood pregnancy test $17
11300 small mole removal from the trunk $133
11730 toenail removal, non-permanent $104

Note also that most doctors use slightly different codes for the office visit charge to new patients. This allows a higher charge to make up for the additional expense of chart creation and computer data entry. I choose not to do this. But for comparison's sake a 99202 is the same level of service as a 99212 visit, just with a new patient instead of a returning one. Likewise 99203 is used like 99213 and 99204 like 99214.

Feel free to call your doctor and ask how much they charge for the same code so you know you are comparing the same procedure. While price alone should not be the only determining factor in choosing your doctor, you have a right to try and get the most value for your money.

I CAN SEE CLEARLY NOW

2007-01-28T22:29:00.000-12:00

I think transparency is an idea for health care whose time is long overdue. It refers to publishing charges for specific procedures (including office visits) so that consumers can price compare as they do for virtually everything else. In the "good old days" this was not necessary as insurance companies paid whatever charges doctors submitted and those without insurance had their bills written off or reduced. As insurance companies became more sophisticated (read: greedy), they decided how much a doctor was allowed to charge.

Nowadays as more and more people are uninsured or have a health savings account, the doctor's charges become much more relevant. This matters little to those with an HMO, PPO, Medicare, Medicaid, or many traditional insurances as the price is preset and bears very little resemblance to what is charged. As all insurance companies pay the lesser amount of the doctor's charge or what the insurance company decides the "usual and customary" charge should be, the doctor wants to make sure his charge is not less than that lest he lose out on some money. Some insurance companies automatically deduct a certain percentage (say 20%) from whatever the doctor's charge is thereby encouraging a falsely inflated charge.

The dirty little secret is that the people who can afford the least get charged the most. Most doctor's offices and hospitals do this. Is it ethical? I don't think so, but I'm in the minority.

One of the reasons for this practice is that Medicare and most insurance companies put wording in the contracts with physicians that state the doctor has to give their subscribers the lowest rate for a given procedure. And since the insurance companies, unlike Medicare (score one for them), go to great lengths to keep a secret of the most they are willing to pay for a procedure, the doctor will overcharge knowing that the insurance company will not pay the full amount, nor will they allow the doctor to charge the patient this inflated amount. Guess who's left holding the bag? The poor schmuck who doesn't have insurance.

For example, say a doctor charges $70 for an office visit, Medicare will only allow $39 for that procedure (and yes, the differences are often this large or larger). Another insurance company that has a contract with the doctor may declare that the "usual and customary" charge for that procedure is $42. This means the doctor cannot collect more than $42 from the patient even if the deductible has not been met and the patient has to pay all of the charge himself. The patient with an insurance which is contracted with the doctor has a built in discount. The sap without insurance is expected to pay the full $70.

Say the doctor charged $45 dollars for the procedure. He's still maxing out on most insurance charge limits, but the problem is with those companies that automatically discount his charges. The $45 charge is discounted 20% to $36 while the doctor who charges $70 might get $56 for the same procedure from the same insurance company. One plan may be willing to pay $49 or $50 for that procedure, but the doctor has no way of knowing this ahead of time and so artificially charges an amount that he knows that no insurance company is going to pay in full. If he charges everyone $70, he is guaranteed to get the maximum amount from each insurance company. The naive doctor who charges a reasonable fee is still forced to provide an additional discount from many insurance companies. Instead of making a reasonable amount from an inflated charge, he is making an unfairly low amount from a reasonable charge. The only person who gets hurt by the doctor doing this artificial charge inflation is.... you guessed it, the patient without insurance.

The solution for primary care doctors, is easy. Charge everyone a fair and reasonable price and don't contract with insurance companies that demand a percentage discount. They often demand a discount in return for sending the doctor those patients in their insurance plan. This discount is not necessary if the charge is reasonable already and not artificially raised in anticipation of having to give a discount to insurance companies.

EVERYONE WANTS TO BE A DOCTOR BUT NO ONE WANTS TO GO TO MEDICAL SCHOOL.

2007-01-16T12:07:00.000-12:00

I think physician assistants and nurse practitioners (known collectively as physician extenders) should have a limited role in our health care system. As a general rule they do not have the quality or quantity of training necessary to function as a doctor though they often do.

Nurse practitioners are registered nurses whose post high school education can be as little as two years for an associate degree in nursing (or up to 5 years for a bachelor of science degree in nursing), and who then undergo as little as under 18 months training, which can be completed online. In Indiana they are required to practice medicine with the "collaboration" of a physician. This does not require the physician to directly supervise or even to be in the same building or city as the nurse practitioner. They are permitted to prescribe all medications that a physician can with the exception of prescriptions for weight management.

Physician assistants are non-physicians who depending on the particular educational program, are high school graduates who may or may not have previous health care experience and/or some college education. The two training programs in Indiana require up to 2 years of prerequisite college work followed by 2-3 years of specific classroom and clinical training.An internship or residency is not required. They are required to be supervised by a physician but the supervision is not necessarily in person. A chart review within 24 hours of the visit is required. They are not allowed to prescribe medicine in Indiana.

A physician's training requires a minimum of successful college undergraduate college degree followed by medical school, usually of 4 years duration. A one year internship in an accredited training program is usually followed by between 2 and 9 more years of education depending on the particular specialty.

The reason for physician extenders depends upon whom you ask. Those that are physician extenders like the work that they do and the money they make for the amount of time and training they put in. The doctors who hire them, like charging patients and making money without having to see any extra people. Patients may like them so that they can get seen sooner than they otherwise could as the doctor's office now has more appointment times available.

I think there are several problems with the whole concept as it currently exists.

First of all, they are not needed. If there were not enough commercial airline pilots, would the solution be to allow a less rigorous and shorter training period and allow those people to have their flight logs inspected within 24 hours of a flight. (That's a rhetorical question by the way.) If we don't have enough doctors we need to have more medical schools. If we don't have enough applicants, we need to make the job more appealing (lawyers, the government , and insurance companies will be addressed in other articles on ways they make the job often unappealing).

Secondly, they do not have the depth of training that a physician has. They may be able to see and treat many conditions, but they may not pick up a serious and/or unusual condition, as many present similar to innocuous ones. If you haven't at least heard about and studied a disease you are not going to be able to diagnose it. They may be good-hearted, hard-working people, but they are not doctors. More often than not, they independently evaluate and treat patients with the physician only briefly reviewing the chart or discussing the case without ever personally examining or talking with the patient.

Thirdly, as a patient, I wouldn't like being charged the same amount for seeing the physician extender as I am when I see the doctor. When you go to law firm, accounting firm, or most other businesses, you get charged more by the people in the organization who are the most knowledgeable and have the most experience. This is widely accepted and makes sense. If I don't need a higher level of expertise I don't want to pay for it. In the doctor's office however, you pay just as much whether you are seeing the doctor or the lesser trained physician extender.

I think the appropriate role of the physician extender is to assist a doctor with various patient tasks or procedures. They should not independently be the first to evaluate and treat a patient. They could also follow along a patient with a chronic condition with a physician to oversee the plan once the physician has initiated a treatment plan.

At an office visit you are paying for an evaluation and treatment by a physician. I guarantee you that if your doctor needed to have a medical problem evaluated; he would not accept being evaluated by a physician extender. I know I wouldn't. You shouldn't either.

WHY SHOULD YOU CARE WHAT DR. DINK THINKS?

2006-12-31T08:48:00.000-12:00

TO BE HONEST, SOME OF YOU MAY NOT. IN WHICH CASE YOU PROBABLY ARE NOT READING THIS.

FOR MY PATIENTS, THIS WILL ALLOW THEM TO BETTER UNDERSTAND MY PHILOSOPHY OF HEALTH CARE AND TO ALLOW THEM TO BETTER COMPREHEND WHY I MAKE THE DECISIONS THAT I DO IN REGARDS TO PATIENT CARE AS WELL AS OTHER MORE PERIPHERAL ISSUES SUCH AS INSURANCE AND OFFICE POLICIES.

FOR INTERESTED CIVILIANS, THIS WILL LEND INSIGHT INTO WHY SOME DOCTORS MAKE THE CHOICES THEY DO IN REGARDS TO RUNNING A PRACTICE IN A CERTAIN MANNER.

IT WILL OCCASIONALLY DRIFT INTO A TANGENT ON WHY THINGS ARE THE WAY THEY ARE AND WHAT CAN OR SHOULD BE DONE TO CHANGE THEM.

SOME OF YOU WILL AGREE WITH MY THOUGHTS. SOME WILL NOT. I AM NOT PARTICULARLY INTERESTED IN USING THIS FORUM AS A VEHICLE FOR DEBATING, BUT PRIMARILY TO OFFER AN OPINION THAT IS DIFFERENT THAN THAT WHICH ONE ROUTINELY GETS FROM THE MASS MEDIA AND LARGE HEALTH CARE INTERESTS RANGING FROM THE NATIONAL MEDIA TO THE LOCAL HOSPITAL ADMINISTRATION AND NEWSPAPER.

THIS FORMAT WILL ALLOW ME TO EXPAND UPON THOUGHTS INITIALLY PUBLISHED IN THE NEW CASTLE COURIER TIMES NEWSPAPER. IT WILL ALLOW ME TO GO INTO GREATER DETAIL IN DEALING WITH A VARIETY OF HEALTH CARE ISSUES.

THE OPINIONS EXPRESSED HEREIN OR SOLELY THOSE OF MYSELF AND ARE DECIDEDLY UN-POLITICALLY CORRECT AT TIMES.

LET THE READER BEWARE.