Realistic Levels of Pain Relief

Patients frequently seek medical attention because of pain. Pain relief is a major motivation for the provider visit but getting a diagnosis and some reassurance about the painful condition is the reason for the office visit. Patients tolerate pain and often self-medicate for pain without seeking medical advice. Pain is ubiquitous and is understood by many patients to be a normal part of living.

Any provider who treats chronic pain knows that complete pain relief is rarely achieved. Patients may have surgery for a disc or radiation for a metastatic bone lesion, resulting in miraculous relief, but even when clear structural lesions are repaired, all pain may not stop. When we surveyed a large sample of patients with chronic pain, we were surprised to find that they did not anticipate or expect complete pain relief. When asked how much pain reduction would be acceptable after treatment in a pain clinic, the most common answer was 50% reduction of pain.

We also know that everyone can get 100% pain relief with total anesthesia. However, many patients are not willing to put up with the side effects (unconsciousness) to achieve the pain reduction. Many patients with terminal cancer opt for higher pain levels to be awake and alert during the final stages of life.

This is not to say that a total absence of persistent pain would not be welcome. Most people with pain desire a return to normal life with normal function, including work, hobbies, sexual activity, sleep, and other activities that are taken for granted when accessing quality of life. Those with persistent pain, especially with of time, know what to expect. They have been through failed drug trials, injections, physical therapy, acupuncture, and even surgery without the desired result.

Knowing that complete relief from the pain is rarely possible and understanding that most patients recognize this dilemma, the provider should not promise this outcome. When discussing the continuing treatment of a patient who has been examined, has failed multiple therapies, and returns to the provider with pain levels of 7 or 8 out of 10, the discussion should focus on other aspects of treatment. Statements from a pain provider such as "There is nothing more I can do," "You will need to learn to live with this pain," or "The doctor who deals with this type of pain is a psychiatrist," are all dreaded phrases to the patient with persistent pain. The provider should instead promise continued support and, despite lack of treatment efficacy, should not give up on the patient or stop being creative in providing help. Appropriate statements include "Even though we have not found anything to stop your pain, I am still here for you," and "You and I are going to continue to work on this pain problem to improve your function." For the patient with persistent pain, promise what you can deliver: comfort, compassion, creativity, teamwork, a caring environment, and most of all, yourself.

Patients seek help and wish for a cure but are comforted by our style and manner. We can always deliver compassion and continuity of care, which may not seem like much, but it is greatly valued by our patients.

Special thanks to Bill H. McCarberg, MD

Pay for Performance May Stimulate Practice Changes

California physicians given financial incentives to improve the quality of healthcare have made important changes designed to achieve that goal, according to the results of a RAND Corporation study reported in the March/April issue of Health Affairs.

"Physician groups are responding to pay-for-performance programs by making practice changes and altering how they compensate physicians to reward quality, but health plans and purchasers say that those investments are not yet translating into substantial gains in quality," lead author Cheryl L. Damberg, PhD, a senior policy researcher at RAND in Santa Monica, California, said in a news release. "The true benefits of these programs may take more time to be realized and it is likely that investments in other quality efforts will be needed in addition to performance-based pay."

Although pay-for-performance is already in widespread use and has grown rapidly in recent years, the effects of this incentive system on physician response and healthcare outcomes are still unclear. What types of financial incentive strategies work best is also still undetermined.

This study looked at 7 major California health plans and 225 physician groups enrolled in the California Integrated Healthcare Association's pay-for-performance program, which began in 2003. The 35,000 physicians employed in these groups have a patient base of 6.2 million people enrolled in commercial health maintenance organizations and point-of-service plans.

Between 2003 and 2007, participating health plans paid a total of $203 million in incentives to participating physician groups. In turn, the groups provided some payments of about $1500 to $2000 annually to individual physicians based on quality measures. These included the number of patients with diabetes who receive recommended blood tests, patient experience regarding access to care, and adopting health information technology capabilities.

Surveys revealed that most of the medical groups felt that the financial incentives were too small to stimulate significant change among most physicians and that the payments should be 2 to 5 times higher to achieve quality improvements.

Although most physician organizations reported that they collected more in financial incentives than they had spent to comply with the program, 6 reported that their bonuses barely met their increased costs.

In response to this incentive system, physician-level performance rating, feedback, and accountability increased; information technology such as use of electronic medical records was more rapidly implemented; organizational focus was clarified; and more support was generated for improvement. Twenty of the medical groups surveyed reported positive changes in practice of their individual physicians, such as more-intensive patient outreach.

"However, after three years of investment, these changes had not translated into breakthrough quality improvements," the study authors write. "Continued monitoring is required to determine whether early investments made by physician organizations provide a basis for greater improvements in the future."

Despite the concern that pay for performance could result in physicians dropping patients who did not follow prescribed recommendations, there were few reports of such events. More than two thirds of the medical groups surveyed believed that the pay-for-performance program yielded more benefits than harms.

Limitations of this study include a small, nonrandom sample of systematically identified physician organizations, limiting generalizability; that data were based on subjective self-assessments; weak incentives; and a limited number and scope of measures.

"Physician organizations face a number of challenges that impede their ability to move forward on quality, including difficulties in engaging and changing the behavior of front-line physicians (particularly if an organization doesn't 'own' a substantial fraction of the physician's practice) and lack of knowledge of what specific improvement actions physicians should take," the study authors conclude. "Meanwhile, purchasers and providers are challenged regarding how to gauge the opportunity costs of investing in [pay for performance] versus elsewhere, and how to expand performance accountabilities given limitations of current performance measure sets and the data needed to generate measures."

Special thanks to Laurie Barclay, MD is a freelance reviewer and writer.

Convenient Care Clinics: Much Ado About Nothing

During the past 5 years, a growing number of consumers have turned to convenient care retail clinics in their search for accessible, low-cost, quality healthcare. These clinics, often found in drug stores and discount shopping centers, are staffed primarily by nurse practitioners (NPs) who follow protocols to treat the most common primary care complaints and refer more complex problems to other providers. Convenient care clinics (CCC) have dramatically improved access to care for patients who have no insurance or who experience other barriers to healthcare. Not only are the clinics convenient, but they also allow patients to shop while waiting to be seen.

For the most part, CCCs have succeeded financially, although poor forecasting of patient demand, bad management decisions, and the declining economy have taken their toll on some clinics. In some settings where physician providers were added, increased operating costs were prohibitive to staying in business. NPs have accomplished the goal of providing care for nonurgent primary care concerns, and in doing so, they have decreased pressure on local emergency rooms that would otherwise see many of these patients.

Of all visits to CCCs, 90% involve 10 conditions: upper respiratory infections, sinusitis, bronchitis, pharyngitis, otitis media, otitis externa, conjunctivitis, urinary tract infections, and immunizations and screening tests or blood pressure checks. Most patients are seen by the provider within 15 to 20 minutes of computer registration into the system. For each chief complaint, there is a computer-generated protocol that the practitioner uses to diagnose and treat the patient. If the diagnosis falls outside the protocol, the patient is referred either to a local clinician who has agreed to work with the clinic or to the nearest emergency room, depending on the urgency of the problem. Each CCC also has a collaborating physician whom the NP can contact to discuss a particular case.

Clearly, the scope of practice in CCCs is narrower than the NP's preparation and education would ordinarily allow. But NPs choose to practice in these settings for a variety of reasons. Some like the independence afforded by the role, the hours, the benefits, the collegiality, or the ability to enhance their expertise with a limited number of conditions. Some NPs who have experienced the rapid pace of family practice clinics enjoy the extra time available in the CCC to offer needed education to the patient. With a limited number of conditions to treat, the NP encounters few obstacles to practice.

Not everyone has been happy about the CCC concept. Some organized medical groups have opposed CCCs, citing concerns related to continuity and coordination of care and lost revenue. As a new business delivery model, clinics have attracted the attention of researchers who have studied and refuted many of these concerns. Researchers have documented, for example, that there is little disruption of primary care relationships when patients seek care in CCCs. Most CCC patients do not have primary care providers (PCP), so there are few relationships to disrupt. Furthermore, most patients are 18 to 44 years of age, a group that otherwise would fail to seek care until more serious symptoms developed, increasing the costs of treatment.

Concerns about communication barriers between providers and patients have largely been resolved. All clinics either provide the patient with a written summary of the visit or fax a copy of the record to the patient's PCP. The financial impact from lost revenue is potentially offset by the PCP's ability to accept a greater number of complex cases whose reimbursement rates are higher than those of the simple acute cases handled in a CCC. The CCCs are also a potential source of referral of new patients whose health concerns fall outside the scope of services offered by the clinics.

In response to articulated concerns about CCCs, standards of care that address scope of service have been developed by the convenient care industry. For example, CCCs do not see children younger than 18 months of age. Electronic medical records provide ready access to visit summaries for PCPs, and all complex cases are referred to appropriate local healthcare providers.

The rapid expansion of CCCs into a variety of settings suggests that these clinics are here to stay and represent a unique way to offer affordable access to healthcare for underserved populations. As the number of physicians entering primary care declines, NPs have demonstrated that they can deliver this type of care, and the CCCs have become an excellent showcase for their skills and talents.

Special thanks to Marilyn W. Edmunds, PhD, NP and Laurie Scudder, MS, NP

Is It Okay to Attend a Patient's Funeral?

Lily, a bright, compassionate medical student deliberating on choice of medical specialty, asked me if I could tell her about one of my most meaningful patient experiences. I reflected for a while and then began to describe attending a patient's funeral. In a surprised tone, she interrupted with, But I thought we weren't supposed to do that-go to a patient's funeral? Isn't that getting too close, too personal?

It has been many years since I attended my first patient funeral, yet I still recall being afraid of the experience itself, not knowing what to expect-a different culture, religion, part of town. It was loud, with exuberant singing, praying. The congregants raised the roof with their energy. When I got home, I told my partner-that's how I want to go out of this world. Wow! They made it joyous, not the depressing ceremony that I had anticipated.

On my drive to a subsequent funeral, I worried about what the family would think about me. I had seen Ms. Tolly in my primary care clinic for years. While I was not involved with her inpatient care at the time of her death from cancer, would the family be accusatory-with thoughts that perhaps I had missed an opportunity to diagnose their mother earlier? Would they be angry that I was not at the bedside when she died? I arrived at the funeral home, took a deep breath, and wished I had a companion to stand by me. My patient's sister and children greeted me kindly. My fears eased, and I felt comforted as the family expressed genuine appreciation for the years of medical care that I had provided to Ms. Tolly.

A few days after my encounter with Lily, one of my dearest patients, Ms. Sanchez, passed away. I was extremely saddened by her death, though not surprised. She had many chronic health problems and had suffered a life-threatening stroke several weeks earlier. One of Ms. Sanchez's grandchildren contacted me to let me know about the funeral on Saturday. I had many commitments, in particular to spend some quality time with my young children. I decided that I would go to the funeral briefly, express my condolences, and leave.

After crying most of the way to the funeral, I recognized that I was using my family somewhat as an excuse-I was genuinely sad and reluctant to end my relationship with Ms. Sanchez. I had visited her in the hospital prior to her discharge to a long-term care facility. Now I was going to finally meet the family about whom I had heard much and seen many photos. I recognized her son Pepe immediately, wearing his Hawaiian shirt and lei, and Charlie, her grandson, who had recently graduated. Here was the family that she so loved and that loved her. Multiple family members recognized me as her doctor, hugged me warmly, and exchanged stories. For the first hour of the funeral, family members recounted her life, described how her compassion had affected everyone there, and presented a slide show about her.

Not one person mentioned her many illnesses and how, despite these conditions, she had accomplished so much. The ceremony was truly enlightening, giving me a new perspective of my patient outside of the public hospital and renewing my awareness of all my patients as individuals-who live full lives with illness. I felt able to complete my farewell to Ms. Sanchez while opening doors for enhanced relationships with other patients.

I appreciate my patients for continuing to teach me beyond the clinic-to be less afraid of death itself, to understand that a patient's death is not synonymous with failure or culpability, and maybe most importantly to recognize that we need closure with some of our patients. So Lily, I think it is okay-you can attend a patient's funeral. It is part of caring for your patient and caring for yourself.

Special thanks to Joslyn W. Fisher, MD

Top 10 Annoying Patient Behaviors

Hey, we're people too. Here's a top 10 most annoying patient behaviors:

1. Skipping appointments;

2. Being verbally abusive with staff. I'm sorry you don't feel well or having a shitty day, but don't take it out on my staff;

3. Having poor compliance with medications or treatment. And they wonder why their condition isn't improving;

4. Being late for an appointment;

5. Not knowing their current medications. Inexcusable;

6. Family members who insist on the highest level of care for terminally ill patients and who later complain of the cost of that care;

7. Drug seekers (you know who you are);

8. Noncompliant patients;

9. Patients who tell the doctor how to treat them. So why are you here wasting my time?

10. Patients who answer their cell phones during office visits. But you'll shut off your phone in a movie theater?

One patient behavior -- that of missed appointments -- not only is annoying but also cuts into my wallet. No-shows and same-day cancellations kill a business. Just like the auto repair shop, we have a fixed overhead (eg, rent, salaries, malpractice insurance) that eats up 70% of the day's gross collections. That's why your charged when you no-show.

Patients frequently research their medical conditions on the Internet. I don't have a problem with it as long as the information used is credible and helps supplement their understanding of their disease process. This can work especially well for a focused problem.

Even as a doctor, you can only stand so much. When this happens I jump on my '52 Vincent and just ride.

Physicians Rise Up to Save Primary Care

"I laugh every time they discuss healthcare policy," says a family medicine doctor. "The real issue should be how to save primary care."

Recent articles in the medical and lay press have focused on the growing shortage of primary care physicians in the United States and the crisis that that shortage is causing in the nation's healthcare system. A long and animated discussion on Medscape's Physician Connect (MPC), a physician-only discussion board, sizes up the problem.

"The only ones of us left in family medicine are those that are too young to retire and too old to retrain into another specialty," says an MPC family medicine doctor. "The major reason?" he continues, "It's underfunded. Salaries need a major increase. I would say double at least, probably triple." A recent article in JAMA documented that family medicine, at $185,740, has the lowest average salary of the medical specialties.

"Primary care physicians are being relentlessly hammered each year. They are getting burned out, and many are going broke," says an MPC internist. A preventive medicine doctor comments, "In the UK, whatever the defects of the system -- and they are many -- they build around GPs, who get $230,000 a year plus 25% performance bonuses. And, of course, they don't have huge medical school debts. We have it backwards. The most valuable doctors -- primary care physicians -- get paid the least."

Money aside, for many MPC contributors, professional dissatisfaction stems largely from the burden placed upon them by insurance companies and Medicare and Medicaid, which demand that physicians comply with an ever-growing number of documentation requirements.

"The intrusion into medicine by third-party payers (better known as the insurance industry, Medicare, and Medicaid) has been coming since the '60s, but this effort to control costs has really become burdensome over the last 15 years," says an internist, "and it has not controlled costs and has not improved quality."

Another contributor remarks, "Every visit has its own catch-22, whether that's a prior authorization, a formulary, a HIPAA rule -- it never ends."

How can the system be changed? One family medicine doctor suggests that doctors largely stop accepting insurance and return to a fee-for-service, out-of-pocket system of payment for routine care. "Why are we even dealing with the insurance companies?" says one contributor. "Go cash-for-service. Supply and demand. As long as we play along, we are doomed to ever-decreasing salaries, increasing hours, and less job satisfaction."

"It makes no sense for insurance to cover routine office visits," offers another family medicine doctor. "If third-party payers no longer covered office visits, the cost of out-of-hospital healthcare would drop considerably."

"Overhead in primary care is ridiculous," says one contributor, "Let's get rid of the billing and coding system. Pay primary care doctors for time spent, by the hour, like lawyers."

One of the major overhead expenses in primary care is the skyrocketing rates of malpractice insurance, which many MPC contributors see as a major target for reform. "End the malpractice lottery," says a family medicine doctor. "Require a review board that has no conflict of interest to decide whether a malpractice case has merit. If it does, send the case into binding arbitration. Only if binding arbitration fails should the case proceed to a malpractice suit. Strictly limit lawyers' compensation and allow no payments for pain and suffering."

The level of dissatisfaction with their practice has led some physicians to advocate for change. "If we don't get politically active and start standing up for our rights and our patients' rights to quality care, then we have no one to blame but ourselves," says one contributor. He recommends that the AAFP or the AMA pay a number of doctors to go to Washington, DC, to lobby and educate lawmakers about how dire the situation has become for primary care physicians.

One internal medicine doctor is investigating the possibility of forming a physician's union. He initiated talks between his local medical society and the Service Employment International Union (SEIU). "Word has it," he says, "we will be sending a representative to New York to meet with the SEIU." He recommends that physicians spur their local medical societies to get involved in talks with the SEIU.

A family medicine doctor concludes, "Let's stop complaining and start coming up with specific recommendations for improvement. Let's be a voice for change."

Many MPC contributors have offered specific strategies for overhauling primary care. The following are some of their recommendations:

Eliminate multiple insurance companies and use a single payer. If a system of multiple insurances companies is retained, make the costs transparent, fair, and reasonable to encourage competition. Provide everyone affordable coverage for catastrophic care. Make office visits reasonably priced but require payment at the time of service. Require small copay from Medicaid patients to limit overutilization. Increase primary care physicians' salaries and award performance bonuses. Give primary care physicians the freedom to order tests and make referrals without subjecting them to red tape. Implement tort reform that limits physician liability, sends most suits into binding arbitration, caps lawyers' fees, and eliminates compensation for pain and suffering. Allow physicians to bill for payable hours, such as time spent with patients, in answering email, and in returning phone calls. Mandate that hospitals operate 16-hour-a-day centers offering urgent care to the working poor at reduced rates or risk forfeiting their tax-exempt status.

Special thanks to Nancy R. Terry medical writer and editor, Jackson Heights, New York

Stress Release

We've all heard that laughter is the best medicine but why was this phrase coined in the first place? Have you ever been so frustrated that you either had to laugh or cry? Do you remember that great feeling you had at the end of a good laugh?Laughter releases hormones that reduce stress in our bodies. Laughter increases the levels of healthy hormones that make us feel good. It increases our antibodies in our system and helps us to reduce the overall side effects of stress.

Laughter provides a good workout for our bodies. Often when laughing we use our belly's and shoulders as we give a whole hearted good old fashioned laugh. We increase our oxygen intake and the laughter encourages deep breathing which gives us an overall sense of well being.

Creating a distraction away from our day to day grind and allowing us to set our troubles in perspective laughter is indeed a good medicine.

Seeing the humor in a situation can often re direct our anger and even create a more positive environment in which to work towards a solution.

Laughter can often redirect a bad situation and help us in diffusing a stressful time in our lives or those of others.

Learning to look at the lighter side of things is often a great way to challenge ourselves to not take everything in life so seriously and to find new ways to solve problems and challenges in our daily lives.

So where does one go to find laughter? Often no further than ones own home. Look for the humor in every day things. Knowing the address of your local snow plow driver so that you can return the berm of snow he left in front of your driveway may not be feasible, but it might be fun to plan it out in your mind. It may even help to reduce your stress and frustration as you dig your car out of the driveway. No, it won't solve it all. It won't necessarily improve the current situation at that moment, but given time you will find the humor in the situation. You will be able to smile and laugh at it one day. Learning to call upon those memories in times of stress will go far in helping you to reduce stress.

Learning to smile when the going gets tough will help you to present a positive attitude, applying laughter to the situation will improve it even more.

A Market for Compassion: Single-Payer Health Insurance

When the ethics and the economics of major public policy agree, we ought to pay attention. House Resolution 676 promises to create a single-payer health insurance system to provide expanded and improved Medicare for all Americans.[1] It will insure everyone, and unlike many competing proposals, it could actually work.

In a single-payer system, the government will fund health insurance, but private providers will continue to deliver care. Economies of scale will save the money to make this possible. Many Americans, including Democratic presidential nominee Barack Obama, concede that single-payer insurance is probably our most efficient option.[2] But they worry that it lacks the spirit of the American market. Nothing could be further from the truth.

A single-payer system will harness the market's strengths while addressing its limitations. The private health insurance market is inefficient, bloated by advertising, duplicated bureaucracies, dividends, and executive compensation. What's worse, insurance policies are so complex and individuals' future needs so unpredictable that consumers cannot make the informed selections that induce competition between insurers.

However, consumers can create competition among healthcare providers. This is paramount because patients need the best healthcare, not the best middlemen to pay for it. Currently, providers are insulated from competition because private insurers often restrict coverage to select physicians. In addition, the 47 million uninsured Americans[3] have little impact on the market. A single-payer system will give all consumers the power of choice and open all healthcare providers to the effects of consumer decisions.

Single-payer works because of the efficiency of specialization. The government will manage the paperwork and private entities will provide the care. Adam Smith would be proud.

So if you believe in the market, ask your congressman to support HR 676. Together, we can restore common sense and common decency to American healthcare.

Special thanks to Prajwal Ciryam, a second-year MD/PhD student in the Medical Scientist Training Program at Northwestern University and a Co-Founding Member of Health Care for All Illinois.

Citations:
1. House Resolution 676: To provide for comprehensive health insurance coverage for all United States residents, and for other purposes. Available at: http://thomas.loc.gov/cgi-bin/bdquery/z?d109:h.r.00676 Accessed August 20, 2008.
2. Macfarquhar L. The conciliator. New Yorker. May 7, 2007. Available at: http://www.newyorker.com/reporting/2007/05/07/070507fa_fact_macfarquhar?currentPage=1 Accessed August 20, 2008.
3. US Census Bureau. Income climbs, poverty stabilizes, uninsured rate increases. US Census Bureau News. August 29, 2006. Available at: http://www.census.gov/Press-Release/www/releases/archives/income_wealth/007419.html Accessed August 20, 2008.

The Dying American Health Insurance Industry

The health insurance industry in America is dying. How can that be -- such a powerful, $300 plus-billion industry with so many lobbyists? Here are some benchmarks of its death march:

* Growing unaffordability of premiums, which grew 87% between 2000 and 2006,[1] and are projected to consume one third of family income by 2010 and theoretically all of it by 2025.[2]
* Forty-six million Americans are without health insurance, and at least another 25 million are underinsured.[3]
* Four of 10 Americans are "somewhat" or "completely" unprepared to cope with a costly medical emergency in the coming year.[4]
* The private market now includes less than 60% of employers, and in 2005, only 6% of US employers covered the full cost of family coverage.[5]
* While the insurance market fell by 1% between 2000 and 2005, its work force grew by one third (mostly new employees involved with denial management).[6]
* Private insurers can't compete with public financing on a level playing field. For example, private Medicare Advantage plans require government overpayments of 112% to 119% compared to traditional Medicare.[7]

Fortunately, we have a solution -- strengthened Medicare for All (H.R. 676), coupled with a private delivery system. Reliable public financing and shared risk across all 300 million Americans creates a win-win for everyone except a failed insurance industry.[8] Physicians can rid themselves of the bureaucracy of 1300 private insurers and have more time and clinical autonomy for patient care. To learn more, read references 9 and 10.[9,10] We physicians need to join with patients in working toward real healthcare reform, thereby asserting the public interest over corporate self-interest.

Special thanks to Dr. John Geyman, Professor Emeritus of Family Medicine, University of Washington.

Citations:
1. Barry P, Basler B. Healing our system. AARP Bull. 2007;48:2.
2. Who will have health insurance in 2025? Am Fam Physician. 2005;72:1989.
3. Schoen C, Collins SR, Kriss JL, Doty MM. How many are underinsured? Trends among U.S. adults, 2003 and 2007. The Commonwealth Fund. June 2008. Available at: http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=688615 Accessed October 14, 2008.
4. Consumer Reports. Are you really covered? Why 4 in 10 Americans can't depend on their health insurance. September 2007. Available at: http://www.consumerreports.org/cro/health-fitness/health-care/health-insurance-9-07/overview/0709_health_ov.htm Accessed October 14, 2008.
5. Freudenheim M. Fewer employers totally cover health premiums. New York Times. March 23, 2005.
6. Krugman P. The world of health care economics is downright scary. Seattle Post Intelligencer. September, 26, 2006:B1.
7. Medicare Rights Center. Medicare private plan overpayments: no bang for the buck. Asclepios. 2007;7(21).
8. Geyman JP. Do Not Resuscitate: Why the Health Insurance Industry Is Dying, and How We Must Replace It. Monroe, Me: Common Courage Press; 2008:185-214.
9. Physicians for a National Health Program. Available at: http://www.pnhp.org Accessed October 14, 2008.
10. Quote of the Day. Available at: http://two.pairlist.net/mailman/listinfo/quote-of-the-day Accessed October 14, 2008.

Reempowering Primary Care

Over the last couple decades, America's primary care physicians -- PCPs -- have been relegated to medicine's lowest caste.[1] But many employers, who pay for the waste that results from tying PCP's hands, now see them as healthcare's most probable saviors.

In 2008, cardiologists take home up to 4 times more than PCPs,[2] who often report they don't have time to properly talk with patients. Now just 7% of medical students enter office-based primary care.[3] Why not become a specialist and make more? Aging boomers will quickly outstrip our dwindling supply of PCPs.

PCP-specialist pay discrepancies are traceable to the AMA's secretive, specialist-dominated RVS Update Committee that has consistently advised Medicare to pay specialists more at PCPs' expense. Medicare heeded them and commercial plans followed, marginalizing PCPs and costs exploded.[4] Then employers noticed that more PCPs and fewer specialists produce more efficient healthcare.[5] America's PCP-specialist ratio is about 30/70, but in other developed countries it is 70/30; their costs are half ours; and their outcomes are often better.[6]

So how do we reempower our 250,000 community-based PCPs?

The Patient-Centered Primary Care Collaborative -- Fortune firms, business health coalitions, primary care associations, and health plans -- laid out steps[7] for leveraging primary care to change our larger health system.

Pay PCPs more to reduce their patient loads with more time for patients. Help them acquire patient management information technology tools. Update the PCP-specialist engagement rules to involve PCPs when their patients need advanced care.

Some will oppose these measures. Health plans are key, but if you're a PCP, show this to your community's business leaders. Suggest they pointedly ask their health plans, "What are you waiting for?"

Special thanks to Dr. Brian Klepper, a healthcare analyst from Atlantic Beach, Florida.

Citations:
1. Bodenheimer T, Berenson RA, Rudolf P. The primary care -- specialty income gap: why it matters. Ann Intern Med. 2007;146:301-306.
2. Merritt Hawkins & Associates. Summary Report: 2008 Review of Physician and CRNA Recruiting Incentives. Irving, Tex: Merritt Hawkins & Associates; 2008. Available at: http://www.merritthawkins.com/pdf/mha-2008-incentive-survey.pdf Accessed November 24, 2008.
3. Johnson CK. US medical students shunning primary care. Seattle Post-Intelligencer. September 9, 2008. Available at: http://seattlepi.nwsource.com/local/378492_fewerdocs10.html Accessed November 24, 2008.
4. Goodson JD. Unintended consequences of resource-based relative value scale reimbursement. JAMA. 2007;298:2308-2310.
5. Starfield B, Shi L, Grover A, Macinko J. The effects of specialist supply on populations' health: assessing the evidence. Health Aff (Millwood). 2005; (supplWebexclusives):W5-97-W5-107.
6. Macinko J, Starfield B, Shi L. Quantifying the health benefits of primary care physician supply in the United States. Int J Health Serv. 2007;37:111-126.
7. Patient-Centered Primary Care Collaborative. Joint Principles of the Patient Centered Medical Home. February 2007. Available at: http://www.pcpcc.net/node/14 Accessed November 24, 2008.

Teaching Moral Reasoning to the Next Generation of Doctors

Right now, the medical profession is on the ropes. The media and Congress continue to flail away at the unseemly relationship doctors have with drug companies and medical device makers.^[1] Accusations of kickbacks for product selection,^[2] unearned "consulting" fees, stock options tied to research results,^[3] and drug-rep supplied pizza for office staff^[4] all imply that our profession puts personal gain ahead of patient welfare.

In medical-legal arena, lawyers and judges realize that favorable testimony can be purchased in a marketplace replete with practitioners of questionable ethical standards.^[5]

Likewise, statisticians find that local and regional variation in treatment for common aliments, such as breast cancer and back pain,^[6,7] correlate with ownership of imaging equipment, testing devices, and ambulatory or in-patient treatment centers.^[8]

Rather than fighting the accusations of unethical conduct with self-righteous assertions by our professional associations, it would be more appropriate to train the next generation of doctors to incorporate high-level moral reasoning in their medical and professional decision making.

Surveys of medical school and residency training programs find that formal education in medical ethics and moral reasoning is sadly deficient,^[9] and no wonder: Discussing ethics in the abstract is both boring and ill-focused.

Since doctors in training have turned increasingly towards review articles (both print and Web-based) as sources of information, it occurred to me that such publications should shine a brighter light on ethics issues arising out of topics their authors cover. For instance, assume a submission reviews the treatment of carpal tunnel syndrome and notes that most workers' compensation patients with electrodiagnostically negative CTS do poorly after transverse carpal ligament release. I believe that manuscripts' authors should discuss whether it's ethical to perform surgery on a subset of patients prone to an unfavorable outcome. In this way, we'll incorporate ethical judgment into all facets of medical education.

I'm concerned that our profession, after repeated conflict-of-interest inquiries (whether appropriate or off target), won't be invited to the table when the final structure of America's new healthcare paradigm is considered. While it seems impossible that doctors wouldn't be involved, remember that Hillary Clinton's health plan was drafted without much physician input. Even more remarkably, when Gov. Schwarzenegger's staff crafted California's monumental Workers' Compensation Reform Act, neither doctors nor lawyers were consulted, only labor and business. Perhaps the governor suspected that workers' comp treaters and claimant attorneys milked the system for their own benefit and thus wouldn't serve either the employers' or the injured workers' future interests.

If we continue to burn through our good will by continuous acts perceived by the public as corrupt, we'll get what we deserve!

Special thanks to Dr. Stuart A. Green, Clinical Professor of Orthopaedic Surgery at the University of California, Irvine.

1. DeFazio P. H.R. 5605: Physician Payments Sunshine Act of 2008. 110th United States Congress. 2008. Available at: http://www.govtrack.us/congress/bill.xpd?bill=h110-5605 Accessed December 29, 2008.
2. Heckman JD. Patient care, professionalism, and relationships with industry. J Bone Joint Surg Am. 2008;90:225.
3. Angell M. Industry-sponsored clinical research: a broken system. JAMA. 2008;300:1069-1071.
4. Ehringhaus SH, Weissman JS, Sears JL, Goold SD, Feibelmann S, Campbell EG. Responses of medical schools to institutional conflicts of interest. JAMA. 2008;299:665-671.
5. Jack SG. In Re Silica Products Liability Litigation, MDL Docket Number 1553: Order #29: Addressing Subject-Matter Jurisdiction, Expert Testimony and Sanctions. US Federal District Court. 2005:150.
6. Sariego J. Regional variation in breast cancer treatment throughout the United States. Am J Surg. 2008;196:572-574.
7. Weinstein JN, Lurie JD, Olson PR, Bronner KK, Fisher ES. United States' trends and regional variations in lumbar spine surgery: 1992-2003. Spine. 2006;31:2707-2714.
8. Becker S, Walsh A. Orthopedic-driven ambulatory surgery centers and specialty hospitals -- a physician and hospital perspective. Health Care Law Mon. 2005:3-6.
9. Manson H. The need for medical ethics education in family medicine training. Fam Med. 2008;40:658-664.

Seven Bad Habits of Highly Effective People

During these tough financial times, many people feel they have to push themselves to unhealthy levels in order to succeed. But high-pressure jobs and long hours take a real toll on their immediate and future health. Whether running for president, moving up the corporate ladder, or juggling the family's activities, success may come at a hefty cost.

The 7 worst habits of these workaholics include:

1. Forgetting to relax: Some stress can be good because it keeps you alert and motivated; too much stress, however, will take its toll on your body.^[1]
   
   
2. Eating on the go: Who has time to sit down for a healthy lunch? But beware of frozen meals, fast, and processed food that can be high in sodium, calories, and fat.^[2]
   
   
3. Putting off sleep for work: Lack of sleep can cause irritability, difficulty concentrating, memory problems, poor judgment, and obesity.^[3]
   
   
4. Not making time for exercise: Humans were not designed to sit at desks for 8 hours a day. Exercise has been shown to reduce the risk for nearly every major disease and to help fight anxiety and depression.^[4]
   
   
5. Working when sick: 3 common-sense reasons to stay home: avoid spreading the infection, you'll be less productive, and you need your rest to get better.
   
   
6. Drinking (too much): Moderate alcohol consumption has some proven health benefits , but excessive drinking can lead to alcoholism, liver disease, and some forms of cancer.^[5]
   
   
7. Skipping annual medical checkups: Depending on age, family history, and lifestyle, a comprehensive medical checkup and special screenings is recommended every 1 to 5 years.^[6]

Eventually, something's going to give. If you patients keep burning the candle at both ends, the flame will burn out faster. But, if you maintain a healthy balance, you will be happier and healthier overall.

Special thanks to Dr George Griffing, Professor of Medicine at St. Louis University and Editor in Chief of Internal Medicine for eMedicine.

Citations:

1. Wilbert-Lampen U, Leistner D, Greven S, et al. Cardiovascular events during World Cup soccer. N Engl J Med. 2008;358:475-483.
2. McNaughton SA, Mishra GD, Brunner EJ. Dietary patterns, insulin resistance, and incidence of type 2 diabetes in the Whitehall II Study. Diabetes Care. 2008;31:1343-1348.
3. Knutson KL, Van Cauter E. Associations between sleep loss and increased risk of obesity and diabetes. Ann NY Acad Sci. 2008;1129:287-304.
4. Berlin AA, Kop WJ, Deuster PA. Depressive mood symptoms and fatigue after exercise withdrawal: the potential role of decreased fitness. Psychosom Med. 2006;68:224-230.
5. O'Keefe JH, Bybee KA, Lavie CJ. Alcohol and cardiovascular health: the razor-sharp double-edged sword. J Am Coll Cardiol. 2007;50:1009-1014.
6. Iglar K, Katyal S, Matthew R, Dubey V. Complete health checkup for adults: update on the Preventive Care Checklist form(C). Can Fam Physician. 2008;54:84-88.