Out of Practice : Fighting for Primary Care Medicine in America [1 ed.] 9780801460609, 9780801449765

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Copyright © 2011. Cornell University Press. All rights reserved. Out of Practice : Fighting for Primary Care Medicine in America, Cornell University Press, 2011.

Copyright © 2011. Cornell University Press. All rights reserved.

OUT OF PRACTICE

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A VOLUME IN THE SERIES

The Culture and Politics of Health Care Work edited by Suzanne Gordon and Sioban Nelson A list of titles in this series is available at

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www.cornellpress.cornell.edu.

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OUT OF PRACTICE FIGHTING FOR PRIMARY CARE MEDICINE IN AMERICA

Copyright © 2011. Cornell University Press. All rights reserved.

Frederick M. Barken, MD

ILR PRESS AN IMPRINT OF CORNELL UNIVERSITY PRESS ITHACA AND LONDON

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Copyright © 2011 by Cornell University All rights reserved. Except for brief quotations in a review, this book, or parts thereof, must not be reproduced in any form without permission in writing from the publisher. For information, address Cornell University Press, Sage House, 512 East State Street, Ithaca, New York 14850. First published 2011 by Cornell University Press Printed in the United States of America

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Library of Congress Cataloging-in-Publication Data Barken, Frederick M. (Frederick Mitchell), 1955– Out of practice : fighting for primary care medicine in America / Frederick M. Barken. p. cm. — (The culture and politics of health care work) Includes bibliographical references. ISBN 978-0-8014-4976-5 (cloth : alk. paper) 1. Primary care (Medicine)—Practice—United States. 2. Physicians (General practice)—United States. 3. Physician and patient—United States. I. Title. II. Series: Culture and politics of health care work. R729.5.G4B36 2011 610.68—dc22 2010041490 Cornell University Press strives to use environmentally responsible suppliers and materials to the fullest extent possible in the publishing of its books. Such materials include vegetable-based, low-VOC inks and acid-free papers that are recycled, totally chlorine-free, or partly composed of nonwood fibers. For further information, visit our website at www.cornellpress.cornell.edu.

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Out of Practice : Fighting for Primary Care Medicine in America, Cornell University Press, 2011. ProQuest Ebook Central,

Copyright © 2011. Cornell University Press. All rights reserved.

In memory of my mother and father, Norma and Herbert Barken

Out of Practice : Fighting for Primary Care Medicine in America, Cornell University Press, 2011. ProQuest Ebook Central,

Copyright © 2011. Cornell University Press. All rights reserved. Out of Practice : Fighting for Primary Care Medicine in America, Cornell University Press, 2011. ProQuest Ebook Central,

CONTENTS

Acknowledgments

ix

Introduction: The Doctor Is Out

1

1

A First Visit with the Doctor

2

“Tell Him Not to Drive”

3

Polypharmacy: The Problem with Pills

7

29 49

4 Poly-Doctoring: A Doctor for Every Disease 5

A Bubble Off

92

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6 On the Road Again

111

7

The Supply Side

131

8

All in the Family

151

9 Practice/Malpractice 10

170

You Get What You Pay For Epilogue Notes

213 219

References Index

190

227

241

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72

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ACKNOWLEDGMENTS

For most of my adult life, busily spent practicing primary care medicine, I wrote nothing longer than a prescription. The prospect of a sustained project involving uninterrupted research, writing, and reflection seemed an appealing personal indulgence, but also a daunting challenge of organization and discipline, resisting the chaos and attention deficit of daily life. Luckily, I had help. I am most grateful for the sage advice and unwavering encouragement I received from my friend Richard Polenberg, professor of history at Cornell University, to whom I first proposed the premise for this book three years ago. His kind words, support, and thoughtful commentary correctly anticipated the unavoidable wrong turns and dead ends inherent in writing. They were medicinal. I wish to give special thanks to David Williams, professor of theater at the Ohio State University at Newark, who volunteered to review and critique my writing, gently tweaking my grammar with his powerful pedagogical red pen. I have the greatest respect for Dave’s high regard of literature, theater, and the elegance of the well-turned phrase. Narrowly trained in the sciences, I admire his love for, and life in, the arts. The writer’s life, I feared, was one of solitude; I could not have been more wrong. I am fortunate to have a group of friends and colleagues, all from diverse fields and life experiences, each with a personal perspective on the matter of health care. It seems as long as I continue to write about the plight of the physician-patient relationship, I will never be lonely. Dave Ahlers, Lorraine Anastasio, David Bick, Tim Cardina, Mitchell Greenberg, Bruce Korf, David R. Lee, and Chris Ober provided challenging critiques and engaging commentary as they graciously devoted their time

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x

Acknowledgments

to reviewing this book cover to cover. I appreciate, as well, the thoughtful reviews of some of the early chapters by Ed Gasteiger and Tony Votaw. With each review came another story, a personal anecdote of a health care encounter gone awry, that confirmed the universality of my subject and the unbounded demand for high-quality primary care. In that, none of us is alone. At the start of my medical career, I was blessed to find and work with Ginny Jones, my first office nurse, secretary, and personal guide to the practical operations of primary care, and to the sometimes whacky world of private practice. In many ways, mine was often the “second opinion.” She, along with Karen Cotterill, maintained a high level of clinical professionalism with feeling, in these most challenging times for the practice of medicine. Judy van Coetsem, my one-person billing department, fought a valiant but frustratingly lopsided fight against passive-aggressive health insurers. I thank each of my key employees for their years of service and dedication to patient care. By the same token, I thank the many thousands of patients who I have seen in my office over the years, all of whom entrusted me with their precious health and private worries. In the new world of corporate care, it is so easy to forget that the practice of medicine is a privilege, granted by patients. I am grateful for the medical library services provided by the Cayuga Medical Center in Ithaca, New York, and I specifically thank Ward Romer, the hospital librarian, for his dedicated and sustained services in the acquisition of seemingly endless references. Susan Enkelmeyer, former dean of the School of Business at Ithaca College, graciously provided me with the use of a vacant office, a quiet and welcome change of scenery. Graham Sterling, while a senior studying gerontology at Ithaca College, did some of the preliminary research on physician home visits. Jennifer Carr and Stewart McGough of the law firm Scolaro, Shulman, Cohen, Fetter, and Burstein, P. C. kindly provided me with anonymous samples of a malpractice summons and complaint. Paige Davis did an early stage edit of the manuscript and Karen Hwa and Katy Meigs brought the editing and formatting process to a successful conclusion. I am most grateful to Ange Romeo-Hall, Senior Manuscript Editor at Cornell University Press, for her instruction and assistance in the editing process. From my first contact with Cornell University Press, I have received nothing but support and affirmation, plus constructive guidance. Suzanne Gordon, co-editor of the Culture and Politics of Health Care Work series, shepherded me through the process, chapter by chapter, helping me formulate and focus my message. I thank her for her collaboration and commend her for her

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Acknowledgments

xi

passionate commitment to improving primary care in America. I am grateful, as well, to Mahinder Kingra, Nathan Gemignani, Jonathan Hall, Susan Barnett, Katherine Liu, Fran Benson, and John Ackerman of the Press for their emphatic support. Foremost to thank, however, it is my wife, Marlene, who helped make this book a reality. A consummate teacher and a congenital optimist, she helped me to channel the frustrations of my field into a contemplative career retrospective. More than providing an “in-house” first edit and tolerating my commandeering of the dining room table and scattering it with papers so that it resembled the aftermath of a tornado, she helped me see the big picture. Each generation in America wishes better for their children. My wish is that my own children, Joanne, Jeffrey, Stephanie, and David, now all young adults, will enjoy good health that is enhanced by ready access to quality primary care and the salutary benefits of a solid physician-patient relationship. If this book contributes to that goal, it will have been a personal success. Frederick M. Barken, MD

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Ithaca, New York

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INTRODUCTION

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THE DOCTOR IS OUT

On June 30, 2007, at the relatively young age of fifty-one, I left the practice of medicine. After nearly a quarter of a century spent building and managing a busy, locally well respected and successful private practice in primary care, I chucked it all and walked away from my professional career. Was I the victim of burnout, a vague but insidious ailment common to busy older physicians that renders them indifferent and inured to patients’ problems and pains? I don’t think so. Rather, it was a resignation. In chess, after a wearying and protracted battle, there comes a moment, shortly before checkmate, when one player realizes that all is lost. Moves and countermoves are exhausted; the contest has played out. The time had come for me to leave primary care, to vote with my feet, and to find personal and professional happiness elsewhere. I chose to resign from the practice of internal medicine ten to fifteen years earlier than is usual, but still with dignity, as I saw the quality and personal satisfaction of primary care medicine eroding. I had lost the match. Who was my opponent in this metaphorical losing game of chess? I could trot out the common cast of characters so often cursed and vilified in hospital doctors’ lounges, at medical meetings, or wherever two or more physicians convene: the evil insurance industry, the bean-counting bureaucrats at Medicare and Medicaid, or the malevolent malpractice plaintiffs’ attorneys. Certainly, they all had done their part to erode the rock-solid footing of my practice. Rather than round up the usual suspects, however, I now reflect that, as a solo practitioner of primary care, I have lived through a slow but tectonic change in American health care delivery, a paradigm shift.

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Out of Practice

I was a premed student during the 1970s, a time when people still could remember house calls made by their family physician, a pillar of the community, a Norman Rockwell American icon. For the Boomers, the first generation raised on TV, there was Marcus Welby, the avuncular family doctor, an ever-available friend and personal physician to only one patient per weekly episode, who had not yet gone on to syndicated reruns. Times change, however, and so did primary care. By the mid-1980s, when I had completed my internal medicine residency and was busy building my practice, the government and private insurers had begun a concerted effort to contain the escalating cost of health care by fiat. The kindly family doctor was diminished, downgraded, and deprofessionalized to the status of a “provider,” a bland descriptor on a clerk’s requisition form. Even worse, New York state’s Medicaid, which insured the indigent, classified me as a “vendor,” a term that sent me into orbit then and that still rankles today. Hemmed in by profession-specific price controls, reams of restrictive regulations, heavy-handed threats of federal penalties and expulsion from Medicare for suspected infractions, I became disheartened. My patients, however, still held the traditional view of their doctor as a knowledgeable authority and a personal source of comfort, advice, and strength. They did not know that the supportive scaffold, their primary care physician’s practice, already had developed dry rot. The years went by and, disregarding exaggerated reports of my profession’s demise, I busily continued to see patients and to practice medicine as I thought best, with a personal touch, a close connection, and a physicianpatient relationship best delivered by a solo practitioner in a small office. In the early 1990s, managed care and health maintenance organizations (HMOs) arrived on the scene. As a primary care physician, I was recast as a “gatekeeper,” the person at the turnstile of a veritable health care amusement park where those with a ticket (a valid health insurance card) could spend an afternoon with a specialist, take a ride in the magnetic resonance imaging (MRI) scanner, or visit the X-ray funhouse. What’s in a name? Whether I was termed a gatekeeper, a provider, or even a vendor, I was where I wanted to be, still practicing primary care medicine in a very traditional way. I cultivated satisfying relationships with several thousand patients and their families, each unique, and I felt rewarded in providing an essential service for my community. Although the bureaucracy and banditry of the health insurance industry was a slowly constricting circle that annoyed as it encroached, in the mid-1990s and even early in the first decade of the twenty-first century, I still could ply my craft.

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Introduction

3

Time passed. My patients grew older. They probably thought the same about me, but they had grown much older. Elderly women, beneficiaries of an elongated lifespan, continued to come see me. Even men in their nineties paid me regular visits. Mirroring a national phenomenon, a trend toward the geriatric, my practice increasingly was composed of the fragile, chronically ill sufferers of multiple degenerative diseases, all laden with the psychosocial complexities of the first superannuated add-on generation in human history. It seemed they were all there, sitting in my waiting room. Medicare apparatchiks and federal “budgeteers,” the bill payers, probably thought so as well. Now, in 2011, the dark cloud of Medicare insolvency hangs on the horizon, saturated with the heavy burden of 78 million nearly geriatric Baby Boomers. My quite traditional small solo private practice, so twentiethcentury in concept, is no longer viable in a modern Walmart-style business environment of “everyday low prices” and paper-thin profit margins. Few primary care physicians today are able to meet the extraordinarily large volume of care demanded by the soon-to-be-senescent Woodstock generation. Something must give. Enter the Harvard Business School. Their mission: to apply their analytic powers to a challenging market problem, examine a service or product and its users, and tweak a business to achieve greater efficiency and productivity, thereby greasing the wheels of commerce. The practice of medicine, in theory, should be no less amenable to analysis than any other business. Harvard’s Clayton Christensen offers The Innovator’s Prescription: A Disruptive Solution for Health Care, his vision of a brave new world of doctoring in the twenty-first century (Christensen 2009). He sees my office as a “solution shop,” a quaint but outmoded and anachronistic storefront akin to a small Main Street hardware store or the premises of a butcher, baker, or candlestick maker. According to Christensen, mine is the last great cottage industry in the United States. Christensen proffers a model of medicine in which the functions of a physician are teased out, stratified, and supplied in bulk by technically optimized deliverers of narrow and specific services. (For example, a hernia is repaired in a hernia center.) Care is commoditized. The wholesale liquidation of traditional holistic primary care, however, recapitulates the creative packaging and repackaging of mortgage “products,” credit default swaps, and the clever “stripping” of securities into tranches (peeled-off profitable portions), which contributed ultimately to the massive financial market meltdown of 2007. As a physician, that is a path I choose not to take.

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Out of Practice

Primary care, as I knew and enjoyed it, is principal care, relational in its very nature. It is delivered in a continuum, sometimes over decades, often across generations of family members. It is not merely a series of short, staccato transactions, technically correct but emotionally empty and dispensed like fast food. The practice of primary care fundamentally does not lend itself to fractionation or focused factories. Primary care is different; it is a unique health resource and a national asset, but its survival is in serious doubt. I am neither the first nor the last to close up shop. By leaving practice, I lost many delicate, slowly cultivated, and sustained relationships with my patients; such relationships are remarkable phenomena that lie beyond the purview of any conventional business model. Yet, it is I who am now out of business, not the economists at the Harvard Business School. The postmortem on primary care in the United States may well read: “Death by Disruption.” To be sure, the practice of medicine is a business. The fruits of my labor as a doctor (along with my wife’s income as a college professor) fed, clothed, and educated our four children, covered the mortgage, and sustained a comfortable and fortunate upper-middle—class standard of living, for which I am grateful. I doubt that future primary care physicians will enjoy the same financial rewards for enduring the rigors of primary medical education, internships and residencies, and the chronically corrosive strains of modern practice. Peter Orszag, the initial director of the Office of Management and Budget under President Obama, admonishes Americans that we are in financial trouble today because each of us consumes too much health care, as though it were an ice cream treat. We gorge on a large or extra-large measure of medical care, rather than show some restraint and order a small or medium portion. This tasty dessert analogy superficially seems plausible, given that morbid obesity has recast the shape of modern man. However, it is a specious argument. Rather, it is to the credit of modern medicine in the United States, including good comprehensive primary care, that we now confront the challenge of a senescent society. The United States burns more bucks today on health care because its citizens are older, more fragile, more dependent on a medical infrastructure for their tenuous survival, and in greater need of ready access to good primary care than ever before. The notion that health care for a sick and aging nation somehow can be streamlined and economized (faster, better, and cheaper) is quite naive; we can have any two, but not all three. Primary care, in particular, is inherently inefficient. Because it is relational, good primary care takes time. Complex matters, convoluted family dynamics, and critical health

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Introduction

5

decisions must be addressed in the context of a continuous, supportive, and trusting physician-patient relationship that is the polar opposite of fast food. Robbed of the ability to develop such relationships, many timepressured, deprofessionalized primary care physicians will choose the route I took: an early exit. Current medical students, future physicians to the Boomers and beyond, have all received the text message gone viral: “Stay away from primary care.” In this book I recount my personal experience, not to elicit sympathy or to wallow in nostalgia for some golden age of medicine in which the physician reigned supreme, powerful, and prestigious, as he (not she) snapped orders, prescribed paternalistically, and enjoyed a work environment unencumbered by regulations or quality control. Good riddance to that. I note, however, that also gone is a kinder, gentler form of medical practice that I knew all too briefly when I was much younger and just entering the profession. There was camaraderie among colleagues. We possessed a willingness to stop and recount an interesting case, help solve a diagnostic dilemma, or even share a joke in the admittedly macabre “gallows” humor of the young physician. The practice of medicine was fun. It was social. It worked. A physician-patient relationship thrives in a socially rich environment; it withers when market-style interactions supplant the social and care devolves into a pure business transaction metered by the minute (Hartzband and Groopman 2009). Like marriage, primary care is there in sickness and in health. To know my patients well, I must see them in good times and bad, be there for their trivial complaints and their tragic events. Primary care is a package deal, not divisible by degree of profitability. Primary care medicine is collapsing, a victim of economists’ tenets of maximized efficiency, profit, and productivity. There is no heading on an accountant’s financial statement for altruism, empathy, a warm smile, or other random acts of kindness that we all appreciate as patients and as people. Physician frustration, alienation, and chronic suppressed anger at such a market model of medicine have done us all, physicians and patients alike, immeasurable harm. Since leaving practice, I have thought long and hard about what went wrong. In the following chapters, I reflect on unfavorable trends in primary care that I personally have witnessed but that are amenable to repair. Consider, for example, polypharmacy, doctors’ propensity to overprescribe, and “poly-doctoring,” the excessive and expensive referral to multiple specialists. Experience the malaise of a malpractice suit hanging like the Sword of Damocles over the heads of health care professionals. Envision,

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if you will, the near-future world of 78 million aged Baby Boomers, many suffering some degree of cognitive impairment, demanding high-quality and personal attention from a scant number of primary care physicians. Imagine the frustration of trying to provide effective medical care to an elderly patient who lacks the support and sympathy of a functional, loving, and close-knit family. This is primary care in twenty-first-century America, and we have a very big problem on our hands. The United States currently is engaged in an uncomfortable soulsearching self-appraisal of its health care system. The problem of millions of people without access to health care, the staggering price tag of modern technologic medicine, and the graying of America are subjects that can no longer be ignored. As a fundamental principle, every American deserves ready access to a compassionate, comprehensive, and sustained relationship with a primary care physician, the backbone of good health care. Models of care have come and gone throughout our history (Starr 1982). The solo private practitioner is one incarnation, which will be replaced by a new and more workable model still in evolution. Regardless of the future format, it is the relationship between a primary care doctor and a patient that must endure for there to be a core of good care. We must stop to appreciate the remarkable and vital, if unconventional, nature of primary care. We need to do it quickly, as though our lives depended on it.

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A FIRST VISIT WITH THE DOCTOR

Compassionate, high-quality primary care medicine, both affordable and accessible, is fundamental to U.S. health care. It is the right of every American, and it is a national moral imperative. It is the cornerstone of care and our best defense against the human misery of disease, dysfunction, and frailty. Elections, geopolitical crises, and economic upheavals may come and go, but the essential need for a good primary care doctor is here to stay. This is not news. Other nations throughout the world, rich and poor, have designed health care systems that prominently feature ready access to effective and efficient primary care (Reid 2009). Their moral commitment is their mission statement. We in the United States, however, are different. We pay lip service to the significance of a strong and sustained relationship between a patient and his or her personal physician. “No one should stand between you and your doctor!” exhorts a paid political advertisement. Although this is a solid sound bite that packs a powerful punch, it is pure fantasy. My small examination room, designed for quiet personal consultation, is already crammed with unobserved “third parties” intruding on an ostensibly very private relationship. Pharmaceutical representatives, those well-dressed young men and women carrying pill samples and wearing corporate logos, are there to persuade me to prescribe their newest and most expensive products. Midlevel managers of health insurance firms and HMOs are also “in the room,” containing costs by restricting and rationing care through the ploy of prior approval. Medicare bureaucrats are there as well, codifying care of the elderly, translating the art of medicine into volumes of digitized diagnostic reference numbers and

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Out of Practice

procedure codes. Soon the bureaucrats will also be scoring the clinical outcomes of care in an arcane formula for physician reimbursement. Last, the plaintiff’s medical malpractice attorney lurks in the corner, never out of my mind for a moment, as I defend myself daily through ever-escalating diagnostics and unceasing documentation, always producing a wellbuffed chart, but not necessarily a healthier, happier patient. Seating is indeed limited in the exam room; patients should be advised that there may be standing room only. A wide chasm exists between the often-touted, lofty ideal of high-quality compassionate primary care for all Americans and the carborundum-like grind of the daily practice of modern medicine. Lost in the abyss is the essential and unique quality of primary care medicine, a valuable but exhaustible national resource. Consequently, the sustaining and supportive personal relationship between a doctor and a patient over a protracted course through thick and thin is in jeopardy. We should mind the gap. It is not sufficient, however, merely to offer a paean to primary care, singing its praises without appreciating what it is or how it works. As with the modern laptop computer, the iPhone, or the GPS direction finder, we depend on good primary medical care without knowing what’s inside. We stand to gain from a look under the hood. I invite you, therefore, for an office visit; the doctor will be with you shortly. Enter my waiting room. It is busy, but not bulging. You sign in at the desk and receive a clipboard, a pen, and a sheaf of insurance forms to complete (the adult equivalent of the issue of Highlights that once kept you occupied as a child waiting in the pediatrician’s office). You take a seat, surreptitiously surveying the status of those who precede you. One is in a wheelchair. Another is gaunt, blighted by malignancy and tethered to an oxygen cylinder. You already feel a little better, relieved at your relative apparent good health. This is not schadenfreude; you are merely whistling past the graveyard. Then you realize, however, that you and these poor sick souls share one thing in common: each is awaiting “fifteen minutes of fame,” an appointment with the doctor. Judging from the condition of the crowd, this could be a long wait. As in the barber shop, where you count the heads to be shorn before yours, you grab a magazine or two, settle in for the duration, and take a further look around the waiting room. The doctor’s waiting room decor is a matter of calculated choice. Soft pastels soothe. Carpeting adds warmth and muffles sound for privacy, but it must not snag a shoe and topple an unsteady patient. The chairs are comfortable but firm. Squeezing three patients onto a plush sofa violates everyone’s personal space, raises the fear of contagion, and evokes

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A First Visit with the Doctor

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embarrassment in a frail patient who will not be able to stand up unassisted when the time comes to see the doctor. The office of today is necessarily equipped with a few heavy-duty, extrawide chairs for the morbidly obese, each chair a space-occupying throne rated to hold well over four hundred pounds, dwarfing other Lilliputian conventional furniture. A low-maintenance potted plant, a philodendron or palm, adds a little life through greenery. (Perhaps it is wise to avoid a physician whose office plants look wilted.) A little bland music from overhead rounds out the neutral, if not numbing, ambience of the physician’s waiting room. The waiting area should be clean, well lit, comfortable, and quiet. It must appear professional, but not showy or opulent, lest patients start to grumble that the doctor is doing too well by their personal misfortune. Patients are natural doctor watchers. They know what car I drive, what shirts and ties I wear, and my taste in office artwork. A new patient begins to form an opinion of her doctor before the front door closes on her way in. Satisfied with my well-appointed waiting room, you flip through a magazine you have chosen from a broad selection of reading material. There is a well-worn, dog-eared copy of People, a variety of news weeklies, National Geographic, and a potpourri of women’s journals that incongruously juxtapose a photo of a large and luscious slice of cheesecake next to a headline in bold about an amazing new diet. There may be an attention-grabbing exposé explaining how to tell if your doctor is incompetent. That’s a perennial feature I always appreciate. Stale magazines in the doctor’s waiting room are a hackneyed joke. (“Doctor, I see from this copy of Newsweek that President Nixon has resigned.”) Complaints about the age, selection, and appropriateness of waiting room reading material, however, illustrate an important aspect of the practice of medicine: it is also a business. “The customer is always right,” I am told. We like to think of health care professionals as poised on a higher moral plane, scientifically confronting disease, aggressively ameliorating pain, and selflessly addressing suffering. Yet, physicians are also a profession of shopkeepers, that must address mundane complaints from disgruntled customers. A rather prudish woman in her forties, leafing through a copy of the New Yorker while waiting to be seen, came upon an article announcing the opening of a current photographic exposition in Manhattan. There, as a full-page feature, was a sepia-toned, artistic, and antique black-and-white photo of a naked woman, in my office! The patient complained vehemently to my secretary that the magazine should be removed at once; we did not comply. I recall this story, though, to highlight the bizarre world of private practice, where the doctor wears many hats, including, it seems, that of censor.

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A patient’s most strident complaints may vary widely from what health policy analysts and lawmakers fret about today: quality of care, access, and cost. The straight-laced puritanical woman rightly should have stood up to complain that everyone seated in my waiting room that day would pay a widely differing fee for professional services rendered, depending on age (Medicare), job (various private health insurance companies), or dire financial straits (Medicaid). That is a fact far more obscene than any risqué photojournalism found in the New Yorker. “How long must I wait?” a man asks as he raps his knuckles loudly against the sliding glass window, only inches from my secretary’s ear, laying the foundation for her day-long headache. Straining to maintain a pleasant demeanor, she replies with a friendly “Good morning,” dodging the man’s pointed question while directing office traffic flow. She invites the man to have a seat, complete his paperwork, and await his 9 a.m. appointment with the doctor. Not an avid reader of People or Popular Mechanics, he strikes up a conversation with the woman sitting next to him. She, he soon discovers, also has an appointment for 9 a.m.! How can this be? He steps up to the window and again raps vigorously against the secretary’s glass enclosure. Her headache, an occupational health hazard, intensifies. Medical appointment scheduling is both art and science. It is a form of fluid dynamics, regulating the flow of individuals, each moving at a different rate and presenting different needs. There is surprisingly little correlation between the severity of an illness and the time devoted to it in the course of a patient visit. Complexity of care is more a function of a patient’s personality traits, such as maturity, adequacy, coping capacity, and social support structure, than of blood test results, X-ray and scan reports, or other objective findings. Hippocrates, primary practitioner of Periclean Greece, presciently summed up the root challenge of medical office scheduling when he said, “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” A middle-aged woman coping with a slow-growing malignant brain tumor is currently comfortable and arrives, accompanied by her supportive spouse. She requires a brief neurologic recheck, a refill of her antiseizure medication, and then she is on her way. A disconsolate young man, however, scheduled to see me for a minor and transient somatic complaint, a sore shoulder, casually mentions as an aside that he is recently divorced, laid off from his job, shopping for a gun, and giving serious thought to suicide. Suddenly his ten-minute visit swells to sixty, triggers unexpected phone calls to secure speedy psychiatric help, and dams the flow of patients

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seated in my waiting room. A modern primary care physician, needing to see as many as thirty to thirty—five patients per day to cover an onerous fixed overhead of a quarter of a million dollars per year, cannot achieve the elasticity of scheduling necessary to provide immediate, comprehensive, and compassionate care and service. Hippocrates never had to hustle. There is no optimal method that maintains a steady stream, guarantees customer satisfaction, and keeps things fair. A classic approach to effective patient scheduling is “the wave.” Three or four patients arrive synchronously, each entering a maze of medical exam rooms, the laboratory, and the front-end business area. They each begin the process of updating personal information and reporting new physical complaints to a nurse. Weights are measured and temperatures are taken. Samples of blood or urine may be obtained, prescriptions are renewed, and a flurry of forms exchange hands. I then perform a “juggling act.” I may obtain a medical history from the man in Room 1, while the woman in Room 2 has an electrocardiogram (EKG) and the man in Room 3 has gone off to the lavatory to produce a urine sample. I move from room to room, as in a game of musical chairs, punctuated repeatedly by the hygienic ritual of thorough, compulsive hand washing. There are inevitable delays in the countdown. The elderly woman disrobing for her EKG conceals a surprising number of layers of clothing, even in July, which she sheds slowly due to the stiffness of her arthritis. If the man in the lavatory has an enlarged prostate, which is quite likely in an older gentleman, obtaining a small sample may take much longer than anticipated. Patient flow is impeded by slow urine flow. It is now only 9:30 a.m., and I am already running late. The next wave, due at 10 a.m., soon will be rolling in. In a busy primary care practice there is no catching up, and it is virtually impossible to make the trains run on time. The artful part of patient scheduling is to keep the appointment book elastic enough to absorb an emergency case, an acutely anxious individual, or a shell-shocked new recipient of a dismal diagnosis. Yet there is little “give” in the system. The woeful shortage and geographic maldistribution of primary care physicians, the demographic of a burgeoning older American population, and the relative sophistication of aging Boomers who rightly demand detailed explanations and full and informative answers to their questions guarantee that doctors’ waiting rooms will remain packed for the foreseeable future. As a physician, I certainly do not intentionally squander patients’ time by forcing them to idle away their hours catching up on the tabloids or by aging them in the waiting room like a fine wine. Time is of the essence for both doctor and patient. Not inconsequentially,

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time is also money. Yet, there is time waste inherent in the system. Like the restaurateur whose greatest business expense is an empty table, I cannot compensate for no-shows, people who call to book an appointment but never appear. Overbooking is the unavoidable result of missed appointments. Unlike an airline, however, I cannot entice a patient with a free ticket for a future physical if she relinquishes her seat. Periodic peak demand, as in a bad flu season, a media-intense transient health scare, or the sudden and unexpected recall of a commonly prescribed medication adds unforeseeable ripples. Immediate physician access for all, with little or no wait, is the Holy Grail of primary care practice. I never found it. Some patients realize that physician access is a shared resource, subject to change at a moment’s notice. Some do not. When I first opened my office in 1984, I wrote letters to local businesses, promoting my practice by offering my services as company physician. A prosperous firm in town, a lumber mill, took me up on my offer. One day the office front door swung open and a young man dressed like a lumberjack stood at my threshold. Wrapped around his hand and arm was a white towel stained with blood-red spirals, resembling a barber’s pole. He had come directly to my office, as instructed by his foreman, rather than to the emergency room, where his company would have incurred a much heftier bill under workers’ compensation insurance. The wounded worker was rushed inside immediately, and I was interrupted to come assess the damage and control the vigorous bleeding before suturing the laceration. Meanwhile, back in the waiting room, the carpet still freshly stained with blood, a seated woman, waiting for her appointment for a blood pressure check, stood up and approached the window: “Excuse me, but I was here ahead of that man.” She was indeed. The doctor’s waiting room is a small community, a microcosm of larger society, and a laboratory of social justice as it applies to health care. Who goes first? The woman, who was “bumped” while I tended to the young man with the laceration, was a libertarian. Having made her appointment long ago, she expected to enjoy her right to be seen on time. A strict utilitarian, had he been sitting there next to her, would have argued differently. Priority care should go to the individual most likely to benefit from my services (the greatest good). Let that man go first. A true economic egalitarian, however, gladly would have allowed her turn to pass while she continued to read an outdated copy of Time so that the poorest patient, often coincidentally the sickest, could have timely access to care. (The last shall be first.) The three armchair philosophers of the waiting room cannot all be correct. “Justice” is a relative term (Sen 2009).

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In 1918 the French gave us the word triage for a method of sifting and sorting among the World War I wounded, which directed scarce emergency medical resources to those most likely to survive a grievous injury. The mortally wounded, dying in agony on the field, did not voluntarily renounce their right to medical care. Rather, that critical decision was made for them by medical personnel following a rigid algorithm. Triage, though, is generally not warmly embraced by waiting patients in the peacetime practice of primary care, where the man ahead of you is neither bleeding profusely nor clutching his chest and gasping for air. Waiting is an imposition, made more irksome by a high-speed, high-stress multitasking modern existence that often leads me to contend with an irritable, impatient patient. From time to time a very sick individual walks into my office, in need of immediate attention. After a rapid assessment, I determine that he requires immediate transport to the nearby hospital for emergency care and admission. An ambulance is summoned. It arrives in a matter of minutes, red lights flashing and siren blaring. The ambulance doors swing open and paramedics rush through my waiting room wheeling a stretcher. The acutely ill person is placed on a portable cardiac monitor, receives oxygen, is transferred onto the stretcher, and soon leaves the office horizontally and in high drama. A profound change of mood immediately prevails among those who wait. Patients seated in the waiting room, all witnesses to the event, are transfixed and transformed. They now are quite willing to wait, however long it takes, knowing that an extraordinary occurrence calls for cooperation. Alternatively, some gladly step up to reschedule, saying, “If it were me on that stretcher, I’d expect the same.” Only during the drama of critical care do we acknowledge that, in our individual access to and utilization of health care, we are all inextricably interconnected, all sitting in the waiting room together. We are not accustomed to thinking of good health as a group project. A patient may sit in the waiting room, an isolated individual among many, cloaked in the illusory privacy of the Health Insurance Portability and Accounting Act (HIPAA), by which each man is an island. In reality, however, we are each members of a larger group, part of a “herd.”1 Public health officials focus primarily on the prevention of communicable infectious diseases. Clearly, it is bad for your health to be seated in my waiting room, exposed for the duration to a man with active tuberculosis who coughs incessantly in your direction. However, another fellow seated in the waiting room, an overweight smoker, an alcoholic, or a man who is noncompliant with his blood pressure medication, is a public health

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hazard as well, sopping up a disproportionate share of health care services. Do we differentiate between the sufferers of self-induced illness, or the diseases of excess, and those poor souls with bad luck or bad genes, by placing them on opposite sides of the waiting room (Segall 2010)? (Do you prefer smoking or nonsmoking?) I pose this question rhetorically, but I never would have posed it at all ten or twenty years ago. Rationing does change the “rules of engagement.” How will we respond, as a society, to the coming world of limited medical resources? What will it be like in my waiting room when soon there are not enough physicians’ services and medical resources to go around? Several years ago, well before the recent worrisome appearance of swine flu, there was a nationwide shortage of the standard seasonal influenza vaccine. Fall arrived and there were very few flu shots to be had. Typically in prior years, I would order five to six hundred single-dose injections for my patients. That year I considered myself fortunate, however, to have sequestered sufficient vaccine for one hundred patients. There was a TVmediated hue and cry over the nationwide lack of vaccine. The Centers for Disease Control and Prevention issued an advisory recommending that the sick and elderly receive priority in vaccination. That was like shouting “Women and children first!” aboard a sinking ship. Patients never before willing to receive the flu vaccine oddly now demanded one. A very nice, very elderly, but very demented older man exited an exam room after receiving his monthly shot of vitamin B12, a clear, reddish liquid that replenishes what he no longer can absorb naturally from his atrophied gastrointestinal lining. Exiting into the waiting area, he cheerfully announced to the crowd, “I just got my flu shot.” Pandemonium erupted. “Why does he get one and I don’t?” asked a now raucous and contentious crowd in unison. Walking a fine line between patient privacy and crowd control, my nurse explained that the man in fact had not received a flu vaccine. Feathers were unruffled once more, but, having no way to distribute equitably only one hundred flu injections and fearful of mob mentality, that fall I donated all of my influenza vaccine to the local health department; none of my patients were vaccinated in the office that year. Judging from what little I already have seen, large-scale health care rationing will not be a pretty picture. Patients may be sitting, waiting in vain. Beyond the waiting room, on the other side of the sliding glass window, is the nerve center of the busy medical practitioner’s office. There lies “Command and Control,” operated by office staff members in white, assuring mission success, but isolated physically from patients. It is an operations bunker housed in a secure location. The physical boundary of the

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sliding glass window ostensibly promotes privacy by sound insulation, but for patients, the barrier seems purely defensive, like a drawbridge, moat, and castle keep. An us versus them mentality unfortunately comes of an old architectural convention in medical office design. The sliding glass portal promotes patient anxiety and apprehension, heightens hostility and frustration, and stands as a seemingly impenetrable barrier to good relational primary care. We should tear down that wall. The office manager is stationed on the other side of the sliding glass. Occupying the captain’s chair, hands-free telephone headset projecting from one ear, she is in command. By the authority vested in this key employee, a physician’s office conducts all business, broadly of three categories: the everyday, the exchequer, and the executive. Everyday duties are the bane of the business office personnel. Scheduling a test, say a spinal MRI for a patient with low back pain radiating down his legs, shouldn’t be too tough. “What kind of insurance does the patient have?” asks the scheduler at the MRI facility, before bothering to obtain the patient’s name, age, symptoms, diagnosis, degree of immediacy, or other pertinent clinical information. Most private insurers demand prior approval if the test is pricey. The call therefore terminates abruptly and another is placed to a nonphysician screener, somewhere far away in toll-free 1-(800)-land, the screener’s full identity shielded by provision of her first name only. “No. We cannot approve the MRI. Your patient, the insured, has not undergone a required preliminary six-week trial of physical therapy and at least two different prescription-strength anti-inflammatory medications. You may appeal this decision by having your physician call our medical reviewer, an MD, next Tuesday.” The wheels of health care grind to a halt. My secretary, cast in the black-hat role of intermediary between a patient and his insurer, must give the patient the bad news: “Your insurance company will not permit you to have the test the doctor has just advised you to undergo.” The patient’s face turns red as he begins to seethe and boil over. His anger at a faceless cog in a remotely situated boiler room phone bank is directed at his only human contact: my secretary, the messenger. The battle of prior approval is but one example of the utter frustration inherent in the everyday business of medical practice. The primary care physician operates within a system of rationing by roadblock. We attempt to provide good patient care, but all the while we are mired in quicksand. It is often only by a medical secretary’s persistence that the job gets done. The squeaky wheel gets the grease in American health care. Medicine is, of course, a business; at some point money must change hands. Before exiting the office, patients are directed to the business area

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counter. It is time to see the exchequer and settle up. “Payment Is Expected at the Time Services Are Rendered” reads the conspicuously placed plastic sign on the wall, a stock item in any medical supply catalogue, yet a physical wonder because of its apparent invisibility. A relatively small copayment of ten or fifteen dollars from the patient at the time of the visit is an insurance company’s method of limiting physician utilization. Like a hypodermic needle, it should sting a little so one is not inclined to come back too soon. The exchequer, fluent in all dialects of insurance-speak, performs a difficult medical procedure: extraction of the co-pay. “I forgot my wallet. . . . Just bill my insurance. . . . My son handles my checkbook. . . . Under our divorce agreement, my ex-husband pays all of my daughter’s medical bills. . . . I’m shocked, shocked that you don’t accept American Express!” Patients who would willingly whip out their wallets for their pets at the vet, for groceries in the supermarket, or for a haircut, suddenly develop tight-fist syndrome in the doctor’s office. Debt consolidators and personal financial consultants advise: “Pay your doctor last.” Financial titans of the health insurance industry know this all too well. Payment delay is their corporate motto, and it is shrewd cash management. The longer they retard disbursement, the longer they reap interest on doctors’ money. It is no accident that so many “clean” insurance claim forms, those without any clerical error, are rejected summarily on the first pass. A computer-generated reply obfuscates with terms like “not a covered insured,” “not a covered service,” “out-of-network provider,” or “goes toward patient’s deductible,” leaving the physician buried in paper and unpaid. The doctor is the unintentional lender of an indefinite, interest-free loan to an insurance behemoth until the matter ultimately is straightened out six to twelve months later. A tenacious health insurance biller is one of a physician’s most highly valued staff members, a specialist in his or her own right, worthy of combat pay. My busy practice required that I maintain one full-time employee whose sole function was to do battle with Medicare and the private insurers on three fronts: telephone, computer, and “snail mail.” For her valiant efforts, my employee received a competitive salary, maximally permitted 401(k) retirement benefits, and her health insurance. How many additional patients must I have seen each year to cover the cost of my contender in this David-and-Goliath battle on my behalf ? More than was humanly possible. I lacked both the stamina and sufficient hours in the workday to meet the challenge. Maintenance of an Office of the Exchequer, focused by necessity on the fiscal fitness of the practice rather than the physical health

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of patients, is ultimately an unsustainable and nonviable business model for the practice of medicine. Advocates of a single-payer system of physician reimbursement argue that it would streamline the payment process by cutting red tape. Such a proposal, though, would be only as reliable as the all-encompassing agency charged with writing the checks. Medicare, the single primary insurer of the elderly, and a federal program barreling toward insolvency, periodically cranks shut the valve of physician reimbursement when the federal coffers dip lower than usual. Typically at the end of the year, starting around Thanksgiving, the U.S. government becomes a doctor’s worst deadbeat, shirking its obligation to pay. Repeated phone calls to Medicare, and even to my congressional representatives, are futile. “The check is in the mail,” they tell me. That phrase seems anachronistic in the age of direct digital transfer of funds, but its meaning is well understood by anyone who owns and operates a small business. A single-payer system that stalls is no solution. The battles of everyday business and the burdensome demand as keeper of the counting house distract medical office personnel from their mission-critical role: delivery of superior health care. It is the executive function of the medical secretary that promotes health and saves lives. All else that goes on behind the sliding glass window is nothing but an unhealthy distraction. What do I mean by executive function? In an era of bank bailouts and Wall Street financial shenanigans, the term carries a negative connotation. Executive function, however, is the ability to recognize and handle that which is novel. When a normally stoic and taciturn man calls, distraught over a new pain or bodily dysfunction, the skilled staff member sees the red flag that others miss and ensures quick physician access. If a normally well-organized woman lingers on the phone, now unable to collect her thoughts or express herself succinctly, a skilled and unfettered staff member detects the decline and sounds the alarm. When a chronic complainer, a daily caller, fails to “check in” for two or three days, that too does not go unnoticed. The person who answers the telephone in the doctor’s office must be a sensitive detector, responsive to that which is novel, not an automaton. The telephone is a medical device; answering it is a medical procedure best performed by an executive health professional. To ferret out the unusual, the doctor’s secretary must appreciate the norm. She must know people well. What is a particular patient’s threshold for pain or panic? Is there someone at home to check on a frail man subject to falls? Is it possible that a young woman, reticent to elaborate about an

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injury, is the victim of spousal abuse? A primary care medical office works best if it retains a degree of intimacy, confidence, and personal trust on the phone and at the desk. A small operation with stable employment over many years creates a zone of comfort through continuity and coziness. “Big box” medical megapractices, with long lines at the counter queued by fuzzy ropes like a Cineplex movie theater, fail to engender trust or a sense of privacy. Privacy is a part of very personal human interaction, not the legislated consequence of a duly signed HIPAA form. The small office, with a caring and unhampered executive secretary at the helm, is best able to handle the most intimate and embarrassing of human malfunctions. Size matters in the practice of primary care. The executive secretary speaks the language of the patient, no matter how the patient may mangle a medical term. The man who calls frantically for an appointment because he fears he has a “bilingual hernia” or the worried wife who wants assurance that the doctor will check her husband’s “prostitute” are understood and handled with aplomb, albeit with a chuckle later on. More perplexing is the patient on the phone for whom good news is bad. Traditionally, I always personally delivered the bad news, a biopsy report revealing malignancy or a life-altering scan result. (You really don’t want to hear your doctor’s voice when you pick up a ringing telephone.) Good news, such as a rock-bottom cholesterol reading or a scan showing healthy rock-hard bone density, may be conveyed by a staff member for speed and convenience. “I have good news, Mr. Smith! The X-ray of your foot is absolutely normal. You may return to work first thing tomorrow morning,” she advises in an animated upbeat voice. Flustered by a favorable report, Mr. Smith snaps back, “There must be some mistake. I can’t possibly go back to work so soon. Put the doctor on the phone!” Nothing is easy. Deciphering a medical malapropism or delicately passing along the “tragic” news of a normal test result is nothing, however, when compared to the executive’s key role in the sales department. What is the best way to convince a reluctant patient to consume the noxious prep for a colonoscopy, use a plastic collection jug to urinate in for twenty—four hours, or undergo countless other uncomfortable, humiliating, but well-intentioned forms of battery? The skilled staff secretary makes the pitch. She can sell ice cubes to Eskimos. It would be far easier for her simply to record that a squeamish patient declined a messy and unpleasant test: “Patient refused stool collection for parasites.” We’d be done. Persevering, though, saves lives. It is a value-added service and an absolutely critical component of good primary care. We compromise care immeasurably when we burden

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the medical staff secretary with forms, fights, frustration, and futility in the health care workplace, effectively tying one hand behind her back and wasting good talent. At last, your long wait for the doctor is finally over. Your name has been called. A new patient to my practice, you have “done your time” in the waiting room, and you have returned the clipboard containing half a dozen completed forms. You have passed by the business hub of the doctor’s office and are ready to be escorted to an exam room, a sterile and isolated inner chamber only a bit larger than your parking space. Once inside, the nurse records your vital signs, your weight, and your list of current medications. Your chief complaint, punctuated by quotation marks denoting your own words, heads that first day’s page in your chart. “My boss gives me hives,” “My stomach aches after I ate an entire watermelon in one sitting,” “It hurts when I do this.” One-liner capsule summaries focus an all-too-brief fifteen-minute physician-patient encounter. “The doctor will be right in,” says the nurse, but you are skeptical. You wait some more until, ultimately, you hear rustling at the door. You are about to have your turn at bat. Outside the exam room, I stand by the door and reach in the chart rack for the thin, crisp, and clean medical file of a new patient. I enter. Neither you nor I know what to expect. I introduce myself and we shake hands. We begin to “examine” each other, both wondering, what sort of a person is this? I note subconsciously the strength of your handshake, the sweatiness of your palm, and whether you hold eye contact. How does this new patient of mine carry himself, express his thoughts, and function physically? Time constraints limit me to a quick gestalt, a snapshot rather than a studied portrait. Frustratingly, I cannot possibly take the measure of a man in only minutes, not only how he enjoys the comfort of good health, but also how he or she might meet the challenge of illness.2 You, the patient, start to size me up as well. Do I seem personable and professional, even though not punctual? Is my handshake warm, my manner comforting and comfortable? Do I hold eye contact? The doctor who awkwardly buries his or her head in a chart or gazes in the direction of a flat screen monitor is an impaired communicator and not one with whom a patient is inclined to build a strong relationship. My new patient attempts to ascertain if I am a “regular guy.” A stranger once walked into my office unscheduled and asked at the desk whether the doctor accepted “regular” people in my practice. I still have no idea what he meant, but I do know that patients strongly prefer that their primary care doctor should be a “regular person,” genuine, believable, one of them. This criterion carries far more weight than framed diplomas on the

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wall or scholarly medical journals on the bookshelf. A new patient cannot gauge a doctor’s competence or proficiency during a fifteen-minute first appointment. She must rely on fuzzy subjective determinants such as perceived warmth, sincerity, and a sense that, for those fifteen minutes, the doctor’s attention is focused solely on her, uninterrupted. Just then, though, there is a knock at the door. Before you and I could tackle even the first item on your tallied list of medical malfunctions, we already have been interrupted. “The radiologist is on line one. He says he must speak with you right away,” whispers the nurse through the heavy wooden door. It has been observed that a physician is likely to interrupt a patient only seconds after she begins to speak, cutting her off midsentence with a question of his own or taking a premature stab at a diagnosis (Groopman 2007). It is more likely, though, that the private and personal physician-patient dialogue will be sidetracked, or even derailed, by a faceless competitor for my attention: the telephone. Radiologists do not make social calls; someone is in trouble. It may be a suspicious squiggle on a mammogram, a brightly lit-up bleed on a computerized tomography (CT) brain scan, or an unanticipated “cannonball” cancerous lesion on a routine chest X-ray, but somebody is about to have a very bad day. What can I do but take the call? It is rude and impolite to interrupt our conversation in the first few seconds of a nascent physician-patient relationship, yet someone else needs me to be there on the telephone, now. During the time I was in practice, the total number of patients under my care, a doctor’s “patient panel,” continued to swell. The panel includes healthy patients, seen rarely, but also many who require constant attention, frequent visits, and a major professional commitment of time and energy. When I began in primary care, a typical panel was about eight hundred patients. Today, there are sophisticated formulae for calculating the optimal number of patients required for a doctor to break even. One guideline, for example, suggests that two thousand is the appropriate number. Today, advice on calibrating the right patient panel abounds on the web, but, like everything else, the number has inflated over the years. At the time I left practice, I bore clinical responsibility for over three thousand patients. As primary care physicians’ patient panels continue to swell, spreading our services and our selves ever thinner, the dilemmas of time management will become ever more difficult. Constant diversions, bumps in the road at every turn throughout a long and arduous day, are as distressing to doctors as they are to patients. No efficiency expert or information technologist has yet devised a technique

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that allows me to be in two places at once. Those who maintain that better information technology will wring greater efficiency from the primary care provider disregard that basic physical principle of time and matter. Optimal patient care moves at an inherently and ideally slower pace than the business of modern medicine demands today. Delays, distractions, and interruptions are a function of the sheer volume of patients we treat, the large array of modern diagnostics at our disposal, the cadre of consultants with whom we must communicate, and the multiple tough therapeutic decisions to be made. We delude ourselves at our own peril when we ignore that fact and incorrectly assume that marginally greater productivity can be gleaned from doctors, if only we had the right software. Practice-management gurus, those who profess to be able to streamline any doctor’s place of business, favor designating a rigid “phone hour.” Separated from the rest of a long day of clinical care, the phone hour stands apart as an uninterrupted opportunity to return calls, report results, and clear up old business. Since the phone hour is often the same as the lunch hour, it is a feat of bimanual dexterity, phone in one hand and sandwich in the other. Alternatively, the phone hour is the last hour of the office work day, after the staff have left, the waiting room lights are switched off, and the front door is locked. It is easy to reach patients then because they are home having dinner with their families, while the doctor is not. A physician’s phone hour, styled like a call-in radio talk show, does not work. Rigidly structuring phone time is as ludicrous as penciling in planned “quality time” with young children. It doesn’t work that way. Medical care occurs in real time. Events unfold. Things happen. Each new phone communication or fresh bit of arriving data vies for my attention and receives it by a rank ordering of significance or criticality, rather than by queue. There is, however, an unwritten protocol for doctor-todoctor phone contact. The physician initiating the call should remain on the line, ready and waiting for the interrupted doctor to apologize and excuse himself, leave the exam room, and head for the telephone. The summoned doctor trusts that the matter is truly important and worth the interruption. She does not want to delay receiving clinically important information or risk entering into an interminable game of phone tag. Multiple phone lines of service, however, place the doctor in jeopardy of simultaneous calls, generating a seemingly endless loop of nested interruptions to be addressed before the doctor can ever return to an abandoned, waiting patient in an exam room, and a lost train of thought. It’s necessary to appreciate, however, that the heavy volume of physician phone calls is a symptom of a swamped system of primary care. We are in over our heads, inundated

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by data, challenged by an unprecedented demand for care and communication, perhaps more than is humanly achievable. Be assured that, when the doctor is called away, she is not sitting in a back room, feet up, surfing the Internet or text-messaging with friends. She is practicing telephonic medicine, a specialty in its own right. As recorded phone messages often remind us, “Your call is important to us.” In fact, though, not all calls are of high-priority ranking or convey information essential to good patient care. The vast majority of phone calls, as well as faxes and forms in the mail, pertain to the “hall monitor” function of the primary care physician. We are the medical police, or MPs, obligated by local, state, and federal government to supervise nonphysician health care professionals, as though our rubber-stamp approval could prevent some unscrupulous occupational therapist from robbing Medicare blind. This is absurd. When the visiting nurse attends a patient in her home, I must sign a form that certifies that the nurse truly was there, guarantees that nursing services were warranted and proper, and verifies that the nursing agency rightfully deserves payment. If a physical therapist is to conduct the craft for which he is well trained, stretching a stiff joint here or mobilizing an elderly stroke victim there, I must sign a form, as though validating his parking stub. I must give my blessing in a paternalistic format demeaning to the therapist, like writing a note to the teacher excusing my child’s absence from elementary school. What about a respiratory treatment for a young adult with cystic fibrosis? There’s a form for that, too. Government agencies, from Medicare on down the food chain of health care administration, cannot and should not lean on primary care physicians as the hall monitors of health care. To propel U.S. industry and foster academic research, we expect our scientists and engineers to do what they do best: make discoveries. Chemists should be busy perfecting a better battery or biofuel, not scrubbing the laboratory glassware. Why are we so foolishly willing to waste doctors’ time and talent on mundane clerical duties? Why did physicians ever allow themselves to be shackled with such nonsense? I was chased out of my own office practice by a rabid fax machine spewing spurious forms for signature. It was the widespread adoption of the fax that enabled the rapid transmission of forms by the pound. Night and day, 24/7, the fax generates paper faster than I can sign my name. By its speed of transmission, it lends a false sense of immediacy to an otherwise trivial document that could have moved slowly and more appropriately by third-class bulk mail. This just in from the nursing home, “Patient may have her hair done” reads

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the faxed form on my desk awaiting my signature. Presumably a woman sits, wrapped in a plastic shawl, her head tipped backward, awaiting my immediate endorsement of this plan by return fax. Is this truly a medical decision? I suppose there is a remote chance that an old woman with stiff, clogged carotid arteries in her neck could suffer a stroke while her head is arched backward during a rinse. Anything is possible. My professional attestation on the record (call it a Beauty Parlor Authorization Form), however, is in no way a medical matter; it is a liability toss. Like a hot potato, the primary care doctor, as guarantor of record, is handed responsibility for any adverse outcome, from wooziness with a head tilt to sudden death under the hair dryer. We think of physician liability solely as a matter of medical malpractice risk, the wrong drug given to the wrong patient via the wrong route of administration. The primary care physician today, however, is a general liability sink, carrying an obligation as the guarantor of a good day. By doctor’s order, all will be safe and secure. It must be; “we have a signed form from the physician.” Yet, life is one long series of risks and, eventually, a losing game, as we all come to recognize at some point. Institutionally, and as a nation, we wrongly look to our primary care doctors to guarantee our everyday safety and protect us from mishap, like Saint Christopher seeing to our safe travels. I am flattered but unable to deliver. The nonclinical physician duties, including being a hall monitor, liability sink, and guarantor, are more than a mild inconvenience for physicians. They are a health hazard by distraction, as deadly as chatting on the cell phone while driving. How many iatrogenic errors occur each year because a doctor’s attention is diverted from her primary charge: good direct patient care? There is no way to measure this morbid statistic, but I will wager that forms kill. Health care policy planners ought to take a good hard look and reflect on how primary care physicians spend their time. We in the United States are so wasteful of our resources. Like water, land, and energy, we squander primary care physician man-hours as though we had an infinite supply. We drive doctors out, and ultimately deny our citizens access to care. We all know intuitively that we need good primary care. As individuals, we sit interminably in waiting rooms, tolerate frequent phone interruptions, endure scheduling hassles, and run the gauntlet of health insurance claim forms, but why do we do it? What do people want from that office visit, that relationship with a primary care physician? The easy and immediate answer is people want competence. Nobody intentionally books an appointment to see a subpar practitioner, an impaired physician, or a quack. It is prudent to put your fate in the hands of

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a doctor who at least tries to stay afloat professionally in a world awash in torrents of clinical trials, emerging therapies, and information overload. Technical competence is objective and assessable by continuing medical education (CME) credit hours logged, periodic board recertification, and hospital credentialing. There is, however, no diploma suitable for framing that proclaims the doctor a “master of sentience,” compassionate, emotionally intelligent, and perceptive of feeling and human hurt. Ill health is a strange and lonely experience. Loss of control, fear of the unknown, and the natural embarrassment of a body laid bare call for physician delicacy and diplomacy at all times. Modern, high-tech scans and screens exacerbate the cold clinical nakedness, piercing the veil of personal privacy and generating terror that “the doctor can see through you like an X-ray.” The only antidote to the awful anxiety is the comfort that comes from repetition and familiarity. Like a religious service with its orchestrated rituals, familiar faces, and its message of comfort and consolation, the sustained primary care physician-patient relationship offers solace. Comfort comes from continuity. Continuity, staying in one place, doing the same thing, slowly and steadily, year after year, is an anachronism in today’s high-speed world of modern American business. “Just in time” inventory control, cost cutting by service outsourcing, and the economics of creative destruction are anathema to a profession built on sustained human relationships. Primary care, fundamentally, is not big business. Any attempt to force the unique physician-patient relationship into a large corporate format, a suit that does not fit, is doomed to failure and to the loss of something precious. Health care, as noted by Drs. Thomas Lee and James Mongan in Chaos and Organization in Health Care (2009), is in a state of chaos. They characterize doctors as well meaning, but disorganized, and consequently inefficient. The term chaos, though, seems a tad harsh. Many physicians like to be busy, constantly in demand, and firmly in command. They wonder what’s wrong when the phone doesn’t ring. The buzz of a fast-paced, high-volume medical practice satisfies a psychological need of the congenital overachiever, the typical sort who is well adapted to the rigors of medical training. It also is the consequence of the doctor’s own need for connection. There is no denying, however, that care today has become quite complex. Acute illnesses may come and go, but chronic ailments accumulate. Mirroring modern life in general, primary care today entails far more treatment options; tough long-term management decision making; and a need for nimble handling of convoluted psychosocial, family, and ethical issues

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attached to living with chronic illnesses. This is not my father’s medical practice. School nurses today are in the same boat. Traditionally, they enjoyed a calm and comfortable day job, checking for nits, screening for scoliosis, administering TB tine tests, and now and then calling a parent to retrieve a child with a cold or an upset stomach. Today it is highly likely that a school nurse will be monitoring a child who is receiving chemotherapy, one who must be catheterized for urine once or twice each school day, or another who is immune compromised by AIDS. The school nurse must dole out the drugs of modern childhood, such as Ritalin or Aderall for hyperactivity, potent anticonvulsants for seizures, and lots of antidepressants. Disabled students and those with special needs, under the Individuals with Disabilities Education Act, have been mainstreamed, fostering inclusion, reducing the restrictions of an inherently unlevel playing field, and creating a broadened new scope of normality in the classroom. Primary care physicians now confront a similar challenge: mainstreaming the complex and chronically ill, a growing proportion of our patient panels, into an already strained work day. The problem for primary care is not that physicians are chaotic; it is that demand for our services far outstrips our supply. What do patients demand? Despite the current complexities of modern, medically sustained life, patients still seek the same fundamental function from their primary care doctors: a special relationship. The physicianpatient relationship is an odd amalgam, demanding of the doctor a unique blend of empathy and authority, a comforting demeanor and an even temper, a familiarity just bordering on personal friendship (but not quite), and advocacy. As with our legal system, in which you would never dare engage your opponent or attempt to resolve a weighty matter of law without counsel, in today’s frightening world of health care you need a strong advocate, someone who will speak for you and guide you through the treacherous, uncharted waters of illness. I was taught by my superiors during my residency training that, as in football, we were there to run interference for our patients, clearing the way for them through the sluggish bureaucracy, tackling stubborn obstacles such as arbitrary insurance coverage denials, and delivering them to the goal line of a good health outcome. At stake in the game, for the physician, was professional pride and reputation, a desire to win for the patient, as well as an entrepreneurial motivation. There was also the intangible positive of having done the right thing—precisely what patients miss now in the age of corporate care, dispensed by detached and deprofessionalized physician-employees in doc-in-a-box facilities, where

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patients may come and patients may go and it really doesn’t matter. Patients have lost their advocates. From time to time I peruse the various websites providing compiled information on local physicians available to prospective patients. A few loyal patients, happy with their care, praise their physicians. The disgruntled, however, have a field day. Terms like “cold,” “aloof,” “distant,” and “vacant” paint an unflattering picture of these doctors. Those who voice their dissatisfaction describe medical offices that have the ambience of the Division of Motor Vehicles. (“You’re in the wrong line!”) They are frosted by a disinterested and dispassionate “take it or leave it” attitude that comes with the care dispensed. This well may be the primary care of our future, delivered by disenfranchised doctors with no vested interest in a patient’s outcome, satisfaction, or emotional well being, each transaction closing with a vacuous and insincere “Have a nice day.” Ninety percent of life is just showing up. Ninety percent of good primary care is just showing an interest in the patient, as remarkable as that may seem. I recall the story about a sick old woman lying in her hospital bed. Surrounding her bedside on their morning rounds are a dozen doctors in long white coats. They include grey-haired attending physicians, young residents, and haggard-looking interns carrying clipboards and charts. The team of academic specialists has recommended that she undergo a difficult and risky procedure, but she is reluctant to sign the consent form. “I don’t know. I really should discuss it with my doctor,” she says. The doctors look around the room, trying to figure out which specialist colleague is missing. At that moment the young medical student walks in, exhausted, unkempt, and needing a shave after having been up all night at the woman’s bedside as her primary source of comfort and contact. The patient rallies, with great relief, and says, “There he is! There’s my doctor.” Critical of an old style of medical practice, Lee and Mongan label the traditional solo physician a cowboy. Taking the reins firmly in hand, the doctor sits tall in the saddle. He is the Lone Ranger of health care. Armed with silver bullets against disease, he personally protects and defends his patients, albeit with needlessly duplicated tests, scant communication, and any semblance of coordinated care. Such physicians, holdovers of late twentieth-century medical training, probably all were young recipients of elementary school report cards that read “Good student, although doesn’t work well with others.” Perhaps the doctors of tomorrow, as Lee and Mongan hope, will be different. Team players and consensus builders, they will offer patients seamless care that is efficient, optimally costeffective, and electronically enhanced by instantaneous data access as they

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replace the swaggering physician of yesterday who seemed to carry it all in his head. Data management, however, cannot supplant good relational primary care. More than managerial, the strong and sustained physicianpatient relationship is of prime importance, now more than ever, because it offers solace and solidarity for a patient and family coping with chronic, complicated illnesses. How quaint this seems in an age of whole-body CT scans, comprehensive multidiagnostic blood analyses, and the entire U.S. pharmacopeia on a chip. Today we are awash in medical data, yet a good primary care doctor is hard to find. For better or worse, the cowboys are gone. Although dismissed by Lee and Mongan as intolerably arrogant, the lone practitioner of the past was intensely proud of the service he delivered. A good internist, it was understood, left no diagnostic stone unturned and would bear any burden to see that his patient did well. As a medical student, I trained at the Jacobi Medical Center, a busy, woefully overcrowded New York City municipal hospital in the Bronx. There, back then, a student or intern who demonstrated a capacity to handle any and all crises, no matter how many seriously sick patients there were to see, was dubbed a “Jacobi Giant.” Ridiculously macho and very much out of date today, the term engendered pride among its recipients and offered recognition of a spark of professional integrity. “Not on my watch,” was the philosophy of the good doctor who stood his ground. In recognition of that tradition of professional commitment, the doctor was regarded as a pillar of the community, which provided him with a source of self-respect and deep personal satisfaction that reinforced the bond of the physician-patient relationship. Nowadays, deprofessionalized and demoted, the victim of death by a thousand cuts, the primary care doctor has lost motivation. Without that 100 percent commitment based on personal pride, primary care physicians cannot provide the patient with that essential element of care: the physician-patient relationship. The new motto of medicine has become “Good enough for government work.” To achieve high-quality primary care for all Americans, our next rendition of a health care system will need to consider carefully professional satisfaction among practicing physicians. A relationship is a two-way street; each party stands to gain by it. Other than a salary, not the prime motivator for the primary care doctor, what does the health care professional derive from the physician-patient relationship in the modern era of a deprofessionalized medical-industrial complex? We had better address this question quickly; there is a storm brewing. Now on the horizon are aging Baby Boomers, poised to “consume” health

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care voraciously and in unprecedented numbers. Although good primary care is the right of every American, we are, to be sure, a senescing society. Demography is destiny. Demand for service will rise precipitously at precisely the same time as primary care physician morale craters. We are now at a crossroads in care, changing the very meaning of what it is to be a primary physician. This is an experiment in progress, a bit of social tinkering, and we don’t yet know the outcome. As we reconfigure primary care for future generations, however, we should be very careful what we wish for; we may get it at our next office visit.

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“TELL HIM NOT TO DRIVE”

Mr. A is an eighty-eight-year-old former World War II bomber pilot who miraculously beat the odds by surviving multiple missions over Germany. His pluck and self-confidence are still evident today, even if his hearing, vision, and reaction time are no longer up to par. One day Mr. A elects to drive alone from upstate New York to New England to visit family. His six- or seven-hour “mission” starts off, though, with a critical miscalculation. Mr. A confuses a.m. and p.m. on his digital alarm clock at home, and he consequently sets out on his journey already quite late in the day. Long after nightfall, he is cruising along in his big Buick when a catastrophic pilot error occurs. Inadvertently, Mr. A neglects to note a do not enter sign, and he enters the exit ramp of a major highway. He is now doing 70 mph down the wrong side of the road at 2 a.m. Fortunately, his wartime good luck is still with him. He is the only driver on the road at this hour of the night. State troopers scramble to intercept Mr. A’s Buick, but not understanding their signals, he merely waves back to the officers who are motioning him to stop. The troopers have no choice but to set out tire-piercing metal strips, and Mr. A’s mission is ultimately ended by four flat tires. His driver’s license is seized on the spot. The police then transport Mr. A to the nearest hospital for evaluation in the emergency room. The medical staff there can find nothing acutely wrong with him. Looking through his possessions, they find in his wallet an office appointment card with my name and phone number. They call and awaken me to ask what should be done with Mr. A. Nothing better exemplifies an emotionally charged, hot-button issue than a doctor’s estimation of an older patient’s ability to drive a motor

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vehicle safely. Octogenarians are no different from teenagers in that they rank driving as essential to the enjoyment of a good quality of life. Certainly, in my clinical experience, this is truer for old men than for old women. The urge to drive must be on the Y chromosome. There is some truth to the perception that for older drivers keeping their license is essential. Mass transportation in suburban or rural communities basically does not exist. Driving is freedom. The elderly are no different from the rest of us who subconsciously harbor the notion that, as Americans, we have an inalienable right to drive wherever and whenever we so choose. The very old, for that matter, remember gas at 10 cents per gallon, when driving truly was unlimited. To the elderly male ego, being behind the wheel is like riding tall in the saddle. Many old men would frankly rather be dead than prevented from driving. I have known patients in their eighties who elected to keep on driving even after losing their licenses. They adopt a sort of kamikaze attitude, figuring that they have nothing to lose, with no consideration given to the safety of other drivers or pedestrians. The HIPAA privacy law trumps the authority of the local Division of Motor Vehicles. As a physician, I am prevented from notifying the local authorities of an illegal or potentially dangerous situation on the road involving my patient. As the law stands, patient privacy comes before public safety. Over the years, a recurring scenario in my office has been that of the frail and unsteady old man who totters into the exam room accompanied by his appropriately concerned daughter. As he slowly proceeds to the exam table, she pulls me aside and whispers in my ear, “Tell him not to drive, but don’t tell him that I spoke to you.” Here is a challenge in diplomacy. This man was driving an automobile long before I was born. Obviously, by the daughter’s look of frustration, the matter has already come up at home and it has caused some friction. Her father will immediately know what’s up and he will view any comment from me as proof of a conspiracy. There is an awkward moment in the exam room as I ask how he is feeling, listen to his chest, and check his blood pressure. I review his medications and lab results. I say, “Well, your blood pressure is good, your sugar is under control—and, by the way, you should turn in your car keys.” Sparks fly. He points at his daughter accusingly and erupts, “You’ve been talking to her !” Now I have stepped in it. I have become a lightning rod for his anger. So much for the physician-patient relationship on this visit! A de facto function of the primary care physician is to arbitrate in family matters that only loosely belong within the category of health. Driving is a prime example. There is no Medicare diagnostic code for participation

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in a family feud. Yet, traditionally, the physician, as an authority figure, has been called on to serve as a judge. The exam room is family court in session. To be sure, the passage of years takes its toll on the quality and safety of our skill as drivers. As we grow long in the tooth, we grow short on vision, hearing, rapid motion, and judgment behind the wheel. Macular degeneration, a progressive loss of retinal cells, degrades our vision, making it difficult to estimate speed and distance. Hearing loss, of course, doesn’t help. Advanced arthritis makes it impossible for the older driver to look fully both left and right before entering an intersection. A joint replacement or the loss of thigh muscle mass may make it difficult for an older driver to brake in time to avoid a child chasing a ball into the street. Poorly controlled diabetes may cause either low or high blood sugar levels with their deleterious effects on brain function. Neuropathy, the loss of the long sensory nerves to the feet, renders old folks unable to feel the foot pedals. Actually, it is truly remarkable that anybody in the geriatric age group can even get out of the driveway safely. Drugs only compound the problem. Sedation is a common side effect of many blood pressure pills. Medicines for diabetes can overshoot, causing hypoglycemic (low blood sugar) symptoms, including loss of consciousness. Hypnotic drugs such as Xanax (alprazolam by generic name) are often prescribed (or overprescribed, depending on your point of view) for anxiety. For the elderly, these medicines are likely to cause an increased risk of falls and to exacerbate memory impairment. They make bad driving much worse (Hindmarch 1979, 671). Even over-the-counter (OTC) medication can lead to disaster. I recall a patient in her seventies who took a single OTC antihistamine, got behind the wheel, and promptly totaled her brand-new Subaru. The little old man cruising down the road toward you may have had trouble figuring out how to start his car because of a “bit” of dementia with apraxia, the inability to perform simple routine sequences like brushing your teeth or turning the car key in the ignition. He may be on six or eight prescription medications with a potentially infinite opportunity for drugdrug interactions. Perhaps he has an implanted defibrillator that might go off, or a pacemaker that might not. This is scary stuff. So, how do we know when to pull the car keys? Who should be the heavy who just says no to driving? Many older drivers have enough self-awareness to limit their time on the road. They give up long trips and restrict their driving to local errands accomplished long before dusk. Higher gasoline prices may further restrict fixed-budget pensioners from driving. Finally, an “old-old” widower, no

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longer able to drive, may seek out and marry a “young-old” woman just for her wheels. Whose license should I pull? Is a fragile, slightly confused, creaky old man any more of an impaired driver than a distracted, texting, iPodwearing teenager with a car full of yakking friends? How about the multitasking business executive, doing deals on his BlackBerry while doing 50 mph in a 35 mph zone? In an era when drivers view red lights and stop signs more as suggestions than law, it is hard to say who can and cannot drive a motor vehicle safely. It is certainly not within the purview of the primary care physician to pass judgment on the older driver. It may be quite reasonable for a surgeon to advise against driving for a few weeks after surgery to let a wound heal and to avoid popping a stitch. It seems appropriate that a doctor advise against driving immediately after a heart attack or other transient major illness and while on certain medications. These are only temporary restrictions for a patient who is fundamentally a proficient driver. The primary care physician, however, should not be the judge and jury who ultimately pull the keys for good. I say this for two reasons. First, doing so permanently poisons the waters for the good physician-patient relationship that I wish to preserve. No one likes to be demoted in status or to have a privilege revoked. A patient’s anger may have been successfully diverted away from the patient’s daughter or other family member, and that is good, but that anger is now aimed straight at me, the doctor. I personally can attest that being an older patient’s punching bag is not so good. Second, a physician, while skilled at practicing medicine, is not trained as a professional examiner for the Department of Motor Vehicles. There is no office-based quiz, diagnostic test, or physical examination that I can perform to determine whether a patient can drive a car safely. The definitive indication of competence and safety behind the wheel is a passing grade on a driver’s test administered by a skilled, state-employed DMV examiner who knows how to evaluate good driving. I believe that the whole matter of elderly driver safety belongs outside of the medical examination room. Drivers over a certain age (which state legislators can and should define) should be required by their state to take and pass a driver recertification exam that would include a vision check, a written exam, and a road test. I personally believe that recertification exams should be administered biannually from ages sixty-five through seventy-five, and annually thereafter. There is a joke that circulates in Florida about two old women sitting on a park bench. One laments to the other about her poor health: “My

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joints ache, I can’t feel my toes, and I’m nearly blind. Thank God, at least I still have my Florida driver’s license.” To be fair, Florida, home to millions of very elderly retirees, does require a vision test for drivers who are eighty or older for them to renew their license (Florida Drivers License). Renewal, however, occurs only every four years (six years if there are no suspensions or revocations on record). When a person reaches his or her eighties a lot can change in four to six years. No road test recertification is required, even if the driver is a centenarian! State legislators are reluctant to impose periodic driver recertification because one thing older drivers are sure to do is vote. The issue of driver recertification for the elderly will gain greater public attention with the progressive graying of America. This is not only an issue between physician and older patient. Rather, it is imperative that we preserve the exam room solely for the delivery of health care. With the coming glut of octogenarians and the dearth of doctors pursuing primary care, no one will have the time or inclination to include the assessment of driver competency as part of the physician-patient relationship. In addition to the issue of driving ability, the high court of the exam room is called on to hear all sorts of cases pertaining to the complex emotional, interpersonal, and marital issues of the elderly patient. Some are remotely related to medicine; many are not. Often I am presented with conflicts that have smoldered for years. For example, a man’s wife may want to leave the Snow Belt and move to an easier, scaled-down patio home in a warmer climate where she can play bridge or mah-jongg. The husband has his workshop in the basement and his buddies in town. He’s not going anywhere. What are they to do? They each present their respective cases, venting loudly as I monitor their rapidly rising blood pressure readings. I can summarize for them the pros and cons of either choice, particularly as it pertains to their health, but I can render no definitive judgment. Their “day in court,” the office visit, is the therapy each seeks. Confrontation with such matters is a remarkably large part of my job description as a primary care physician to the elderly. Emotionally charged, complicated issues do not fit neatly into a brief appointment originally booked as a blood pressure recheck. It is like trying to squeeze an in-depth documentary or minidrama into a thirty-minute TV time slot. No wonder doctors run late! Nothing in my mind, though, better exemplifies the exasperating role of doctor as marital arbiter than the recurring theme of the husband who cannot hear. Hearing loss is one of the many consequences of the passage of time. The tiny conductive bones of the middle ear stiffen and the delicate receptive

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cochlear hair cells fade away. By our fifties, we are all a little hearing impaired, whether we know it or not. Many geriatric patients today, who were children in the pre-penicillin era, had recurrent ear infections that left them with substantial hearing impairment. A lifetime of noise exposure is another culprit, from which men suffer more than women. Military combat or years of industrial labor in the pre-OSHA era have left their mark on the husband who habitually says, “What?” Baby Boomers of both sexes will suffer the same fate for having attended too many rock concerts in their youth, and the iPod generation will have its troubles too. Our loss of hearing, however, is uneven. We lose the highest frequencies first, and the lower notes go much later. Unfortunately, most of the information within a woman’s soft speech is contained in the highest frequencies. To his wife, an old man’s poor hearing and inattention appear suspiciously selective. Who knows for sure? Maybe a man does have selective hearing. Many years ago I took care of an old couple who routinely came to the office together. He was a laconic retired farmer who quietly sat on the exam table while his wife ran the show from her seat in the far corner of the room. She worked her way through a long list of “his” complaints while rhythmically pounding her cane on the linoleum floor. As I stood next to the old man, she concluded the organ recital with “and he can’t hear worth a damn!” The quiet little old man suddenly leaned closer to me, impishly winked, and whispered, “I can hear you just fine.” So much of the role of the primary care physician in geriatrics is, in essence, nonmedical. Hearing aids and driver’s licenses are just two examples, but they are the sort of issues that may cement or fracture a physician-patient relationship, depending on how they are handled. The life-advisory aspect of the physician’s care falls widely outside the narrowly defined procedure codes devised by private health insurers. It is conspicuously absent from the Medicare physician manual, and it also fails to appear in the stepwise diagnostic and treatment protocols that are established by government and health insurance companies that champion efficiency and uniformity of care. Medical care of the elderly is theater. When the exam room is not family court, it is a stage or arena where real life dramas, tragedies, and comedies unfold. Today’s emerging movement to systematize the delivery of medical care into a set of algorithms, with quantitative measurement of results and their variance from the norm, does not jibe with the realities of caring for old people. The visit that included a rendition of the husband who can not hear was probably billed to Medicare as a “brief” or “limited” office

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visit for the management of the man’s high blood pressure, and it did not reflect the time, effort, grief, and frustration that went into achieving marital accord. Real doctors treating real patients understand the difference between what actually happens in the exam room and what Medicare codes must be chosen to comply with an arbitrarily restricted billing format that fits the computer. The coding is not an accurate representation, but it will have to do, as the technological paradigm of our era is the conversion of our analog world into a digital format that is compatible with the modern computer. As applied to geriatric medicine, however, we risk losing the qualitative art of medicine, as we morph health care into a sequential set of recipe steps that are, if not personalized, at least uniformly administered. The enormous variability that exists in the quality and cost of geriatric medical care perplexes and perturbs health policy academicians and Medicare administrators. Vast discrepancies exist from region to region of the United States and even from doctor to doctor. Why is it that diabetes management costs more in one region of the United States than in another? Why does one oncologist have a better survival outcome for breast cancer than another does across town? How did it come to pass that one colonoscopist charges and receives 25 percent more in one state than is allowed in another? These are valid and pertinent questions. The lack of uniformity of care and its costs has led to a push for nationwide standardization. The notion of uniform and standardized medical care in the United States has a certain appeal. After all, this is the nation that brought the world interchangeable parts and mass production. I can pull into a Holiday Inn off any U.S. highway and confidently expect that it will be like every other one that I have ever checked into. A Big Mac in New York, Los Angeles, or Des Moines will look and taste exactly the same. To an economist, there is no patent reason why medical care should not be as fungible as motels or burgers. Perhaps doctors are just interchangeable parts on a health care industrial assembly line. Standardization of medical practice offers the allure of uniform and measurable outcomes at controlled and acceptable cost. It is hard to reject such a promise summarily. The devil, however, is in the details as to the meaning of the word “measure.” What is just the right quality and quantity of medical care to be delivered to a geriatric patient? Thus far, we have taken only our first baby steps at standardization by measuring only that which is easily measurable. Auditing of the medical record has been limited thus far to screens for simple, narrowly defined markers of good care. For example, did the patient receive a beta-blocker (a drug that slows and protects the heart) after

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a heart attack (Beta-Blocker Heart Attack Study Group 1981, 2073)? Mark “Yes” or “No.” Does the patient with a chronically irregular heartbeat called atrial fibrillation receive the appropriate blood thinner, warfarin (Falk 2001, 1067)? “Yes” or “No”? Health insurers do random chart reviews checking for items in primary care such as the administration of a flu vaccine. Again, “Yes” or “No”? In keeping with the digital technology of our time, questions posed are structured in binary format (off or on, zero or one). Measuring the easily measurable in this fashion is analogous to the drunk who searches for his lost keys under the lamppost because that is where he can see. The Twenty Questions binary format of screening has no place in the evaluation of the fuzzier, more social and subjective element of caring for the elderly. For instance, consider the crusty, cantankerous old man brought to the office by his family because he has refused to take a bath for six weeks. Did the doctor convince him to bathe? “Yes” or “No”? Can the husband who says “What?” be coaxed into wearing his hearing aid? To drive or not to drive? These are not easy, yes-or-no questions. The nuances of good medical care for the elderly are not so easily measured, tabulated, or statistically manipulated. The modern movement toward standardization in medicine has a counterpart in public education. The No Child Left Behind Act of 2001 was a government response to the inadequacy of our public primary and secondary system of education. The first function of NCLB was to create standards of accountability for school districts through scientifically based research. Measurement by student testing remains an integral part of the program, although states still have a great deal of latitude as to the design of their testing protocols and data analysis. One unintended consequence of NCLB is that a school system can potentially game the system by “teaching to the test.” Why spend class time on a more advanced or challenging math problem that the teacher knows will not be on the exam? Like the Heisenberg uncertainty principle in quantum physics, the very process of making a measurement alters that which is being measured. For the sake of argument, let us assume that we could devise a workable computerized system of screening for quality and uniformity of medical care. Let us further assume that such a testing protocol is administered through random sampling of medical records in a fair manner nationwide. We might expect to find, as in a classroom midterm or final exam, that the resulting grades form something resembling a bell curve distribution with a median grade and outliers at either end. On the low end of the curve are the true medical malpractitioners who are unequivocally deficient in their

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standard of care. At the opposite far end of the curve is the perfect doctor, or God’s gift to medicine. He is the very model of a modern medical practitioner. He or she routinely exceeds all metrics for good medical care. The rest of us doctors fall somewhere in-between along the curve. By rigidly imposing a strict set of clinical criteria, we should be able to slide the worst doctors up the curve, at least a bit closer to what is considered nominally acceptable care. At the same time, those doctors who are severely deficient might be nudged to leave practice altogether. That sounds like a good thing. On the high side of the curve, however, something else could happen. The doctor with the most to offer in terms of clinical acumen, warmth, compassion, and understanding has only to achieve the median “score” to rank as a good doctor. Why go the extra distance? Why should she try to individualize each patient’s health care plan? As long as all of the right boxes are checked, why should the doctor deal with the complex social issues of aging that have no easy answers, for which they are not properly reimbursed and which are not even “on the test?” The net result of our quest for uniform quality is a forced regression to the mean. The analogy, again in the field of education, is that of teaching to the middle of the class at the expense of the exceptional students on either end of the bell curve. I fear that we are moving toward an era of uniformly bland medical care that is mathematically correct yet devoid of the human relationship between doctor and patient. Years ago, after I had completed a strained recital of a piece from Bach’s Notebook for Anna Magdalena, I was told by my piano teacher, “Every note was played absolutely correctly, and yet it wasn’t music.” How will we preserve the music of medicine in our digital, statistical age? I am not a Luddite. I embrace technological innovation in health care, and I am grateful for it, both as a doctor and as a patient. Advances in modern diagnostic equipment and sophisticated high-tech treatments are a welcome addition to the practice of medicine. Currently, computers are finding their way into health information management through the electronic medical record (EMR). Health care policymakers and the Obama administration highlight EMR as an absolutely necessary component of a modernized, efficient health care system. It is safe to say, though, that no politician ever lost a vote by criticizing a doctor’s handwriting. Nevertheless, I acknowledge that computerized records and computer-generated prescriptions should be a real advance against medical error. Ideally, the computer should outshine paper charts when it comes to the organization and retrieval of health information. With a stroke on the

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keyboard or the click of a mouse, a patient’s sequential blood studies, chest X-rays, or mammograms should be accessible for immediate review. The potential errors of a lab report misfiled in the wrong patient’s chart, or a critical lab result that goes unnoticed, should be prevented by a computer-based system of data storage and recovery. Every minute saved from searching through a thick paper chart could be utilized by the physician for direct care of the patient. Unfortunately, the computer does not score as well with regard to the efficient and effective recording of a physician-patient encounter. Software that is presently available demands that the physician personally input all data, obviating the cost of a transcriptionist, but it dips into time that should be spent with the patient. Such programs utilize templates rather than providing individualized narratives of a particular patient’s medical history and physical findings. Templates allow the physician to generate, again with just a keystroke, a huge volume of documentary boilerplate for the chart. A prepackaged Review of Systems with what are called “pertinent negatives” can be added to the record of any office visit, in effect making it look more detailed and complex than it truly is. Medicare coding rules permit substantially higher remuneration if the chart is supported through thicker documentation; so, in effect, the doctor is paid by the word. The current appeal of EMR is its ability to support and justify “up-coding” of physician charges by “bombing” the chart with paper. Was the man who was referred to the ENT (ear, nose, and throat) surgeon for a simple nosebleed actually asked if he ever contracted malaria? I doubt it. Proponents of EMR argue that it is certainly an improvement over the scribbled, illegible chart notes that still pass in some medical offices. Most doctors’ records today, however, are dictated and then professionally typed, using standardized abbreviations and nomenclature, concisely conveying an individual patient’s complaints, findings, studies, diagnoses, and a plan of management in a manner that is sharp, to the point, and universally understood by other physicians. The computerized EMR of today cannot yet beat that. Regardless of my reservations regarding EMR, the integration of the computer into daily medical practice is about to be a done deal. Unfortunately, there is a very large capital outlay required for office computerization with the hardware, software, and staff training that is necessary. The solo primary care physician, already suffering from relatively low Medicare reimbursement rates, will not be able to make the transition. Government-required computerization will at best be an unfunded federal

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mandate or at worst drive the primary care practitioner closer to an early retirement. My major concern is (and again I say this not as a Luddite, but more as a humanist) that the next step in the evolution of health care will be the complete adoption of the computer in medical decision making. The very essence of what it means to be the patient’s doctor is about to change. A doctor acquires a traditional medical knowledge base through years of clinical practice by individualized case-by-case learning. Today, however, we have access to a massive medical electronic database that is compiled from many times the number of patients that any one doctor could ever see. Databases are statistically evaluated, and the small discrepancies in outcome that correlate with differing treatments can be identified. Such differences would never have become evident to an individual doctor, because one medical practice is too small in sample size (Ayres 2007). This is the era of evidence-based medicine (EBM). Proponents of EBM argue that much of what we physicians do in our practices is outmoded, unproven, stale, and often just wrong. We recall pearls of wisdom imparted to us a quarter of a century ago by a professor in medical school. He had learned those clinical tips from his professor in medical school, and so on. Our own personal anecdotal experience biases our case management. A surgical colleague once remarked to me that his decision to operate was always influenced by the last patient that he had “killed.” I am fairly sure that he was being facetious. However, I do recognize that I have a tendency, for example, to order excessive CT scans of the chest in the weeks following a case of a newly diagnosed lung cancer. It is a very human form of decision making, albeit not a cost-effective one. EBM promises to do better (Sackett et al. 1996, 71). For any given case, somewhere deep in the compiled annals of medical research there exists a published study that is evidence based, timely, beyond reproach, and that tells me exactly what to do. I can find it on the web using my laptop computer, and it is irrefutably supported by evidence (i.e., fact). To paraphrase the late Senator Daniel Patrick Moynihan, I may be entitled to my own opinions, but I am not entitled to my own facts. Being over fifty, I cannot help but feel nostalgic for medicine as it was, but I acknowledge that EBM has something to offer. Its adoption is a foregone conclusion, and it is here to stay. The laptop is the newest addition to an already crowded exam room. I wish to focus, therefore, on how the physician-patient relationship will fare in the age of EBM. Envision how EBM will work in a typical scenario of office-based geriatric practice. Consider a patient like Mrs. B, a ninety-two-year-old woman

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in decline, who is precariously perched on the exam table with the vaguest of complaints, a complicated chart, and a fifteen-minute appointment. The doctor, having collected what information he can by history and physical examination, turns to the computer and consults the Oracle. The complaint is vague, so the search is long. Minutes go by. The doctor is mouse-clicking away as the patient and her daughter sit quietly through what appears to them to be a rude interlude. Mrs. B is escorted to the lavatory and back while the doctor continues to Google. On their return, he has printed for Mrs. B a set of test requisitions and a neatly computer-generated prescription for a trial of a medication. Patient and daughter now begin packing up and slowly heading for home. The doctor, laptop in hand, heads for the next exam room. Mrs. B and her daughter wanted their fifteen minutes with the doctor and they didn’t get them. The minutes spent by the doctor in isolation with the computer would have been better spent eye to eye in conversation with the patient. Patients like Mrs. B expect and deserve the doctor’s full and direct attention during their brief turn onstage. EBM does not take into consideration that often the visit with the doctor is the therapy. The skill of listening to an elderly patient is far too nuanced and subjective to fit into a one-size-fits-all template. Often, it is not the complaint of “chest pain” but the subtle wince and the fist-to-chest gesticulation that alerts the doctor that here is a serious problem. The doctor is processing the information within a context of prior knowledge of that patient’s own unique degree of stoicism, educational level, and ability to articulate. Matters of culture and colloquialism are factored in as well. I did my internship and residency in central Virginia, culturally a long distance from the Bronx, in New York City, where I had gone to medical school. Shortly after starting my internship, I was confronted with a patient who complained of a “right sharp” pain. I poked and prodded the right upper quadrant of his belly, but I could not elicit a tender spot. Some time later I learned that, in Virginia, “right sharp” was a measure of severity, not a location. He had a backache. Computerized EBM cannot possibly handle regional, colloquial phrases. It took me a while to learn that, in western Virginian slang, “low blood” was anemia, “high blood” was hypertension, and, embarrassingly, “bad blood” was syphilis. Keyword searches on EBM won’t be of much help here. Real doctors seeing real patients are translating a unique story that may or may not fit neatly into a package. Often, applying EBM study results to my patient is like trying to pound a square peg into a round hole. It just doesn’t fit. Personally, as a patient, I will take the doctor who listens and

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thinks over the one who recites medical studies about patients who may or may not be like me. I concede that there will be particular situations where the computer will be a welcome addition. I have practiced medicine in a college town. Professors who are patients are highly educated, computer savvy, and research oriented. They are likely to have already done considerable webbased searching before calling for an appointment. Some will come in with elegant Microsoft Excel spreadsheets and graphs of their blood pressure readings or finger-stick blood sugar levels, including tolerances, p-values, and multicolor graphics. The articulate patient with a well-defined complaint and a penchant for computers will leave the office happy with EBM. My computer search will have been merely a second opinion to the one he already found at home on his own. What will be the role of the doctor in this brave new world of medicine? It appears to me that it will be more passive than active. The situation is reminiscent of the plight of the original Mercury 7 astronauts whose story is told by Tom Wolfe in The Right Stuff (1979). Each was an experienced test pilot or was combat hardened by many critical missions. They each had many thousands of hours of flight experience, and they could “feel” the performance of their aircraft and adjust accordingly. Suddenly these seven sharp pilots had a new assignment. They were to be the human payload atop a modified ICBM, a job that most recently had been held by a monkey. There was very little in the way of skilled flying required in those first Mercury flights. The astronauts even had to demand a window from NASA engineers so that they could at least look outside the spacecraft while the mission was run from the ground. Under EBM, the “best” doctors of the future will be those who are protocol compliant, who tend the machinery well, and who can readily interface with the computer, rather than those with a skilled “feel” for the patient. The Oracle will pronounce the best supported and most appropriate therapy to be dispensed. The doctor will be there to explain to the patient “what the computer said,” serving only as interpreter in a computerpatient relationship of sorts. A course of therapy will be established algorithmically as a defined clinical pathway. (Such clinical pathways are already being written as checklists or series of “if-then” statements that form a decision tree.) The doctor will input the data and make sure the patient is proceeding properly down the path. The critical role for the doctor will be to avoid what computer scientists call “garbage in, garbage out,” or GIGO. It is easy with a little faulty data, a fuzzy set of symptoms, or unintentional tunnel vision to send a patient down the wrong clinical pathway

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and toward a battery of inappropriate tests and incorrect treatments. Once the boat sails, it is hard to turn it around. There is something deceptively appealing to Americans about a technological fix for what is in truth a social problem. Since the inception of so-called expert systems utilizing artificial intelligence, there has been the promise and prediction that they would do a better job than the people who preceded them. I find it curious that despite our perpetual optimism about computer technology, our modern science fiction literature has never been quite so sanguine. Recall that HAL, the omniscient computer of 2001: A Space Odyssey, ultimately required a decapitation of sorts due to a bug in its software. Computer-enabled EBM isn’t HAL, but it isn’t Dr. Marcus Welby either. Eventually, the computer will achieve its proper place in the delivery of primary care medicine to the elderly. However, that place will be alongside other diagnostic aids and devices such as the patient’s history and physical exam, appropriate lab work, an X-ray or the EKG. By narrowly focusing on the “high-tech” solutions, we ignore the big issue, which remains the lack of time for physician and patient to spend together in direct communication. Viewed from that perspective, the computer, as evidencebased Oracle, is a distraction. It siphons off valuable minutes from each physician-patient interaction that is already squeezed for time. Typically, an appointment with the doctor, excluding an emergency or the delivery of “bad news,” will run about fifteen minutes. At that pace, the doctor will see between twenty-five and thirty patients per day. Factoring in payer mix, a certain number of uncollectible or charity cases, and the management of patients of varying degrees of complexity, that is what the doctor needs to accomplish each day to cover office rent and other rising overhead, to make payroll and its associated taxes, and ultimately to end up with the average income generated in the field of primary care. A specialty surgeon may perform one or two surgical operations in a day, generating four-digit revenues in the process. The primary care physician, however, makes his or her living on volume. It probably will not sit well with those who go to the doctor (and that is just about all of us) to know that that they can be classified as “volume,” like hypothetical “widgets” coming down a factory assembly line. The public, and our legislators for that matter, do need to appreciate that a medical practice is a small business, subject to the same microeconomic principles as any other. It may be unique in that it is altruistic, but a medical practice is also an entrepreneurial endeavor.1 Not to be crass, but time is money.

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With that brief introduction to the elementary math of private practice, I now focus on how we typically spend time in geriatric care, rather than take the traditional congressional approach of looking at Medicare’s expenditure of dollars. To fully appreciate what transpires in a fifteen-minute geriatric office visit, I introduce the little old lady with the crumpled list. The public has been rightly counseled by on-the-air TV health commentators on shows such as Today or on brief local news health segments that it is best to write down one’s complaints prior to an appointment with the doctor. This is sound advice. It decreases the likelihood of omitting a symptom or physical abnormality during the all-too-brief fifteen minutes onstage, when one is likely to become flustered. A written list sets an agenda. A little old lady arrives, plunks herself down in the exam room chair, and removes from her pocketbook a small, crumpled, piece of notebook paper or a cancelled envelope that contains a penciled list of eight to ten items. It looks like, and may even be accompanied by, her grocery list. The elderly woman likely has sat for an hour in the waiting room while other patients’ crumpled lists were addressed, and she has every expectation that hers will be covered in full. Note that, for a fifteen-minute appointment, a list of ten items will allow only ninety seconds per medical matter. This clearly is not going to happen! A discrepancy exists between the patient’s unrealistic expectations and the physician’s capacity to satisfy them in the course of a routine office visit. Some doctors handle this problem by permitting the woman with the crumpled list a selection of any two items for discussion on that day. The remainder of the list is then to be saved for a future visit. This allows the patient to prioritize with some autonomy, while the doctor still sets a limit. In my mind, this approach is too much akin to ordering in a familystyle restaurant where you get a choice of any two side dishes, soup, or salad. To date, I have never found an effective technique for truncating a crumpled list without incurring resultant “customer” dissatisfaction. In How Doctors Think (2007), Dr. Jerome Groopman has explored the process by which the physician sorts clinical information in order to arrive at a proper diagnosis. The pitfalls of practice include erroneous assumptions, a bias in favor of the common malady and against the rarity (“If you hear hoof beats, don’t think zebras”), and a tendency to incorporate into our thinking only that data that “fits.” Well before the diagnostic process begins, however, with all of its inherent opportunity for judgment error and mishap, the doctor must first zero in on what it is that primarily bothers the patient. This is not always so easy.

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We are taught in medical school to identify the patient’s one chief complaint as the issue on which to focus. The balance of a patient’s other complaints, prior diagnoses, and chronic ailments come under the heading of past medical history in our effort to organize and to break down a long, complicated story into a more manageable outline format. What the patient’s chief complaint is, though, may not truly be the chief problem. Buried somewhere toward the bottom of the crumpled list may be an oblique reference to an episode of breathlessness or a fleeting episode of slurred speech that carries real portent. It may well be obscured by a lengthy recitation of minor ailments or age-appropriate malfunctions. The task of the primary care physician is to separate the wheat from the chaff adeptly in a matter of seconds. The critical, and truly chief, health concern may be on the crumpled list, but it may be well camouflaged. Two or three of the items on the crumpled list are reminders to ask the doctor about a particular OTC product. The list is often stapled to clippings from the local newspaper consisting of syndicated columns touting the health benefits of a supplement, vitamin, lotion, or potion with imputed medicinal properties. The older female patient is perpetually subject to endless weight-loss hoaxes. The old men, carrying already empty pill bottles, ask for my opinion on the newest “male enhancer” or putative aphrodisiac that promises to restore their virility to that of a twenty year old. Some such products are, at best, only toxic to the wallet, and are otherwise harmless. Some pose a real risk. Ma huang, or ephedra, an herbal supplement used for weight loss, carries a significant risk of cardiac harm. I had in my own practice one seventyyear-old woman who came in with a bag of ma huang under her arm and a fresh heart attack on her EKG. Another developed a cardiac arrhythmia (irregular heartbeat) as a result of using the same product. Because of such problems, New York, California, and Illinois have banned the substance. The message is, obviously, caveat emptor, but the elderly are often easy prey to hucksters. One of my tasks, as I work my way through the crumpled list in the sparse time allotted, is consumer protection. Purveyors of herbs, vitamins, and other supplements that fall below the radar of the Food and Drug Administration (FDA) are not the only companies that target my patients. The major pharmaceutical corporations through direct market advertising on TV and in print bombard consumers, effectively selling the disease along with its treatment (Rose 2007b). In chapter 3 I address how such marketing leads to the overmedication of the elderly, but here I will state that such ads have a deleterious effect, particularly on geriatric health, simply because they squander time.

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Each ad terminates with, “Ask your doctor if [our pill] is right for you.” As so instructed, that is precisely what patients do. Every minute wasted discussing an ad about the relatively obscure restless leg syndrome or the “heartbreak” of toenail fungus is subtracted from the already scant time reserved for private and personal conversation between patient and doctor. More relevant and pressing concerns such as screening for depression, assessing the risk of a fall at home, or discussing proper nutrition come only after the obligatory product review is completed. More likely, those and other important matters will go unaddressed because time runs out. How much healthier would my patient be if there were no direct market advertising of pharmaceuticals? There is no direct way to measure. I do know, though, that, more often than not, I end each office visit with a vague disquiet that all of the important items on my list have not been touched on. Could I have prevented a broken hip if I had had a minute or two more to tell a patient to toss out a slippery throw rug or to buy a nightlight for the bedroom? I strongly suspect so. When we finally come to the bottom of the crumpled list, an elderly woman will sometimes pause, with a look of consternation. She has forgotten to include something and she cannot remember what it was. I wait while she struggles to think. Some minutes go by. Then, with an “Aha!” she recalls that the missing item on her list is the complaint of mild forgetfulness. Elderly patients dread Alzheimer’s disease more than a fatal cancer. The “Aha!” moment, however, is more indicative of the benign forgetfulness that comes with age, and it is worth taking the extra few minutes to see if she can make the recollection on her own. I can then reassure her that she is likely not becoming demented. That would be a more productive use of our time than much of what preceded it. There is another factor that impedes the rate at which a doctor can see older patients. Like everyone else, the elderly are naturally reluctant to bring up health matters that are embarrassing, strange, and new or that are likely to result in an unpleasant workup or to portend an unfavorable diagnosis. Proper and dignified women, who came of age long before the sexual revolution of the 1960s, are not willingly going to discuss matters that originate below the waist, such as rectal or vaginal bleeding. Also, many women of this era have no knowledge of their past gynecologic surgical history. They may have had a “procedure” in the 1950s, but they don’t know if they still have their ovaries, or, if one ovary remains, which one it is. Such things were not discussed. There is a natural reticence about very personal and sensitive matters. Sometimes the reticence is due to the patient knowing that the symptom

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is definitely not a good thing to have and that it means real trouble lies ahead. Other times, patients engage in magical thinking, in which they believe that talking about a possible problem will make it real. Regardless, it can be difficult and time consuming to extract a patient’s story. An old man may come in for a routine checkup. We have a pleasant conversation. I review his lab work and update his health maintenance list. Next, I renew his prescriptions. We shake hands, plan a return visit for six month, and, with my right hand on the doorknob to leave the exam room, the man says, “Hey Doc, it doesn’t mean anything if I’ve been coughing up blood every morning for the past two months, does it?” My hand comes off the doorknob. We start the visit over from scratch to address yet another “Doorknob Diagnosis” (Casalino 1999, 1147). Such reluctance to reveal trouble is quite human. The extra time required of the physician to get the full story is just the nature of the business. Speeding up patient care with faster visits so as to see ever more patients only makes it less likely that the patient will muster the courage to tell me what is really wrong. Human nature is the ultimate rate-limiting factor, regardless of what patient volume may be mandated by an HMO or by the economic constraints of private practice. To provide high-quality care to an aging nation, we are all going to have to slow it down a bit. To grasp the true complexity of primary care of the elderly, we must appreciate the extent to which psychiatric factors color and intertwine with our overall health and our perception of bodily well-being. Depression in the elderly is rampant (Unützer 2007, 2269). It is underdiagnosed and undertreated. Each small decrement of function, such as a decline in vision or agility, is accompanied by a grieving process. The latter phase of life is one long series of adjustment reactions. Those who don’t adjust well are likely to suffer from depressive illness. Loneliness and isolation, a sense of vulnerability, and a perceived lack of purpose in life put the elderly particularly at risk. Some elderly patients express to me the keen self-awareness that in their life, contrary to the English poet, Robert Browning, “the best has already been.” Depression can be as lethal as cancer. Suicide is the most dramatic manifestation, but many of the elderly who suffer “the dwindles,” lose weight, and fade away, do so at least in part because they are depressed. Additionally, there is evidence to suggest that depression directly promotes coronary artery disease, and perhaps cancer as well. Chronic anxiety disorder is another psychiatric malady that afflicts the elderly to an excessive degree. I cannot specify why this is so, although I think that older patients have a sense that the world today moves faster

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than they can go. The immediacy and rapidity of modern communications is not particularly healthy for the aged nervous system. Constant, frequent repetition of video clips of war atrocities, gruesome murders, natural disasters, and other emotionally charged images and sounds leads to an input overload that is a personal health corollary of the “CNN effect” (i.e., instant reporting and a short news cycle demand immediate governmental response). The repetitive cycling of the news amplifies its anxietyprovoking effect. Turning off the TV, which many older, isolated people leave on all day as background noise and as a companion, may be the best solution. We must remember, though, that severe anxiety is as agonizing as a kidney stone or a severe migraine. These old people really hurt. Remarkably, the terms “depression” and “anxiety” are not in the lexicon of Medicarespeak when it comes to geriatric primary care. A non-psychiatrist cannot bill Medicare for diagnoses that are psychiatric in nature. To clarify, I can see a patient for depression, I can treat it, and I can bill for it, but I will never get paid for my efforts. Physicians must creatively concoct diagnostic codes for the symptoms of depression such as “insomnia,” “fatigue,” or “weight loss,” but we cannot use the D-word itself with Medicare or private insurers as though, by fiat, the problem simply does not exist. The refusal by Medicare and other insurers to acknowledge and cover psychiatric illness in primary care is appalling and primitive. It is an early twenty-first century application of seventeenth-century philosophy. It was French philosopher René Descartes who postulated a distinct split between the body and the mind. One of the greatest impediments to primary care of the elderly remains the need for the acceptance of mind and body as inseparable. A person in chronic pain may secondarily become depressed, but conversely, a depressed patient may come to the doctor because he hurts. Cartesian dualism of mind and body does no one any great service. We need to get past it and move on to a more modern, all-encompassing paradigm. Medicare bureaucrats need to rewrite their manuals. There are far too few psychiatrists in private practice to accommodate the demand for their services. They schedule appointments rigidly by a time clock (i.e., thirty-minute or sixty-minute sessions), and thus they cannot readily “squeeze in” a new patient in crisis. Older patients, in my experience, are reluctant to accept a referral to a county mental health center that, to them, seems cold and institutional and that carries the negative connotation of being for “crazy” people. So, whether insurers acknowledge it or not, most psychiatric care for the elderly is delivered by primary care doctors. A phenomenal improvement in the treatment of depression occurred in 1988. Prozac, the first of the new class of antidepressants called selective

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serotonin reuptake inhibitors (SSRIs), was released (Kramer 1993). With its enhanced effectiveness, relative safety over older drugs known as tricyclics, and its ease of dosing, the treatment of uncomplicated depression became routinely within the capacity of the primary care doctor. In the course of my career, I probably have written more prescriptions for Prozac than for penicillin. Future drug development, which goes beyond serotonin and the SSRIs, will someday further enable primary physicians to treat psychiatric illness effectively (Thase 2007, 2400). What we lack, though, is adequate time with each patient to do the important personal counseling that should properly accompany drug therapy for depression and anxiety. Once again, caring for the elderly, mind and body, is all about having enough time for physician and patient. Medical care of the elderly remains more art than science. It requires considerable reflection on the individual nature of each patient’s personalized management. Compassionate geriatric care does not lend itself well to algorithmic “cookbook” formulas. It does, however, take a great deal of time. And what became of Mr. A, the aged bomber pilot who was grounded by the state police? He showed up in my office a few days later, carrying a packet of forms and requesting my signature so that he might restore his status as a legal driver. I could not, in all good conscience, affirm that he was fit to drive. After a lengthy and lively discussion, he left in a huff and subsequently found another physician to sign his forms. Mr. A was not at all interested in the latest evidence-based protocol for managing his hypertension. He could not care less about his neatly formatted medical chart showing the results of his neurological examination. He just wanted to drive. The pressure on me to sign his forms was intense, and the visit was consequently strained, but in the business of medicine, the customer is not always right. Mr. A continued to drive for nearly a year, until his frailties finally caught up with him. Until that point, he could be seen about town, cruising in his big Buick, more than sixty years after his last bombing run over Germany.

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3 POLYPHARMACY

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THE PROBLEM WITH PILLS

We are a nation of pill poppers. In the United States, it is culturally acceptable, if not expected, that one should turn outward (i.e., take a drug) to relieve the pain, suffering, or bodily dysfunction that stems from within. A drug is an exogenous substance (from outside the body), ingested or infused, smeared or inhaled, that changes us in some way. Since all drugs, even a lone aspirin tablet, have side effects, it would be more proper to say that every drug affects us in some ways. Our modern pharmacopoeia, the full collection of our chemical bag of tricks, is enormous and ever growing. We can subdivide the drugstore into areas for prescription medications, over-the-counter (OTC) formulas, alternative remedies, or dietary supplements, but it is all pharmacology of one sort or another. The term polypharmacy means simply “many drugs.” It lacks either positive or negative connotations. Yet our pharmaceutical armamentarium is a double-edged sword. The same pills that can push back death, when taken in the wrong dose, in the wrong combination, by the wrong person, or just with bad luck, can lead to disaster. Any physician who has ever written a prescription that led to a catastrophic complication knows the power of the prescriber’s pen. Polypharmacy may be quite appropriate in certain cases. The elderly patient with an end-stage failing heart requires fine-tuning with six or eight medications plus supplemental oxygen therapy (also a “drug”) to reduce the burden on her weakened heart and to keep her from drowning in her own bodily fluid overload. Management of such a delicate patient is like a constant high-wire circus act, in which a bit too much of one medicine or too little of another will nudge the patient out of balance and result in a

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precipitous “fall.” The careful and thoughtful titration of pharmaceuticals in such a case represents the art of medicine at its finest. In contrast to appropriate polypharmacy is the inappropriate, if wellintentioned, inclination to heap pill upon pill without consideration given to the downside: serious allergic reactions, sedation and confusion, falls, drug-induced poverty, or even an early grave. Like all other aspects of primary, and particularly geriatric, care pharmacologic management is complicated. It requires careful observation, titration (adjustment of dosage), and flexibility of therapy, as well as good communication by the doctor and accurate reporting by the patient. For this reason it is also one of the most complex and vexing activities of the primary care physician, especially in an era when pharmaceutical companies assail both young and old with advertisements on TV and newspapers, while magazines and the Internet proffer medications that promise to “fix” everything from diabetes to sex lives. All of this makes the challenge of the proper usage of our pharmacopoeia, which revolves around two well-established medical principles, ever more daunting. The first principle is a medical aphorism attributed to Hippocrates: primum non nocere (first, do no harm). That seems like sound advice—if only it were so easy. The second principle, more modern but of uncertain origin, is that “there ain’t no such thing as a free lunch.”1 In medical school, my professor of pharmacology opened his course by stating emphatically that “every drug has side effects.” At the time, I could not appreciate how right he was, but I do now. Today, I would propose a corollary that “all patients should be told all of the time that all drugs have side effects.” As we explore the successes and pitfalls of polypharmacy, we must remember that drug therapy, as practiced by early twenty-first-century physicians, is still a uniquely tailored form of care for an individual patient by a physician who knows him as well, if not better, than she knows the chemistry involved. In this respect, it is humbling to acknowledge that the physician of today remains very much like the shaman of primitive cultures who selected just the right herb, potion, or incantation to ameliorate a tribe member’s personal and particular ailment. For at least 2,500 years of recorded history, all medicine was herbal (Nixon 2006). Physicians and botanists were one and the same. Hippocrates (460–370 BCE) prescribed approximately two hundred different herbal remedies in his private practice, and there is evidence that his contemporaries in China did the same. Theophrastus (372–287 BCE), the “father of western botany,” devised a system of classification for trees, shrubs, and herbs that he collected throughout the Mediterranean. Physician-botanists

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collected and classified their specimens and prepared various extracts and poultices on a purely empirical basis, while being good naturalists they kept careful records. Trial-and-error investigation of botanical remedies was a painstakingly slow way to stock the drugstore. Our modern herbal pharmacopoeia was built in tribute to the countless botanists of prehistory whose tragic last dying words may have been, “Don’t eat the little red berries.” While the early physician-botanists were long on empirical observation, they were short on the understanding of an herb’s mechanism of action. There was neither scientific method nor any notion of the randomized double-blind, placebo-controlled study that is today the foundation of our modern drug-approval process, regulated by the Food and Drug Administration (FDA) (Hawthorne 2005). There was, however, the doctrine of signatures. If the shape of a particular herbal leaf or flower approximated the shape of a particular human organ, then that was believed to be a clue to its clinical usefulness. Pulmonaria, a shade-loving garden plant commonly called lungwort, was employed to treat respiratory diseases (hence its name) because its shape resembled that of the human lung. Its shape was its “signature” as an herbal remedy. Philip Theophrastus Aureolus Bombastus von Hohenheim (1493–1541), or Paracelsus for short, was the Swiss physician, alchemist, and herbalist who promoted this doctrine throughout late-medieval Europe (Ball 2006). He could be considered the first traveling pharmaceutical representative, or “drug rep.” It is tempting to look back and laugh at an era long ago when a drug’s mode of action was completely absent from the medical curriculum. It is also humbling, however, to look through today’s Physician’s Desk Reference (PDR), a thorough compendium of modern drug therapy, and count the number of pharmaceuticals with the mechanism of action still listed as unknown. Despite a total lack of understanding of mechanism, empirical herbal drug discovery did lead to some striking successes. The two aspirin I took this morning for my sore back contain a compound, acetylsalicylic acid, once extracted from the bark of the willow tree. Malaria, which had been a periodic scourge of southern Europe, was at least partially suppressed by quinine, a derivative of the bitter bark of the cinchona tree, imported from the New World in the 1600s (Rocco 2003). Digitalis, a chemical from the crushed foxglove plant, is still in use today for abnormalities of cardiac rhythm, and, more recently, Taxol, first extracted from the bark of the Pacific yew, has been established as a potent chemotherapeutic agent. With regard to certain herbals, it has been difficult to improve on nature.

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It is intriguing to speculate that the world’s shrinking jungles and forests are teeming with species that could yield the next blockbuster pharmaceutical or the cure for cancer or AIDS. Plants are able to synthesize myriad foul-tasting or toxic chemicals as a defense against insects and herbivores. In theory, biochemists should be able to “bioprospect” for such pharmacologically active chemicals, but, thus far, this approach has had only limited success. Shaman Pharmaceuticals, a formerly publicly traded, San Francisco–based drug firm, abandoned its natural approach to drug discovery because it could not obtain FDA approval before running out of cash in 1999. Presently, the Chinese have embarked on the Herbalome Project (a neologism derived from the Genome Project) to identify and catalog the constituents of centuries-old traditional herbal medicines (Stone 2008, 709). Even if ultimately unproductive, the allure of undiscovered medicine in the rain forests at least remains a strong argument for conservation. At first glance, it would seem a bit of a stretch to go from the botany of the forest primeval to the heavy prescription and consumption of modern pharmaceuticals in the developed world. Why do we take so many pills? The overzealous prescribing habits of time-pressured doctors and the slick marketing strategies of Big Pharma corporations are only partly to blame. It is in our very nature, as human primates, to seek and consume medicine. In fact, there is evidence that certain great apes including East African chimpanzees, bonobos, and gorillas, intentionally self-medicate by ingesting nutrient-poor barks, leaves, and bitter plant pith for pharmacologic effect, rather than for any general nutritional value (Huffman 1997, 171). Such botanical remedies appear to control parasitic infestations and relieve gastrointestinal upsets. Similar behavior has been demonstrated in wild chimpanzees in the Kibale National Park in Uganda (Krief, Hladik, and Haxaire 2005, 1). These primates ingest several plant species that are touted by local traditional healers for their medicinal benefits for humans. Zoopharmacognosy, or the knowing, intentional self-medication conducted by animals, may offer some insight as to why we so readily accept prescriptions from our doctor and why we swallow fistfuls of pills on a daily basis. It is in our nature as a species to do so.2 Today, our drugs are synthesized, not picked from trees. Systematic screening of thousands of chemical compounds has replaced serendipity in drug discovery. Vast libraries of compounds now exist that can be tried off the shelf for any new clinical application that may arise. Despite the current bad boy image of the pharmaceutical industry due to perceived price-gouging, their decades of past research and development have given

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us a remarkably effective, albeit nearly unaffordable, medicine chest. Thus, the second reason that Americans take so many pills is that we have so many effective ones at our disposal. Nothing better illustrates the gift of modern pharmacology than a case history that predates the modern era of drug therapy. This is a clinical history from 1944–45, well before my time. The patient, President Franklin D. Roosevelt, was a sixty-three-year-old overworked executive who carried the weight of the world upon his shoulders. He was normally known for his trademark exuberance, positive attitude, and jaunty style. His primary care physician, however, had begun to notice in late 1944 that FDR appeared much older and quite haggard. He described FDR as “in the best health for a man his age” (that qualification gives insight into the perception of what constituted longevity sixty-five years ago), but the president was, in fact, a very sick man. A cardiologist, Dr. Howard G. Bruenn, was quietly consulted, and on performing a thorough physical examination of the patient was appalled by what he found. The president was seriously ill with an astoundingly elevated blood pressure. He was visibly short of breath, and his chest X-ray confirmed a failing heart. In the 1940s there was no medical therapy for high blood pressure. Dr. Bruenn tinkered with the president’s diet, and he encouraged rest and weight loss, but these were the clinical equivalents of rearranging deck chairs on the Titanic. Digitalis, the ground-up leaf of the foxglove plant, was administered for heart failure, and it appeared to have been briefly and marginally beneficial. Dr. Bruenn, stymied by a primitive pharmacology, had nothing else to offer. He kept detailed records of his patient’s disturbingly high blood pressure readings, but he could not intervene. On April 12, 1945, the president succumbed to a massive cerebral hemorrhage. The case of FDR’s demise is often presented for review by medical historians because of the pivotal importance of presidential health, the detailed medical documentation by Dr. Bruenn, and because it is so tempting to ponder the “what if” aspect of this sad chapter in American history (Ferrel 1998). I recount it here to remind us that the polypharmacy we embrace today is a remarkable human triumph, a fact that is obscured by the current bickering over who will pay for our pills. A sixty-three-year-old man presenting to his doctor in the first decade of the twenty-first century would receive a cocktail of medications to lower his blood pressure and to relieve his failing heart. He would take a potent diuretic to flush out an overload of fluid and salt. His squeezed, hypertensive arteries would be relaxed with a class of drug called angiotensin

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converting enzyme (ACE) inhibitors, and the deleterious effect of his own hormone, adrenaline, would be countered with a beta-blocker to slow his heart and improve its efficiency. What was previously called malignant hypertension (malignant in the sense of lethal, not cancerous) today would be labeled treated hypertension, just another line on a patient’s problem list of chronic but manageable disorders. Having given due praise to the achievements of our modern pharmaceutical chemists, consider now whether patients today really need to take so many pills. One reason that we do consume a slew of pills is that modern man suffers from a combination of “diseases of excess,” the physiologic downside to our affluent standard of living. With our inexorable progression to obesity,3 our high-stress but sedentary lifestyle, and our food chemists’ clever skill at salting, sweetening, and “trans-fattening”4 packaged food products, we have morphed into a new, modern form of man that suffers from the “metabolic syndrome.” That is the term now given to the combo of obesity, high blood pressure, diabetes, and elevated cholesterol. This constellation of maladies, if unchecked, leads to heart disease, stroke, and an early death due to vascular disease. The metabolic syndrome now looms as a potential cause of the first decline in recorded American life expectancy. Hippocrates wrote that strong disease requires strong medicine. The modern corollary is that combo diseases require combinations of medication. The overweight man or woman of today will likely take one or two pills for hypertension, a few for high blood sugar, a statin (e.g., Lipitor, Zocor, or the equivalent) for high cholesterol, and a blood-thinning low-dose aspirin tablet thrown in for good measure. There has been some thought given to combining all of these various substances into one large daily pill as a sort of “multivitamin” for twenty-first-century man. At some point we must acknowledge that a portion of polypharmacy is of our own doing. It is much easier to take a handful of pills each morning than to lose thirty pounds and adopt a prudent, healthy lifestyle. Nevertheless, the costs add up. A sufferer of the metabolic syndrome, taking six medications, each with a $20 insurance co-pay at the drugstore, is spending $1,440 per year in prescription medication costs, beyond the baseline contribution to an employer-sponsored health insurance coverage. We curse the pharmaceutical companies as we leave the drugstore, but much of the blame for high expenditure on medication can be found when we look in the mirror. Traditionally, it would not have been considered appropriate to administer a medicine to a patient who did not have a physical complaint or who did not appear to be sick. This philosophy of practice falls under the rubric

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of “if it ain’t broke, don’t fix it,” a slogan not attributable to Hippocrates. I can recall an instructor in medical school who preached that we were to treat the patient, not his isolated abnormal lab result. Today, with better diagnostics and an improved understanding of diseases, there has been a shift in our approach to the seemingly well patient. We now take a proactive approach and treat “proto-diseases” (Rose 2007a, 84–85). An elevated lowdensity cholesterol, or LDL (the “bad” cholesterol), is treated long before it can clog the coronary arteries. The earliest sign of osteoporosis, seen on a screening bone-density scan, is treated with a drug called a biphosphonate (e.g., Fosamax, Actonel) to prevent a fracture decades hence. Intuitively, an ounce of prevention should be worth a pound of cure, but, again, the net result is that nearly all older Americans now have a row of little plastic medicine bottles on the bathroom shelf. A patient of mine once remarked that, on average, it came to a “pill per decade.” He was just about right. The taking of medicine, once reserved for the amelioration of, and later for the prevention of, disease, now has been applied to the selfimprovement of body and spirit. This is the age of “designer” drugs. If one wants a poker face at the negotiating table, he can get a shot of Botox to make his emotions unreadable. If a music student at Juilliard is nervous before a performance, she can take an Inderal tablet (propranolol, a betablocker) to take away the shakes and the butterflies. The SSRI antidepressants offer the option of designer personalities. Why be shy? There is a pill for that. Our evolving pharmacopoeia one day may lead to an Alicein-Wonderland world where, as the song goes, “one pill makes you larger and one pill makes you small.”5 The market for designer drug use is not limited to the young. A ninetyeight-year-old man came into my office one day and requested that I prescribe a single tablet of Viagra “just to refresh his memory.” I could not comply with his wish because he had a complicating heart condition, but I admired his spunk and his sense of nostalgia. Once the link between disease treatment and drug use is broken, there is no longer any way to measure the appropriateness of polypharmacy. Bioethicists debate the implications of a pharmaceutically enhanced human being. Is it a cheat, or is this better living through chemistry? I personally have no qualms about prescribing medication for what would not conventionally be called an illness. If the patient seeks to better himself in some way through a new, legal technology, in close consultation with his physician who has explained the risks and benefits, then it would be paternalistic to deny such drug usage. Just as plastic surgeons augment breasts, we will be able to augment many other aspects of our bodies and

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ourselves with the aid of a prescription pad. The geriatric Baby Boomers of the near future will embrace a new pharmacology wholeheartedly in their old age, perhaps in a way reminiscent of their willingness to “experiment” with other kinds of drugs in the 1960s. Homo sapiens, with our primitive primate inclination to self-medicate, is evolving into a new, higher-order form of Polypharmaceutical Man. Turn now to the dark side of polypharmacy. The direct marketing of drugs to those whom the pharmaceutical industry calls consumers, or whom I call patients, undermines the rational and proper use of our blossoming pharmacopoeia. Slick TV promotions, using warm-and-fuzzy filters, mood-manipulating music, and attractive celebrity spokespersons, result in an irresistible urge to ingest a pill that is so advertised. By causing patients to appear in their doctors’ offices with a request for a specific drug by name, rather than with a chief physical complaint, direct-market advertising turns the physician-patient encounter on its head and pressures the physician to overprescribe. The advertising of patent medicines, otherwise known as snake oil, dates back to the days before passage of the Food and Drug Act of 1906. For most of the twentieth-century, the American Medical Association was able to suppress direct advertising of drugs. Pharmaceutical ads were restricted to professional medical journals, where physicians could evaluate them in the proper context. By the 1990s, however, a wave of consumerism forced the reassessment of the direct marketing of pharmaceuticals. It was argued that consumers should be “empowered” to know their “options” and to consume with “autonomy.” The advent of the Internet led to the new process of disintermediation, or getting rid of the middleman. Why blindly accept the recommendation of your doctor when you can view an ad on TV or on the computer, pick your pill, and take charge of your health? The drive toward direct marketing of drugs in the past decade has not been a matter solely of freedom of speech or consumers’ rights but is a part of a larger trend in our society that eschews authority figures in general. In this regard, the doctor’s professional status, respect, and esteem have been diminished, just like those of politicians, lawyers, police, and teachers. There is, however, one fundamental difference between drug advertisement and all other forms of direct product marketing: the patient still needs a prescription. That is why the persuasive voice in the ad says, “Ask your doctor.” Here is the real “gatekeeper” function of the physician. I hold the keys to the drugstore. The TV ad promises my patient that a new sleeping pill will give him sweet dreams, inner peace, and a sunny

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morning. The patient says to himself, “If only my doctor weren’t standing in the way and would just give me the damned prescription.” Never mind that the product may cause addiction, memory loss, sleep eating, or zombie driving as side effects (no free lunch). I, as the prescribing physician, will carry much of the legal liability for this transaction when the drug is recalled two months later due to inadequate postmarketing evaluation. I will be the one accused of professional negligence. Further, it seems to me, at least anecdotally, that where the indication for treatment is the softest, the side effects are most consequential. It is true that the TV drug ads do mention side effects, but they do so in small print, at high speed, dumbed down, and in contradiction to the subliminal and emotional message which is “It’s OK—Go ahead. Take the pill. Those side effects are for other people.” Now is the time for us to modify our approach to the direct-market advertising of pharmaceuticals. We need to restructure policy so that U.S. citizens remain patients first and consumers second. It is, of course, the goal of a pharmaceutical company to sell as much of its product as it is able, thereby returning maximal value to its shareholders. That is what a corporation is supposed to do. More insidiously, though, by hawking its product, it also is able to set a health care agenda. Big Pharma has a predilection for the development of remedies for chronically remunerative disorders, thereby ensuring a long and steady return on companies’ investment in research and development. That is why there are plenty of pills for chronic arthritis, enlarged prostate, leaky bladder, and erectile dysfunction, yet few new oral antibiotics (taken for no more than ten days). By engaging the patient through TV ads to “ask your doctor,” the drug company effectively seizes control of the exam room and hijacks health care. Omitted is any discussion of nonmedical remedies such as diet, exercise, or physical therapy. We go directly to the prescription pad. The pressure to prescribe is not so subtle. Patients have told me outright that if I don’t prescribe “the purple pill,” or whatever they want, then they will find a physician who will—and they do so. An older doctor, with a well-established practice, may not feel particularly threatened. A new physician, however, building the medical practice that is her livelihood, may be more likely to buckle. Regardless, all primary care physicians are pressed for time. It would take me a lot longer to explain why a patient should not take the pill seen on TV than to “just write the damned prescription.” Interference with the physician-patient relationship amounts to nothing less than a threat to public health. When viewed in this light, it is palatable to accept a return to an era of tight governmental control of the advertisement of pharmaceuticals. The role of the FDA is not just to protect us from

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unsafe medicines and foods but to save us from the deleterious effects of their advertisement as well.6 The pendulum must swing the other way. Consumerism must now take a backseat. The first TV ad for a drug aired in 1983 and was a frank but bland offering by Boots Pharmaceuticals for their version of ibuprofen, a commonly used OTC pain reliever in products such as Advil. (See chapter 13 of Inside the FDA by Fran Hawthorne [2005] for more on the history of drugadvertising regulation.) There was no glitz. It was simply a public service message with a sober review of side effects. In 1997 the FDA dramatically liberalized its criteria for acceptability of TV drug commercials to consumers. The floodgates opened. Potent pharmaceutical agents with significant side effects were then legally marketed to the general public, few of whom had the disease remedied by the pill that was for sale. The general public, and especially vulnerable seniors, could not possibly make a rational evaluation of the pros and cons, benefits and risks, or the cost of treatment versus an alternative therapy. They could not gauge the probability that they indeed might not even have the ailment featured in the ad. Today the situation remains out of control. I propose, therefore, that the government enact legislation to revamp the FDA guidelines to achieve a more proper and beneficial form of directmarket advertisement to consumers (patients). The following criteria will serve to establish firmly that drug advertisement, although a right of commercial free speech by the pharmaceutical firm, should serve primarily as a public service spot and not as a means by which to hawk pills in the same manner as shampoo or deodorant: 1. No music to create a subliminal message or an emotional response. 2. No celebrities or actors to enhance the desirability of the product. Any spokesperson must be a currently licensed physician, registered nurse, or pharmacist with no financial conflict of interest involved (and this should be so stated in the ad). 3. Clearly state the commonest side effects in a blackboard format, rather than as background noise to a slick and persuasive audiovisual sales promotion. 4. Clearly state the cost of the treatment, expressing it in an easy-tocompare format such as dollars per year. Compare the cost to that of competitors’ drugs and to a generic, if one exists. 5. Clearly state the known incidence of the disease being treated, noting what the probability is that the viewer (the patient) has the illness and even whether the ad applies to the viewer.

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The pharmaceutical industry certainly would not be overjoyed at the idea of turning back the clock on FDA marketing restrictions, and corporations will argue vehemently for free speech. Their lawyers and lobbyists will defend the status quo. What I propose, however, is not a ban on direct marketing of drugs. It is a shift in approach from one of manipulation to education. Patients are not stupid. They seek reliable, factual, and useful information about medications in an easy-to-understand format. They can get straightforward nutrition facts off the side of a cereal box. Now is the time to bring daylight to the process of selling medicine in the era of polypharmaceuticals. A curious sideshow to the debate over direct advertising by Big Pharma is our view of the relationship between doctors and pharmaceutical salesman, or “drug reps” (Rubin 2008). Drug reps are those young and enthusiastic, neatly dressed men and women (often recently graduated marketing majors at their first jobs) who used to sit in my waiting room holding briefcases stuffed with corporate logo pens, sticky memo pads, and other silly sales promotionals. More important, the trunks of their leased corporate cars contain hundreds of environmentally unfriendly little packages of sample pills. The mission of the drug rep is to make contact with the doctor, even if only by a handshake or a wave, and to get a signature verifying that his payload of samples has reached its target. If the drug rep carries a good and useful product, is not too obsequious, and is in the good graces of the office manager, then she may be “granted” a lunch, something drug reps equate to having an audience with the Pope. The rep treats me to a sandwich and coffee while she tells me, in twenty minutes or less, about the company’s products. I personally found it a convenient way to get a quick briefing on usage and dosages of new medicines, and it forced me to sit down and briefly stop moving. Academics and ethical purists have come to view my free sandwich as a prostitution of medicine. After all, as we already know, there’s no such thing as a free lunch. I must have been subtly corrupted by this contact and coerced to push those pills that are displayed on the box containing my tuna fish sandwich (and that well may be so). While I cannot condone the fully paid physician junkets to the Caribbean that were once part of the industry’s promotional efforts, I consider my sandwich a trivial matter and, at worst, a venial sin. The pathetic fact is I need the samples for my patients. Perhaps that is prostitution. It used to be that my office medicine closet contained drug samples reserved for patients who were truly indigent. Without samples, these patients would have gone untreated. In the more recent past, however, even

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middle-class patients with good jobs and health insurance relied on my closet as a cost-saving insurance supplement to offset their steadily rising drug co-pays. One local and prosperous health insurer at one point sent out a letter to its insured advising them to seek physicians’ samples as a means of corporate cost containment. Talk about ethics! The real ethical travesty is the Madison Avenue–style coercion of the public into consuming too much medicine through direct-market advertising, thereby tampering with the physician-patient relationship. I look forward to a day when physicians can forego the lunch-for-samples exchange program and when prescription polypharmacy is a private matter between doctor and patient. In the last few years, pharmaceutical companies voluntarily have begun to rein in the drug rep lunches, dinners, and even the gifts of logo-labeled ballpoint pens. Big Pharma correctly anticipates forthcoming governmental policy in the absence of corporate self-regulation. We have no problem spotting the ethical lapse of a light lunch, but we miss the bigger picture: the shame of the absence of a universal prescription insurance program that provides the pills my patients need. I can live without the sandwich; my patients will not survive without affordable, reliable access to the modern prescription pharmacology that has made primary care effective and essential. Pills taken by prescription are just the tip of the iceberg. For every prescription medication ingested, many patients are likely to consume two or three nonprescription capsules or tablets labeled as “nutritional supplements.” These pills are obtained in a health food store, beyond the surveillance of the FDA. Such patients in my practice were often quite reluctant to admit the extent of their usage of supplements, herbals, or botanical agents. Either they assumed that I would disapprove angrily, or they did not consider these substances to be “drugs” worthy of inclusion in a list of medications taken. A dramatic demonstration of the market penetration of the supplement business could be had by instructing patients to come to the office with a large plastic bag containing every pill that they take, including vitamins, minerals, herbs, or anything else procured at a health food shop or by mail order. The bag would be emptied on the exam room counter, and six or eight large, 500-pill plastic bottles would go rolling. These would contain substances such as gingko biloba, echinacea, elderberry extract, propolis (from bees), St. John’s wort, and black cohosh, to mention a few. The supplement industry is the “rest of the story” of polypharmacy, lying beyond my prescription pad. What is the appeal of these

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products? Why do my older patients, living on a fixed income, readily shell out good money on substances that are not of proven benefit, are not necessarily safe, are beyond FDA scrutiny, and which may not even be present to any measurable degree in the pills that are pedaled? Why do younger patients, sophisticated shoppers I am sure, readily accept TV testimonials and embrace OTC supplements, tonics, and antioxidant elixirs as panaceas without prescription? The polypharmacy of OTC supplements, or “neutraceuticals,” thrives today because of the relaxation of FDA regulations, which put consumerism ahead of drug safety and efficacy. Traditionally, the demonstration of a drug’s safety and effectiveness has been the responsibility of the pharmaceutical corporation. A putative drug candidate must proceed through a lengthy, rigorous, and expensive evaluation. This sequence involves preclinical animal studies followed by small clinical trials designed specifically to ascertain only that the drug is not too toxic (phase 1). After passing phase 1, the drug then proceeds to further analysis involving a small group of patients to demonstrate that it is in fact effective (phase 2). Assuming that the drug is a winner in phase 2, larger clinical trials are established, involving thousands of patients, to confirm efficacy using a randomized, doubleblind, placebo-controlled methodology. By far, most drug candidates don’t make it, and many of the small, innovative biotechnology firms in the business don’t make it either. However, the manufacturers of nutritional supplements were able to carve out their own special niche in the FDA approval process through a sweet-deal piece of legislation called the Dietary Supplement Health and Education Act of 1994, or DSHEA (Nestle 2007). The passage of DSHEA represented a swing of the pendulum at the FDA, from protecting patients’ safety to maintaining their rights as consumers, not to mention enhancing the ability of manufacturers to sell their products unencumbered by federal regulatory monitoring. DSHEA inverted the paradigm for establishing the safety of supplements. Supplement manufacturers could sell a product without any proof of safety. Instead, the onus was thereafter on the FDA to prove a “neutraceutical” was unsafe after the fact and to then have it removed from the shelves only after trouble had already arisen. Producers of supplements cannot advertise that their product treats or prevents a particular ailment or symptom (e.g., “cures cancer” or “prevents a heart attack”). Under DSHEA, they are able to promulgate vague claims that their pill can, in an undisclosed manner, enhance some aspect

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of bodily structure or function (“for healthy bones,” “promotes prostate health,” or “supports your immune system”). The net result is obfuscation. Because these phrases are hollow, it is left to consumers to fill in the void and to take the product based on a belief that it must be good for what ails them. Marketing has triumphed over science. Even the lax regulatory function of the FDA under DSHEA, however, does not fully explain why patients gobble down billions of dollars worth of supplements, including minerals, vitamins, and herbals. DSHEA expands the availability and the advertisement of such products, but it does not force the pills down patients’ throats. People desperately want to believe that there exists an absolutely safe, “natural” nonprescription remedy or a magic elixir for their problem. In harboring this belief, they neglect the tenets of drug therapy that I have already enumerated: 1) A “natural” product is not necessarily a safe or effective product; 2) Strong disease really does require strong medicine and nothing less; and 3) Every drug has side effects. As long as the consuming public disregards these fundamentals and self-medicates simply on hope and faith, the supplement side of polypharmacy will flourish. For all of our sophisticated biomedical advances, we remain in an era of shamans and snake oil. With more pills comes an ever-greater chance of mishap, and the opportunities for medication error are many and varied. Human error can occur anywhere along the chain from the pharmacy to the patient’s lips. Most often, in my experience, mistakes occur because 1) drug names can sound quite similar; 2) a drug may be filled one time as brand name, then later as generic, so the patient takes both; 3) a new drug is substituted for a prior one, but the patient mistakenly takes both new and old medication; or 4) elderly couples “share” prescriptions, either knowingly or not, resulting in disaster. Many years ago I took care of a pleasant but slightly demented couple in their eighties. One day, each was seen for an office visit and they both had blood drawn. Inadvertently, my office nurse filled out the requisition for the husband’s lab work on his wife’s tube of blood and vice versa (the opportunities for human error in medicine are endless). To our surprise, we discovered that he had a critically toxic blood level of her medication, Digoxin. I suspect such medication errors are far more common than we can ever know. Elderly patients are not the only ones who can get it wrong. Drug names are just too similar. I recall a case in which a pharmacy dispensed Cytoxan, an oral chemotherapy agent, instead of Cytomel, a thyroid pill (big mistake). The bottles were adjacent on the pharmacy shelf. Physicians’ poor

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penmanship is often correctly cited as a cause for error, but that problem should resolve as computer-generated prescriptions replace pen and pad. However, one can still do a lot of damage with a point-and-click menu and a mouse. The chance of adverse drug reactions or of medication errors associated with polypharmacy is exacerbated when the patient uses multiple pharmacies. Many insurance plans mandate that maintenance medicines be obtained by mail order under a low-bid, bulk-contract arrangement between insurer and wholesale supplier. Short-course medications, or initial one-month trials, however, can be obtained from the local drugstore. It is not uncommon for an elderly patient to arrive in the office with a paper bag containing prescription pill bottles from three or four different pharmacies. Obtaining an accurate and current medication list can consume the better part of a visit to the doctor. Moreover, the elderly patient may be seeing three or four different doctors at any given time. Besides a primary care physician, she may be visiting a cardiologist, urologist, rheumatologist, or other “-ologist,” each of whom has a prescription pad. “Poly-doctoring” begets polypharmacy. The specialists’ consultation reports, containing new and revised lists of medications, may come to the primary physician’s attention in a week or two, but in the meantime, there is opportunity for disaster through too many cooks spoiling the broth (Tamblyn et al. 1996, 1177). What is needed is a simple and universal code that uniquely identifies every pharmaceutical prescribed by any doctor, in all of its varied dosages. Such a compendium of the U.S. pharmacopoeia should be federally established to avoid confusion as a patient moves from one state to another. I propose that all prescriptions filled carry a unique identifying alphanumeric symbol, stamped in large, bold print, Braille, and bar code on the bottle, box, or tube. For example, atenolol in 50-milligram tablets would show “A50” on every bottle of that medicine and dose filled anywhere in the United States. Digoxin .125-milligram tablets would be “D125.” Lipitor 10-milligram tablets, “L10.” It would be much easier for the patient to request a refill of “C10” than to ask for cyclobenzaprine 10-milligram tablets. The full and proper name of the medication, with dosing instructions, would appear below the alphanumeric code in less bold print. In the event that a drug is nongeneric, the proprietary name would be shown, thus protecting the pharmaceutical company’s patent right, but both a proprietary pill and its generic would carry the same bold alphanumeric code.7 A complete listing of the U.S. pharmacopoeia already exists. It should be an

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easy matter to assign a simple, logical code for each drug and dosage. This is analogous to the assignment of a unique ticker symbol for every stock that is publicly traded on an exchange. Just as the task of the FDA is to protect the public at large, it is the role of the primary care physician to be sure that each drug prescribed is reasonably safe and effective for that patient. Determining that a drug is acceptably safe for a geriatric patient is a challenge. Almost all drugs are metabolized and cleared through either the liver or the kidneys. These organs degrade with age, leading to the need for careful titration of ever-smaller dosages as the patient progresses through later life. The correct dose is a moving target. As the “old-old” become frail and wasted, their medications are contained in a smaller body and, consequently, reach higher concentrations due to a smaller volume of distribution. At some point this may lead to an adverse reaction. Drugs that target the central nervous system may gradually go from tolerable to toxic as the brain ages. The role of the primary care physician or geriatrician is one of constant surveillance, reassessment, and adjustment of polypharmaceutical therapy. It is a highly individualized process, as patients are unique in their handling of medications and in their response to therapy. There is no simple good drug/bad drug dichotomy. What works miraculously for one older man may hospitalize the very next one that I see, due to an unforeseeable, life-threatening side effect. Subtle, sometimes even dramatic, variations in a patient’s response to therapy are likely attributable to inherited traits that regulate rate of metabolism and physiologic effects of therapy. The young field of pharmacogenomics promises, through genetic testing prior to treatment, to offer a better targeted therapy and wiser drug selection based on a knowledge of a patient’s particular pattern of inheritance (Evans and McLeod 2003, 348). For now, though, polypharmacy is roulette. While I have affirmed that there is no simple distinction between a “good” drug and a “bad” one, it is readily apparent that not all drugs are created equal. Older pharmaceuticals often cause the worst side effects (although not always), as the progressive evolution to newer “designed” molecules has selected for beneficial effects and excluded more toxic substances. Nevertheless, the older pills persist on the formulary as they are quite cheap and they have a certain following among longtime patients and older physicians. A woman in her seventies transferred her care to me when her physician of many years retired. She carried with her a dog-eared chart with notes written in fountain pen, dating back to the mid-1950s, all in the same

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hand. Her high blood pressure had always been treated with reserpine, first released in 1954, which she still was taking fifty years later. Reserpine was notorious for causing fatigue and serious depression, even leading to suicide. Today, reserpine has been supplanted by very fine modern antihypertensive drugs that are more effective and much safer. In the context of modern pharmacologic therapy, reserpine may be the closest thing there is to a purely “bad” drug. I urged my new patient to switch to another blood pressure pill. She refused. The drug worked fine. She had never been depressed, and the pills were dirt cheap. Each time I would write a prescription refill for reserpine, however, I would cringe. I was sure that the pharmacist would call to tell me that I was an idiot, but he never did. A choice of pharmacologic therapy, even if well outside the bounds of conventional wisdom, remains a personal matter between patient and physician. There are no absolutes. There are, however, some general guidelines for steering clear of disaster when physicians treat the elderly with drugs. The Beers criteria (Beers 1997, 1531; Flick et al. 2004, 2716) were proposed in 1997 as a groupconsensus compilation of medicines, or classes of medicine, that generally should be avoided in those sixty-five or older. Inclusion of a drug in the Beers classification occurred if a drug was voted ineffective or posed an unacceptably high risk, or if there was a safer alternative at hand. Additionally, a particular drug could be flagged for nonuse in patients with a particular medical condition (a specific contraindication to its use). The Beers criteria dissuade physicians from prescribing hypnotic, anxiety-relieving, or sedating medications. In the elderly, these drugs are particularly likely to cause confusion, memory impairment, motor vehicle accidents, and falls, with resultant hip fractures, head injuries, and a rapid downward spiral and death. It is not hard to addle an older brain with a few pills. However, it is also not a pretty sight to have a ninety-six-yearold man in the office crying, begging for Valium. Such a man is not at all interested in the Beers criteria, which can be a dispassionate and arbitrary barrier to personalized drug therapy. Contrary to Nancy Reagan, it is not so easy to “just say no to drugs.” The consensus approach of the Beers criteria, or any other canned guideline of drug therapy, does not tell me what will work for the particular patient who is sitting in my exam room, looking for a solution to her problem. The precision and objectivity of modern pharmaceutical chemistry doesn’t necessarily translate well into the highly subjective world of geriatric care. The case of Mrs. C illustrates the point.

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Mrs. C was a seventy-four-year-old, 287-pound woman well known to my office staff as a “frequent flier.” She was single-handedly a major consumer of U.S. health care. She suffered from hypertension, diabetes, high cholesterol, low thyroid, chronic back pain, neck pain, migraines, and chronic arthritis. Her most recent office visits, though, were for a sore left shoulder. Examination of her shoulder joint revealed that she was suffering from acute bursitis, inflammation of a lubricating pad that can be quite painful. Mrs. C was advised to rest and to ice the joint. A sequence of painrelieving, anti-inflammatory medications was prescribed over several weeks, all to no avail. She declined a steroid injection but dipped into her cache of narcotics that she kept at home for other chronic maladies. Weeks went by with daily phone calls from Mrs. C, until one day . . . nothing. When I saw her the following month for a routine office visit, I asked her about her shoulder. She flashed a smile and told me that she had fixed the problem on her own. Her brother, a truck driver, had explained to her that bursitis of the shoulder is, essentially, a rusty hinge. Like the Tin Man in The Wizard of Oz, what she needed was the oil can. He “prescribed” the application of WD-40, a household universal lubricant, rubbed into the skin overlying the shoulder as often as required. It worked miraculously—no pain, and no pills! The chemical composition of WD-40 is a trade secret. It is a good product for its intended purpose, but the FDA has not examined its safety or effectiveness for “rusty” shoulders.8 Further, those using it for their health should want to know of any potential side effects. (What was wrong with WDs 1 through 39?) Assuming that topically applied WD-40 has no actual anesthetic or anti-inflammatory properties, I must conclude that Mrs. C’s miraculous recovery from an agonizing bursitis was attributable to a placebo effect. The concept of the placebo seems deceptively straightforward; the sugar pill or sham surgery of clinical research comes to mind. The placebo is supposed to be the control, or dummy, intervention, against which all other therapies are measured. There is general consensus, however, that the intentional prescription of a placebo has no place in clinical practice other than in the setting of a research protocol (Hrobjartsson and Gotzsche 2001, 1594; Bailar 2001, 1630). After all, it is a deception, and it would not seem to benefit a physician-patient relationship built on trust. Yet, physicians utilize a form of placebo effect when we talk to patients about symptoms and treatment. The placebo effect, in fact, preserves the practice of medicine as more art than science, especially in the age of polypharmacy.

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Why did Mrs. C feel better after she “oiled” her “rusty” shoulder? It is likely that the bursitis, having run its course, was due to improve anyway (the natural history of the illness) and the WD-40 was merely coincidental. Alternatively, one could look at it from a statistical point of view, arguing that the bursitis had been so severe that the chances were that it would more likely improve, rather than get any worse (regression to the mean). Also, knowing Mrs. C as I do, I am sure that she took a little pleasure in having outdone the doctor with her brother’s remedy. What her brother had accomplished, which I had not, was to create what has been called a “meaning effect” (Moerman and Jonas 2002, 471). A placebo, to the purist, is inert. It is devoid of benefit or harm, either physical or psychological. That, however, is not how medicine is dispensed. A medicine bottle comes with a message in it, and the message is that I, the physician (white coat, stethoscope), “feel” your pain and that I enthusiastically offer you, the patient, a remedy with hope, support, and optimism. The therapy is pitched in a language that the patient can understand readily, and its benefit is conveyed nonverbally as well. This is more of a “physician effect” than a placebo effect. In the case of Mrs. C, her brother the truck driver beat me at my own game. His slippery remedy and his simple explanation for its effectiveness reached Mrs. C at a level that I missed with my anatomical discussion and my prescriptions for anti-inflammatory pills. I was “out-doctored.” For the patient being treated, receiving a drug therapy is like dining at a trendy restaurant, where the quality is not just in the good food, but in its presentation. At the same time, polypharmacy gives doctor and patient an extensive menu of effective therapeutic options. The real nuance of practice, however, lies in the refined tailoring of therapy, using just the right medication for just the right patient. Such individually fitted polypharmacy does not come cheap. Ours is a time of great paradox in medical therapy. Never before have we had such a depth of understanding of our molecular biology and such breadth of effective pharmaceuticals at our disposal, while the exorbitant price tag for this modern gift threatens to put it out of the reach of the average person. We operate in a free-market system. Big Pharma management argues that the staggering prices for their proprietary products are justified by the high cost of research and development in order to keep the pipeline flowing and the future bright. In fact, the lengthy FDA approval process does sop up a good portion of the life of any drug patent, leaving little time for a pharmaceutical giant to make its profits before moving on to its next prospective blockbuster drug.

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Governmental and insurance industry efforts at cost containment thus far have aimed at clipping costs a bit here or there through favoring generic prescriptions, by limiting drug selection within a covered formulary to those medicines that are cheapest if not as effective as others, and by pestering primary care physicians by fax, phone, mail, or e-mail to “consider an alternative.” There is intense pressure on today’s physicians to prescribe as they are told. Patients do not have to be health care economists to sense that something is rotten in drug therapy when their prescription medications are changed every few months based on the most current negotiated low bid. There is a pervasive attitude among my patients that they are being “screwed” by the insurance and pharmaceutical companies, even if they are not exactly sure how this is so. A healthy relationship between doctor and patient cannot blossom in such a poisoned atmosphere of suspicion. Consider the man in his mid-thirties who came to my office with an infected leg wound that he had sustained while playing soccer. He was generally quite healthy, and with regard to utilization of his health insurance, he was a novice. The infection was rather severe. It required an antibiotic that is effective against the Staphylococcus aureus bacterium, a particularly pricey medicine. I warned the man that the necessary antibiotic was not covered by his particular insurer, as it is not on its approved formulary. He blithely said, “No problem, Doc—whatever it takes to get better!” The wound was dressed, the prescription written, and he left the office a satisfied customer. Thirty minutes later I received a phone call from a local pharmacist. My patient was standing at his counter, throwing a tantrum because the bill for his medication came to $150 and he was simply “not going to pay that.” He was angry with me, the druggist, the pharmaceutical and insurance companies, and with the world in general. I could acquiesce and change the prescription to a less effective drug with a tolerable $10 co-pay, accepting professional and legal responsibility when the infection progressed, or I could stick to my guns and deal with an irate patient. Neither was a pleasant prospect. (I chose the latter.) A patient’s first experience with the high price of pharmaceuticals is often one of “shock and awe.” Most handle it better than the man with the infected leg wound. All start off with an optimistic assumption that, when they need it, drug therapy will be there for them in a form that is safe, effective, and affordable. They incorrectly assume, however, that their doctor somehow has control of the price of their medication. Some patients suspect that there exists a “medico-industrial complex,” consisting of doctors and pharmaceutical companies that control the flow of overpriced

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medications and thereby profiting. At the very least, physicians may be easily coerced dupes of the drug reps, all too ready to commit prostitution by prescribing (Kassirer 2004). Occasionally, a patient will ask me, before accepting a new prescription, whether I own stock in the manufacturer of the pill, such as Merck or Pfizer. (I don’t.) In recent years, prescribing has become as challenging and personally distasteful as selling overpriced used cars. It can take some real arm-twisting salesmanship. The unaffordability of our medicines, and the connections between some physicians and the pharmaceutical industry, is taking its toll by altering and eroding the professional relationship I have with my patients through their loss of trust. Older patients are more accustomed to the expense of medications as a part of later life and see it, like rising gas prices, as part of the balancing act of living on a fixed budget. They rarely are irate about their high drug bill, but, rather, they seem resigned to it. It is what it is. Some are too proud to accept samples. Others take them gratefully. Many older patients add another twist to the physician-patient relationship: deception. They “forget” to take their medicine. They may elect to take a daily pill once every two or three days to save money while saving face. These patients already must bare their bodies when on the exam table; they do not want to bare their teetering financial status as well. Most often I can tell that the patient is not complying with treatment because I cannot achieve a target blood pressure, blood sugar, or other parameter, no matter how hard I try. In other cases, a blood test for a drug level reveals a counterproductive cost-saving scheme. The physician in this situation takes on the undesired role of detective. Again, what is lost are trust, confidence, and a sense that both doctor and patient are on the same team. To begin to grapple with the problem of drug unaffordability, we need to examine the “tiered” structure of our current drug formulary. Private health insurers generally offer a drug-coverage plan that includes layers, or tiers, of medication choices. The cheapest medicines, often costing only pennies per pill wholesale, are on tier 1 and cost the patient a “trivial” copay of somewhere between $5 and $15 per one-month supply. (This would not be so bad, if only the patient were on just one medication. Co-pays accumulate, however.) Tiers 2 and 3 become progressively out of the reach of patients through financial disincentive. It is rare indeed that a patient will tolerate a co-pay of $30 per month or greater for very long. Whether we like it or not, this is a form of rationing in health care. The ethical implications of rationing

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medicine can be debated at length, but, in the meantime, we need to make available to every American a basic package of the most commonly prescribed, cheaper generic medications at no cost. Tier 1 of our nation’s drug formulary must be viewed, first and foremost, as a matter of public health. Give me fifty of the most commonly prescribed pills with which to do my job as a physician, and I will be sure that I can deliver a basic modicum of care to all covered patients, regardless of their socioeconomic status. The exact composition of a universal tier 1 formulary could be established by a federally appointed commission consisting of physicians from a broad range of specialties, pharmacists, an economist, and a statistician, and, yes, even an attorney with experience in pharmaceutical product liability. Their index of drugs, which I will dub the “Pharma 50,” would be subject to periodic revision. I propose that changes in the Pharma 50 could occur by committee vote, no more frequently than every three years. Otherwise, patients would be forced to change medications far too often, as is currently the case with medication selection by private insurers’ fiat. The Pharma 50 initially would be available free by prescription to enrolled Medicare beneficiaries. Private insurers, which skim the younger, healthier patients from the insurance pool, would be mandated to provide the same Pharma 50 to their insured as a basic covered service with no copay. In the event that the United States one day achieves a true, universal nationalized plan of health coverage, then this basic pharmaceutical benefit would be extended directly to Americans of all ages. Since provision of the basic Pharma 50 is truly a matter of U.S. public health, it should be viewed as similar to a government’s efforts to drain a mosquito-infested swamp to prevent malaria or to provide clean water and sanitation to avoid an outbreak of cholera. Distribution of a free Pharma 50 would give the government a similar bang for its buck through the prevention of costly complications of untreated chronic diseases such as hypertension and diabetes. Here we can take a lesson from the ministries of health of Third World nations around the globe, which focus on the delivery of free (or at least cheap) basic care to as many citizens as possible so as to achieve the greatest public good. The higher tiers of drug therapy pose more of a dilemma in public policy. It is clear that everyone benefits when we control chronic manageable diseases through the provision of basic, affordable medications. How do we handle the high-end medications that occupy tiers 2, 3, and beyond? Insurance companies do offer an appeal process. If I, as physician, feel that Drug X clearly is required, rather than Drug Y, I can complete and fax a lengthy application form showing that I have exhausted cheaper

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options and that I regret that I must use a particular brand-name agent. Though I have submitted numerous such forms over my years in practice, I cannot recall ever having such an appeal granted. This mechanism of appeal seems to be pro forma only and rarely benefits the patient. Some denials of appeal are downright paternalistic. Older men with erectile dysfunction (ED) often seek to have their Viagra, or an equivalent drug, covered by their insurance. Some insurance companies arbitrarily will pay for the Viagra only if the ED is due to prior surgery for prostate cancer, but not if it is from another medical cause. Some grumpy insurers will pay grudgingly for two or three Viagra tablets per month, and no more. I have often wondered if the exact number allowed was pegged to the CEO’s own frequency of sexual intercourse. This is no rational way to administer our modern pharmacopoeia. We are poised today on the threshold of increasingly sophisticated, personalized, but pricey, drug therapies. “Biologicals,” (very large molecules such as monoclonal antibodies designed to target a cancerous tumor or neutralize a mediator of inflammation in rheumatoid arthritis) are already at hand and many more will follow. A year of such therapy can cost more than a new car. Such drugs are difficult to manufacture and are not particularly amenable to generic replication, so they are not likely ever to be cheap. While I view access to tier 1 drugs as a right of every citizen and a matter of public health, I fear that the top-of-the-line deluxe forms of modern drug therapy will remain a privilege for only the select well-insured few. The only option at the top tier of drug therapy is government regulation of prices. The few large pharmaceutical firms represent an oligopoly similar to the electric or natural gas utilities, which provide other essential public services. Therefore, in my view, it would be perfectly appropriate for the federal government to set drug prices for the high-end pharmaceutical agents such as the biologicals, where free-market competition does not apply, as with the utilities. Reduced revenues to pharmaceutical firms may very well slow research and development efforts, but, on the other hand, there is no value in bringing a drug to market that no patient, and no nation, can afford.

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4 POLY-DOCTORING

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A DOCTOR FOR EVERY DISEASE

To the toga-clad physician of classical Rome or his chiton-wearing counterpart of ancient Greece, all of medicine was encompassed by a balancing act of the four humors: black bile, blood, phlegm, and yellow bile. A preponderance of one of these four bodily humors resulted in a patient who was melancholic, sanguine, phlegmatic, or choleric, respectively. Treatment involved countering the excessive and offending humor. Fever, for example, was thought to be a hot and dry disorder, due to an excess of yellow bile, and it therefore was treated with cold baths. Conveniently, for the physician-philosopher of the time, the four humors also corresponded to the four elements, earth, air, fire, and water, and to the four seasons as well. The expectation was that a competent practicing physician of that era readily could handle any patient who arrived at his “office” with an abnormality of any of the four humors, without the need of a referral to a specialist. The humoralist theory, as promulgated by the Greek physician Galen (131–201 CE) was the accepted paradigm of Western medicine until the mid-nineteenth century. The science of pathology, or the study of disease through the direct examination of organs and tissues, thereafter supplanted the archaic four humors. With the aid of a decent microscope, the German physician Rudolf Virchow (1821–1902) recognized in 1858 that diseases could be described at a cellular level. Medical understanding from that point on has subdivided bodily malfunctions into an organbased classification scheme. Ultimately, each organ got its own doctor; the era of specialized medicine was born. By the mid-1960s, the drive to specialize was in full swing among young medical school graduates and even among middle-aged practitioners who correctly foresaw declining opportunities and reduced reimbursement in

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the general practice of medicine. My father, who had been a general practitioner for twelve years and who had a wife and two young children at home, closed up shop in 1966 and enrolled at forty in a residency training program in psychiatry, a field that, particularly in that era, carried a certain cachet. He foresaw that, with age, he would not be able to continue trudging up several flights of apartment stairs, carrying a heavy medical bag, in order to make a house call. Psychiatry was respectable indoor work with no heavy lifting. At the same time, rapid technological advances and new discoveries in pharmacology, as we have seen, were transforming all of medicine into a massive skill set and knowledge base that no single physician had the time or capacity to master. As the human body was balkanized (Myerburg 1994, 1453), turf battles ensued. Was a patient with low back pain due to a herniated disc to be referred to the neurosurgeon or to the orthopedic spine surgeon? Did a patient with impaired kidney function due to a stone see a nephrologist (medical specialist of kidney function) or a urologist (surgical specialist of kidney and associated plumbing) or both? In the 1970s, at some hospitals, cardiologists successfully blocked general physicians from admitting patients with chest pain to the then relatively new facility called a coronary care unit, or CCU. Quarterly physician staff meetings at hospitals became battle zones with shouting, swearing, and threats of legal action, one against another, for restraint of trade. Somebody had to emerge at the top of the heap. General practitioners were placated by a new oxymoronic appointment as “specialists of primary care.” In the new age of specialty medicine, however, to paraphrase George Orwell, all doctors were special, but some doctors were more special than others. Consultation of the dictionary reveals that to be special one must, in addition to performing a specific function, be exceptional or distinct, and must surpass what is common.1 Practically speaking, though, a specialist is, in reality, one who knows more and more about less and less. He possesses a well-honed, albeit restricted, subset of clinical skills and experience that is of special value only when selected appropriately and only when applied wisely. In short, it is the primary care physician’s proper and intelligent usage of consultation and referral service that makes the specialist, well . . . special. Unfortunately, the advent of specialty medicine, in effect, from a logical standpoint, rendered generalists not special but simply common. The primary physician, although she may have been board certified in internal medicine or family practice—an accreditation conferred by a board after the physician passes a difficult and comprehensive examination—was

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perceived by patients and by colleagues as occupying the lowest rung on the ladder of medicine: a jack-of-all-trades, but master of none. Managed care of the 1990s cemented that view by tacking on the further demoralizing job description of “gatekeeper.” Vertical integration was the model. Patients started at the bottom, visiting their regular doctor, and moved up the health care food chain to progressively more specialized practices. The high priests of health care were those specialty surgeons or medical subspecialists at the pinnacle who commanded the greatest prestige, the highest pay, and the most clout with insurers and hospital administrators. Medical practice by specialty, organized by organ system, conformed to the notion popular in our country that you are what you do. (Pity the proctologist.) A dermatologist does skin. A hand surgeon does hands. Today, with the refinement of highly sophisticated, technological skills, we now subdivide specialists by the narrow procedure they perform. A colonoscopist scopes you to screen for colonic polyps. An echocardiographer gets an ultrasonic picture of your beating heart. An interventionalist will “intervene,” but that is a euphemism for sticking you with something sharp in order to unclog or repair an internal problem. Specialists are now defined by what procedure they do to you. The specialist, in addition to enjoying the perquisites at the top of the ladder, also appreciates the luxury of dealing solely with one organ and not so much with the complex person who owns it. He may, after completing a series of esoteric tests, diagnose a rare and devastating disease. The patient and family, however, then will return promptly to their primary care doctor, requesting that he “tell them what the specialist just said.” They will ask him to “put it into English.”2 How will this new diagnosis affect their lives? Should their son overseas in the military be notified and brought home? What does it all mean, and what should they do? I would argue that, as a patient, your true specialist is the doctor who knows you, and your family, best and who can weave a plan of care that incorporates specialty consultations along with other diagnostics and treatments. The patient is far more than the sum of his parts. Organ by organ, fragmented care is bad medicine, and, as patients well know, it is easy today to become overdoctored. Just as the number of pill bottles on the bathroom shelf grows with one’s age, so does the number of doctors’ appointment cards magnetically stuck on a patient’s refrigerator door. Geriatric patients are poly-doctored. Medicare beneficiaries between 2000 and 2002 typically saw up to five specialists each year (Anderson and Knickman 2001, 146). Those with multiple chronic ailments may see up to sixteen physicians in a given year (Pham

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et al. 2007, 1130). Such dispersed delivery of health care has the obvious disadvantages of poor coordination, duplication of efforts, excessive testing and procedures, and polypharmacy, with its attendant risk of serious drug interactions. Even more troubling to me, this is a fragmented system of care devoid of the warmth of relationship, and it can be a soulless process that doesn’t see the big picture. To the patient it may appear that nobody is driving. How is it that in her later years, a woman, or her frail, wobbly husband, comes to be under the care of five to sixteen different doctors? What leads to a referral to a specialist? Broadly, the rationale for referral can be divided into four distinct scenarios: Scenario 1: I, the primary care physician, know exactly what is wrong with the patient and what is required of the specialist to deal with the problem. An elderly man, who notes a new, painful bulge in the groin after pushing his heavy wheelbarrow, is found to have an inguinal hernia. He is referred to a surgeon for repair. This is a self-limited referral, as surgical matters tend to be, and when the incision is healed, the referral is complete. To take another example, an older man experiences chest pain while shoveling a little snow. His primary physician diagnoses angina (exertional chest pain due to blocked coronary arteries), and the man is referred to a cardiologist for the evaluation and management of that problem. Here the expectation is that the cardiologist will continue to follow along with the primary physician, as this is a chronic condition, subject to progression with age. The patient has, in this case, gained another doctor for life. Doctors accumulate. When the same man develops a nonhealing sore on the tip of his nose, he is referred to a dermatologist, and a skin cancer is excised. The man is subsequently advised by the dermatologist to return to that office every six months for complete skin exams to monitor for recurrent cancer. Now there are three chronic doctors for one elderly man. When the disease in question is chronic, the patient will always be provided with a follow-up appointment. For reasons that include appropriateness of care, avoidance of allegation of malpractice through abandonment, as well as physicians’ financial interests, a specialist will rarely send a patient home without setting a date for a return visit. Thus, the number of doctors per patient can only grow with time. The process is limited only by the number of organs possessed by the patient and by the number of hours an older person can tolerate sitting in doctors’ waiting rooms.

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Scenario 2: I, the primary care physician, have no idea what is wrong with the patient, and I consult a specialist for help with the diagnosis of a perplexing problem. This scenario tends not to occur very often. From time to time, a patient will develop an odd constellation of symptoms that does not fit neatly into any one diagnostic package. She might have a fever that doesn’t resolve after two full weeks (called a fever of unknown origin, or FUO, and a real diagnostic challenge). Consultation with a specialist is intended to pose the question, “Does this patient have a disorder that pertains to your organ of expertise?” A rheumatologist or an endocrinologist, for example, will then render an opinion, yes or no. It is something like playing the game Go Fish, and, indeed, serial consultations for the patient who is a mystery can be akin to a fishing expedition. Generally, in my experience, this consultation scenario does not tend to be very productive. The patient may have an illness that just has not quite yet declared itself and that will remain undiagnosed until further, more specific, symptoms clarify the cause. Alternatively, the patient has no demonstrable disease. Symptoms may be caused by stress, anxiety, hypochondriasis, or some other phenomenon that we understand poorly and that we cannot pigeonhole into a particular category with its own specialist. Scenario 3: The patient and family make their own “referral” to a specialist, without the recommendation, consent, or possibly even the prior knowledge of the primary care physician. Self-referral, I suspect, occurs far more commonly than the primary care physician can ever know. The patient may make the appointment surreptitiously so that the primary doctor’s diagnosis or treatment plan can be validated, without the patient suffering the embarrassment of letting the primary doctor know that there is any lack of confidence. He may go out of town for the consult and not list a primary care provider, so that no consultation report is ever forwarded. The patient also may not allow the consultant to obtain my records for review, resulting in much duplication of effort, because the patient feels awkward about abandoning me. In this case, the close relationship between patient and primary doctor actually hampers communication between physicians. Specialty referrals are frequently established at the urging or insistence of the family. They see that Mom is dwindling and they demand that “she must see a specialist.” This is the “Do something” response. A son or daughter, who visits from afar, after a long hiatus, is appalled to see that dad has visibly declined. He or she promptly packs the elderly man off to the city for consultation at a medical school or other tertiary care center, with the frail, somewhat resigned, old man reluctantly hauled hundreds of miles.

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In some cases, as when a new and grim diagnosis has been made, it is wise for the family to seek confirmation at a medical center. They should request it of their physician without fear or embarrassment. Patient and family need to feel that they have exhausted all options when the news is bad. In other situations, however, referral to a specialist by a longtime inattentive adult child is a relatively quick and easy way to assuage guilt for prior neglect. In either situation, there is a natural inclination to assume that, as familiarity breeds contempt, medical care must be better out of town. The grass is greener on the other side. Last, within the category of the self-referral are those elderly patients who doctor shop. Blessed with Medicare plus supplemental Medigap insurance coverage, they roam from specialist to specialist in a quest for a magic cure for a chronic, degenerative condition such as arthritis, but often it is more of an opportunity for social engagement and a way to fill idle hours. When a new rheumatologist arrives in town, little old ladies line up to give him a whirl, just as they may give a newly opened restaurant a shot. This is poly-doctoring as hobby. Scenario 4: I, as primary care physician, know exactly what is wrong with my patient and what is required in the way of treatment. Care of the patient is well within the scope of my clinical competence. Nevertheless, for other reasons, I choose to refer the patient to a specialist for management of his or her care. With the understanding that a medical practice is a small business enterprise, why would I, as proprietor, want to turn away customers by referring them elsewhere? Much is written in the lay press and on the Internet about the importance to patients of finding just the right doctor, meaning one with whom they will have a good rapport. It is not considered proper, however, to acknowledge that the physician does not have the same flexibility of choice when “selecting” his patients. To my dismay, I must report that not all elderly patients are sweet little old ladies or their male counterparts. Some older men or women can be quite nasty or rude. Nothing demoralizes doctor and staff and sours a day of patient care more than a scene in the office with a belligerent patient. Referral is a professionally respectable way to unload a difficult, nasty, or noncompliant patient. On the surface, I am upgrading their care while, practically, I am cleaning house. This will sound crass and insensitive, but it is important to acknowledge that not all physician-patient relationships are destined for success. Specialty referral can defuse a tense situation and offer a divorce without abandonment. Even the whiff of possible malpractice litigation will give rise to prompt referral for specialty consultation. In a business environment where there

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is a huge surplus of patients seeking physicians, as is currently the case in southern Florida and will be the case everywhere in the United States in a decade or two, why would any rational physician tangle with a patient who is suspected to be litigious? Specialty referral, in court, appears as a wise and responsible move, and it spreads the risk as far as legal liability. Also, it combats the “Tag, you’re it” aspect of medical malpractice in which one unfortunately may be the attending physician of record when catastrophe strikes. Better to pass the ball than to be tackled while holding on to it. Here we have poly-doctoring as a form of malpractice risk management. The managed care plans of the 1990s promised improved containment of high medical costs through an expanded role of the primary physician and reduced patient access to the more expensive specialty practices. A good gatekeeper demonstrated a reluctance to refer but also showed a willingness to manage sicker, more complicated patients, who were perhaps at the margin of the scope of his skills. In 1999 “the finding that nearly one in four primary care physicians reported that the scope of care they were expected to provide was greater than it should be arouse[d] concern about the potential impact of changes in the delivery of health care” (St. Peter et al. 1999, 1980). Today, a decade later, I see that the situation is changing. Time pressure now necessitates referral sooner rather than later. As we already have seen, the primary care physician needs to see volume to stay afloat. A patient who requires meticulous fine-tuning and frequent, lengthy counseling, such as a poorly controlled diabetic with wildly fluctuating blood sugars, takes too much time. Today, there is strong financial pressure on the primary physician to refer earlier in the course of a disease. There is, amazingly, no time or room for sick people in the doctor’s office. The poorly controlled diabetic patient quickly is referred to an endocrinologist for care of her illness. Specialty referral is becoming, by necessity, a calculated business decision based on time management. Regardless of the particular reason for specialty consultation, it is quite apparent that care of the complex elderly patient with multiorgan disease has become, and will remain, a group project. Each specialist, by necessity and by training, takes a restricted view of the clinical situation, focusing on his small piece of the puzzle. Specialists argue that they are appropriately performing the narrowly defined task for which they were trained and at which they excel. Some patients will boast when they have been referred to a professor at Man’s Greatest Hospital3 or marvel that they have been examined by the best “liver doctor” there is. Others aren’t so sanguine. When some patients go from their generalist to a partialist (Bodenheimer 2008, 1064), they have a sense that they have lost more than they

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have gained. Patients often return from consultations with a feeling of detachment. Conversation was restricted to a few laser-guided questions about their urinary flow or digestive function, depending on the particular specialty, but the patient felt no sense of an overriding vision of their health status and no warmth of a personal and human relationship. The orthopedist may order an X-ray of an old man’s knee before even stepping into the room to introduce himself to the poor uncomfortable fellow. The gynecologic surgeon’s office staff may instruct a very proper and dignified, but terrified, older woman to remain seated on a cold, uncomfortable examination table, waiting for the doctor, who is reputed to be special. She appreciates that he is academic and well-respected in his field, but she resents the dehumanization that can come with detached and fragmented medical care. Why is this doctor so special? As has been mentioned earlier, medical training teaches young physicians not to think of zebras when they hear hoofbeats. We were taught that common things were common. For the specialist, however, it is acceptable, if not expected, that he should be the one to think about zebras. To tell the truth, finding the zebra can be a lot more exciting, and certainly is more financially rewarding, than managing the more common maladies of man. In medical school and residency the more esoteric a doctor’s differential diagnosis (a list of possible diseases that fit the symptoms), and the more obscure the right answer, the more impressed would be his superiors and his colleagues. Unfortunately, the long-inculcated one-upmanship of medical training and the challenge of the zebra hunt can suck a patient into a black hole of medical diagnostic excess from which there is no escape. It begins with the phrase, “I’d like to obtain a few additional tests.” If all goes according to plan, a patient referred to a specialist will arrive at that office carrying a packet of medical records.4 Included in those records are a history of the patient’s symptoms, the physical findings observed, and the results of any laboratory and X-ray studies done thus far. The referral for consultation, to be most productive, should pose a question or request a particular service to be performed. For the purpose of the immediate discussion, let us assume that the channel of communication between doctors works as I have described, although this is often not the case. Almost without exception, after seeing my patient, the specialist will order at least one additional test, and often many more. If the patient is being seen at a major academic facility, the doctor very well may repeat every test that I have already performed. There is an inherent mistrust and bias against laboratory work done elsewhere. No specialist will want to

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hang his hat on data that he doesn’t trust. At the same time, there is no financial disincentive to having the patient contribute one more tube of blood. X-ray studies, if hand carried by the patient, often will be accepted, though I can recall many cases over the years, in which films were repeated because the specialist had more confidence in the interpretive skills of a particular radiologist at his facility. After duplicating at least a portion of the ground that has already been covered, the specialist must then, by definition, go a bit further. Special doctors order special tests. It is self-affirming. A proliferation of procedures ensues, in which the specialist attempts to add some value through his contribution to the case. If I have obtained a chest X-ray, then the pulmonologist will perform a CT scan of the patient’s chest. If I have already obtained a CT scan, then he will order an MRI scan, or even a PET scan,5 in a kind of diagnostic arms race. To health care economists, this escalation is a form of health care value-added tax. The specialist, however, has not completed his mission until he has searched for zebras. Consider the case of a moderately overweight sixty-five-year-old woman who sees her doctor for a checkup. She feels perfectly well, but her blood chemistry profile shows some abnormalities of her liver function. Her primary physician establishes that she does not drink alcohol to excess, have viral hepatitis (an infection of the liver), take any potentially liver-toxic medications, or work in a toxic-chemical plant. There is no obvious cause for her abnormalities. The now anxious woman is referred to a hepatologist, a specialist of the liver only, for further evaluation. A CT scan of the liver ordered by the hepatologist also shows no abnormalities. A group of infrequently ordered blood tests, appropriately referred to in the lab as special chemistries, are ordered to rule out zebras with names like primary biliary cirrhosis, autoimmune hepatitis, or Wilson’s disease. They are all normal. The hepatologist recommends a needle biopsy of the liver, but the patient declines. She is referred back to me with the conclusion that she merely has some fatty deposits in her liver because she is overweight, and she is advised to diet. The patient returns to see me a few weeks later, still feeling fine, but now bearing medical bills well in excess of $1,000 for the consultation, CT scan, and assorted lab work. She asks me about the consult, “What was that all about?” She is not particularly happy or relieved to hear about the list of rare diseases that she does not have, especially since she didn’t feel sick in the first place. This sort of scenario played out for me over and over again in the practice of primary care. An abnormality was identified and an appropriate

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referral was promptly made. The work-up done by the specialist was thorough, having left no stone unturned. The patient was reasonably compliant. Everyone did what they were supposed to do, and yet the patient came away dissatisfied with the whole process and angry about the hefty bill. What if the outcome of the consultation had been different? Say, for the sake of argument, that the exact same diagnostic evaluation had been undertaken by the hepatologist but that it did indeed reveal the presence of Wilson’s disease, a rare (1 in 30,000 incidence) but manageable abnormality of metabolism of copper. The patient would then marvel at the fine liver specialist who had shrewdly gotten to the root of her problem. The bill would be the same, but it would now appear to the patient as money well spent. Remarkable as it may seem, some patients return to me disappointed and dissatisfied when the specialist’s work-up is unrevealing or negative. I cannot count the number of patients, over the years, who paradoxically expressed dissatisfaction that the specialist could find nothing wrong! Since zebras are by definition rare, this poses a real problem in customer satisfaction, as patients often may return from a specialty consultation with no apparent benefit, but definitely poorer for the experience. The pecuniary side effect of poly-doctoring is not the only matter of concern. Just like pharmaceuticals, all tests have side effects that go well beyond their wallet toxicity. Intuitively, the more invasive tests such as catheterizations, biopsies, or scopes of one sort or another, carry the greatest likelihood of serious mishap. Even the commonplace phlebotomy, or drawing of blood, has its risks. Elderly patients, with their fragile skin, complain bitterly about the massive purple splotches that migrate down their arms for weeks following a blood draw. Those colorful souvenirs are harmless but temporarily disfiguring. Patients dislike them because they are a visible sign to themselves, and to others, that they are old and that all is not right with them healthwise. More important, physicians can render a patient anemic from frequent, overzealous, or redundant blood sampling. Furthermore, it takes still further tubes of blood to establish that the patient has been bled dry and has become iron deficient. Even with optimal communication between physicians, which we certainly have not yet achieved, the more specialists involved, the greater the bloodletting, as each specialist does her own thing. There has been recent concern voiced that doctors’ low threshold for ordering CT scans is causing excessive exposure to radiation throughout our population and among patients of all age groups (Brenner and Hall 2007, 2277). Ionizing radiation, such as X-rays, poses a dose-related risk

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of mortality from cancer, as was demonstrated in studies of survivors of the atomic bomb detonations in Japan in 1945 (Preston et al. 2004, 377; Preston et al. 2007, 1). CT scans, which involve multiple X-rays, deliver significantly more radiation to the patient than a single film like a chest X-ray. The problem is compounded when the neurologist is scanning the patient’s brain, the nephrologist is scanning the patient’s kidneys, and the pulmonologist is scanning the patient’s lungs. Each specialist may be quite correct in doing so, but the net effect is a patient who has been overexposed. No one is counting CT scans. No one is coordinating care to prioritize scans and see where the radiation burden to the patient might be reduced. Further, it has been estimated that “one third of all CT scans are not justified by medical need, and it appears to be likely, perhaps 20 million adults . . . per year in the United States are being irradiated unnecessarily” (Brenner and Hall 2007, 2283). Still another problem for the poly-doctored patient is that tests beget tests. An eighty-year-old man with a known aneurysm of his aorta, a widened and weakened major artery that carries a risk of rupture and sudden rapid death, is sent by his vascular surgeon for a CT scan of the abdomen. The report from the radiologist indicates that the aneurysm is small and stable. This is good news, but there is a little density in the right adrenal gland that wasn’t there before—bad news, maybe. The radiologist concludes his report by recommending that the patient undergo a repeat CT scan at three months, and again at six months to ensure radiographic stability, that is, to be sure that it is not a growing cancer, rather than a benign, harmless growth called an adrenal adenoma. This sort of unexpected, or incidental, finding is sometimes referred to as an incidentaloma (Mirilas and Skandalakis 2002, 1026). The suffix -oma means “a mass,” so this neologism means an incidentally noted mass lesion of uncertain significance. It is not what we were looking for, but now it too commands our attention, resulting in more CT scans with more radiation to the patient. The problem of the incidentaloma highlights three negative aspects associated with frequent utilization of diagnostic imaging. The first is that the more you look, the more you find. The patient gets caught up in a vortex of testing. The second is a potential pitfall in the reporting and follow-up of test results. In the case above, a vascular surgeon was checking on a vascular problem. Who will now follow through on obtaining the repeat CT scans advised for the monitoring of the incidental adrenal mass? That is not what vascular surgeons do. Does responsibility default to the primary care physician? There is no simple, consistent answer. The rule in my residency

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training program was that if you ordered the test, then you were responsible for obtaining the result, notifying the patient, and taking follow-up action. Here, communication between doctors proves to be inadequate, and we run the risk of having a patient fall through the cracks. The third problem, exemplified by the case of the incidentaloma, is that it is often the radiologist who ends up driving. If his report on a frail, generally declining, geriatric patient’s scan reads “Recommend repeat CT in 3 months to rule out adrenal tumor,” then I have absolutely no choice but to repeat the scan in three months. Both medico-legally and for the absolute safety of the patient, I cannot countermand that order unless the patient happens to refuse the scan and I so document his refusal. This is often to my relief. The patient can say no, but I cannot. Through modern diagnostic imaging, the physician ends up managing a CT scan rather than an elderly patient. Technologic medicine, even though delivered appropriately by the specialist in radiology, can come to supplant rationality in patient care, and there is no effective off switch for this process. The problem is one of context. The radiologist, by trade, sits in a darkened room and reviews cases as a series of black-and-white films that lie against a bright panel or as sequential images on a computer monitor. The clinical information provided to the radiologist about the old man who belongs to that scan is likely limited to a one-liner such as “85-year-old man with history of abdominal aortic aneurysm.” That’s it. There is no transmission of information about the man, such as the fact that he has been sad and lonely since his wife died five years ago, that he has indicated to me that he is “ready to go,” and that he would never consent to any surgery or chemotherapy if he did indeed prove to harbor a cancerous tumor in his adrenal gland. The radiologist’s recommendation is the right response to the limited picture he has of the patient (just the scan), but it is a meaningless instruction for this patient’s situation. The radiologist is, in fact, not at all interested in the patient’s philosophy or his outlook on life unless, perhaps, the man happens to be his father. The radiologist’s slice of the pie is purely to be sure that a tumor is not overlooked on a CT scan. Even if he knew and appreciated the patient’s situation, his report still, by necessity, would read “Recommend repeat CT in 3 months,” and the primary care physician who received that report would disregard it at his or her own medico-legal peril.6 It seems logical to assume that the most value can be obtained from a specialty consultation when the fullest amount of information is conveyed to the consultant, preferably well in advance of the patient’s visit.

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I wouldn’t book an appointment with my accountant without first making sure that he first had a shoebox full of receipts, cancelled checks, pay stubs, and whatever other scraps of paper that he would need to complete my tax return to the satisfaction of the IRS. Physician-to-physician referral information, shamefully, is often much less thorough or informative. Studies show that primary care providers are often delinquent in providing letters of referral that clearly state the problem, that offer a reason for the referral, or that provide a sufficient background health history with a list of current medications (McPhee et al. 1984, 1265; Jenkins 1993, 111; Williams and Peet 1994, 292). By the same token, feedback from specialists tends to be too little, too late (Cummins et al. 1980, 1650). One study demonstrated that “four weeks after a specific referral visit, 25% of primary care physicians still had not received any information from specialists” (Gandhi et al. 2000, 626). I personally find it frustrating when a patient is sent to me by a surgeon for medical clearance for surgery, a sort of preoperative blessing, yet the surgeon neglects to tell me what particular surgery or type of anesthesia is contemplated.7 This is just sloppy care, and there is plenty of blame to go around. How, then, can we improve doctor-to-doctor communication and get more useful results for our poly-doctored patients? In the comparatively low-tech era of one generation ago, before the advent of cell phones and the Internet, physicians were a more collegial and socially interactive professional group. Each doctor, regardless of specialty, most likely made morning rounds on his patients in the hospital. As two doctors passed in the hallway or grabbed coffee and a bagel in the doctors’ lounge there was an opportunity to interact by casually presenting an interesting case. The term for this was a “curbside consult,” and it consisted of a quick, “Hey, what do you think?” or “What would you do for a patient like this one?” Often the curbside consult would lead to a full, formal consultation, but with much more of a feel for the psychosocial aspects of the patient and not just the objective lab data. For example, I might say, “Would you see Mrs. Jones, an eighty-five-year-old woman with declining renal [kidney] function? She’s definitely not the sort of person who would tolerate a kidney biopsy, and she’d never consider dialysis, but it would be helpful if you just took a look at her for me.” A lot of information about Mrs. Jones was thereby conveyed in a short but personal, casual conversation. Fast-forward to today. The physician making rounds now carries on his belt an electronic beeper, a cell phone or BlackBerry, and a PDA (personal digital assistant) loaded with information. He is likely to be carrying a

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laptop computer from bedside to bedside as well for record keeping. He looks like some sort of commando from Mission Impossible. Yet, for all of his telecom apparatus, he actually is communicating less effectively with his peers than did his predecessors who made rounds before him. Charting, or the writing of daily physician’s notes in the hospital record, was once done on the hospital wards at large, centrally located, open tables with up to four doctors to a table. Today, the structural layout tends to be that of individual cubicle-style work stations at which each physician reviews lab work and charts electronically at a computer terminal, all in relative isolation. Furthermore, the time pressure of a necessarily packed office waiting room has cut into the precious few minutes at the hospital once allotted for the consultation as a form of schmooze. It is likely that a patient’s primary care physician may not make hospital rounds at all any longer. Over the past eight to ten years there has been an extraordinary redistribution of responsibilities for the delivery of patient care in and out of the hospital. Traditionally, primary physicians attended the hospital first thing each morning, and then they headed for their offices for a long day of outpatient, or ambulatory, care. With luck, no hospitalized patient would become critically ill and thereby necessitate a doctor’s speedy drive back to the hospital with the consequent cancellation of office hours. Prior to 2000, when I decided to forego hospital care, there were frequently days when I would get an emergency call from a nurse at the hospital, grab my coat and keys, and run out of the office, leaving behind a waiting room full of angry, glaring patients to be rescheduled. Today my critically ill, hospitalized patients are cared for by a hospital specialist, or hospitalist.8 The hospitalist movement (Lindenauer et al. 2007, 2589; McMahon 2007, 2627), based on the model of medical care employed in the United Kingdom, caught on rapidly. Coincidentally, many of the illnesses that once required prolonged hospitalization could at that point be treated effectively at home with superior drugs such as once-daily antibiotic injections given by home nursing services and with not-so-subtle pressure from Medicare and private insurers to discharge patients earlier. Critics argued that this meant sending patients home from the hospital quicker and sicker, but this was not necessarily so. Shorter hospital stays meant reduced exposure to virulent hospital-acquired (called nosocomial) infections, medication errors, or to other breaches in quality of care at the hospital. Hospitalists, with no office responsibilities, could devote their full attention to hospitalized, seriously ill patients. This was fortunate because those patients who did require hospitalization, although fewer in number, were quite sick indeed.

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Hospitalists, as specialists of inpatient care, offer a much more efficient use of medical manpower and a more rational division of labor by splitting off hospital duties and by allowing office-based primary physicians to do what they do best. As a primary care physician to predominantly elderly patients, this offered me the advantage of being able to say “come right over” when a fragile patient called from home with a problem that needed rapid attention. There is no doubt in my mind that the advent of the hospitalist specialty improved my patients’ access to prompt primary care in the office. What hospitalists have not done, however, is improve doctor-to-doctor communication on a patient’s discharge from the hospital back to the care of his primary physician. Each time a patient is admitted to, or discharged from, the hospital, there is a handoff from one doctor to another. Hospitalists need to have a feel for the patient for whom they take charge. Similarly, on discharge, the primary physician requires from the hospitalist a timely discharge summary (a document reviewing the course of the hospitalization, procedures, results, and complications, discharge plan including home care, physical therapy, etc.), a revised list of medications, and instructions regarding a follow-up office visit. At present, this is not the case. Just as primary physicians are swamped with patients and paperwork, the hospitalist may be caring for an entire hospital floor of critically ill patients, and there is simply no time to communicate personally with each referring primary physician in town. Evolving technological remedies, such as universally compatible webbased medical records, will facilitate transmission of objective data from office to hospital and back again. What is lost in the transmission, however, is the relational aspect of a doctor’s care. That is sacrificed with the changing of the guard. Patients entering the hospital, unless they are so sick as to be in and out of the hospital frequently enough that they get to know the hospitalist team well, express to me a great fear of the unknown doctor. In adopting the hospitalist model of specialty care, we have improved the overall efficiency of care at the expense of patients’ comfort. Chronically ill, fragile, elderly patients have lost the continuity, comfort, and intimacy of the relationship they had with one doctor. An illness caused by a physician, albeit unintentionally, is referred to as iatrogenic (from the Greek iatros, physician). Now there is a new iatrogenic ailment of the modern, multiply sick, and poly-doctored patient: doctorfatigue. Elderly patients complain to me that they are sick of doctors.9 They are likely to be tired anyway, especially if they suffer from enervating

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illnesses such as heart failure, kidney disease, or cancer (or all three). In my experience, however, chronically ill old people, seeing three or more specialists, complain most bitterly about the logistics, the personal intrusions, the high cost, and the ultimate futility of the ministrations of multiple doctors. Prolonged, fragmented care is an iatrogenic ailment, and it appears to patients as a slow death by a thousand cuts. The case of Mrs. D is illustrative. She was a lovely eighty-six-year-old woman who had suffered for years from a severe cardiomyopathy, a diffusely thinned and weakened heart muscle that left her chair-bound, easily breathless, and always exhausted. Despite aggressive pharmacologic therapy, her condition slowly but surely progressed, and her visits to the cardiologist became more frequent and more exasperating for both patient and doctor. She was taken by her family for consultation at a most prestigious tertiary care center in the Midwest, known for its cardiac expertise, but there they had little better to offer her. The woman was started on weekly infusions of Natrecor, a then-new intravenous drug intended to improve her cardiac function, but merely showing up for the infusions made her even more tired. She and her husband, whom I had known for some years, came to my office and asked me, their doctor, to intervene. Mrs. D was very reluctant to return to see her cardiologist, but she was even more reluctant to tell him so. It is remarkable that a patient in a dire situation can be quite so sheepish about terminating a specialist’s care, even if it is ineffectual or intolerable. In such situations, patients will come to me and request that I, as their representative, call the specialist to ask that therapy be halted. They want me to cancel their next appointment with the other doctor. This is exactly what Mrs. D and her attentive husband, a retired attorney, asked. At first, I thought this odd since both Mrs. D and her husband were quite intact mentally and were still handling their own affairs. I now appreciate that there are two reasons, however, why the doctor-exhausted elderly patient would ask the primary care physician to step in as terminator of specialty care. The first reason is old-fashioned courtesy and respect. The specialist is seen by the patient and family as an authority figure, like a professor from the old school, and you don’t say no to the professor. The second reason is more complex. The specialist, relieved from the burden of caring for one whole patient, body and soul, focuses her efforts on the perpetual maintenance and tune-up of one organ. The cardiologist will continue to tweak a failing heart with one drug or another until either

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it no longer beats or somebody finally says stop! In the era of medical care by a cadre of overzealous specialists, it often falls ultimately to the primary care physician to come to the aid of the patient by saying “enough.” At the moment that Mrs. D asked for my intervention, she displayed a visible sense of relief. She received home oxygen therapy promptly as a comfort measure, and she was enrolled that day in the local hospice program. I notified her cardiologist of Mrs. D’s request, and I think she was relieved as well. Mrs. D survived for another six months, having benefited fully from hospice care, before she had a final downturn and an expected, inevitable, but “good” death at home with her family. In the course of medical school and subsequent training, physicians are introduced to the ethical concept that, as a doctor, one can do too much. Amid the gallows humor of medical training, I often heard the term “flogging the patient,” meaning delivery of undue and excessively aggressive care with little to be gained but with much pain and anguish inflicted. Patients were said to “die the Harvard death” when they underwent every imaginable blood test, biopsy, scope, scan, or surgery before passing, leaving behind a challenging case study worthy of publication in the New England Journal of Medicine but ending in a tragically miserable and coldly technological death. Today, in private practice and long after my years in training, I find that unintentional flogging still occurs, particularly when a high-tech specialist “misses the forest for the trees” and carries aggressive treatment beyond all hope in the absence of a relational, primary care physician who can step in and say “enough.” Consider the following case history of a woman who was not a patient of mine, but with whose case I am all too familiar. She had been a widow for ten years and was quite competent, routinely managing her own health care affairs. She was seventy-seven-years-old when diagnosed by her gynecologist with cancer of the uterus. Although she had a nephrologist who managed her high blood pressure, the woman did not have a true primary care physician. She consented to a total hysterectomy, or removal of the cancerous uterus and the adjacent organs, and initially she did well. She dutifully completed a lengthy and very fatiguing course of radiation treatments to eradicate any remaining tumor cells. Despite this effort, within a year the cancer was back, causing her abdominal pain and distention. She was referred by her gynecologic surgeon directly to an oncologist, who offered her the standard first-line chemotherapy regimen. With that she endured the slow-motion body blow that is chemo, including the repeated pokes, hair loss, numbness of fingers and toes, malaise, and profound exhaustion.

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The chemotherapy “worked” briefly in the sense that certain tumor markers improved on the blood tests, but by appearance she was failing fast. The oncologist enthusiastically endorsed a second, and then a third, round of various other chemo drugs. These were agents not routinely used for uterine tumors but that were thrown into the mix when the others failed to work. At each turn the oncologist pitched the therapy as promising, although the objective statistics were dismal. The strong, or, more correctly, the overly aggressive stance of the oncologist, whom she really did not know at all, led her to choose treatment over nontreatment at every turn. The absence of a primary care physician as a sounding board left a vacuum in which the oncologist was prepared to continue treating the tumor, not the patient, ad infinitum. The patient’s condition continued to worsen. She was hospitalized with an obstruction of her intestine due to the spreading tumor. The oncologist’s advice was again “more chemo,” to which the beleaguered woman replied, “Whatever you think best.” Her son was her health care proxy, but she remained competent and stated that she could still make her own decisions. The oncologist proposed surgery to relieve the obstruction. Finally, however, after five weeks of persistent vomiting, she disappointed her oncologist and opted instead for hospice. Less than twenty-four hours after transfer to the hospice, she died of a complicating pneumonia. To the horror of the patient’s family, the oncologist prescribed an antibiotic to treat the pneumonia, sometimes referred to in this situation as “the old man’s friend,” just hours before she mercifully passed away. As deaths go, this was a very bad one. It highlights the hazard of unchecked, overzealous specialty medical care ad absurdum, in the absence of a primary physician-patient relationship in which the patient might have voiced her misgivings in comfort and confidence. It demonstrates the potentially Frankenstein-like nature of highly aggressive modern, technologically complex therapies by an organ-specific or disease-specific physician. Although there always may be one more drug to try or test to do, that does not mean that it is the wisest thing. The poly-doctored patient must have a primary physician to add a dose of compassion to the treatment regimen, to supply some patient-specific wisdom, and to be a voice of reason.10 How can we devise a system of care that will benefit from the technologically sophisticated treatment options of each specialty but which will preserve the relational quality of primary care, with its commission to govern, or rein in, the specialists if they exceed a rational degree of intervention? The totem pole vertical organizational model, with primary physician as the low man, certainly does not work.

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Health policy analysts envision a better model to come in our near future. In “A 2020 Vision of Patient-Centered Primary Care,” Karen Davis and her colleagues imagine a new and different approach. What will make such practices patient-centered “includes 1) respect for the patient’s values, preferences, and expressed needs; 2) information and education; 3) access to care; 4) emotional support to relieve fear and anxiety; 5) involvement of family and friends; 6) continuity and secure transition between health care settings; 7) physical comfort; and 8) coordination of care” (Davis et al. 2005, 953). In this idealized environment, patients will be actively involved participants in their own care and will be in partnership with their primary physician. They will be part of a team. In this idealized future vision of optimal medical care, there is effective coordination of all aspects of a patient’s care, including all specialty referrals, through the primary care physician’s office, which will become a patient’s refuge from the cold, or a home base. The primary care doctor will serve “as [the] patient’s agent—providing the care the patient would want if the patient had the information that the physician has” (953). Organizationally, the primary care office will be the hub of a wheel with many spokes. As I look out on my packed office waiting room, I must admit that I am skeptical. Many of the frail, demented octogenarians sitting out there can barely negotiate the short path to the lavatory, let alone navigate a complex, fractionated system of health care, no matter how much help and support they may get from their medical home. With the inexorable approach of the silver tsunami of aged Baby Boomers, the system is likely to buckle under the sheer weight of our collective, infirm mass before we can ever achieve the idealized vision of care for the year 2020. Nevertheless, keeping an open mind, let us consider the policy proposal of an “advanced medical home,” as promulgated by the American College of Physicians (ACP) in 2006 (American College of Physicians 2006a). This monograph proposes a fundamental change in the manner in which primary care is to be delivered and financed in the United States. The authors view this transformation as a comprehensive public policy initiative. The change hinges on a shift to a chronic care model, rather than the presentday focus, and a physician-reimbursement policy for a lifelong series of intermittent, acute care problems, which is like forever putting out an endless series of small fires. The concept is considered advanced because it is to be fortified by the latest in computer-based information technology and it will utilize the very best practices in modern medicine, as demonstrated by evidence-based

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studies. Furthermore, physicians who conform and who register themselves as participants in an advanced medical home will be subject to measurement of key quality indicators as part of an ongoing nationwide clinical experiment. As coordinators of care and as managers of patients, not diseases, the primary physician will be compensated favorably for participation. As stated in the report of the ACP, “the advanced medical home would utilize the internist’s skill as a coordinator of services patients need from multiple other diagnostic and therapeutic specialties.”11 How am I to maintain my burgeoning geriatric practice, with all of its stressful demands, while at the same time assuming the new role of clinical information manager and expert in health information technology? During office hours in a busy practice there is barely time for a doctor to make a phone call, grab a bite to eat, or even to go to the bathroom. I am not exaggerating. At present, the image of the doctor’s office is more like a crowded bus station than a quiet, peaceful home. Something has got to give, if the advanced medical home is ever to become reality. There are simply too many geriatric patients and far too few primary physicians for this model to gain traction, unless reinforcements arrive soon.12 What else is wrong with this model? It incorrectly presupposes that a physician can be either a touchy-feely relational communicator or an Ozlike, imperious, noncommunicating, specialty wizard, out on the rim of the wheel. Both images are wrong. To be a physician, regardless of specialty or narrow focus of practice, is to be both technically competent and relational, a communicator, a teacher, and a healer. No model of care can compartmentalize compassion. Even the high-tech superstar surgeon must be able to sit down and talk with patient and family in order to serve them well. Somehow, in the course of medical specialization as a form of subcontracting, we have all forgotten our Hippocratic mission statement. With the proposal of the medical home as a restoration of primary care as it once was, we now have come full circle. We are back to a place where an imbalance of any one of the four humors can be remedied, perhaps with the aid of a specialist, with care originating at the center of a wheel of medicine through a close personal relationship between primary physician and patient.

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A BUBBLE OFF

Today’s two o’clock appointment is with Mrs. E, a seventy-nine-year-old woman who returns for follow-up of a recent complaint of abdominal pain. At her last office visit, one month ago, she and I discussed her symptoms, and we elected to obtain a CT scan if her pain did not resolve spontaneously after two weeks. She called me last week and indicated that her pain had persisted. The CT was performed, and the films sit on my desk. She is scheduled to return today to discuss those results. I have cared for Mr. and Mrs. E for about three years, since they moved to town to be closer to their son, a successful local businessman who has been attentive and devoted to his aging parents. Mr. and Mrs. E, however, both still drive, manage their own affairs, and express their good fortune at being reasonably healthy, financially secure, and able to enjoy each other’s company, as they have for over fifty years. I greet Mrs. E, her CT films tucked under my arm, and she gives me the same warm hello, as always. She is alone. After a brief update of her symptoms and a limited re-examination, I remove the films from a large manila envelope and I ask her to step closer to view her CT scan with me. “My what?” she asks quizzically. “The CT scan of your abdomen that you had the other day,” I remind her. “I didn’t have any CT scan,” says Mrs. E, now a bit huffy. I gently continue, “Yes, you did. Here, look—it has your name on it.” As I speak, I note to myself with great relief that the date of the scan, patient ID number, and birth date all support my contention that this is indeed her CT. Mistakes have been known to happen. “Not mine—not my CT scan,” she repeats emphatically.

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I step out of the room for a moment to verify with the Radiology Department by phone that Mrs. E was in fact the woman who hopped into their CT scanner last week. The CT technician remembers her quite well and confirms that the scan is truly that of Mrs. E’s abdomen and no one else’s. I return to Mrs. E, who has been pacing in the exam room and who now has her coat on, ready to go. She accuses me of incompetence for having mistaken someone else’s scan for hers, and she leaves. Two days later I receive an authorization from Mrs. E to transfer her medical record to another physician in town. Her chart, including a CT scan of the abdomen with her name on it, is forwarded promptly but with simultaneous regret and exasperation. The CT films, which were in truth those of Mrs. E, fortunately were normal. Her new and abruptly odd behavior, however, was not. Mrs. E had just entered the twilight zone of mild cognitive impairment (MCI) (Petersen 1999; Petersen 2003; and Fratiglioni et al. 2001). In an earlier, less clinical era, Mrs. E would have been labeled “eccentric.” Her quirky emotional lability, poor memory, and air of suspicion would be tolerated respectfully about town because of her elder status. Today we are more precise, if less kind or euphemistic, when we label Mrs. E with a diagnosis of MCI. Mrs. E is not demented,1 but, then, she’s not quite right either. She might squeak by with a passing grade on formal neuropsychiatric testing. By outward appearance, she might seem to be managing well at independent living. She is, however, early on the cusp of cognitive dysfunction where, paradoxically, she may cause the most anguish and exasperation for both family and physician. Compared with those who are level-headed, Mrs. E is “a bubble off.” Without doubt, none of us is as sharp as we once were. A missed appointment, a forgotten name, or a word that escapes us is a deficit easily attributable to normal aging. “Benign forgetfulness of the elderly” was a clinical term once popular among neurologists (Kral 1962, 257). It characterized the nonmalignant type of mild memory impairment that does not presage a dreaded diagnosis of Alzheimer’s disease (AD). More accurately, I think, it labeled the forgetfulness that afflicted older neurologists. The patient with MCI has more than a benign degree of forgetfulness, yet she is not truly demented. Studies have shown, however, that those with MCI are at an increased risk of developing AD at a rate of 10 to 12 percent per year (Petersen 1999, 303). Thus, they are a group worth following closely because they might benefit from early and truly effective pharmacologic intervention should it become available eventually,

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or by well-timed assistance through supportive social services. The aging Boomer cohort will represent, on an unprecedented scale, a continuum ranging from memory loss of normal aging through MCI to the severe dysfunction of advanced AD. Witness a neuropsychiatric pandemic in the making. My focus, however, is on primary care. What will become of the physician-patient relationship when more than a few patients on my daily office schedule are quirky, irritable, egocentric, or a bit paranoid? Of the 78 million aging Baby Boomers (Croker 2007), a certain percentage is destined to be, in the not-so-distant future, like Mrs. E. She is the vanguard of a coming phalanx of exasperating, mildly cognitively impaired Boomers who will demand and require an extraordinary degree of patience, reassurance, repetition, and physicians’ time. The case of Mrs. E is a preview of coming attractions. Early in my career in medicine, a relatively small percentage of patients seen each day were mildly cognitively impaired. A typical patient mix on any day in the office included an ample number of young and middleaged people with acute illnesses such as a quick and simple sore throat or a respiratory infection. They perhaps might come in with a sore shoulder or other musculoskeletal injury that was easy to diagnose, treat, and explain to a receptive and articulate patient. The rapid pace of that type of general practice provided enough flexibility of scheduling to handle the special needs of an occasional older patient with MCI or dementia who was irritable, suspicious, or who had lost the normal degree of inhibition that allows for polite social intercourse. The future of primary care will be quite different. The young, mobile, well-insured patient with a sore throat or a backache will be treated at a walk-in, doc-in-a-box Urgicenter or at a Walmart (American Medical Association 2008) or Rite-Aid pharmacy chain store by a licensed nurse practitioner. Financially upscale patients will select a boutique- or concierge-type of capitated care package (Brennan 2002, 1165), thus bypassing the crowds and eliminating the hassles of conventional health insurance. This medical economic trend amounts to picking the low-hanging fruit. What will be left, occupying nearly every seat in my waiting room, will be a disproportionately large segment of the population that communicates poorly, displays at least subtle abnormalities of personality, and exhibits a disturbing loss of social graces. The primary care physician’s job is about to become much harder than it is already. Family members and caretakers of patients with dementia are all too aware of the extraordinary personal challenge of caring for an elderly

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A Bubble Off

person with paranoia, constant repetition, and odd behavior. In The 36Hour Day (1999), Nancy Mace and Peter Rabins of the Johns Hopkins School of Medicine provide a comprehensive and very supportive manual for those who bear the burden of caring for one cognitively impaired individual at home. Those caregivers who put in the thirty-six-hour day do so out of love and compassion for an elderly spouse or parent. The devoted family member risks physical and emotional exhaustion, depression, or serious illness. Tragically, a depleted and devastated caregiver may predecease the one to whom he or she is so dedicated. The physician who cares daily for hoards of cognitively impaired patients likely will suffer from similar frustration, exasperation, early burnout, and compassion exhaustion. Instead of the strain of round-the-clock comprehensive care of one individual at home, the primary care physician will be subject to a slow erosion of morale and loss of a sense of professional purpose from an endless procession of the elderly, many mildly cognitively impaired or even frankly demented, each with a fifteen- to thirty-minute appointment, but absent the tireless, loving devotion and commitment of a member of the family. Geriatric medical care, under the auspices of Medicare, is, after all, only a government job. What possibly could be so difficult about caring for an older woman who is just a bubble off or who is referred to euphemistically as “pleasantly” demented? Mild memory impairment or disorientation may impede good medical care through a missed office visit or a patient’s unexpected appearance on the wrong day, at the wrong time, or both. In good conscience, I cannot refuse to see a frail old man, for whom just getting to the office was a triumphal achievement, even if the appointment card he carries is for next Tuesday. Someone else will have to wait. We can deal with that. An easily confused old man is likely to forget to comply with a low-salt diet, diabetic restrictions, or other important instructions from the doctor. As we have seen in our discussion of polypharmacy, it is doubtful that even an old woman who is as sharp as a tack can take her medications exactly as prescribed. The cognitively impaired patient certainly won’t get them right. We can deal with that, too. It is the alteration of a patient’s personality that makes primary care of the elderly with MCI or mild dementia so difficult. Paranoia is a problem. It is not at all uncommon to have a suspicious older patient, with a remarkably well-preserved recall of scatological vocabulary, accuse my secretary of attempting to cheat him on a bill. One man in his eighties, addled a bit by years of alcohol, would sneak through the shrubbery in front of my office to spy through the window on the activities of the person doing the .

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billing. We managed that problem by drawing the blinds on the day of his scheduled appointment, but even a little paranoia in the office is creepy. It creates an unnerving work environment for doctor and staff. Some years ago, before hospitalists had assumed the care of hospitalized patients, I was called in late at night to see an old man in the ICU who was experiencing chest pain and shortness of breath. He was delirious at the time, perhaps from medication or inadequate oxygen to his brain, compounding an underlying degree of MCI. I examined him, wrote some orders for the nurses, and I returned several times to his bedside throughout the night to monitor his progress. He subsequently did well, and eventually he made it home. Several months later I received a scathing letter from the fellow, in response to a submitted bill, stating in no uncertain terms that we had never met that night. He articulately, but confusedly, wrote to the fraud division at Medicare, accusing me of attempting to cheat that federal agency of approximately $100 for services never rendered. Shortly thereafter, with no official investigation of the patient’s medical chart, formal notice arrived from the government that I indeed had committed Medicare fraud. Although there was an option provided to request a hearing on the matter, it was of course neither practical nor cost-effective to close my office for a day to defend myself against the insulting accusation. I let it go, but perhaps that was a mistake, as it still bothers me years later. Shortly after this incident, however, I did permanently give up doing hospital work and restricted my practice to the office, then the last bastion where a doctor still had any control over his work environment. Hippocrates wrote nothing in his physician’s oath about having to endure the abusive ranting of a paranoid, cognitively impaired older patient. In the future, when primary care is regarded by all as merely a job and not a calling, who will choose to care for the coming wave of such patients? Self-centeredness is an undesirable personality trait that can creep insidiously into the workings of an aged brain. The egocentric elderly patient, who at one time in her life may have been a caring, self-sacrificing mother and an active, charitable member of her community, becomes focused solely on herself. The man who for years had greeted my secretary at the desk with a cheery “Good morning! How are you?” now announces each arrival by growling, “How long do I have to wait?” Families endure this behavior at home when grandma visits and is inconvenienced by a late dinner or when, at a restaurant, she berates a waiter unduly because the soup is cold. Although, as a clinician, I recognize that egocentrism is a component of early cognitive dysfunction in the elderly, I find the persistent, demanding,

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and self-centered behavior grating, especially when dealing with a multitude of these patients on a daily basis. As we might say to our young children, “Now, we can’t all go first.” It is the egocentric behavior of a disinhibited elderly parent with MCI that gives rise to the concept of a sandwich generation, since grandma may sound just like the kids.2 The burgeoning geriatric population, displaying egocentrism as a manifestation of MCI, will become the true and ultimate “me” generation. A son or daughter’s tolerance for quirky, inappropriate behavior derives from filial duty, moral obligation, and a loving remembrance of a parent in the past, as he or she once was, when times were better. The next generation of primary care physicians to come, charged with the care of millions of mildly cognitively impaired old Boomers, will not have that moral commitment of family, or possess the saintly temperament and patience required to cope with odd behavior on a societal scale. We can’t all go first. Disinhibition can get ugly. The normally reserved and polite older patient on the exam table may blurt out, “That’s an ugly tie” or, my perennial favorite, “Doc, you’ve gained weight!” A once sweet, eighty-eight-yearold woman who returned every six months for her high blood pressure would complain on each visit that she never liked her son-in-law. This was unsolicited information as, each time, I had merely asked how she felt. As the years went by, polite inhibition receded still further. Each visit now included a progressively lengthening anti-Semitic diatribe about how her blood pressure was high because her daughter had, thirty years ago, married a Jew. I quietly tolerated this (I am Jewish), but I was personally relieved when her daughter had her placed in assisted living, somewhere far away from me. Family members may report that grandma recently has become clingy. She is reluctant to be alone, phones incessantly, sometimes in the middle of the night or during an important meeting at work, and she is inconsolable. Authors of popular books such as The 36-Hour Day advise that a family should seek the advice of a health care professional when dealing with such troubling behavior. Be aware, however, that primary care physicians are in the same boat as the family. Slightly befuddled, anxious and alone, one single elderly patient may call my office eight or ten times in one day for no clear reason, clogging our phone lines to the point that other patients complain that they never can get through. The number of calls and the severity of clinginess rise dramatically when a patient’s son or daughter must go out of town for a few days on business or takes a much-needed vacation. Geriatric patients

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with MCI or early dementia rely on constant close human contact to get by day to day. Primary care physicians serving future addled Boomers will face a Sisyphean task of offering constant emotional support and reassurance, plus repetition, repetition, repetition. Contrast this somewhat grim peek ahead at future geriatric care with the oddly optimistic governmental opinion that the problems of medicine will be solved by ever-better technology. Medical care for Mrs. E and the other patients that I have introduced here will not be enhanced by better software, office websites, or paperless electronic records. These patients are, as Barbra Streisand sang, people who need people. The future of adult medicine belongs to those providers who, by temperament and natural inclination, can communicate constantly, compassionately, and effectively with those who are, at the very least, mildly cognitively impaired. Ahead we face a people problem, not so much a technological challenge. The prospect of a senescent America, populated by millions who are at least to some degree cognitively dysfunctional, is daunting. It is anticipated that in the next fifty years, the number of Americans who suffer from the dementia of Alzheimer’s disease will quadruple, and that one in every forty-five of us will suffer from it (Kawas and Brookmeyer 2001, 1160; Wolfson et al. 2001, 1111). How can we hope to thrive, prosper, and grow as a nation when saddled with such a heavy burden?3 I believe that if we channel our human and economic resources wisely we can meet our societal obligation to the elderly who become mildly cognitively impaired or worse. On a grander scale, how we handle the coming avalanche of citizens afflicted by MCI and dementia will clarify and define the moral priorities and the social commitment of a now mature nation. Our approach to the coming epidemic of dementia will determine who we are. The Americans with Disabilities Act of 1990 (ADA) was passed by Congress to remove the barriers and tacit discrimination faced by those who lack full physical or mental capabilities. Although the act covered mental illness as well as physical infirmity, the visible result of the ADA has been that public facilities, including doctors’ offices, are today wheelchair accessible and have bathroom safety bars, levered doorknobs and faucet handles, and other structural modifications that level the playing field for the physically handicapped. Now we must adapt our facilities to accommodate the coming wave of the mildly cognitively impaired. How do we create a user-friendly medical office environment for the patient with MCI? Can we do better at making a visit to the doctor more dementia accessible? This task may prove to be much tougher than the construction of a wooden ramp or the installation of a safety bar in the

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lavatory. Again, this is a people problem. Health care analysts lament the coming shortfall of physicians trained in the specialty of geriatrics. What is more immediately critical, however, is the lack of trained, professional medical office staff who, by their attitude and demeanor, offer the elderly patient with MCI a health care environment that is calm, courteous, and consistent. For these patients, the office must feel like home.4 Perhaps the most critically important individual in the doctor’s office is the one who sits at the front desk and answers the telephone. She, or perhaps he, is the portal of entry. She must not impose a barrier to the patient with MCI. A warm greeting, in a somewhat daughterly yet respectful tone, creates an air of calm and defuses what otherwise would be a confrontational challenge for a mildly cognitively impaired old man. Contrast such an introduction to the blunt, detached salutation, “I need to see your insurance card” that makes me cringe when I am the patient at the window in another doctor’s waiting room. It is disgraceful that common courtesy and polite, respectful communication are skills in need of honing, but that is the current sad state of affairs. Medical office staff, doctors included, will need an adult education crash course in medical etiquette (Kahn 2008, 1988), something akin to taking an accelerated Berlitz course to become bilingual, if they are to communicate effectively with the elderly who are cognitively impaired. The staccato text-message style of modern interpersonal exchange won’t fly with elderly patients who are a bubble off. Change is hard. It is even more imposing for the patient who suffers from MCI. The maintenance of a routine eliminates a barrier and makes for a more user-friendly medical office. This means that a stable, preferably long-term group of employees is essential to the provision of effective geriatric care. The bond formed between a fragile old woman with MCI and a cheerful, responsive receptionist well may be stronger than the relationship between physician and patient. How do we reduce employee turnover? Aside from the obvious solution of competitive salaries and generous benefits, we need to find employees who are right for the job in the first place. It is the exceptionally even-tempered individual who can deal with thousands of calls and visits annually from patients who are a little irritable, suspicious, or disinhibited. Perhaps applicants for medical office jobs should undergo pre-employment psychological screening to determine if they possess the right temperament for working with patients with MCI. Not everybody is cut out for this line of work. At the same time, we need a national awareness campaign to teach all Americans to recognize and understand the behavior patterns of MCI, just as we all ought to know

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the warning signs of a heart attack or how to use an automated external defibrillator (AED). We must become dementia ready. Paperwork is another barrier for the cognitively impaired older patient. On entering the office for a first visit, a nervous woman is handed a clipboard, a pen on a string, and a formidable stack of forms as a required task to be completed before she may be granted access to the great and powerful Oz, the doctor. While the gauntlet of insurance forms and signature pages may be a minor bureaucratic annoyance to the younger and more functional individual, it is an embarrassing impediment that heightens frustration, anxiety, and irritability for the older person who is just on the margin of normal recall and mathematical and language skills. Such patients are challenged at once by this cognitive stress test before they even have had a chance to shake hands with the doctor. Many older, slightly confused and forgetful patients must face this challenge alone. The lucky ones have a son, a daughter, or other family member who accompanies them and helps to navigate the paper trail of Medicare cards, explanation of benefits forms, insurance releases, and health history intake forms listing medications, surgeries, allergies, plus family data that even the cognitively unimpaired would have trouble generating extemporaneously. The ordeal in the waiting room, however, is not over until the elderly woman with MCI has reached the summit of the highest peak among piles of paperwork—the HIPAA form. The Health Insurance Portability and Accountability Act of 1996 is legislation that allows individuals the freedom to move from job to job without risking the loss of health insurance coverage. Tacked onto the bill was a provision to maintain the privacy of personal health information in a new era of supercomputing information technology and massive, faceless managed care corporations. It was designed to protect the little guy. Yet, in the case of a patient who is just a bubble off, HIPAA exemplifies the law of unintended consequences. If a patient is competent, like you and me, he may sign the HIPAA form, designating those family members or friends with whom the doctor may share clinical information from the medical record. Conversely, by omitting the name of a loved one, a patient specifically can block access to information by one or more family members who are currently out of favor with him. Few families function absolutely harmoniously, and the HIPAA form offers subtle clues about family dynamics. In the event that the patient is incompetent and unable to complete the HIPAA form due to severe dementia,5 a family member must do so by proxy. But what of the elderly patient with MCI who is not demented but

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who is not making sound, rational decisions either? She may be in the midst of an argument with her daughter over a trivial family matter. When she arrives at the doctor’s office, it occurs to her, at the moment, to delete her daughter’s name from the HIPAA form, thus registering her dissatisfaction with her adult child. That will show her! A week later, when the old woman has a massive stroke and is suddenly near death, I am left with her daughter on the phone and, in my hand, a recently revised HIPAA form that says in big block letters “Do not discuss my health with my daughter.” What am I to do?6 HIPAA, as a means of protecting privacy, works well enough for the cognitively intact and, with the aid of a health care proxy, for the seriously demented. It does not meet the needs of the minimally cognitively impaired patient who falls somewhere along the continuum from perfect rationality to the ultimate loss of her thinking self. As I have attempted to demonstrate through examples, it is the earliest phase of cognitive dysfunction that proves the most distressing and challenging for family and doctor alike. We know well what is required in the way of bodily and custodial care for an older patient with advanced Alzheimer’s disease, but what of the woman who is sporadically a little paranoid, sometimes a bit forgetful, or at times oddly self-absorbed and quirky? I do not know the full answer, and I certainly have never found a comfortable way to deal with such patients in my own practice. I do know, however, that we must give the matter serious thought because the Boomers are coming and there are a lot of them. First, though, I wish to explore some aspects of primary care of the patient who, being more than just a bubble off, is very much demented. What must it be like for my elderly patients who gradually progress to severe dementia? Let’s discount the common but frustrating problems experienced with retrieval of a lost word, neglecting to pay a bill on time, or being perplexed to find oneself at the top of the stairs and unable to recall why. Consider instead the isolated, personal experience of a slow unraveling and dissipation of the soul. It is a disintegration of the self through the evaporation of shared experiences in life and of the bond of commonality with spouse, family, and friends. We are, at least in part, what we remember. The nature of the experience of dementing is as varied, from one person to another, as are people themselves (Sacks 1985). To some degree, the premorbid personality traits, meaning a person’s inherent and distinctive nature before they become a victim of dementia, may dictate whether

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one ends up placid and tractable or paranoid and combative. This, though, is not always the case. A refined, dignified, and erudite former professor may, through worsening disinhibition, become verbally abusive and vulgar, psychotically bizarre, and even a physical danger to caretakers and health care workers. Conversely, consider the case of a woman in her nineties who was at one time under my care. She was a dour, demanding, and deflating downer of a patient. For years she constantly had made her daughters miserable and had caused her doctor to become transiently grumpy after each of her visits to the office. When she developed Alzheimer’s disease, she mercifully was transformed, at long last, into a sweet little old lady who was pleasantly demented. Dementia, however, whether pleasant or not, is still dementia—a loss of the self. A critical question regarding the primary care of an elderly population with Alzheimer’s disease is whether a doctor can have a physician-patient relationship with a person who has no self.7 Complicating the matter is the fact that functional decline may be restricted to select cognitive spheres, leaving other skills relatively intact. A semiretired professor in his eighties, an internationally recognized authority in his field, one morning had been seen in my office for a routine checkup. That evening, when I got home from work and picked up the newspaper, I was astonished to see that he had been interviewed and quoted extensively as a knowledgeable source for an article in that day’s Wall Street Journal. Only hours earlier, he had presented himself as a disheveled, unbathed, cantankerous, and confused old man who was wearing bits of his breakfast on the front of his shirt. From this I concluded that, first, the Wall Street Journal must conduct its interviews by telephone and, second, a man can be quite demented in one sphere, as in the attention paid to personal hygiene and grooming, while retaining adequate command of the facts in a professional sphere, at least enough to get by for a long time before anyone at work notices a problem. Recall President Ronald Reagan’s highly publicized but delayed diagnosis of AD. Cognitive dysfunction, like the stock market, has its ups and downs. A patient may have lucid moments punctuated by strange lapses in judgment and social behavior, even while his remote memory remains remarkably preserved. To the annoyance of caregivers, especially the spouse, such patients often are able to rise to the occasion and give a brief but dazzling performance at the doctor’s office, only to lapse back into another world when the show is over. Does a relationship exist, even if ephemeral, between a physician and his patient whose self-awareness fluctuates by the minute?

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In the gallows humor of medical school, a very demented patient was said sarcastically to be “not exactly quoting Shakespeare.” One night, though, a retired English teacher in his eighties was admitted to the hospital with pneumonia. He had been suffering from slowly progressive AD for years. That night, delirious with fever, he lay in bed and recited the sonnets and other works of Shakespeare in what seemed to be perfect iambic pentameter. In the morning, with his infection clearing on antibiotics, he slid back to his vacuous and noncommunicative baseline. Dementia is a process.8 The self, with its unique wit, charms, and personal memories, wavers up and down in the short run while, inexorably, it fades away. For the physician, maintaining a personal and professional relationship with a dementing patient is like hitting a moving target. Can there be a relationship between a severely demented patient and his physician? This is a question with both ethical and quotidian implications. I have pitched the personal physician–patient relationship as the foundation of good primary care medicine for the elderly. It is the plinth upon which all of our other modern, sophisticated, and technologic care is based. How does this model hold up when, as a hospital nurse once characterized a very demented patient of mine in her daily nursing assessment, “the lights are on, but nobody’s home?” Much of the pleasure and professional satisfaction in primary care medicine derives from communication with patients and long-term observation of the course they take. We prefer the rush we feel when we cure an ailment, but more often than not, we are satisfied by providing good long-term care of a patient with a chronic condition. Like avid followers of a favorite soap opera, where characters come and go over the years, we watch the drama of life continuously unfold. Much of the professional pleasure in medicine derives from simply knowing the people involved and watching to see how their stories play out. In the case of a severely demented elderly individual with AD, there is no rapport, and, furthermore, I know how the story likely will end—with isolation and loss of dignity for the sufferer as well as for the spouse or caregiver. This is not an appealing clinical situation to manage, and it explains, at least in part, the current and anticipated worsening shortfall of specialists in geriatrics. Specialists in other fields of medicine seem to cope well with the care of patients with depressingly hopeless situations. The oncologist often is confronted with ghastly diagnoses, yet the success of her work may hinge more on an ability to convey bad news than to provide a meaningful fix. The same goes for a good neurologist who cleverly, but sadly, makes a

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diagnosis of a fatal, hopeless neurodegenerative disorder like ALS,9 but who has something to offer by forming a compassionate bond of communication, trust, and support. Even the neonatologist, caring for the smallest of the sick, forms a physician-patient relationship, albeit a relationship with the baby’s parents, serving as proxies. Can a primary care physician form a professionally satisfying and effective bond or a physician-patient relationship via the caregiver of a patient with severe AD, by proxy? The quality of medical care for the demented elderly is determined largely by the quality and constancy of the personal care available at home. The “fortunate” victim of AD has a dedicated and observant spouse— perhaps relieved from time to time by a professional caregiver or agency—who is finely attuned to the subtle nuances of the patient’s status day to day and who knows to contact the physician’s office when indeed appropriate. Such a caregiver prides herself on her ability to tell that her demented husband, who no longer communicates verbally, is getting a bladder infection, a stool impaction, or an early pneumonia, days before any professional health care worker might detect it. She is a superspecialist to her one patient. She micromanages the daily bathing, dressing, feeding, and round-the-clock health assessment of her very demented spouse. She is the keeper of the flame and, as such, consents to be the donor in a sort of transplantation of psyche. Perhaps she does so in honor of a marital covenant made half a century ago—”till death do us part”—or as a form of psychological displacement. If she cannot have her husband back, as he was, at least she can serve out her lifelong vow by focusing on that which is fixable—keeping him clean, wellfed, and free of pain. She is there to preserve his personal dignity, which has outlived his sense of self. Such a good caretaker offers an excellent opportunity for me, as physician, to make a meaningful connection and to contribute to the quality of this man’s physical condition. We should all be so fortunate as he.10 Many of our nation’s severely demented elderly lack the protective umbrella of “24/7” home care provided by a spouse who is dedicated, capable, and physically healthy enough to be up to the task. In an aged and fragile couple, the second to die is at a distinct disadvantage. Furthermore, there may be no responsible family members left. If the patient is in her nineties or is a centenarian, the “kids” may be long dead. The United States is a mobile population. A “nearest” living relative may be thousands of miles away. Remarkably, one in every one hundred U.S. citizens is now incarcerated and thus definitely less mobile (Katzman and Fox 1999). It is safe to assume that a grandson in jail will not be attending grandma’s visits to the doctor. The advent of the dual-income family, now

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a full generation ago, reorganized family priorities to the detriment of the old and demented whose care is no longer viewed as a woman’s primary duty and obligation (Martin and Post 1992). Who will take grandpa to his appointment and talk with the doctor? Often, nobody. The Family and Medical Leave Act of 1993 provided a mechanism for an employee to take unpaid time off from work for a protracted period in the event of a family health crisis, without fear of termination. However, the law does not obligate an employer to grant a two- to three-hour leave from an assembly line or a busy desk job to take a confused and disruptive parent to the doctor. Perhaps it should. Too often, the arrival of an old, demented patient, accompanied by an unhurried, focused, and informative surrogate, can occur only at the whim of a factory foreman or a crabby clerical supervisor. Geriatric care, in this setting, gets short shrift. This policy reveals where we, collectively, place our parents’ care among the priorities on our national To Do list. I cannot begin to estimate the number of times a severely demented, noncommunicating octogenarian has been deposited in my waiting room by a nonfamily member who carries no useful information from home, is not an authorized proxy, and may not personally know the old woman he has delivered.11 The driver—and that is all he is—will ask my secretary at the window when he should return for pickup, and then he is gone. He leaves behind a disheveled and bewildered old woman who is uncomfortable and uncomforted, slumping to one side in a borrowed wheelchair. There is not so much as a note from home pinned to her coat. What shall I do for this woman? Aside from bordering on elder abuse by family neglect, this is health care delivery in the absence of any form of physicianpatient, or physician-proxy, relationship. By far, most caregivers and families have absolutely no intention of neglecting a demented parent. American families, however, are stressed to the maximum and are under siege from all sides. An adult child with a low-paying hourly job cannot afford to spend an unpaid afternoon in my office with her mom. The recent extraordinary rise in energy and food costs while wages have remained relatively stagnant makes it even less likely that a child can afford the luxury of a half-day off to accompany a parent and to participate in the coordination of her care. Nevertheless, getting a demented parent to the doctor’s office is not an errand like dropping off the dry cleaning. We need to think of the office visit as, at least in part, a business meeting in which primary caregiver and primary physician discuss current problems, map out a long-range plan, and address ethical considerations of end-of-life care for a demented parent. A family’s

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provision of good home care and the physician’s delivery of quality medical care are closely intertwined in the overall management of the elderly patient with advanced dementia. It is pointless to attempt to measure a physician’s performance—as Medicare has begun to do through “pay for performance”—without factoring in the degree of family commitment and support as well. This is a group project. Inadequate caregiver or family supervision does not necessarily correlate with wealth or poverty. I have seen confused, unkempt, but financially fit patients come in with skin ulcers that obviously had festered for weeks unattended, while a well-to-do son or daughter was away and no close supervision had been arranged. In contrast, I have witnessed relatively poor families providing beautifully coordinated, loving, compassionate, and medically sophisticated care to a demented parent in the home to the very end. Quality of care at home for a patient with severe AD is more a matter of a family’s organizational skills and its commitment of time and energy than solely its financial resources. Smoothly functioning, effective families will delegate tasks among family members, rotating responsibilities such as transportation, prescription refills, dental visits, foot care, a haircut, or whatever else it takes to preserve the health, comfort, safety, and the dignity of a patient with dementia. Can this skill be learned? Organizational behavior is taught in business schools. Group dynamics, cooperative effort, delegation of duties, and the self-assessment of performance are learnable management skills, not necessarily inherent traits. Education about the needs of a family member with AD should begin in high school health classes and incorporated into a curriculum that currently focuses on more immediate concerns of the young such as eating disorders, teen pregnancy, and sexually transmitted diseases. Students need to know that, in all likelihood, they will either end up caring for a family member with AD or having it themselves. Dementia care should be part of a comprehensive look at a globally well-adjusted life cycle and as a step toward the rehabilitation of family in the United States. Note that a rational and proper approach to a family’s handling of a demented elderly member is not purely a matter of undying love or blind devotion. A demented patient may have a very dedicated spouse or other caregiver and still not receive the compassionate care that is appropriate or desirable. Dementia care can be thorough yet misguided, as in the case of Mr. F. Mr. F was an eighty-year-old man who suffered from the steadily worsening rigidity of Parkinson’s disease along with an associated

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progressive and profound dementia. In a former life, years before, he had been a successful entrepreneur. Now he lay bedridden, long gone in spirit and self, unable to experience any of the joys of human interaction or of life itself, more because of the dementia than his disorder of movement. Mrs. F, a bright and capable octogenarian, was committed to her husband’s bodily maintenance, no matter what obstacles might come their way. She requested and received a hospital bed when Mr. F could no longer be positioned in a chair. Mr. F, frozen and withered in both mind and body, shriveled and easily lost in his big electric-motorized bed, became the centerpiece of a cluttered living room. Pill bottles, boxes of nursing supplies, and tube-feeding equipment had transformed their small home into an intensive care unit for one. Mrs. F and I enjoyed what I considered to be a good physician-patient relationship. She too was under my medical care. We also had a functional physician-proxy relationship, even if I did not concur with her philosophically. With her husband’s first productive cough, Mrs. F would call each time for an antibiotic to block an incipient pneumonia. Should the urine in his catheter bag turn cloudy with infection, she would tap off a sample and bring it in for immediate analysis. I made occasional home visits, addressing Mrs. F’s immediate concerns, but I always left her house shaking my head and wondering what it was that I was doing there. I hoped that nobody would ever take such “good” care of me. Somewhere along the course of Mr. F’s slow, dwindling dementia and physical deterioration, but before his actual demise, he had ceased to be the patient. A transference had occurred. With each new problem and each new prescription written for him, I was treating Mrs. F and not her husband. I was forestalling her terror of isolation and preventing the pain of loneliness that would come inevitably when Mr. F was truly gone. That such a shift had occurred should not have surprised me. I suspect that Mr. and Mrs. F had been fortunate to have had a close and enduring marriage that had bordered on symbiosis. So often in primary care, we are treating more than one person when we write a single prescription. The patient is not necessarily the one with the disease. For Mrs. F, the situation, as horrible as it seemed to me, was tolerable and stable. She had her husband. He was with her at all times, and she was comforted by his presence, such as it was. She spoke to him, even if he gave no reply. Each November she would fill out his absentee ballot and cast “his” vote along with hers. Preserving Mr. F, in whatever limited form, gave Mrs. F’s life purpose and meaning. For some caregivers, loneliness is

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the worst agony, and the supportive care of a demented spouse should be viewed as a form of pain management. We physicians are not particularly good at controlling chronic physical pain in the elderly; I think we score even lower at managing their emotional pain. I did not meet Mr. F until late in the course of his illness. However, I would be willing to wager that, if he could have gazed into a crystal ball, he would have shuddered to learn that he would spend the last five years of his life in the undignified manner of a helpless and unaware subject in a sort of sustained science project. Could Mr. F have prevented the protracted, well-intentioned, but ill-conceived, heroic effort made by his wife in those dreadful final years when his heart still beat but the man was gone? Remarkable developments in life-sustaining technologies since the 1960s led to the creation of instructional advance directives (Perkins 2007, 51). Patients wanted a legal mechanism by which they could have a say in their ultimate care in the event that corporeal existence outlasted the cogito, or cognitive self. Can a physician sustain a relationship with a demented patient via an advance health care directive written long ago, when the person was intact and autonomous? Is it possible to have a physician-patient relationship that is set well in advance, one day to run on autopilot, no matter what may come? A living will, or an advance directive, expresses a personal wish. Through a legal document, we attempt to set some parameters on the extent of care we will receive in the event of a few, select, hypothetical, but bleak clinical scenarios. Should I become severely demented or, for some other reason mentally incapacitated, do I want my body supported, or perhaps I should say sustained, with a mechanical ventilator breathing for me, while I am fed by a tube, watered by an intravenous line, fortified against infection by antibiotics, and shocked electrically to restore a faltering heart rhythm? My own living will is organized in this menu-style format with a list of hypothetical dire scenarios and corresponding multiple-choice selections. In reality, none of us can ever know exactly what lies ahead on the bumpy road of life. Just as I cannot write a will that might control my children’s future from beyond the grave, I cannot provide enough specific advance direction ever to serve as a stand-alone substitute in a workable physician-patient relationship. That is why we also must select a spokesperson to be a health care proxy. We all need to have someone with whom we can convey the personal philosophy we hold about sustained life after the onset of severe dementia. We all must express the spirit and the intent behind the legal document that is our own advance directive. In other

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words, we need to communicate (Moody 1992), and we need to do it now, when we are not yet even the slightest bubble off. The execution of an advance directive is nothing more than an opportunity to establish an open dialogue between a patient and his or her surrogate or family. It is a chance to lift the heavy burden of guilt that may one day come to hang on the caregiver of a demented spouse, reluctant ever to be the proximate cause of death through some perceived act of neglect. It is absolution in advance. We have examined, in the case of Mr. F, a scenario in which, I believe, the overzealous efforts at life prolongation by the patient’s proxy were detrimental to the quality and dignity of the life she sought to preserve. By the same token, just as we don’t want to overdo it, we must not be too quick to restrict care based solely on a patient’s diminished cognitive function. We live in an age of steadily contracting national resources. Bioethicist Daniel Callahan in Setting Limits (1987) views medical care for the aged as a matter of resource allocation subject to the proper crafting of public policy. No one would argue that the pursuit of a better life for my patients, rather than simply a longer life, should be my goal as a physician. The family of a severely demented old man may come to me and say, “Don’t do anything heroic.” Heroism, as we have seen, however, is in the eye of the beholder. I must address each clinical situation on a case-by-case basis, realizing that I am treating a family with all of its unique and peculiar dynamics, and I am not limited in the extent of my care by government fiat. Rather than viewing the demented as a group competing for scant health care dollars, we should view their care as an opportunity for innovators and entrepreneurs in the private sector. The hospitality industry already has begun to recognize the coming need for more assisted-care living facilities. The impending wave of demented old Boomers will spawn an entirely new service industry that is geared to the proper care, safety, and supervision of the elderly cognitively impaired. As I propose in chapter 6, the home visit, or an updated, technologically more sophisticated version of the old house call, deserves reconsideration as an efficient means to provide comprehensive and compassionate geriatric medical service. Just as the growing demand for depleting petroleum supplies surely will lead to a new energy technology, the challenge of creating socially responsible expanded dementia care could also be a stimulus to our service economy. We can do well while doing some good for our demented. At present, though, we stand at the summit of an ethical slippery slope. I must summarily dismiss active euthanasia of the demented elderly, regardless of what they do in Holland, as morally repugnant. Passive euthanasia,

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or “letting nature take its course,” is the tacit and socially acceptable way in which we currently set limits in the United States. We may, after appropriate thought and deliberation, elect not to implant a pacemaker in a demented individual who needs it to continue existence. The loving husband of an old woman suffering from severe AD who has collapsed to the floor may first take a shower and get dressed before calling the rescue squad. These are sad and private matters. Were we to draft U.S. governmental policy restricting the access of the demented to sophisticated medical care, we would create a second, diminished tier of citizenship. Here is where we risk “slipping” downward toward the unthinkable immorality of the Nazis. If the demented are in the second tier, what about the mentally retarded, the deformed, or the members of a minority? We live on a planet where human life is valued very cheaply. I say so not only because of senseless wars, ruthless dictatorships, or the genocide of ethnic cleansing. Millions of Americans willingly and willfully toss away their lives by smoking cigarettes, an act of slow-motion suicide. We in the United States at least should distinguish ourselves among nations by taking the moral high road in the care of our elderly demented. We should state emphatically that a demented citizen of the United States, while lacking a self, still possesses basic human rights and dignity. Regardless of any debate held by philosophers or ethicists, we should assume that they do because we consider ourselves an enlightened and benevolent people. Give the demented the benefit of the doubt. We had better proceed on the assumption that there is no silver bullet for AD waiting just around the corner. Even if a safe and effective memoryenhancing drug were to emerge from the laboratory, its adoption would only forestall inevitable cognitive decline, and the societal challenge of a demented geriatric population would, in the future, still loom large. We must be prepared for this. More than being prepared, we must learn to take pride and satisfaction from the proper and dignified care of our nation’s demented elderly, who are perhaps the largest group of disenfranchised U.S. citizens. We must revise our cure-based concept of medical care and focus instead on removal of the stigma of dementia, the isolation and shame experienced by caregivers, and the slow erosion of dignity that is a hallmark of the disease. The preservation of dignity for the demented is a laudable goal for the noble profession of medicine. It is also good social policy for our country precisely because it is the moral and right thing to do.

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ON THE ROAD AGAIN

Mrs. G failed to show for her doctor’s appointment. She was to have been seen that day in 1981 at the rural health center in bucolic Orange, Virginia, a regional satellite office of the Medical Center of Mr. Jefferson’s University of Virginia in nearby Charlottesville. She was due to see me, an overwhelmed and anxious new intern. Since I didn’t feel like a physician, it didn’t strike me as odd that she hadn’t appeared for her doctor’s appointment. In fact, I was relieved. In the first months of internship, well before my metamorphosis from book-smart medical student to barely competent physician, a clinical encounter was far more stressful for me than for the indigent but brave patients assigned to my care. They knew what to do; I didn’t. Fortunately, my attending preceptor, who was there to teach me, but also to protect my patients, recalled Mrs. G’s case, and her absence raised a red flag in his mind. Mrs. G had no telephone. There was only one way to check on her—“we” elected to make a house call. Our scenic excursion on a warm and sunny day took us along country roads among the rolling hills of central Virginia on the eastern edge of the Shenandoah Valley. Eventually, we slowed to turn down a long and rutted dirt road with no signpost and no signs of life. Kicking up dust, we drove about a quarter of a mile along the meandering, narrow road, turned a final gradual curve, and came to a halt. The doctors had arrived. There before us stood a decaying remnant of the antebellum South, a badly weathered, sagging, and dilapidated wooden structure with not a single straight-line edge or right-angle corner. The condemnable old structure appeared on the verge of collapse and probably had been for quite some time. Chickens pecked at corn scattered near the rotted front door, and the smell of wood smoke came from a dirt-floor kitchen that lacked

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running water. There, forty minutes from one of the wealthiest zip codes in America, was our poor patient, Mrs. G, propped up by pillows in a makeshift recliner. Her badly swollen right leg was elevated on a wobbly wooden chair that, like her, had seen better days. Here, on my first house call, I confronted a patient with a disturbing and humbling diagnosis: abject rural poverty. Badly weathered like her house, Mrs. G had an emotionally stunted and withdrawn affect, a look of low expectations from a hard life. Her cheeks were hollowed by the absence of either teeth or dentures. Although not gaunt, her wrinkled face bore the stark black-and-white contrast of a Depression-era Margaret Bourke-White or Dorothea Lange photograph. After I paused to fathom this scene from another time and another world, I turned to the task at hand; I began to assess Mrs. G’s bad leg. The turgid extremity had been “tended to” by Mrs. G’s daughter. Looking as impoverished and only a bit less weathered than her mother, she evidently was a devoted daughter and a well-intentioned caregiver who, as women did during the Civil War, bound the wounds of her loved one. Strips of stained linen dressings were wrapped around the lower leg and secured by twine. As I cut away and bagged the putrid, pus-laden wrappings, I realized that I was a long way from my “home.” This was not the sterile, sanitized world of medical care on my terms, with white walls and white coats, shiny floors, cool fluorescent lights, and the antiseptic odor of the clinic. This was medical care on another planet, a third world house call made not far from where I lived. As I probed Mrs. G’s deep and nasty leg ulcer in the dim squalor of her own home, I uncovered an appalling atavism for modern medicine: maggots. Even I, a neophyte medical apprentice, recognized immediately that this was one serious infection. I urged Mrs. G to allow us to transport her to the hospital, where she could receive proper aggressive treatment with surgical debridement of her gaping wound and potent, high-dose intravenous antibiotics. She flatly refused. Under no circumstances would Mrs. G leave the “comfort” and familiarity of her own home. She was in command, albeit aboard a slowly sinking ship. Here she was the matriarch where she could keep her throne, personally attended by her daughter, a dutiful lady-in-waiting, if a grossly inadequate medic. In the office I probably would have labeled Mrs. G as “noncompliant.” Here, in her home, she was a woman coping with misery the best she could. Since Mrs. G would not budge, we would do things her way. I cleansed her wound vigorously, applied a sterile gauze dressing, and prescribed as strong a dose of antibiotic as I safely could give by mouth.

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I arranged for daily wound checks through a visiting nurse service provided by the county at no cost to the indigent. Remarkably, and against all apparent odds, Mrs. G’s leg began to heal. Within a few weeks, she was once again up and about, feeding the chickens and keeping her home. Soon thereafter, she agreed to pay me a call in return; she accepted a follow-up appointment at the clinic on my home turf. It seemed proper and southerly genteel to return the favor of a visit by soon calling on me. The poignant memory of this house call, made so early in my career, remains etched in my mind. I was shocked by the sight of a nasty wound treated only by primitive nineteenth-century methods and the stark context of an elderly patient living in poverty in rural America. Yet, I was struck by the stubborn pride and retained dignity of a woman from rural Virginia who would not leave her home for the sterile, impersonal world of the big hospital in Charlottesville. More surprising still was that a house call had worked! Contrary to the conventional wisdom of academic medicine at that time, Mrs. G had made a full recovery, without the disruption, cost, or traumatic intensity of a protracted hospital stay. She had made the right choice. Sadly, my visit to Mrs. G’s home in rural Virginia was both my first house call and one of my last. I can count the number of calls I have made in the past ten years on the fingers of one hand. Among older physicians and patients alike, a romantic nostalgia lingers for the days of the house call, when a dedicated doctor slogged through snow, trudged up stairs, and crossed the threshold, black bag in hand, as an appreciated visitor and a welcome guest (Greengold 1995; McWhitney 1997, 430; Allen 2003, 574). Far more than the brusque modern medical “encounter,” this was also a social call. A home visit was intimate and personal care by a physician for a patient, long before the modern era of industrialized medicine in which providers deliver services to health care consumers under contract with third-party insurers. It seems so simple and appealing. Why, then, had the house call never become a routine part of my practice? If I could save Mrs. G’s leg in the comfort and privacy of her earthen-floored shack nearly thirty years ago, why had I never been willing to take the show on the road as an integral part of the modern practice of primary care? A national survey of physicians in 1992 demonstrated that “the great majority (over 75%) of family physicians and internists still regard the physician home visit as important for the care of selected patients” but that “only about half report making one or more home visits within a 12-month period” (Keenan et al. 1992, 2025). Like me, it seems, most doctors readily acknowledge the clinical value of the house call, the personal

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gratification it affords us, and the comfort and satisfaction it offers our patients and their families. Yet we choose not to participate (Meyer and Gibbons 1997, 1815). House calls seem to be a very good thing for other doctors to do. According to a study done in Utah in 1987, older physicians are more inclined than their younger colleagues to visit a patient in the home setting (Schueler et al. 1987, 92). A house call is more likely to occur if the patient is elderly and the doctor is a family practitioner rather than an internist or specialist. Despite longer distances and greater travel times, doctors in rural and suburban regions make more house calls than do those in large metropolitan areas, perhaps reflecting the busier pace of city life or urban physicians’ fears about personal safety. Overall, the average number of house calls documented in the Utah study was only 2.6 per month, far lower than the 6 per month found in an earlier study from New Jersey in 1977 (Warburton, Sadler, and Eikenberry 1977, 223; Bodenheimer 1999, 1324). Broadly, home health care is emerging today as a growth industry, with public agencies and private corporations now actively addressing a need for in-home specialized forms of care such as intravenous, respiratory, physical, and occupational therapy, as well as skilled nursing services for frail and recently hospitalized elderly patients. Conspicuously absent from the homeward-bound movement of health care, however, is the physician. Doctors still make house calls only with reluctance. As I reflect back on my own practice experience, there were occasional circumstances in which making a home visit clearly was the right thing to do. A bedridden, terminally ill patient, racked with cancer, justified a special trip. I visited the patient in his own home to assess comfort and pain control, but I think the visit also served as atonement for my failure to restore health or forestall death. I reserved the house call as a consolation to a dying patient and as a respectful and private courtesy. Occasionally, I would agree to see a patient in the home when the situation was particularly pathetic, such as when a care-giving spouse was in way over her head but steadfastly refused to surrender her invalid, demented husband to the nursing home. Personal friends, colleagues, and a few patients with whom I had a particularly close relationship warranted a bedside visit in the privacy of their own home. At all times, though, a house call was in my mind an add-on service, performed as a personal favor, beyond the scope of my regular day job. A house call was a special gift. Physicians’ knee-jerk response, when asked why they don’t make home visits, is that it costs them too much money ( Jauhar 2004, 2149). Poor reimbursement and inefficient time utilization are commonly quoted reasons

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why doctors say no to a request for a house call. Lack of necessary medical equipment and an undue fear of greater exposure to malpractice liability also are proffered by reluctant doctors, although these truly are not valid reasons to shun patients in their own homes. One legitimate concern, however, is the paucity of home-care training offered by medical schools and residency programs (Hayashi et al. 2007, 1287). If each successive generation of young doctors is not taught by their preceptor role models, the house call is sure to become a lost art. Teaching the “how” of home care is straightforward. All physicians, regardless of future specialty, should be able to evaluate, comfort, and advise a patient or his family in a low-tech environment, without sophisticated scanners, a full diagnostic laboratory, or a cadre of consultants. Proficiency in home care is a matter of national security; all American physicians must be taught and prepared to deliver basic care at the bedside in the midst of a blackout, a flu pandemic, or a terrorist attack. In a catastrophe, absent a functioning hospital or medical infrastructure, home care may be the only care there is. Visiting the frail, elderly homebound patient reminds us that, with very little advance warning, we are all members of a vulnerable population. It is essential that we teach young doctors why they must see patients in the home setting, not just how to do it. Money, of course, does matter. Historically, Medicare has always favored acute short-term, high-intensity in-hospital care and has rewarded it accordingly. Being none of the above, a geriatric home visit was considered a quaint relic of care and it commanded only token remuneration. Subsequent minor tinkering with reimbursement rates under Medicare’s resource-based relative value scale (RBRVS) of physician reimbursement never overcame the consequential lost earnings of a physician stuck in city traffic or lost in the boonies on treacherous snow-covered roads (Goldberg 1995, 121). Perpetually rising office overhead has exacerbated the problem. To cover rising business expenses such as insurance, payroll, rent, and medical supplies, a physician must operate at all times as a well-oiled health care machine. Frederick Winslow Taylor, the nineteenth-century industrial efficiency expert, promoted faster steel production through his scientific analysis of time and motion in the mill (Kanigel 1997, 18). To maximize output there could not be a single wasted moment or movement. Man served machine. By necessity, Taylorism, as it is called, now rules the doctor. As the sole engine of profitability, I cannot “shut down the line” or compromise “throughput” by leaving the office to make a house call. That’s bad business, even if it might be good medicine.

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No conceivable recalibration of Medicare reimbursement under RBRVS, even if generous, can make the house call a profitable venture for the office-based doctor. An overworked primary care physician hardly can step outside the office for a quick breath of fresh air, let alone grab his bag and leave for an afternoon on the road. However, a full-time home care physician, unshackled from the burden of managing and supporting a brick-and-mortar office, would have that freedom (Boling 1997). She would not resemble the horse-and-buggy doctor of old. Unencumbered by an office, she could rely on cell phone, laptop computer, and wireless Internet access for electronic record-keeping, access to lab data, and transmittal of charges to a remote billing service. She would tote lightweight portable diagnostic gear, materials for blood collection, and, of course, a black bag. The modern specialist in home care medicine would deliver high-quality, technically sophisticated, yet personalized, care via a change of venue: she would bring it home. The promise of the paperless office never materialized, but the concept of an “officeless” doctor is intriguing. Whatever the format, the concept of an efficient house call of the future may well be an oxymoron and an undesirable goal. Physicians’ preoccupation with efficiency of time and motion in office-based care has led to the in-and-out herding of patients and to swift and scripted ten-minute appointments with perfunctory salutations, clipped conversation, overly narrow focus devoid of any rich personal context, and a mutual lack of satisfaction in the experience for both patient and physician. Furthermore, speed kills; I suspect this is true in the steel mill, and I know it is certain when the doctor is rushed. It may seem iconoclastic to say at a time when health care reformers demand maximal demonstrated return for every dollar spent, but in our quest for peak productivity, we have altered the product: what was a relationship is now strictly a service. The real appeal of a return to the home visit is that it may restore the physician-patient relationship to its rightful place. In his own home, the patient achieves a one-on-one closeness and commands the sole focus of the physician. In the office, he is one of many, receiving the divided attention of a harried, multitasking doctor. The take-a-number format of the busy bakery or delicatessen may work to serve food efficiently, but it doesn’t foster the personal and social component of a visit with the doctor. Done right, a house call takes time; that is a good thing. Efficiency, of paramount importance to the modern practitioner, gives rise to physician arrogance. My time is worth more than yours. Otherwise, you wouldn’t make the trip, spend the money on gas, or sit patiently in my aptly named waiting room. A doctor trained in the last decades of the

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twentieth-century, unaware of the broader trends in American medicine and of the former prevalence of the house call, knows no other style of practice or way to behave professionally (Starr 1982). In reality, however, institutional or facility-based care is a relatively recent development and “a peculiarity of modern Western medicine” (Keenan and Fanale 1989, 1076). The general ownership of automobiles and telephones, and the widespread geographic distribution of medical offices, not the supposed supremacy of the clinic-based physician, sounded the death knell for the home visit. The public, however, bought the package as advertised. They accepted that they must rally when ill, collect themselves to make a trip, and serve their time in the waiting room before they could hear a nurse say, “The doctor will see you now.” The net result is that physicians, while technically sophisticated and armed with diagnostic gadgets, professional jargon, and information technology, nevertheless have lost a critical social skill: how to pay a visit. We no longer know how to be a polite guest in a patient’s home, there at his invitation, on his turf, and abiding by his rules of social conduct. We don’t want to play where the patient has the home-court advantage and the rules are different. To be fair to physicians, we are not the only ones who have foregone the art of the social call. According to Robert Putnam in Bowling Alone, “visiting with friends and acquaintances has long been one of the most important social practices in America” (Putnam 2000). While it was once commonplace to receive guests in the home, in recent decades, that practice has given way to socializing only on neutral ground such as a bar, restaurant, movie theater, or other place of public entertainment. All but gone are the traditional dinner parties in the home, served by a gracious host or hostess, later reciprocated, and affording an opportunity for the pleasure of engaging conversation. Since the late 1970s, the period coinciding precisely with my career in medicine, the domestic social visit has withered to a rarity now headed for extinction. It will prove difficult to promote the merits of the physician’s house call to young medical students when a home visit has no popularity among the general public. All Americans, not just doctors, should resume making house calls. One group, historically, maintains unwavering support for the home delivery of health care: visiting nurses. Whereas the modern physician eschews a field trip beyond the familiar, sterile, cold, and controlled environment of the office, the visiting nurse dutifully continues to traverse great distances and conquer steep stairs. She contends with the hazardous obstacles of a cluttered home, perhaps an unsavory neighborhood, or a

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family’s dog that greets her with glassy eyes, curled lip, and the raised hair characteristic of canine aggression. Why does she do this when my physician colleagues and I will not? There must be something in that home that yields the visiting nurse a great sense of accomplishment, professionalism, and personal satisfaction that makes the trip worthwhile for the traveler. Karen Buhler-Wilkerson in No Place Like Home (2001) has written a vivid history of nursing and home care in the United States. She has examined the mission and operations of the Ladies Benevolent Society (LBS), a forerunner of a visiting nurse service in antebellum Charleston, South Carolina, in the early 1800s. Illness was a domestic matter, handled primarily by the woman of the house, and often was accompanied by poverty. Although a germ theory explaining transmissibility of infections was still decades away,1 women serving as agents of organizations such as LBS already recognized a correlation between health and hygiene, both physical and moral. Their focus was narrow. Women of the LBS sought to provide comfort, relief, and supplies to unfortunate sufferers of the ravages of acute illness or injury. Their services were not intended as a charity for those without financial means or who lacked a supportive family; that was the function of the poorhouse. Nor were the members of the LBS to provide chronic care for the frail elderly or a fragile, lame patient with a slowly withering ailment such as leprosy. A home visit by a woman from the LBS was a laudable Christian offering of salvation from a squalid, vile, vice-ridden, and nonvirtuous life, but it was intended to provide only transient relief of acute suffering. Today, little has changed. Skilled nursing at home, as covered under Medicare, typically is provided only for elderly patients recently discharged from the hospital, only for a very short course, and only when the physician “rubber stamps” a nurse’s care plan, verifying that it is warranted (Cluff and Flatley 2000). For visiting nurses, this is an indignation leveled by a bureaucracy. Medicare, historically, has treated home care as a posthospitalization afterthought, not as part of a well-conceived continuum of chronic care (Benjamin 1993, 129). The government’s low regard for home health care was reinforced under the Balanced Budget Act of 1997, which severely curtailed reimbursement to Medicare-approved agencies delivering such care. Closure of over one thousand home health agencies nationwide, and the downsizing of others, resulted from the federal government’s belt-tightening effort to contain health care costs (Flaherty 1998, 6). In 2000 Medicare coverage of home health services was revised under a somewhat more supportive policy of prospective payment (Centers for Medicare and Medicaid Services 2009). However, Medicare’s grudging

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and belated acceptance of home care, as provided by both physicians and nurses, has caused delayed development of a critical component of the continuum of care. In the later decades of the nineteenth century, particularly in cities in the Northeast, densely concentrated populations of poor immigrants lived in filthy, unsafe, and unsanitary urban tenements. If fortunate enough to find work, they faced backbreaking and repetitive labor that was hazardous to life and limb and that exposed them to the occupational toxins of an emerging, but still unregulated, industrial America, long before the Occupational Safety and Health Act (OSHA). Well-meaning women of high society believed, according to Buhler-Wilkerson, “that urban poverty was caused by the moral deficiencies and character flaws of the poor.” Urban poverty, they asserted, robbed people not only of their health, but also of the self-awareness and natural instinctive desire for cleanliness and a salutary lifestyle. The poor needed to be taught good hygiene. With industrialization, the role of the visiting nurse moved beyond charitable intervention for acute illness. The focus shifted to promoting the beneficial and disinfectant qualities of sunlight and fresh air and to inculcating the hygienic benefits of good, clean living. Doctors, on the other hand, closed ranks to protect their professional guild. They, and only they, retained the authority and the credentials to diagnose. Visiting nurses, therefore, would come to occupy a different niche but play a critical role: to promote the public health. As Buhler-Wilkerson states: “While the doctor diagnosed disease, the nurse diagnosed the whole situation.” A bifurcation had occurred in the evolutionary tree of health care delivery. Modern home care, if it is to succeed, will require a reunification of purpose between doctors and nurses, and a redoubling of effort toward a new common goal: care of the chronically ill and elderly in the comfortable and familiar setting of the home. Whereas filth and contagion were the focus of the late-nineteenth- and early twentieth-century home visit, protracted frailty, isolation, and loneliness become the enemy when life is long and relentlessly riddled by functional impairments. We soon will be a nation of caregivers. A coordinated team effort of community-based health care will be essential to maximize functionality of a senescent Boomer generation and to prevent a national epidemic of caregiver burnout (Hughes et al. 2000, 2877). Who are the patients most likely to benefit from home delivery of health care by a dedicated team of professionals? As a third-year medical student, new to the wards, I was handed several old-fashioned, heavy metalbacked charts to review. I was to familiarize myself with “my” cases and

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learn the language, style, and format of the written medical record. The first patient’s chart was that of a fully dependent, severely demented, and bedridden old woman. The last entry read “Awaits transfer to NH.” I assumed she must have family in New Hampshire and that they would be coming soon to take her back home. I proceeded to the next patient’s chart. The story was the same and it concluded “Plan transfer to NH.” Quickly, I flipped through other patients’ charts in the rack. They were all heading for New Hampshire! Suddenly, it dawned on this clever med student that this was not a geriatric mass migration to New England; these severely demented, multiply dysfunctional old men and women were stacked up, awaiting nursing home placement, like planes queued for takeoff at a busy air hub. Today such patients still are best served by institutionalization. They are not the intended target of an enhanced form of home health care (Weissert 1985, 423). In-home medical care will not reduce the costs associated with institutional care of the severely demented and debilitated. It will not prevent “the trip to NH” required by that particular subset of the elderly for whom a turn toward institutional care is the proper tack. Rather, expanded home health care services, including a physician’s visits, would be a boon to those elderly individuals suffering from an element or two of the disablement process (Verbrugge and Jette 1994, 1) but who are not severely dysfunctional or necessarily destined for long-term nursing home placement in the foreseeable future. Those potential beneficiaries of home care will encompass the vast majority of soon-to-be-geriatric Boomers. The latter phase of life comprises a series of accumulated physical and mental impairments, of variable sequence and severity from person to person, that ultimately restrict activities, behaviors, and functionality. The process is subtle but steady. Reading glasses, the jar-opening rubber gripper in the kitchen, and the To Do list written on a three by five card are affordances that squeeze more years of dependable service out of the depreciated physiology of later life. Canes, walkers, hearing aids, and handicapped-parking stickers round out the process of decline. Daily living becomes constricted, like the painter who inadvertently paints himself into a corner, and the essential benefit of social contact consequently shrinks as well. Sad is the sight of a grandmother who cannot lift her grandchild to her knee because of a bad back, muscular weakness, or the cumulative ravages of progressive frailty. She, and millions like her who suffer from decreased mobility, mild cognitive impairment, and the challenge of preserving a household and an independent life, are the potential beneficiaries of home health care.

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Medicare, always biased by a strictly medical model, has never supported the social side of care. Coverage is provided for the hospitalized patient in need of surgery or intense medical therapy. For the terminally ill Medicare beneficiary, there is hospice care, which may be delivered at home and is a covered service. However, an older woman recuperating at home from knee-replacement surgery receives only a few weeks of inhome physical therapy and nursing services, and only while the treating physician declares her to be “homebound.” That term, as defined by Medicare, arbitrarily and paternalistically stipulates that the patient may leave her house for a doctor’s appointment, but she is not to venture out for groceries, to mail a letter, or to have her hair done. Considered beyond the scope of Medicare’s mission, long-term in-home nursing care goes unreimbursed. The absence of good nursing, medical supervision, and supportive services at home creates a gaping hole in geriatric care that has been termed by Carroll Estes and James Swan the “No-Care Zone.” In their book The Long Term Care Crisis (1993) they write that “the paradox of the demographic imperative is that the medical care contributing to expanding longevity is the same care that threatens to vanquish the provision of chronic, community-based, and long term care supportive services.” Home health care for the elderly long ago fell victim to a faulty premise: it is not merely a supplemental service delivered episodically, a postscript to a procedure, or an addendum to acute in-hospital care. Home care is good primary care practice. It provides the continuity and compassion sought from the strong bond of a physician-patient relationship. It affords the patient and the caregiver a degree of contentment immeasurable by any metric of the modern health care economist. Home care is not strictly for the homebound. The home visit adds context for the caring clinician. The term ecology can be linked to the house call, from the Greek, oikos, meaning “home.” Ecology, therefore, is the study of life within the natural home environment. This may conjure an image of primatologist and ecologist Jane Goodall, camouflaged among chimpanzees, in the rugged habitat of Tanzania. The notion of physician as field biologist may seem harsh to patients, but the concept of an ecology of the elderly is quite sound. One glance inside a diabetic’s refrigerator can tell me more about her diet than any in-office discussion or nutrition questionnaire. A peek in the medicine cabinet detects polypharmacy, and a quick pill count reveals medication noncompliance. Inspection of the patient’s “den” may uncover safety hazards such as loose rugs, sharp corners, or the absence of night-lights. Accumulating mounds of household clutter may be an early warning of incipient

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dementia, as an old person falls behind in organizational capacity. The clues are all right there in the home environment. For many patients, an office visit is showtime. An old woman applies a little lipstick and makeup to conceal her pallor. She musters the fortitude to get behind the wheel and drive to the doctor’s office, where she puts on a fifteen-minute grand performance of forced vitality. Later, back home and out of my sight, she suffers a total collapse due to utter exhaustion and requires a full week to recover. A younger woman, sapped by chemotherapy and radiation, does no better. More useful to me, as the patients’ physician, would be a more natural encounter at home, without the theatrics. Does she get up to greet her guest? Can she navigate within her own home? Is she managing independently? Where is she on the variable but relentlessly downward-sloping curve to frailty? What will her needs soon be? The home visit is anticipatory, not reactive. As a sensitive functional assessment, for the elderly in particular, the home visit offers screening for the four common geriatric syndromes that herald a coming loss of independent living: risk of falls, dementia, depression, and urinary incontinence (Ehrlich 2006, 38). These are the most common culprits that lurk, ready to render a once functionally independent older person into a sadly dependent and declining nursing home resident. They are the four horsemen of the geriatric apocalypse. A physician’s house call, as part of a multidisciplinary in-home team evaluation, performed by a nurse, occupational and physical therapists, and a social worker, can root out the four syndromes that jeopardize independence and signal impending decline. However, do in-home assessments and earlier detection of the four perils of late life produce tangible health improvement? Can they forestall the slippery slope of frailty? Intuitively, preventative home visits should reduce the incidence of falls and cut the consequent misery and mortality associated with a fractured hip. Surprisingly, however, that is not easy to prove. A study from the United Kingdom evaluated the results of an intervention program provided by a “health visitor,” a non-MD caseworker, to elderly patients at home to reduce the risk of falls and fractures (Vetter, Lewis, and Ford 1992, 888). Excessive medication, nutritional deficiencies, lack of muscle tone or fitness, and environmental hazards such as poor lighting and slippery surfaces were addressed. Despite in-home surveillance, when compared with a control group, those visited in the home fared no better in avoiding slips and falls or broken bones. Why? Perhaps the periodic home visit was enabling, permitting elders greater mobility and more confidence but, consequently, greater opportunity to fall, which

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offset any reduction of mishap achieved by the safety screening. Presumably, greater functionality and a better quality of life, at least until the ultimate moment of hard impact, are benefits of the home visit. Can better assessment by home visit and earlier detection of the four perils of later life produce tangible health benefits for the elderly? And can it reduce the coming bulge in health care costs of a geriatric Boomer generation?2 Surely there must be a demonstrable health benefit from social contact. The social intervention of a home visit to an isolated elderly patient should combat loneliness, improve morale, and have a salutary effect on physical health as well. Another controlled study from the United Kingdom was not so sanguine (M. Clarke, S. Clarke, and Jagger 1992, 1517). Randomized patients of a large group general practice received periodic home visits by lay workers and were studied for a three-year period. Compared to controls, they showed no measurable benefits, such as a delay in death, improved physical status, or a reduced demand for medical and paramedical services. Home visits did offer one significant benefit: improvement of self-perceived health status. Those elderly, isolated patients who received visits at home felt better. That is a highly significant achievement, albeit difficult for health care economists to quantify or to affix a price tag. Is a preventive house call to a geriatric patient cost-effective care? Granted, it is not generally recognized as an efficient form of health care delivery, but perhaps there are savings to be reaped from home visits through a reduction in future health costs. In Sweden, a recent cost-utility analysis of the home visit indicated that we should not expect to receive a health care dividend any time soon from preventative home visits (Sahlen 2008, 265). Whereas the Swedish study reported a net savings over a yearto-year period, there was a substantial anticipated increase in cost over a lifetime perspective. This was due to higher costs associated with greater anticipated longevity achievable through home care, a sum quoted as €14,200 per quality-adjusted life-year added. Measured in Euros or U.S. dollars per aged Baby Boomer, this would soon amount to a very large bill. Despite the bad financial forecast, however, the author of the study subjectively and optimistically concluded that preventative home visits represent a cost-effective intervention, stating that “the costs are justified by the outcomes.” Data from the general medicine teaching practice in Orange, Virginia, where Mrs. G had been a patient years before, confirm that economic benefits of home visits are dubious (Philbrick, Connelly, and Corbett 1992, 522). Their report stated: “Physicians engaged in a prospective study judged that 80% of home visits made represented appropriate use of their

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services. In addition, 46% of home visits made an emergency room visit unnecessary, and 9% made a hospital admission unnecessary.” Rural home visits, however, certainly were not cost-effective for the physician. A house call required a mean of 7.1-miles of one-way travel and a mean of 48 minutes, including travel time, to conduct. It generated only $36 of practice income (measured in 1992 dollars). I would not have been able to see Mrs. G in her home had that rural teaching practice not been heavily subsidized by an academic institution. Furthermore, the study from Virginia found that home visits generated, as well as prevented, the use of medical services. The impact of home visits on the overall cost of medical care therefore could not be determined. Attending a frail, sick, and elderly woman entails the cost of tests, treatments, and provision of services, regardless of the site of care. Three hours south of central Virginia, Duke Medical Center in Durham, North Carolina, operates a program called Just for Us, a partnership between a large academic health facility and the local community. Just for Us was established to promote health and maintain independence for medically fragile low-income seniors and for the disabled. The premise of the program is that an academic health center, cooperatively coupled with community agencies, is well suited to lead the way toward home care. Major medical centers already possess the administrative infrastructure, the clinical staff and resources, as well as an advanced system of information technology. Susan Yaggy, chief of Duke’s Division of Community Health, cites a healthy shift in Medicaid expenses for enrollees in Just for Us as evidence of success: fewer ambulance rides and hospitalizations, yet more personal care, pharmacy usage, and outpatient visits (Yaggy et al. 2006, 271). She describes Just for Us as a financially sustainable “system within a non-system” of health care. Just for Us operates as a conventional fee-for-service care model, not an all-inclusive capitated health plan. Established in 2002, it has been slow to achieve break-even operation. To its advantage, Just for Us serves a community located in tightly clustered housing, about three hundred patients living in ten buildings in close proximity. Financial success, sans subsidy, hinges on minimal clinician travel time, as well as employment of nurse practitioners and physician’s assistants, and the optimal coordination of various agency services. Across the United States, however, few communities are so fortunate as to have a large, sophisticated academic medical center as their neighbor. Just for Us, and similar programs, firmly established the validity of long-term comprehensive care, including home visits, for the successful

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management of a frail and elderly population. Like a “concept car” on display at a Detroit automobile show, this is a model of care that we all might be “driving” one day in our old age. The concept, however, is not new. In 1986 the Robert Wood Johnson Foundation and the U.S. Health Care Financing Administration (HCFA, but now called the Center for Medicare and Medicaid Services, or CMS) funded the Program of AllInclusive Care for the Elderly, or PACE. At select sites around the country, PACE clinics operate under a reimbursement system of capitation derived from Medicare and Medicaid funding. PACE is a model of care earlier proven effective at a clinic called On Lok (“peaceful, happy abode” in Cantonese) in San Francisco’s Chinatown (Eng et al. 1997, 33). On Lok, and the PACE programs it spawned, deliver long-term care that is comprehensive, including home health care and social, transport, and other supportive services for a group of frail elderly participants who could not live independently, but who don’t require a nursing home either. Philosophically, the On Lok model emphasizes the home as a natural, more serene environment for care of the elderly. Pragmatically, it and PACE programs around the country must contend with inadequate capitation rates paid by Medicare and state-administered Medicaid programs. They must achieve a fair distribution of services in an age of restricted resources. PACE fills only a tiny niche. Presently, there is no nationwide program of comprehensive long-term home-based care that can keep “pace” with the swelling ranks of elder Boomers. That is a pity. We have an opportunity to forestall frailty and to preserve the functionality of the largest cohort of Americans ever to make it synchronously to old age. A home-based program of health intervention and intensive physical therapy can retard functional decline in the elderly, a preemptive intervention that has been dubbed “prehabilitation” (Gill et al. 2002, 1068). A clinical trial of in-home physical therapy, far more than Medicare presently allows, can retain the essential activities of daily living, the personal and private achievements that preserve independence and human dignity: walking, eating, dressing, grooming, bathing, and use of the toilet. Preventive home visits are most beneficial when they target persons who still retain fairly good functional status, before an irreversible slide in strength makes it too late to make a comeback (Stuck et al. 2002, 1022). In-home assessment must be multidimensional, examining medical, functional, psychosocial, and environmental factors that contribute to loss of function. Comprehensive geriatric assessment, performed right in the patient’s own home by a team of health professionals, will become the

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modern house call. It will be a much-needed weapon in a war on frailty, a recognized syndrome of decline that foreshadows death (Boockvar and Meier 2006, 2245). This is why physicians, as well as RNs, should make home visits. Going into the home directly provides the information I have discussed earlier. This information, as well as the information the nurse obtains, is essential to how we, as physicians, plan care. Going into a patient’s home allows us to perform simple standardized screens, such as the Timed Up and Go (TUG) test. The TUG test is a quick observation of an elderly patient as he rises from his chair, walks ten feet, turns around, and returns to be seated once again. Clocked at greater than thirty seconds on the TUG, a senior citizen is heading for a fall. A nurse’s Outcome and Assessment Information Set (OASIS), done in the home, is a comprehensive screen for the four common geriatric syndromes. A short mental status exam is performed by an occupational therapist, and an inventory of muscle strength and mass, range of motion, coordination, and dexterity is compiled by a physical therapist. Can an old man function on his own within his own personal domain? Can he perform the activities of daily living such as bathing, grooming, toilet use, and dressing? Can he safely continue to age in place in his own home? The house call, once a personal and private visit paid by a physician to a patient’s bedside, becomes proactive global maintenance of function and health. Coordination of care and unity of purpose among the ranks of home health care providers will be essential for success. At present, nonphysician home services are provided by a disjointed cadre of personal care providers, home-health aides, and employees of various agencies performing narrow duties, sometimes at cross-purposes. A rehabilitation therapist may encourage an elderly woman to bathe and dress herself, yet the homehealth aide might readily step in to perform those tasks, reinforcing dependency and sedentary behavior when it may be avoidable. The role of the physician will be to prescribe and confirm delivery of coordinated, comprehensive care and to change the “culture of clinical home care, moving beyond disease management to focus on functional independence” (D. Baker et al. 2001, 257). A cooperative study conducted under the auspices of the Department of Veterans Affairs has shown that team-managed home-based primary care lightens the burden on the family member who serves as principal caregiver (Hughes et al. 2000, 2877). That is a potentially lifesaving benefit. The heavy and unrelenting demands of chronic care correlate highly with poor mental and physical quality of life for a dedicated care-giving spouse, as well as to their own premature death (Schulz and Beach 1999,

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2215). A team house call is a two-for-one bargain in health care. A comprehensive package of health and social services, provided by home delivery, offers its recipients greater functionality, prolonged independence, and overall “customer” satisfaction. Comprehensive care and services in the private home offer the same benefits that have been demonstrated within the context of the residential retirement community. Continuing-care retirement communities or independent-living communities with associated licensed adult homes offer multiple care levels, ranging from full independence to assisted living, and ultimately to skilled-nursing care, all within one comfortable enclave. Residents typically relinquish management of their own homes when they face deteriorating health, declining functional status, or the death of a spouse. Contractually, applicants for residence in such retirement communities are assured access to on-site health care and supportive social services that enhance the quality of life and prevent the isolation that is devastating to the elderly. Longview, an Ithacare Community, located in Ithaca, New York, achieves this goal.3 Residents of Longview, beneficiaries of an integrated approach to elder support and care, demonstrate enhanced functional status and a favorable degree of self-reported health (Young et al. 2009, 167). Close attention paid to safety and environment, socialization, and specific medical needs tailored to the individual create an ecology in which the elderly can thrive and flourish, keeping frailty at bay as long as possible. Comprehensive coordinated care leads to physical and psychological well-being, as well as to greater functional independence and preserved autonomy. The same philosophical approach and business model of care should apply to older patients still residing in their own homes. It is tempting to assume that in-home comprehensive geriatric assessment will reduce or delay the ultimate need for nursing home placement. Intuitively, a program that fosters functionality and forestalls frailty should afford the elderly the benefit of prolonged independence at home. This may or may not in fact be true. In 1993 a study by A. E. Stuck and colleagues, a meta-analysis of controlled trials,4 indicated that comprehensive geriatric assessments including periodic home visits could lower mortality and preserve independent residence in the home (Stuck et al. 1993, 1032). Jolanda van Haastregt and associates, however, challenged those results, arguing that the multidimensional character of intervention and poor targeting of population subsets made it impossible to prove by meta-analysis any benefit from home visits. In fact, they called for cessation of preventive home visits unless a measurable improvement in

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physical and psychosocial function and reduction of mortality and institutional admissions could be demonstrated unequivocally (van Haastregt et al. 2000, 754). Yet another review and meta-analysis, published by Ruth Elkan and associates in 2001, came to a different conclusion: home visits to older people decreased mortality and admissions to institutional care facilities (Elkan et al. 2001, 719). The matter remains unresolved. If we are to reinvent the house call as a component of a modern, effective continuum of care, we should proceed for reasons other than an expectation of reduced nursing home utilization. We should accept the current evidence that “multidimensional preventive home visits have the potential to reduce disability burden among older adults” (Huss et al. 2008, 298). Proponents of home care look to high technology as a means to restore respectability and bring sophistication to the house call (Landers 2006, 366). Electronic miniaturization does indeed bring the power of the computer and the convenience of the cell phone along for the ride. Portable diagnostic equipment such as electrocardiography, ultrasound, and oximeters (to measure blood oxygen concentration) are useful adjuncts to home care, but they are not the reason to make the trip. It is the relational aspect of the visit, empathetic and tactile but very low-tech, that justifies the trip. House calls would make sense, even if batteries were not included. The lay press shows an inclination to report on remarkable developments in home care that are technologic. The Economist hypes, “Simple accessories could turn mobile phones into useful medical devices” (46). An add-on to a cell phone called a CellScope, they say, may allow transmission of a blood smear image from a remote village hut to a laboratory technician able to screen for malaria. Home drug infusion therapies, reports the Wall Street Journal, would eliminate many hospitalizations (if only Medicare would pick up the tab for the electronic pump and related supplies) (Landro 2008). Gadgets are glamorous. A reporter’s column on the personal warmth and respectful privacy of an empathetic doctor’s house call, however, won’t survive an editor’s cut. Technological devices are useful tools, convenient adjuncts of the physician’s craft, but it is the visit itself that is truly remarkable. In home medical care, the physician’s presence is the message. Technology, taken to the extreme, runs the risk of bringing the hospital home with the patient, converting a cozy family living room into a private intensive care unit, replete with incessantly ringing bells, blinking lights, and other special effects reminiscent of a bad sci-fi movie. Such devices range in complexity from the relatively innocuous medical alert button worn around grandma’s neck (“Help, I’ve fallen and I can’t get up”) to

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oxygen compressors, infusion pumps, feeding tubes, and even home ventilators (Arras 1995). Families vary considerably in their willingness to accept medical technology into the home. An old man, a former patient of mine, suffered from severe emphysema and was increasingly short of breath. I prescribed home oxygen. His wife, however, refused to allow installation of a large metal tank and an oxygen compressor in her home; the unit didn’t match the color scheme of her living room. (She didn’t seem to mind that her husband was blue.) Other caregivers accept in-home medical technology as a personal challenge, becoming technically proficient at setting IV drip rates, flushing catheters, and tending to the machinery that sustains life with a severe illness. The physician, in the house as an invited guest, is best able to gauge the extent to which a family is prepared to turn their home into a hospital. Having firsthand experience, he or she can consult with homecare nurses and others to deliver the care the family deems acceptable. As an ecologist, the physician must remember that the introduction of high-tech medical equipment, elements common to the doctor’s world, necessarily changes the “natural habitat” of the home. The focus shifts, by necessity, from normal family interactions and the peaceful enjoyment of home life to an unrelenting, extraordinary, and depleting family commitment. In our effort to minimize hospital utilization, we may inadvertently off-load an excessive burden of medical technology on the caregiver and family at home. Just as nursing homes have their place, providing a necessary service for some, the modern hospital, not the home, is where to turn when care is complex, round-the-clock, and technology laden. Perhaps the ultimate reason for the physician to cross the threshold and enter the patient’s home is to recognize when it is time to stop. The home of a patient in the final months or weeks of life is a scene of utter devastation. Unopened mail piles up on the kitchen table. Food spoils. Pill bottles are strewn haphazardly. Boxes of medical supplies (sterile gloves, pads, and bandages) become a centerpiece of the home. House plants wither and die, foreshadowing what is to come. The house call may make it plain for the physician when an illness has played out and that it is time to engage the services of a hospice. Regular home visits can foster earlier enrollment in hospice care, avoiding crises and achieving a smoother transition for patient and family. The modern twenty-first-century home visit should be part of a “comprehensive spectrum of services in a seamless system of care” (Taler 1998, 246). The physician who makes a house call enjoys a unique opportunity to assess thoroughly a patient’s physical, social, and emotional needs (LoFaso

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2000, 83). With the support of a multidisciplinary team, targeted services can be delivered effectively and under direct supervision. Caregivers and other family members, under the same roof, necessarily become part of the assessment process and the treatment plan. The relationship between physician and patient endures. It is strengthened by a visit that is beneficial and mutually satisfactory. Restoration of the house call, which by no means precludes continuing nursing care in the home, affords the doctor a return to a sense of professionalism and personal satisfaction now lost in the office. Primary care, particularly of the elderly, a service-sector job in its present form, can be restored as an honored and appreciated professional calling, if indeed we choose to call on our patients. Nobody on his deathbed ever said, “I wish I had spent more time at the office.”5 Future physicians caring for chronically ill younger patients as well as an aged Boomer generation, however, may find it personally rewarding to make more house calls.

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THE SUPPLY SIDE

At the dawn of the twentieth century, the education of young doctors was, like the old Wild West, a rough and unregulated territory. There were no standards of excellence established by accrediting organizations or by law, and the concepts of physician credentialing and quality assurance were alien. Before the advent of the large, technologically sophisticated modern teaching hospital of today, medical education, as with other trades, was by apprenticeship. Today, physicians may joke that surgical procedures are taught in the manner of “see one, do one, teach one,” but one hundred years ago that was standard practice. Since most medical interventions of the era were at best placebos, the technical shortcomings of medical training made little difference. Care was primarily relational. The practice of medicine was long on art, but woefully short on science. To the credit of the Robber Barons, philanthropic spin-offs from the new fortunes being made in steel and oil began to flow to the nation’s dreadfully deficient system of medical education in an effort to incorporate new advances in life sciences and to improve public health (Chernow 1998, 491–93). Established in 1905, the Carnegie Foundation for the Advancement of Teaching selected Abraham Flexner, a respected educator and the brother of Simon Flexner, who headed the Rockefeller Institute for Medical Research, to inspect each of the 155 operational “medical schools” of the day and to issue a report on the state of medical education in the United States and Canada. He was shocked and appalled at what he found. Many so-called medical schools were nothing more than back-office side businesses run by doctors looking to boost their personal income. There were no premedical course requirements for admission. In some cases, a high school education and cash in hand were all it took to guarantee a diploma

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and a career in medicine. Cadavers were putrid; microscopes were not to be found; and there was no uniformly accepted curriculum or standardized testing to assure a student’s proficiency at the profession of medicine. The Flexner Report, released in 1910, was an awakening (Starr 1982). Backed by the largesse of John D. Rockefeller, Flexner cast the medical school at Johns Hopkins University, his alma mater, as the model institution of physician training, with its high entrance standards, full-time dedicated faculty, rigorous four-year scientific curriculum, and modern laboratories. A majority of the small schools, substandard by these newly defined criteria, soon closed their doors, leaving only the most enlightened and scientifically sophisticated facilities to grow and prosper through the generous support of extraordinarily wealthy private donors. Flexner’s original goal was to raise the bar of medical academic excellence, but an unintended consequence of his restructuring of medical education was the establishment of a rigid Ford-like uniformity in an assembly line of doctor production. Just as a customer for a Model T could have it in any color as long as it was black, every medical student received a black bag and a regimented preclinical curriculum followed by a measured dose of clinical work in fields such as internal medicine, surgery, obstetrics, and pediatrics. As a student cramming for the all-encompassing test called the National Medical Boards in the late 1970s, I could take a little comfort in knowing that, at that same moment, other medical students at every school across the country were equally miserable, stuffing their heads with the exact same set of facts for the exact same test questions. Uniformity was not Abraham Flexner’s intended goal, but it remains today, a full century later, the prime characteristic of the education of young physicians-in-training. It is the mechanism by which the deans of medical schools can guarantee delivery of a basic standard of quality care from their graduates, who are poised to take on the task of managing the health of over 300 million Americans. Uniformity of medical training is what allows the Secretary of the Department of Health and Human Services (DHHS), guided by the advisory Council on Graduate Medical Education (COGME),1 to consider physicians, like replaceable parts, as fungible commodities called FTEs (full-time employees), when they forecast the future demand, supply, and distribution of doctors in the United States (Council on Graduate Medical Education 2007). The crisis a century ago was one of quality of medical education; the challenge for our time will be about the quantity of well-trained doctors who will opt to provide primary care for an aging American population. We must prepare to meet a bulging demand for the services of effective

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primary care physicians in the coming decades, certainly at least until the last senescent Boomer is laid to rest sometime around midcentury. The Obama administration acknowledges that a severe shortage of primary care physicians is a significant impediment to any sweeping plan for a health care overhaul. Vague administration proposals include raising the pay scale for primary care practitioners and governmental tuition assistance for medical students who commit to becoming primary care doctors. Both suggestions seem less than credible in the era of an unprecedented budget deficit and looming Medicare insolvency. The Patient-Centered Medical Home, a comprehensive, evidence-based computer-enhanced, yet personal and holistic, package of comprehensive primary care, is a conceptual model with presidential appeal but that remains stuck in neutral, more a concept than a commitment. Every American citizen, from cradle to grave, benefits from a close relationship with a competent, compassionate, and caring primary physician. No single factor is more important to the health of our nation than the maintenance of an abundant supply of busy, productive, and professionally satisfied providers of high-quality, efficiently delivered, and closely relational primary care. The health problems of twenty-first-century men and women, including smoking, depression, obesity, and lifestyles that risk cancer, heart disease, HIV infection, and preventable trauma, can be addressed most effectively through open communication between primary physicians and their patients. More primary care physicians means better medicine (Starfield et al. 2005, 457). Evidence confirms that overall health is superior in those communities where more primary care physicians are available (Shi 1992, 321; Shi 1994, 431). Physician supply, as measured by the number of primary care doctors per ten thousand U.S. citizens, correlates with lower mortality rates from heart disease, cancer, and stroke. The positive correlation persists even considering confounding factors such as the percentage of older, minority, or poor patients, the extent of poverty, levels of education, exposure to pollution, and unhealthy personal habits such as smoking or nonuse of seatbelts. It has been calculated that as many as 127,617 deaths per year in the United States could be prevented through an increase in the supply of primary care doctors by just one physician per ten thousand patients (Macinko et al. 2007, 111). Large statistical studies only confirm what seems intuitive: primary care physicians save lives. For the patient, securing a stable working physicianpatient relationship is as crucial a step toward a long and healthy life as is exercise, maintaining a proper diet, or other salutary lifestyle habits. The

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supply of primary care physicians is a national resource, but not necessarily one that is guaranteed to be renewable. Meeting the demands of a growing nation for an adequate supply of primary care physicians is an imprecise science practiced by health planners, medical schools, and residency programs as well as by the federal government. Over the past four decades, the conventional wisdom among those in the know has oscillated from predicting a physician shortage in the early 1970s to fear of a surplus in the 1990s that never materialized to an expectation of a severe shortfall in primary care by 2020 (Cooper 2004, 705; Iglehart 2008, 1741). In 1971 a report to the Board of Directors of the National Fund for Medical Education was published by its president, John Millis (1971). The Millis Report, entitled A Rational Public Policy for Medical Education and Its Financing, correctly observed a trend toward a perception of access to health care as a human right rather than a personal privilege and a transition from a focus on curing acute ills to long-term care. As Millis wrote, “We must recognize the insufficiency in the number of primary physicians. . . . We need more physicians so that we may concern ourselves with health as well as disease.” By the end of the decade, medical schools were meeting Millis’s challenge by adding physical facilities, expanding entering class size, and affiliating with more hospitals to enlarge residency programs, producing more well-trained young doctors. After an expected lag time due to the lengthy process of training, production was up in the business of manufacturing new physicians. By the mid-1990s, the paradigm for regulation of physician supply had shifted once more. The rapidly rising costs of health care were attributed to the profligate and unmonitored spending habits of physicians. It was reasoned that too many exotic tests, high-tech procedures, and sophisticated surgeries soon would break the bank. Doctors, particularly the highpriced specialists, needed to be reined in, or managed. The era of managed care, still satirized today by comedians and in cartoons in the New Yorker, is portrayed as a period of intentional corporate-imposed obstructions to care. The unofficial mission statement in the managed-care business was to save health care dollars by just saying no. Less well appreciated by the public is the fact that the restrictive philosophy of managed care also was applied to the regulation of physician supply through a forced contraction in the graduate medical education (GME) of physicians and surgeons.2 Fewer doctors trained, it was argued, meant fewer dollars spent. With passage of the Balanced Budget Act of 1997, federal funding of GME was frozen at levels from the preceding year, despite steady growth in the U.S.

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population. The die was cast for future physician shortages, critically including primary care, a decision that will soon come back to haunt us. To patients, particularly the elderly ones who have enjoyed access to a personal primary care physician for many decades, there may be no present indication of a coming shortage in primary care manpower. After all, they already have a doctor. If you live on either coast of the United States, in or near a major metropolitan area, or in a desirable community where a doctor might wish to live and raise a family, then you probably have never contended with the problem of lack of access to primary care. One only has to open the phone book to the Yellow Pages and choose from a long list of physicians. You might be dissatisfied with your current doctor, perhaps because of a prior bad outcome, poor rapport, long waits, or a discourteous staff. Alternatively, you might be “inclined” to move on because of a large delinquent bill for prior medical services. Maybe it is just time for a change of scenery. Whatever the reason, the freedom to choose a new primary care doctor is founded on the assumption that it is a buyer’s market and that there are plenty of doctors to go around. Certain people in our society, however, have no such luck. If you live in a small farming community with no cosmopolitan appeal or magnetic attraction for young doctors, then you are already physician-access challenged and a victim of the geographic maldistribution of doctors. If you reside on an Indian reservation or in a dilapidated portion of a rust belt city, then you already appreciate that any physician-patient relationship, let alone a good one, is an extraordinary find. Those patients who carry a Medicaid card, a state-issued mark of poverty, generally expect not to gain easy access to a physician’s private office. It is generally understood, even among its recipients, that Medicaid reimbursement doesn’t begin to cover a physician’s costs and that a doctor will try to avoid the bureaucratic headaches that are associated with being a Medicaid provider. The newest group among the medically disenfranchised, however, is the elderly—the beneficiaries of Medicare.3 As the physician-to-patient ratio sinks slowly under the weight of an aging Baby Boom and a declining number of medical graduates pursue careers in primary care, we face a growing doctor gap that those patients on Medicare, who are sixty-five and older, are about to experience firsthand. While external forces closely regulate the flow of trained doctors ready for work, physician supply hinges equally, perhaps even more so, on how hard those physicians are willing to work. To be an FTE in medicine is not what it once was. As a noble profession, medicine once commanded the

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full attention, commitment, and personal sacrifice of its dedicated practitioners. It was accepted just a generation ago that a doctor, then usually male, was “married to medicine.” It is remarkable that doctors’ wives tolerated this seemingly bigamous relationship for as long as they did. How times have changed. The most remarkable aspect of the old entrepreneurial private practice of medicine, now virtually an anachronism, was the drive not just to work hard, but to overwork. The economist John Kenneth Galbraith in Economics of the Public Purpose (1973) recognized that a sole proprietor is “almost wholly free, as the organization is not, to exploit his labor force since his labor force consists of himself.” The ambition to build my own business, to establish a solid professional reputation, and to become a pillar of the community had, symbiotically, very tangible benefits for my patients. It meant that an acutely sick or anxious individual somehow always would be squeezed into an already overflowing waiting room. No words to a worried patient on the phone gave more relief than “Come right over.” There was always room for one more. A successful shopkeeper doesn’t turn away a customer, even if it is closing time. Just as the Protestant work ethic contributed to the success of the early corporation, as Max Weber observed in 1905 (Weber 2003), the intense entrepreneurial spirit of overworking solo physicians in private practice fulfilled the needs of their patients for prompt access and attentive care. The physician-as-businessman did well by doing good, albeit at high cost to his family and personal life. Today we operate within a culture of commerce in which care of the sick is a business transaction above all else. Health care has been commoditized (Hart 2006, 93). An old-fashioned doctor with the peculiar mix of individualism and entrepreneurship, simultaneous scientific and smallbusiness acumen, functioning as a self-driven workaholic, has no place in today’s medical-industrial complex in which a visit with the doctor is just another bland product to be consumed. Newly trained physicians today seek a balance in life that leaves room for family and fun, as well they should. As a group, doctors are keenly aware that life can be both short and unfair. Lifelong deferred gratification is out; a balanced lifestyle and a rational workload is the way to go today, even at the cost of reduced personal income. The entrance of women into the physician workforce has spurred a very healthy reappraisal of what it means to practice medicine (Boulis and Jacobs 2008). Female physicians today wisely choose to work fewer hours per week and to do so for fewer years than their male counterparts. Since

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women now make up more than half of medical school classes, we can expect a significant reduction in the average number of patients seen during the careers of those physicians in training today. Medical residency programs are already beginning to downshift to a slower pace of patient care. In 1984 a young woman died tragically at New York Hospital due to errors made by overworked, sleep-deprived, and inadequately supervised medical house staff. The sad case of Libby Zion led to the institution of the 80-hour rule in residency training programs (Lerner 2006). Interns and residents today are permitted by law to participate in patient care for “only” 80 hours per week, just as commercial pilots are intentionally grounded at periodic intervals to protect the flying public from catastrophic pilot error. Retirement of the macho 120-hour intern’s work week of my era, and the utter physical and mental exhaustion that accompanied it, was a major advance in public health and a blessing for both doctors and patients. I believe that the 80-hour rule thankfully has broken the tradition in training programs that fostered a culture of future workaholics. Most patients today likely would agree that it is better to be seen by a well-rested, welladjusted, and well-rounded doctor than by one who is married to medicine without moderation.4 Like everyone else, doctors in practice today are getting older. Those who entered medical school in the expansive era of the late 1970s to early 1980s are now, to use a hackneyed phrase that describes my cohort, aging Baby Boomers. Physicians experience their peak productivity in patient care when they are in their forties. In that decade of life a doctor’s clinical skills are well honed. She or he is still young enough to muster the energy required to handle a high patient volume and is still a motivated worker burdened by school loans, a mortgage, kids’ college costs, and other financial obligations. For doctors in their fifties and beyond, however, physical fatigue begins to set in. At the least, it becomes much harder to maintain the stamina required for a busy practice, and, at worst, a doctor may begin to show serious signs of burnout, which include a reluctance to take on new and challenging cases, a failure to stay current with updates in treatment, and a hesitancy to go the extra mile for a patient in need. Regardless of the degree of doctors’ fatigue, we can be certain that a substantial portion of today’s practicing physicians will continue on a trajectory of slowing down and that physicians over fifty will not be true FTEs much longer. We have already given our best years at the office. Medical students graduating today have options. It is not a foregone conclusion that on taking the Hippocratic Oath at their graduation ceremonies, they will don a white coat and stethoscope to then spend a lifetime

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in patient care. Witness the growth of physician-executive positions in the health insurance industry. Armed with dual MD/MBA degrees, spreadsheets, and business calculators, these graduates of medical schools see no patients and therefore skew the physician-patient ratio downward. Other young doctors today, perhaps reluctant to deal with Medicare, malpractice suits, and the current malaise of medicine, elect to work in the pharmaceutical industry or in other corporate positions. Some even become lawyers. Medical graduates today seek flexibility in their professional lives. It is not unreasonable today to desire more than one career in a lifetime. Some physicians may elect to abandon medicine altogether at an early point in their careers to pursue an unrelated interest or passion. Others may want to work part-time only or to job-share with a colleague. The concept of the FTE in the field of medicine now seems quaint and out of date. Declining physician productivity will necessitate an enlarged pool of practicing doctors, particularly for the rising number of seniors demanding access to primary care. While my focus in this chapter is on the provision of a sufficient quantity of primary care physicians for the future, physician supply is not simply a matter of the number of doctors. Doctoring in the twenty-first century is a very different business from what it was in earlier years. As primary care is attracting fewer young medical school graduates, it also now appeals to a very different personality type as well. Younger doctors today make a pact with the devil, accepting the regular hours, a lower but certain paycheck, and a nonentrepreneurial complete removal from the business-management side of practice, substituting the coglike regimentation of working for a health corporation as employees on the job (Kassirer 1998, 1543). This is a new form of physician FTE. Patients notice the difference. Back in 1970 the Carnegie Commission on Higher Education issued a report entitled Higher Education and the Nation’s Health. This short monograph correctly anticipated rising demand for health care, which it recognized as a right of every American, and it made recommendations for fast-tracking physician training and for financing the education of more physicians. What was remarkably prescient, however, was the prediction by the Commission that “gradually we are likely to shift toward a situation in which health care is a public utility”—and here we are. Like Homer Simpson, the TV cartoon character at the controls of a nuclear power plant, I don’t see myself as a particularly competent operator of a public utility. From a purely economic perspective, however, utility is the power to satisfy a public need or to provide an essential service. In that light I do accept that, as a primary care physician, I am indeed a utility. The

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significance of utility, more than semantic, becomes clear when we explore the relationship of U.S. economic expansion to our “consumption” of physician services. We have thus far considered the personal work habits, the modern lifestyle choices, the graying of the physician workforce, and the demise of entrepreneurship in medical practice as factors that limit physician supply. While these trends are all significant, no single factor determines the supply and use of physician services more than the macroeconomics of growth. Economic expansion, as measured by real per capita GDP, correlates in a remarkably linear fashion, albeit with a ten-year time lag, with per capita health care labor and physician supply. Using several different confirmatory statistical techniques, Richard Cooper, Thomas Getzen, and Prakash Laud (2003, 675) demonstrated an increase in physician utilization of 0.75 percent for every 1.0 percent rise in U.S. GDP. The more we make, the more we see doctors. Economic expansion drives the consumption of physician services, a finding that lays to rest the false premise of the managed care of the 1990s that physicians drive U.S. health care costs. Rather, it appears that the opposite is true—economic growth begets increased physician demand on a national scale. In the language of economists, we suffer from health care inflation caused by the demand pull of patients rather than the supply push of physicians. It is disturbing that we can readily graph the positive correlation of consumption of health care services versus GDP just as we can for purchases of flat-screen TVs, SUVs, designer handbags, or any other discretionary purchases of goods and services. Health care is in fact a commodity. As a nation, we chew up as much of physicians’ services as we can with the financial resources we have at hand. This occurs because decisions about reimbursement are made well in advance by insurance companies acting as third parties in a business transaction, and because the absence of significant up-front fees means there is no meaningful disincentive to having another helping of health care. At the more progressive U.S. companies that offer their employees the benefit of a preventive health program, blue-collar workers may get a periodic physical examination by a company doctor. Those employees in the upper echelons of management, however, get an “executive” physical, which commands a higher physician fee. Since I know only one way to take a medical history, listen to a heart, discuss a high cholesterol reading, or do a rectal examination for any patient, this attempt to stratify the benefits of health care by income level, corporate rank, or caste seems absurd

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(Rank 2008, 1424). It appears that a good portion of the health care demanded and supplied in the United States is a form of conspicuous consumption akin to driving a luxury automobile, living in a McMansion or wearing a diamond ring the size of a doorknob. Primary care for an aging society, however, ought not to be about conspicuous consumption. We need to supply the right number of physicians, who will provide the right amount of primary care, driven by a rational estimate of need, and planned for the long haul, rather than simply spending money like a kid in a candy store. The concept of sustainability, now gaining traction in an era of dwindling resources and rising temperature, has a place in medicine as well. A closer examination of the data from Cooper and his colleagues is illuminating. The correlation between the number of actively practicing physicians per one hundred thousand population versus personal per capita income is quite strong specifically for the medical specialties. Although not quite as steep a slope, the relationship between the number of practitioners of surgical specialties and personalized GDP is also positive. There is, on the other hand, no correlation between the number of family practitioners or generalists and national economic growth. That curve is flat. The conclusion to be drawn from this study is that from an economic perspective there are two distinctly different tiers of medical service. It is specialty care that follows a supply-demand curve typical of a discretionary, or what economists call a “normal,” good or service. Our national demand for primary care, however, is unrelated to our level of national wealth. We all need it, whether rich or poor, in good economic times and bad. Basic and essential, primary care for an aging U.S. population is totally nondiscretionary and therefore demonstrates no income elasticity. It is indeed a public utility. As such, the stable, adequate provision of such an essential service as primary health care, particularly as we now face an aging demographic bulge, is a goal worthy of increased governmental and institutional oversight. In the near future, supplying a sufficient number of primary care doctors will require stronger financial incentives to medical students, a new call for volunteerism among specialty-bound medical graduates, or even a period of mandatory service in primary care as a requirement to be met before ultimate acceptance into specialty training. How many primary doctors does it take to care for a growing population of patients who live longer with chronic illnesses? Although the question sounds like the lead-in to a corny joke, it is truly a matter of public health policy that we must answer correctly. A 2008 article in Health Affairs

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computed a shortfall of 35,000–44,000 adult-care generalists (Colwill, Cultice, and Kruse 2008, w232). Population growth and aging will increase the workloads of family physicians and general internists by 29 percent: “These forces threaten the nation’s foundation of primary care for adults.” Poor reimbursement of the generalist relative to the specialist certainly is a factor putting downward pressure on the supply of primary care physicians.5 Another problem is the uncertainty regarding the pipeline of international medical graduates (IMGs), who already constitute 25 percent of the practicing generalists here in the United States. It is not clear that they will fill the coming void, or even that they will want to stay here rather than return to their native countries after they are trained and experienced in their profession. In a new era of globalization, IMGs may have strong financial incentive to turn in their visas and head for home. We will come to rely more and more on those who are called midlevel practitioners, a group that includes nurse practitioners (NPs) and physician’s assistants (PAs). When they first entered the health care system, they were derided by many physicians and patients as Hamburger Helper, but today they are picking up the slack as MDs steer clear of primary care or scale back their commitment to patient care. So far, NPs and PAs have tended to work in facilities such as community health centers, hospital clinics, and inpatient service, under the direction of an administrative physician. They will soon become, however, the de facto primary providers of health care to millions of Americans. Whether it is an IMG, an NP, or a PA who steps up to the plate, the lineup of deliverers of adult primary care for the elderly is about to change dramatically. On an October day in 2020, I will receive in the mail my own little red, white, and blue Medicare card. Will there be a primary care provider, physician or otherwise, for me, another aging Boomer in need of basic but essential primary care? One approach to expanding the pool of primary care practitioners could be to turn to the presently untapped pool of doctors who have recently retired from medicine and to entice them to return to practice in a parttime, voluntary capacity. Older physicians who, in an earlier era, would have simply slowed down the pace of their practices, today are squeezed out by a staggering rise in office overhead, demoralizing malpractice exposure, and the loss of autonomy as physician-employees. Those doctors, like me, are closing shop early and completely. Twenty-eight percent of the current estimated 817,500 physicians in the United States are fifty-five or older, and primary care will be hit disproportionately as their ranks are thinned by premature retirement (Bureau

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of Health Professions 2006). Can these well-trained, experienced, and still vital older physicians be enticed to return to patient care, either on a limited work basis or as Good Samaritans, fostering a new era of medical volunteerism? A survey was conducted recently by Philip Sloane and colleagues at the University of North Carolina at Chapel Hill (Sloane et al. 2008, 317). Physicians fifty-five years old and older living in North Carolina, currently licensed and registered with the Board of Medical Examiners were polled. The study was restricted to those physicians who practice, or had practiced, in the direct care of adult patients during their medical careers, thus excluding pediatricians, radiologists, pathologists, and administrators. Among the respondents, very few expressed interest (2.0–6.5%) in volunteering for medical boards or committee work, a result that affirms my own personal distaste for participation in the bureaucracy of medicine. There was, unfortunately, little interest shown among older MDs for volunteering at long-term care facilities or hospices. Among current part-time physicians, however, 33 percent expressed a desire to volunteer in free clinics and to teach; 43 percent of physicians currently working full-time indicated the same interest. Among those already retired, 27.9 percent expressed a desire to return to some form of direct patient care, albeit in attenuated form, as volunteers. This study suggests that there is a large reservoir of clinicians’ skill and enthusiasm that we are presently squandering. Those older doctors polled still want to see patients, if only they could be freed from the institutional grief and aggravation of modern medical bureaucracy. We must make it possible for them to do so. To succeed, any such program of physician volunteerism must provide participants with the rich personal satisfaction of community service. It must be as unfettered by bureaucratic red tape as possible, thus avoiding the hassles that led retired physicians to leave practice in the first place. A lingering fear of malpractice litigation dissuades many older doctors from donating their time and effort. They worry that their good deeds will not go unpunished. A good place to start on the road to malpractice reform, therefore, is the extension of the concept of the nonliable Good Samaritan who steps forward to serve the sick or injured on a city sidewalk or on an airplane at thirty thousand feet to the volunteer-staffed medical clinic. Alternatively, affordably priced malpractice liability insurance could be obtained for part-time volunteer physicians by state or local government, as long as such a policy is not considered a form of taxable compensation to the doctor and the insurance coverage is intended only for professional medical services provided gratis under the auspices of a free clinic. Given

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the size of the untapped pool of medical talent that is willing to serve, it behooves us to make this work. Volunteerism by retired clinicians can and should be an important component of any plan to expand physician supply to meet the coming demand for primary care posed by the chronically ill and geriatric Baby Boomers, but, by itself, it is admittedly only a small step toward satisfying the coming need for primary care. Prospects for recruiting young physicians for primary care look bleak. According to Wayne Guglielmo, a senior editor of Medical Economics, family practitioners and general internists lead the list of physician-recruitment searches by Merritt Hawkins and Associates, a national physician search and consulting firm (Guglielmo 2008). It is not hard for a newly minted generalist to find work. In New York in 2007, primary care physicians, on finishing training, received an average of 3.7 job offers, up from 2.7 in 2002. The problem is that too few young physicians are enticed by these offers. Guglielmo quotes Phil Miller of Merritt Hawkins: “Increasingly, primary care is one of those things Americans don’t want to do.” The number of U.S. residents in family practice dropped from approximately 9,800 to 9,395 between 2001 and 2006, and the percentage of residents in internal medicine planning to practice as generalists has plummeted. Fewer medical residents are going into primary care as we move into the second decade of the twenty-first century, and more and more family medicine residencies are being filled by international medical graduates. Miller is quite right: like ads for grimy, repetitive factory work, primary care is a job posting likely to go unfilled in the United States.6 If we cannot expand the supply of primary physicians sufficiently by promoting volunteerism among retired doctors, and if we cannot attract newly trained medical graduates to general medicine, then we must give serious consideration to a third alternative: a government-imposed period of mandatory medical service by young physicians in the delivery of good basic primary care. Shocking as this option may seem in the land of free enterprise, the concept of a civilian physician draft is not at all new; we just haven’t yet been forced to give it the serious consideration it deserves. Precedent exists in twentieth-century U.S. history for the imposition of mandatory military service requirements specifically aimed at physicians. In 1950, at the onset of the Korean conflict, the Doctor Draft Law was passed, which ensured a continuous and adequate supply of physicians to serve the nation in wartime. In an era when the male life expectancy at birth was only 65.5, physicians’ vulnerability to a call-up extended to the advanced age of 50. By 1954 a refined plan was devised by Dr. Frank B.

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Berry, assistant secretary of defense for health, that continued to guarantee a steady stream of physician manpower to meet the needs of the U.S. military, both at home and abroad. Additionally, it enrolled physicians as commissioned officers in the U.S. Public Health Service (USPHS), with its mission to promote and protect the health of our citizens in peace as well as in war. The Berry Plan, as it came to be known, permitted physicians a degree of flexibility in career planning while it still required them to serve their country (Barton 1961, 57). Young doctors were given three choices. They could elect to serve their nation immediately after internship, to start one year afterward, or to begin service on completion of a full residency program. The latter option was offered only as a special deferment and only if the additional training happened to be in a particular specialty in demand by the armed services. The Doctor’s Draft Law terminated in 1973 at the close of American involvement in Vietnam and at the dawn of the era of an all-volunteer U.S. military. According to Col. Roger Lalich, Wisconsin Army National Guard state surgeon in 2004, “the President’s Commission on an All-Volunteer Armed Forces stated that the medical profession had borne the heaviest burden of military service of any group in our society” (Lalich 2004, 21). Thus, a commitment to national service is nothing new to doctors. That is fortunate. A recurrent, sudden, or severe demand for military medical services in our modern age of sustained war against terrorism and in a world constantly in combat is, according to Dr. Lalich, a contingency for which the Department of Defense is well prepared. The health care personnel delivery system, a return of the doctor draft, could be implemented swiftly and could mobilize a total pool of 3.4 million health care professionals up to age fifty—five (including both physicians and nonphysicians), and it would address problems of distribution so that Americans at home might receive all the medical care they require, even in a time of world conflict. It is expected of physicians, as a unique professional group providing an essential and compassionate human service, to be called on to serve their country when needed for the care of military personnel. Is there not the same implied duty or moral obligation of service at home as well? Should we not ensure a steady and ample supply of competent primary care physicians for the aging U.S. citizens that our military proudly protects? The concept of a civilian form of mandatory service for physicians or a compulsory National Service Corps is not new (Rosenblatt 2006; Graham 2006; Campos-Outcalt 2006; Stead 1971, 89; Johns 1993, 3156). However, no such proposal has ever gained any credible recognition or any real traction with legislators. Rather, the scant literature on mandatory national health

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service has shed more heat than light through a firestorm of angry letters to the editors of reputable medical journals that have shown the fortitude even to raise the issue (Aberman 1971, 859; 31). The vigorous negative responses to past proposals of mandatory medical service in the civilian sector rested on three key arguments: First, our nation was founded on the concept of individual liberty. Mandatory medical care is nothing more than involuntary servitude, not in keeping with the spirit of our Constitution. Free enterprise rules. There must be no governmental meddling or socialist central planning. Call this the rugged individualist argument against public service in health care. It is a specious argument, as we shall see. Second, newly released physicians don’t have the depth of experience to serve our nation as the backbone of a system of primary medical care. They just don’t know enough. Young physicians would merely be a group of drafted warm bodies, unable to contribute meaningfully to patient care. This too is a specious argument and is insulting both to our esteemed institutions of medical education and to the gifted, hard-working, and enthusiastic young doctors who are their product. Each year, on July 1, patients in teaching hospitals across the country come under the care of a newly released crop of interns and residents. Somebody has to be the first patient. Under proper supervision by experienced, grey-haired preceptors, young physicians can serve with distinction. Third, why should doctors be singled out to serve? After all, my lawyer, mechanic, and grocer are not being “punished.” Anyone who has raised more than one child will find this response quite familiar: “It’s not fair!” The Not Fair argument, however, is perhaps a better rationale for a period of public service required of all, rather than against such a commitment by physicians alone. Can we design a program of mandatory health care service that meets the needs of an aging U.S. population, that affords young doctors maximum flexibility in their career paths and personal lives, that fairly compensates its draftees, and that is uniformly administered on a national scale? I believe that this objective can be achieved and that physicians can serve as archetypes in a coming era of renewed expectation and acceptance of public service as a part of life in America. The overarching philosophy behind such a program is this: primary care comes first. Just as primary care must be the principal foundation of any revised overall U.S. health care policy, its practice must be the first-laid cornerstone of every physician’s clinical experience and training. All doctors, first and principally, should be able to deliver good, basic primary care.

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My proposal for mandatory social service by physicians, like most prior plans, begins with a required two-year commitment to the practice of general primary care as a prerequisite to further training in any medical, pediatric, psychiatric, or surgical specialty. As in the Berry Plan of half a century ago, physicians would retain some autonomy. They would be permitted to choose whether to serve their two-year term immediately after a general medical internship or on completion of a residency program in family practice or general internal medicine, if primary care is their ultimate career goal. Such draftees might serve at approved community clinics or in underserved regions, under the auspices of hospital-based ambulatory care centers, within approved group private practices with older physicians serving as preceptors, or through already existing federal agencies such as the USPHS or the National Health Service Corp (NHSC). The two-year commitment would not be a period of indentured servitude; fair salaries would be set annually with appropriate cost-ofliving increases and would reflect the number of years of experience. A young physician who has completed an internship would receive a salary higher than that of an intern but lower than that of practicing primary care doctor with more years of experience. A pay scale could be devised similar to that of the U.S. Government Services Agency (GSA) scale for federal employees. Paychecks would go to the doctor-draftees directly from the practice where they are employed, but essential federal subsidies would flow to those supervising practices and clinics to make this a viable plan. Alternatively, a loan payback program could be constructed to assist those participants who leave medical school with enormous personal debt (Petersdorf 1993, 651). Malpractice premiums would be covered as well, since serving physicians effectively are employees of the federal government. A computerized matching system would be devised that is similar to the one already in place, known as The Match, which links graduating medical students to internship and residency programs. Such a matching system is an automated optimization software package that finds the best fit of candidates and institutions based on the rank orders submitted by each. Such a system, if applied to a doctor draft, would minimize the personal hardships of geography in the case of two-career marriages or distant significant others. Philosophically, a two-year stint of mandatory general medical service is not meant to be punitive. What if a rebellious, rugged individualist young doctor refuses to serve his two-years in primary care? Unlike the Berry Plan, what I propose here

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is not a true military draft or form of conscription. The nonconformist who goes AWOL or refuses to serve would not end up splitting rocks at Leavenworth. He or she would, however, be barred from entry into any accredited specialty residency training program in the United States that receives federal funding. In the absence of a certificate of completion of a two-year period of primary care at an approved office, clinic, or federal agency such as USPHS, the Indian Health Service, federal (or state) prisons, or the NHSC, a physician would be blocked from obtaining a national physician ID number, a Medicare provider number, and any contract arrangement as a participating provider with private health insurers. These are all essential credentials a doctor needs to make a living at the practice of medicine. Any proposal for a mandatory period of physician service in primary care is best achieved through a sweeping, comprehensive fresh piece of federal legislation.7 Those doctors who use the rugged individualist argument will call this plan coercion. I prefer to think of it as persuasion. Just as the Internal Revenue Service encourages certain behaviors desired of taxpayers, such as saving for retirement through tax-deferred accounts or homeownership via the deductibility of mortgage interest, so can we steer physicians into the essential provision of primary care. Again, the motto, and the social goal to be achieved, is that “primary care must come first.” Looking globally, mandatory medical service is nothing new (Cavender and Albán 1998, 1937). Cuba, Ecuador, the Dominican Republic, and Bolivia all employ compulsory service. Thailand requires three years of public health service of its medical graduates. Developing countries, where primary care may be the only care for most, have a strong vested interest in securing a steady supply of general practitioners. Problems noted thus far in the administration of such programs derive from the lack of an underlying solid medical infrastructure and the fact that graduating medical students are immediately tapped for duty without the benefit of a year of internship training. However, a two-year commitment by U.S.-trained graduates following completion of at least a year of postgraduate training, working within a solid, supporting framework of modern U.S. health care facilities and under the aegis of a properly supervised and administered national program could offer much more. What is needed to achieve the proper role of primary care in U.S. health policy is a bit of national soul-searching and self-reflection: “to see ourselves as others see us.”8 For decades we have been transfixed by the sophistication of our highly technological form of medicine, and we have assumed mistakenly that any country that has such fancy medicine must,

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intuitively, have the best basic care as well. This has been a serious misperception. If health care here at home is truly a right and not a privilege, then we need to take a lesson from the countries of Latin America, as well as others in the third world, and focus on the distribution and delivery of high-quality primary care first. Puerto Rico, a U.S. territory, already has dabbled with a health draft, or compulsory service, to ensure adequate physician manpower across the island (Ramírez de Arellano 1981, 70). There is, therefore, already a precedent for mandatory civilian medical service on U.S. soil. We are no different from our neighbors to the south or around the world. At the time of the collapse of the old Soviet Union in 1991, U.S. taxpayers were assured that they would reap the benefits of the close of the cold war in the form of a “peace dividend.” I waited patiently by my mailbox, but the check never came. What is far less well appreciated by the same taxpayers, however, is that they subsidize the graduate training of American physicians. In fact, they have done so since the earliest days of the Medicare program in the 1960s. Those taxpayers, many of whom are now elderly patients, deserve to collect their medical dividend in the form of ready access to good primary care. At its creation, Medicare was authorized to distribute federal dollars to teaching hospitals to foot a share of the bill for graduate medical education (Mullan 1996, 250). There is no logical reason why a program that was intended specifically to provide for its elderly beneficiaries should also be in the wholly different business of financing physician training. Nevertheless, that is how the law was written, and it is unlikely to be changed. Today, after decades of steadily rising costs, Medicare funding of GME is a massive government subsidy program for the education of our future physicians. No other professional group such as lawyers, teachers, or engineers enjoys the largesse of the U.S. government. In the mid-1960s, when the number of medical residents was smaller than it is today, the cost of training was much lower. There was little in the way of expensive diagnostic equipment or pharmaceuticals, and a smaller medical faculty sufficed. Medicine, however, soon became a growth industry. Under the Social Security Act Amendments of 1983 (medical education funding by Medicare), Medicare’s generosity was split into two categories. Direct GME payments covered the salaries of interns and residents, as well as those of faculty, and compensated hospitals for their fixed overhead. Additionally, a separate subsidy was established for hospitals as compensation for the inefficiencies inherent in teaching, such as the time “wasted” by faculty when lecturing to students or stopping to

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answer a question at the bedside on morning rounds. Indirect medical education (IME) subsidy was a fudge factor that gave strong incentive to teaching hospitals to take the tough cases, which are typically big moneylosers, and to keep their doors open to the indigent. Since compensation to hospitals was computed by the number of intern and resident house staff per hospital bed, a floodgate of residency positions opened in the early 1990s, as teaching hospitals throughout the United States grabbed a larger share of the GME pie by taking on more and more house staff as a way to make more money. As interns and residents, young doctorsin-training were not only cheap labor, but we were also a high-margin product. Such was one unintended consequence of the initial drafting of Medicare legislation in 1965, later compounded by years of growth, inflation, and manipulation. According to data from the mid-1990s, the average amount of federal support of GME came to $70,000 per resident per year. Subsidies vary, however, from state to state. New York mandates that all payers, both Medicare and private insurance carriers, contribute to physician training. Hospitals in that state consequently receive a remarkable $190,000 per resident per year (Iglehart 1998, 402). Every doctor who is in practice today, or soon will be, receives a huge societal gift in the form of a “scholarship,” which many do not even know they have won. The rugged individualist, who espouses free-market enterprise, in fact owes a good portion of his or her marketable skills to a secret benefactor, the aging U.S. citizens who have dutifully paid their taxes for decades and who are about to require primary and geriatric care in unprecedented numbers. We owe them their dividend. A two-year period of mandatory medical service would have far-reaching beneficial consequences for our nation and for doctors as well. When medicine became a commodity, a generation of physicians came along who lacked the important sense of altruism in their craft. Medicine as public service was replaced by a corporate model that is cold, aloof, and more pecuniary than personal. Restoration of a sense of humility to all physicians would be a good thing for everyone involved. A service commitment would restore honor, dignity, and the sense of calling to a tarnished profession. Participation in a two-year draft would be an enforced stop on the road to the superspecialized, highest-paying care to which today’s medical trainees aspire. It could be an opportunity for doctors to establish new and more humane priorities. There are many compelling reasons to adopt the remedy I have proposed. Some medical draftees may discover that primary care offers them

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the satisfaction of caring for people, rather than their parts. Some may fall in love with a more remote part of the country than they otherwise would have considered. Even if they still go on to choose a subspecialty, the two years of service in primary care should give them an appreciation for the work of the generalist. Such service only can foster better communication between specialists and generalists, which, in itself, would be a great relief to patients. In addition, since the horror of 9/11, the calamity in New Orleans of Hurricane Katrina, and the environmental disaster of the BP gulf oil spill, much attention has been focused on our national preparedness for disasters, both manmade and natural. We can effectively strengthen our defense of the public health in times of crisis by making every American physician experienced in the delivery of at least some degree of basic primary care. In the event of a catastrophic bird flu epidemic (Flu home) or a bioterrorist armed with anthrax as a weapon (O’Toole et al. 2002), it will be of no use to call up narrowly trained doctors such as cosmetic surgeons or weight-loss specialists. Like cross-training for athletes, doctors cross-trained in primary care will give us the flexibility we need when it is demanded of us. Finally, a civilian mandatory doctor draft can pave the way for restoring public service as a national expectation of every citizen. This is the spirit of the Peace Corps and Teach for America. Each of us has something to offer, whether physical or intellectual. The Not Fair argument holds no water if we are all recruited to serve in one capacity or another. A physician draft, while proposed specifically to provide sufficient high-quality primary care for our citizens, may do a great deal more for us than that. It may help to remind each of us to heed JFK’s stirring call, “Ask not what your country can do for you—ask what you can do for your country.”9

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ALL IN THE FAMILY

Only weeks earlier, Mrs. I had been an independent, self-sufficient, and active woman. In her mid-eighties and a longtime widow, she was accustomed to living on her own. She had navigated bereavement and widowhood successfully, just as she had triumphed over the childhood hardships of the Great Depression and the personal sacrifices demanded of her during World War II, two traumatic events that uniquely tempered her generation. Now she faced another challenge: she was very sick. Mrs. I had suffered a massive heart attack, which, in the seeming blink of an eye, had transformed her from a fully functional “young-old” to a frail and fragile “old-old” woman who no longer could manage the simplest tasks of daily life on her own. Mrs. I now faced a downward slide to assisted living and the loss of autonomy that comes with a lingering and debilitating illness in the ultimate phase of life. Mrs. I had two daughters. Both were in their late fifties, bright, welleducated, and successful in career, marriage, and motherhood. One lived nearby in upstate New York. The other was located in coastal northern New England, a seven- or eight-hour drive when the winter weather cooperated. There was nobody else. After a lengthy hospitalization complicated by several setbacks, it was clear that Mrs. I would require transfer to a rehabilitation unit and, ultimately, a new residence in an assisted-care facility. She would never return to her own home. What she needed most now were the support, comfort, and reassurance of a daughter close by. Both daughters were capable and up to the task, and either would do. As Mrs. I’s physician, I asked her daughters to decide who would serve as the primary supervisor of her care. Once that was determined, Mrs. I could be transferred to an

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appropriate facility. The practicality of geography and the harsh reality of a failing parent necessitated that a decision be made; the two daughters, however, could not decide. Would Mom be moved to a facility here in western New York or would she be relocated to a residence in New England, close to her other daughter? Weeks went by. Mrs. I sat in limbo, stuck in the hospital, much to the consternation of the hospital’s utilization review administrator, who strives for prompt patient discharges as a crucial cost-saving measure. The final resolution to this palpably uncomfortable family dilemma came as a shock when I received a telephone call from one of the daughters. They had selected a rehab center in Worcester, Massachusetts. They had signed the papers and placed a substantial deposit. It was done. “Who lives in Worcester?” I asked. “Nobody,” she said, “but it is exactly equidistant and therefore it is the only approach that is fair.” For reasons that still remain unclear to me, two rational adult children came to an irrational and very poor choice, isolating their mother from the only family that she had at the very moment when she most needed loving support and close contact. More than physical therapy, effective medication, or good nursing, although those were essential, Mrs. I needed the emotional warmth and hand-holding of an adult child nearby who was prepared to offer it in the final phase of a long parent-child relationship, the inevitable physical decline of a parent in old age. What went wrong? Perhaps there had been a lifelong sibling rivalry for Mom’s affection. Maybe they were afraid that a “good daughter/bad daughter” dichotomy would be established if one alone became the daughter who cared. Then again, maybe Mom had never been as nice to her two children as I had assumed. What is clear is that health care for the elderly is tightly interwoven with the fabric of the family. Critical medical decision making hangs on family relationships, sometimes remarkably dysfunctional, that may extend backward over half a century or more. The delivery of high-quality primary medical care for the elderly cannot be delivered in isolation from family matters. For a majority of the coming geriatric Baby Boomers, the physician-patient relationship will one day, by necessity, become a physician-family relationship. Poorly functioning family units, even when the younger members have the good intention of meeting filial duty, utilize primary care resources ineffectively. The elderly suffer for this. Rather than grasping for high-tech answers to the problems of U.S. care delivery, we need to look introspectively, as a nation of parents and their adult

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children. There are some low-tech solutions for improving the health care of the elderly that lie all in the family. What do adult children owe their elderly parents (Callahan 1985 32)? That is a moral matter as old as the Bible. “Honor thy father and thy mother: that thy days may be long upon the land which the Lord thy God giveth thee” (Exodus 20:12). The Fifth Commandment,1 setting filial obligation in stone, is the only one of the Ten Commandments that offers a reward for compliance: longevity. Yet, the biblical promise of long life through care of an elder parent is an offer adult children do not take literally and find easy to refuse. The sense of filial obligation, a component of a moral compass, seems inborn rather than acquired. Some people have it; others do not. This is a fact critical to social and health policy today, as a ship of 78 million Baby Boomers steams toward senescence. Caregiving is a private, deeply personal matter between parents and their children, but it is also a source of national intergenerational conflict in a time of simultaneously expanding needs of the elderly and contracting family resources of time, stamina, manpower, and money (Daniels 1998). Caregiving to the elderly is gender biased. Daughters far outnumber sons in direct hands-on personal care. Largely, it is “women’s work.” Bathing, dressing, medicating, and hauling an aged parent to the doctor’s office represent a daughter’s socially expected discharge of her filial duty. As with rearing children of her own, an adult daughter typically “takes responsibility for tasks that are unrelenting, repetitive, and routine” (Bleiszner and Hamon 1992). Remarkably, even some daughters who were childhood victims of parental abuse, alcoholism, or abandonment may maintain a strong sense of obligation to a mother or father who was a far less than adequate parent. Nurturing and the female socialization of caregiving run deep. Some women tell me that they find it satisfying to show a now aged, but once abusive, father the proper way to care for another family member, accepting a heroic task of exemplary personal care. Adult sons focus on financial affairs, household repairs, and other forms of assistance that are episodic and clean. Rarely will an adult son perform personal hygiene or assist with dressing an elderly parent, especially his mother. Male offspring appear on the scene when a big decision is to be made, such as consenting to a major surgery for dad or nursing home placement for mom. Daughters are more likely to suffer from filial anxiety, a nagging sense that they never have done enough. Such gender differences are deeply engrained on a societal scale. Filial role enactment is a sex-linked trait. The majority of adult children, if asked, express a commitment and an intention, when the time comes, to care for their elderly parents. This is

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contrary to an enduring myth that modern Americans shirk responsibility for care of their parents, a theme voiced repeatedly throughout prior generations, yet generally not correct. We want well for our aged parents. If not for moral reasons, then perhaps reciprocity compels us; our parents took care of us, and now it is our turn. An adult friendship develops between like-minded parent and child, much to the consternation of a nonfavorite offspring or one who holds little in common with an elderly parent. Undoubtedly, our conscientious care of a frail parent is a self-serving model of behavior for our own children to follow, a template for them to trace a few decades hence when we are old and grey. Caregiving by an adult child is probably best appreciated as a very late manifestation of childhood attachment (Cicirelli 1989). Child psychiatrist John Bowlby argues that the parental attachment formed in childhood lasts a lifetime and sustains psychological closeness, security, comfort, and freedom from anxiety (Bowlby 1976). In preindustrial America, the filial obligation expected from a child by his elderly parent was primarily economic. If lucky, the aged mother or father (rarely would both survive to an advanced age) was supported financially by kin. The elderly parent, if a landowner, in return would leave the farm to an adult child as an inheritance, a strong incentive for maintaining a social contract between generations. For those less fortunate, financial insecurity was as much a part of old age as achy joints, failing senses, and other physical infirmities. Any notion of the preindustrial three-generation extended family living happily, harmoniously, and continuously under one roof is a perpetuated myth. No such golden age of the American family truly ever existed (Hareven 1995). The early American family was more fluid and flexible than it is today, as needs changed and supportive relationships constantly were revised to meet the demands of individuals during personal crises. A young widower might move in with his parents. A newlywed couple shared space with the bride’s parents until they could afford a house of their own. The youngest daughter might be persuaded by her elderly parents to delay marriage and remain at home as a caregiver, before starting a life of her own after their deaths. The family was like a local bus—people got on and people got off, all along the route. The urbanization and industrialization that later transformed the United States in the nineteenth century might have altered job descriptions, imposed the rigid work schedule of the factory, and tied the fortunes of workers and their families to that of the firm, but it did not alter the fundamental organization of the family, which continued to function as

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a cooperative effort benefiting those members in need (Hareven 1982). By contrast, families today progress lockstep through a normative sequence of transitions as children are born, grow up, and leave home, culminating in an “empty nest” (Brody 2004). Eventually, there comes the isolation of widowhood, followed perhaps by a period of assisted living or nursing home care. World events can disrupt the circumstances of the family. Elderly patients whom I have known over the past twenty-five years, now mostly gone, were all children or young adults during the Great Depression. Few individuals among that cohort were unscathed by economic hardship (Elder 1999). Lives were disrupted, confidence and optimism were shattered, education and careers were delayed or lost, and a lifelong culture of caution and risk aversion was engrained in an entire generation. Baby Boomers grew up hearing remarkable stories told and retold about life in the hard times of the Depression, and we still feel its ripple. Regardless of the historical vagaries of macroeconomics, the tragic disruptions of war, or other large-scale cataclysmic events, one principle holds constant regarding the relationship between modern American elders and their children: given a choice of living arrangements, elderly parents prefer by far the oxymoron of “intimacy at a distance” when it comes to the relationship they hold with their adult children (Rosenmayhr and Kockeis 1963, 410; Laslett and Wall 1971). Our parents cherish their privacy. Individualism and autonomy define the desirable lifestyle of the modern, functional “young-old,” at least for those of middle-class or higher socioeconomic status. Isolation, agesegregation, and a loss of mutual assistance across the generations are the result. Contact between an elderly parent and an adult child today may consist of no more than an obligatory weekly telephone call on Sundays (Shanas 1979, 3).2 Whether mom and dad live down the street, across town, or in a far-off sunny enclave for senior citizens, they live apart from children and grandchildren. The “intimacy” of the modern extended family is dubious. It is more romanticized than real. Asked why they choose to live at a distance from their offspring, elderly patients tell me, “We don’t want to be a burden to our children.” Posed as a laudable self-sacrifice, the decision to reside apart from family seems socially quite acceptable. Successful seniors today frolic in the sun, travel the world, paint, or perhaps go back to school. Personal fulfillment, however, comes at a price paid by their kin. While not a burden, physically absent, geographically dislocated parents are of little practical benefit to their children and grandchildren. The continuum of the family is disrupted by the

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cult of geriatric individualism. The elderly joined the “me-generation,” albeit a little late. They “aged successfully,”3 having climbed to the summit of Maslow’s triangle. In 1943 psychologist Abraham Maslow geometrically described a hierarchy of human needs and wants (1943, 370). At the base of his triangle are the basic physiologic needs: food, water, and other matters of life support. Next come safety and security, followed by love and belonging, then selfesteem. At the apex of the triangle and the pinnacle of life comes (to the lucky) self-actualization: a chance to explore personal creativity and curiosity while coming finally to accept life as it is. The prize is the personal enjoyment of the golden years. More than half a century of postwar economic prosperity and the social safety net of Medicare have lifted the “burden” of our elderly parents. The unintended consequence of this success, however, is a fracture of the extended family and our parents’ emotional isolation in the final phase of life, just when they most need a close family, close-by. To be fair, hectic life under the same roof with busy kids and screaming grandchildren really is not a viable option for the elderly. Dual-income families and the rapid comings and goings of a youthful household can cause anxiety and agitation in the elderly. Ringing cell phones, a barking dog, clutter, haphazard meals served too late at night, and the frenetic, hyperkinetic nature of modern family life are not salutary to an octogenarian with high blood pressure, a little cognitive slowing, or just the rigidity of habit that comes with advanced age. I do not advocate a family life like that of the Waltons, the bucolic but fictional Depression-era extended family portrayed on 1970s TV, in which three generations managed to live together, calmly bidding each other “Good night” every evening as the lights went out. Nobody wants that. For the elderly and their families, there is a delicate balance between intimacy and distance. Our model of the family is due for revision. It is not simply a cluster of individual agents, each member serving her own particular interests as she marches through well-defined stages of life, more part of a cohort than a family. By the same token, the family of the twenty-first century is not the local bus, with its frequent stops and starts, merely meeting the shortterm needs of daily life. Rather, in our modern era of longevity, chronicity, and slow physical decline, the family must become a convoy (Antonucci and Akiyama 1995). A convoy of naval warships sails together for mutual support and protection. There is safety in numbers; older, slower vessels are guided and guarded by sleeker, newer, and better-armed boats. Social psychologist Robert Kahn argued in 1979 in an article on aging and social support that

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families must do the same. Just as it may “take a village to raise a child,” it requires a convoy of individuals, providing sustained attachment, understanding, reassurance, and close support to reach the ultimate destination. Friends and contemporaries constitute only a small part of the convoy; most are members of the family. In today’s world of modern medicine, with its resultant increase in life expectancy, the journey is now longer and perhaps bumpier than it was in 1979. That is all the more reason, metaphorically, to travel together. Why did the concept of the family as a convoy of social support for the aged not catch fire when it was first promulgated thirty years ago? A contemporaneous and more compelling issue emerged and dominated discussion of the time: patient autonomy. The patient, so it went, was the sole master of his body and his fate, free to choose among doctors and alternate forms of treatment. Banished was the ancient, paternalistic style of medicine in which only an omniscient doctor knew what was best and discussion and informed consent were thought counterproductive to care. Jay Katz, author of The Silent World of Doctor and Patient (1984), noted that, historically, “the Hippocratic Oath makes no reference to physicians’ obligation to converse with the patient” (4). A modern, enlightened doctor, he argued, should educate, recommend, and advise an individual under his care, but the patient, and the patient alone, was the one in the driver’s seat. This new prevailing social and bioethical precept emphasized the patient as an individual, an autonomous free agent, not as a member of a family or as one ship in a convoy. Once the supremacy of patient autonomy in health care had been asserted, there was still another bioethical matter to address: protection of patient privacy. A goal of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)was to protect the health care consumer from the indiscriminate leakage or the intentional dissemination of private, sensitive, and potentially embarrassing medical information. Medical data or privileged conversation between doctor and patient, as recorded in the medical record, was not to fall into the wrong hands or be used to discriminate on the basis of health status. The Internet was still in its infancy in 1996, and there was good reason to fear the loss of privacy that might come with electronic medical record keeping in a netherworld of computer hackers and viruses. Privacy was paramount. However, the cure, the ubiquitous HIPAA form signed perfunctorily by every patient in every doctor’s and dentist’s office, was worse than the disease. Privacy certainly has been protected. I cannot speak to anyone about my patient unless their name appears at the bottom of the HIPAA form.

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Typically, an elderly woman may fill in the name of an adult child with whom she is close, both emotionally and geographically. A solitary family member thereby is appointed as the family’s spokesperson and the conduit of information flow. There may well be six or eight adult children, all with distinct opinions and useful information regarding mom’s wishes and philosophy on crucial matters at the end of her life. I may not speak to them when they call or stop by, unless they present me with a proper release through a newly revised HIPAA form. Privacy currently trumps communication and cooperation with the family, to the overall detriment of my patients’ care. Just as no man is an island, no ship in a convoy travels in privacy. While individuals come and go in life, the family is a unit in continuum. The family physician treats a family, hence the name. The medical ethic conflicts with the ethic of the family. The physician’s focus, classically as per Hippocrates, is on the sick individual. With the establishment of a physician-patient relationship, comes my solemn commitment to do everything in my power to maintain the health of that individual, regardless of complications or cost. It is my sworn oath; my duty is clear. Placing grandma on a ventilator for a month in the intensive care unit may seem a valiant attempt to salvage a fading life but, while heroic, it may well sap the emotional, constitutional, and financial resources of her family in the process. The doctor’s directive, primum non nocere (first do no harm), is in reality a moral commitment to more than one individual. The family is a collective. As such, it may elect to distribute scarce resources such as time, money, and emotional energy unevenly to its members. For example, one gifted child in a large family may get more than an equal share of financial assistance with tuition. An entrepreneurial offspring may receive family financing disproportionate to that given to her siblings. A sick or disabled child’s needs somehow will be met. These are all family decisions. The challenge for the primary care physician is to reconcile his own ethical imperative to do the most he can for the good of his elderly patient with the ethic of the family that optimizes resource allocation among its members. The family is built on commonality of experience. Shared traditions and memories are the glue that binds them together. Solidarity is a source of great satisfaction, and the family is strengthened by a “mosaic of shared meaning” (Nelson and Nelson 1995). When an elderly patient’s autonomy and privacy are held paramount, separate from the context of the family, we obscure a fundamental social aspect of our species: till death, we each exist as one member of a family, part of a greater whole.

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I do not advocate a strict utilitarian view in which each member of a family is treated impartially. Rather, the challenge for doctor, family, and an older patient is to find just the right balance, case by case, in which goals are best achieved, needs are best met, and balance is maintained between two different ethics at odds. Bioethicist Jeffrey Blustein refers to a communitarian view of family medical decision making, naturally setting bounds to the intensity and duration of treatment (1993, 6). Family communitarianism checks the self-absorbed individualist inclination for prolonged but futile diagnostics and therapeutics often expressed by an elderly patient as “I might as well try one more round of chemotherapy, Doc. I have nothing to lose.” The language of Medicare, words like “entitlement” and “beneficiary,” foster the all-you-can-eat-buffet approach to health care near the end of life. A purely patient-centered ethos of care cannot endure into the eighth or ninth decade of life. Health care cost containment and intelligent resource allocation require a well-functioning family unit that is sympathetic, supportive, loving, and affectionate, but that also is willing to apply the brakes for their common good. Dysfunctional family dynamics drive excessive expenditures on patient care that are sometimes futile and often counterproductive. The health care crisis imposed by a pending geriatric Baby Boom generation will have to be solved, at least in part, by families. To reach this end we will need to lighten up on our national obsession with patient autonomy and privacy, as we foster better, much earlier, and more continuous communication among aging patient, family, and physician. Convoys sail in radio contact, ship to ship. If there is a fault in the concept of the convoy, it is that in fact many of today’s elderly have chosen to hit the road. Nothing better exemplifies the loss of continuity in family, community, and physician-patient relationship than the annual flight of the snowbirds. Rather than a metaphorical convoy of care, a true mass migration southward occurs each fall by RV, automobile, train, and plane. Come spring there is a reverse migration northward. Whether flocking to Florida or other sunny climes such as Arizona, Texas, or Southern California, snowbirds are ready and willing to abandon the family homestead from November to May each year. As beneficiaries of Social Security, Medicare, private pension plans, and as holders of AARP senior citizen discount cards, young-old Snowbirds are comfortable and generally enjoy good health (McHugh and Mings 1994, 111; Marshall et al. 1989, 150). Their utilization of medical services while in the south is low (Buczko 1994, 308), and some elect to coast through the winter with no local primary care physician on hand. More likely, those with at least one

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or two chronic conditions have a Sunbelt doctor in the winter and another doctor up north in the summer, something akin to the seasonal rotation of a closet wardrobe. Young-old patients, for whom retirement is still novel and enjoyable, anticipate wintering in warmth with enthusiasm. Couples come into my office each fall for a preflight checkup. Snowbird couples, I have noticed, like to be seen simultaneously, in the same exam room at the same time; they go two by two, as though boarding an ark. They each receive a flu shot, six-month prescription refills, a reminder to complete all healthscreening tests before they leave town, a pat on the back, and a return appointment for the spring. With their release, the snowbirds are set free, and a geriatric hand-off occurs between the physician-of-the-north and her southern counterpart: “Tag, you’re it!” (Sheahan 2003, 105). Two primary care physicians is an oxymoron. There are obvious pitfalls to be avoided, such as a failure of communication between doctors, opposing philosophies of care, or two treatment plans at variance. Patients partial to one doctor over the other may stall for time, seeking treatment only with the next change of season, as did an older man with a large and rapidly growing skin cancer that appeared on his back early in the winter, a malignant melanoma. He saved it for me till he came north in April, a little late. More than discontinuous or fragmented, care of the snowbird is commodified care. The physician’s services are switched on and off seasonally like the cable TV, Internet, and the local newspaper. There is no sustained attachment. Lacking is an essential sense of continuous connectedness between patient and doctor. Robert Putnam in Bowling Alone (2000) explores the loss of social capital prevalent today. We are isolated, one from another, with no sense of community, commonality, or belonging. This is more than an interesting sociological phenomenon; this is also a matter of public health (House, Landis, and Umberson 1988, 540). Humans are social creatures who fare better through close communal contact. Snowbirds, however, don’t live anywhere. Some patients lament that they cannot achieve a personal connection with an empathetic, warm, and understanding primary care doctor with whom they feel a sense of security and attachment. Yet, if they are snowbirds, they themselves are making only a half-hearted, part-time commitment to such a relationship. With the relentless turning of the seasons and the inexorable passage of time, young-old snowbirds grow old-old. An adult child notices that this fall, the leaves are turning color but mom and dad aren’t packing as usual. There has been a flight delay. The process of getting organized to go suddenly seems onerous. Anxiety reaches new heights. A little confusion, a

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side effect of a new medication, a surgery recently performed (or one that should have been but wasn’t) now make winter migration increasingly problematic. A sudden, dramatic change in health status may ground a snowbird and, for the first time ever, my geriatric patient arrives in the office accompanied by an adult child, newly nominated by the family as primary caregiver. The formerly strong and independent old man is now dejected, withdrawn, and terribly embarrassed. If he served in the military, he recognizes that he has been relieved of his command. Not uncommonly, I might meet the entire family of a man whom I have treated for ten or fifteen years, now massed around his bedside in the intensive care unit, all strangers to his doctor and to the particulars of their father’s long health history. An older patient’s loss of autonomy and medical privacy may be very abrupt, leaving his family ill-informed and ill-prepared to meet the emotional challenge of medical decision making. More commonly today, with the emergence of chronic ailments over acute illness, and the prevalence of the “dwindles” rather than a sudden medical catastrophe, patient autonomy becomes a relative term. It is a moving target. Autonomy recedes gradually, like hair, in one’s later years. It is not an all-or-none dichotomous attribute. An adult daughter may take note the first time she needs to give her father a boost as he rises from a park bench. A son who visits his parents might find it odd that mom no longer insists that he stay for her home-cooked dinner. The man who signed his HIPAA form three years ago, then proudly in command of his own affairs, begins to falter. He is not demented or legally incompetent, but neither is he quite autonomous any longer. Like the crossed lines of an economist’s supply-demand curve, family intervention, supervision, management, and ultimately direct caregiving need to ratchet up gradually as autonomy fades. It is a dance—think of it as a delicate balancing act—and, if done right, an artful achievement and a successful group project. HIPAA, albeit written with the good intention of preserving privacy, is a legalistic product that stands in the way of the family. Reams of paper have been printed outlining the statute’s regulations, implementation, compliance, and the penalties for its violation. It is bread and butter for attorneys who practice health law (Rovner 2004, 399). HIPAA is, however, inherently antifamily. Typically, there is but one designated communicator, authorized to speak to the doctor as proxy for the patient, but serving indeed as family spokesperson. The doctor’s view of the patient’s situation at home is seen through the eyes of a single observer, who may well suffer from tunnel vision or have an old axe to grind with a sibling. Just as

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history books are written by the victors, the “story” of the ailing parent is told by the one child with the closest relationship: the one whose name is on the HIPAA form. What is needed, instead, is the opposite of a HIPAA form. Start with the premise that it is natural, beneficial, and expected that all family members deserve the right to speak with a parent’s doctor. Keep the channels open. Only in cases where a patient expressly forbids communication with a specific family member (there is so often a “black sheep” in the family) should contact be denied. Call it the converse HIPAA form. The converse of HIPAA accentuates the positive: wider discussion and exchange of information within the context of the family. It eliminates the negative: sole responsibility of one individual as the nominated family representative, relay, and medical translator. It does, however, reestablish a burden on an older patient’s family as a whole: they must all talk to one another. That is no easy task. Old sibling rivalries, differing personalities and agendas, irresolvable squabbles, and varying functional levels of maturity all can make intrafamily dialogue and decision making a far greater challenge than it ought to be. Additionally, ours is a mobile and scattered society. Modern telecommunications, in all its forms, must compensate for the lack of close face-to-face contact and the comfort that is lost due to geographic distance. I have made my case for a converse HIPAA form as a functional family dialogue and permission for a more inclusive doctor-family exchange. I must acknowledge, however, that not all families can cooperate and function effectively; some do harbor a seriously dysfunctional element. Mrs. J was “actively dying.”4 She was old. She had suffered from a host of chronic diseases that had taken their toll, and she was exhausted. Mrs. J had three attentive daughters who routinely accompanied her on office visits and who were devoted, competent caregivers. They knew the score, and, as proxies, they were prepared for what was coming. I soon learned, however, that there was another adult child; Mrs. J had a son. He called one afternoon. This was the era before HIPAA, so I took the call. “I’ve just been to see Ma,” he said eerily, like a cast member from Deliverance. I began to summarize Mrs. J’s grave status when he interrupted, “Looks to me like you’ve about killed her! She looked fine when I last checked on her.” I wondered how long ago that must have been, but I had the good sense not to ask. “I’ve got my rifle in my hands and I’m comin’ right over to even the score. I’m a Vietnam vet and I know how to use a rifle.” Click.

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I knew immediately that this was to be more than just another bad day at the office. I panicked. Immediately, I called the local sheriff and blurted, “There is an angry guy with a rifle coming to shoot me, and he says he’s a Vietnam vet!” The sheriff interrupted to advise me that he too was a Vietnam vet and that “we aren’t all crazy, you know.” Things were only getting worse, it seemed. The sheriff informed me that there was nothing he could do until the fellow actually came to my office with his finger on the trigger. I was to call him back at that point. Deriving no comfort from that advice, I took a deep breath and called Mr. J back. I proceeded to talk him down with a long, detailed, but compassionate update of his mother’s deteriorating condition. We never did meet face to face that day. I went home that night, poured myself a stiff drink, and contemplated career alternatives. Physician assault with a deadly weapon, certainly in my view, is not a healthy coping mechanism. That threat was a dramatic and pathologic response to a natural family transition: the impending death of an aged parent. Was Mrs. J’s bellicose son suffering from a severe form of the sudden sense of mortality that comes with the loss of our parents, who serve as a buffer generation between each of us and death? Was he racked with guilt over decades of prior neglect of his mother? Had his sisters unwisely insulated him from the ugliness of the dying process until it could no longer be concealed? Perhaps they had isolated him from their mother, as the unloved child and the odd man out. I don’t know. It is clear, though, that families have distinct “personalities.” Elaine Brody (1974, 23) notes that “the capacity of the family to achieve a new equilibrium in accommodating to the changing needs of its members is a mark of ‘health.’ ” Middle-aged children, typically in their forties to fifties, achieve filial maturity when their “parents can no longer be looked to as a rock of support in times of emotional trouble or economic stress, but may themselves need their offspring’s comfort and support.” Filial maturity is not role reversal; the child does not become the parent (Blenker 1965). Achievement of filial maturity is a late developmental milestone for an adult child, and it is a step in preparation for that child’s own old age. Ideally, it should not come as a crisis. Anecdotally, in my own clinical experience, I have seen the full spectrum of family responses and remarkably varying degrees of filial maturity among the adult children of ill and dying older patients. I can find no correlation between level of education, income, or social status and the health of a family’s “personality.” A well-to-do and knowledgeable man

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in his sixties asked me to review the medical records of his ninety-twoyear-old mother who had lived elsewhere. He told me that she recently had died, suddenly and “prematurely.” He was outraged, inconsolable, and could not accept that she was gone. “This couldn’t be!” Certainly we would find a smoking gun of medical malpractice and a wrong would be righted. (I declined to undertake the investigation.) Stoic and pragmatic farmers, again from my own anecdotal experience, seem to handle life’s last transition with greater equanimity and grace. Perhaps filial maturity comes more naturally to those who harvest the wheat. It is an essential but underappreciated role of the primary care physician to know an aging patient within the context of the family and not as a subject in isolation. It does not suffice for me to listen only with my stethoscope. The doctor who does so risks missing the message. How does this family function? Are they attentive or detached? Do they instinctively offer affection, affirmation, and the emotional aid that is a natural remedy and the best medicine, albeit no cure? “Helicopter” adult children may hover over a sick parent’s hospital bed, demanding that the doctor be summoned at once or barking that a picked at dinner tray be removed immediately, but doing so offers no solace and makes no meaningful contribution to a parent’s care. It is a poor substitute for emotional engagement and the quiet comfort of mere presence. An observant physician can read the verbal and nonverbal messages, the body language, loud and clear. It is easier than interpreting an electrocardiogram. How will this family cope when their fragile elderly mother falls and breaks a hip, needs a new heart valve, or confronts cancer? How will they handle an inevitable decline? It is indeed certain that something will happen to this patient eventually. Nothing lasts forever: “In the long run, we are all dead.”5 So much of primary care today amounts to no more than putting out fires, running from one acute issue to another, giving a flu shot here or prescribing an antibiotic there. The doctor is hemmed in by time constraints and paperwork. There are too few doctors for too many chronically ill and elderly patients. In such a climate we cannot possibly begin to address the bigger picture: the homeostasis of the family as it responds to the stresses placed on it by the failure of its oldest members. The family is an ecosystem (Connard and Novick 1996). What is needed is a primary doctor with an opportunity to take a “systems perspective” of seeing the patient within the family context (Kreppner and Lerner 1989), providing a social service that goes above and beyond conventional primary medical care. The geriatrician is a student of the final phase of human development.

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The only clinical setting in which family and patient are addressed as one functional unit is the hospice, a service provided to those with a life expectancy of less than six months, most commonly due to malignancy. The hospice is as close as we currently come to holism in health care. Physical comfort and pain control are a principal concern of the hospice nurse, but spiritual well-being, emotional expression, and achievement of peace within the family are equally important goals. A cadre of social workers, psychologists, and clergy follow in procession. Family grief counseling continues after death comes, the only Medicare-approved form of medical therapy to extend beyond the patient’s date of death. Only when we, the treating physicians, “give up” on a cure or disease containment are we able to shift our focus from the patient as an individual to the patient as part of a greater whole, then turning our attention to the family. So deeply entrenched is our medical model of “war on disease” that it is not until the war is lost that we are able to step back and see the bigger picture. Future primary physicians and geriatricians must attend to the family, an integral part of the patient, in all cases, not just when the patient is at death’s door. The challenge for government (Medicare, or what may follow) and for private health insurers will be to acknowledge the intrinsic value of the family in health care by adequately compensating for medical services they receive: dialogue, counsel, comfort, and coordination of effort to achieve a common goal by family and physician. The current reimbursement format of one patient, one diagnostic code fosters excessive individualism, isolation, and exclusion of the family from participation in the health care of a loved one. When an adult daughter and I sit in the exam room in the presence of an elderly person (her parent, my patient), we do not see the same individual. As a physician, I instinctively formulate a prognosis. What lies ahead for this eighty-year-old woman with Alzheimer’s and emphysema? Based on past experience, I can make a safe wager that in six months she will need home oxygen, in twelve months a walker, then a wheelchair and a home health aide for assistance.6 She probably will follow a predictable trajectory. In two years she quite likely will be institutionalized in a nursing home, unable to recognize her family or manage the simplest of personal tasks. Statistically, I know that within three years, she probably will be dead. It is a grim business, peering into the future. Her daughter, at least to a degree, sees her mom as she was, especially if their relationship was strong and affectionate. For family, any accurate present assessment of an elderly parent is clouded by a reminiscence of days past, when the parent was strong, vital, and protective. It is human

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nature to retain a gauzy nostalgia of our parents in their prime, a phenomenon most apparent when a sudden health crisis strikes. An adult child, having not seen dad for several years, flies in from the opposite coast. He rushes to the bedside, where he is shocked to find, not his father, but a shriveled shell of a sick old man. His father, as he remembers him, is already gone. “What have you done to Dad?” he asks. Family members, as ships in a convoy, need to know the “heading.” Where are we going with an elderly parent, and what can we expect? A family that anticipates needs will be ahead of the curve, making the transitions to in-home care, assisted living, or hospice enrollment much earlier, more effectively, and when each service can be utilized optimally. “Where do you see yourself in five years, or in ten?” is a question commonly asked of an applicant at a job interview. The question also has relevance in the final phase of family planning: elder care. Advance directives, such as a living will, anticipate an acute health crisis. The focus is immediate and short term. As a catastrophe unfolds, decisions must be made quickly. The advance directive, endorsed legislatively by the Patient Self-Determination Act, is really an extension of informed consent. It preserves the wishes of an incapacitated individual through the designation of a surrogate decision maker. Advance medical planning, more broadly, should constitute a periodic assessment of the overall health status of an elderly patient (Gillick 1995, 621; Gillick 2004, 7). Like shareholders reading a company’s annual report, family members should review a periodic report card, an executive summary of the situation. Regardless of his current degree of legal competence (capacity), a family needs to know whether grandpa is robust, frail, becoming demented, or, frankly, dying. What remains of his capacity to withstand the next acute illness, intense therapy, or major surgery? Annual assessment must be comprehensive, not organ specific. It is a job best left to the primary care physician, offering a personalized, periodically updated risk-benefit calculation, distinguishing, in advance, care that is beneficial from that which is nothing but futile. Living wills do not serve this function (Tonelli 1997, 6; Lynn 1991, 101); families and doctors do. Successful care of a massive aging Boomer generation will mandate forward thinking by families, not an easy task for adult children barely coping in a time of economic recession, job insecurity, and generally accelerated pace of life in the present tense. A critical question for health-policy planners charged with the redesign of an American system of health care that is both satisfying and solvent will be whether filial maturity and anticipatory family action are teachable traits. More than a vaccine or a screening test,

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an educated and participant family is real preventive medicine. At the very least, we somehow must inculcate in all families a strong sense of responsibility for our aging parents, setting in place a national moral imperative. Other countries, particularly those facing a geriatric preponderance in the next few decades, are grappling with the same challenge. The traditional Confucian ethic of filial piety has prevailed in the East for over two thousand years, fostering familial harmony, interdependence, honor, responsibility, and self-sacrifice. That ethic is at variance with our Westernstyle individualism, independence, and self-absorption. However, recent industrialization and urban migration in East Asia now may be eroding filial piety by physically distancing the generations: “Korean elderly persons now prefer to live separately from adult children” (Bengston and Putney 2000). Intimacy at a distance does have a strong, modern, and universal appeal. Will a sense of filial obligation to elders endure as individualism triumphs over familial interdependence to become the new universal norm? Governments worldwide should worry. Elder care, in fact health care of all sorts, is a delicately balanced see-saw of familial and community obligation and governmental support. More frightening than the presently projected budgetary shortfall posed by Medicare in the next decade (and it truly is staggering) is the worry that families simply will get off the seesaw, leaving the federal government to strike the ground hard as it bears the heavy weight of care for a large, senescent old-old Boomer cohort, all demanding extended and expensive services and support. Medicare and Social Security were created to assist, not supplant, the family in care of the elderly. They cannot bear any burden. Any future policy supportive of a nation of elders must engage the family as an equal partner in their care. Families cannot walk away. Consider the case of Mrs. K. Mrs. K, a woman in her mid-eighties, arrived unaccompanied for a late-afternoon appointment. She suffered from a host of common geriatric afflictions: a cancer under control, high blood pressure, and a skeleton riddled with arthritis. Most damaging to her health and happiness, though, was a lifetime affliction with alcoholism, a disease that had slowly eroded her body, mind, and family. Mrs. K was quite inebriated. Moving slowly and unsteadily, slurring her words, she staggered with assistance and managed to mount the exam table. She was in no physical distress, but she clearly was in no shape to drive home. I called her daughter, who, fortunately, was at work just a few miles down the road. I summarized, “Your mom is here in the office. She presently is intoxicated, and I cannot allow her to get behind the wheel to drive home.”

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Mrs. K’s daughter drew a long and heavy sigh. “I have spent the last fifty years dealing with my mother’s drinking, and I just can’t do it any longer. I’m sorry, but I will not come get her.” It was now nearly 5 p.m. and my office soon would be closing. My staff and I wanted to go home. I told Mrs. K’s daughter that, as much as I would accept responsibility for her mother’s medical care, I really could not take the woman home with me for the night. My wife and children would find the situation awkward, to say the least. She was, after all, not my mother. I had no alternative but to threaten, “If you do not come promptly to retrieve your mother, I will have to call the police to deal with the matter.” Within twenty minutes, some other family member appeared at the door to collect Mrs. K, leaving her car parked where it was until she was again sober and safe to drive. No one possesses the luxury of choosing his birth family. You go through life with the family you have. Ethicists argue that biology alone does not mandate any special obligation of an adult child for the care of an older parent who is faltering. Elder care can be unrelenting, particularly for a parent with alcoholism, a disease that carries a strong social stigma and the frustration of frequent relapses. Resentment, repressed anger, and a fervent wish to unload a difficult parent may lead to a maladaptive and dysfunctional use of a physician’s services. The physician-patient relationship, no matter how strong a bond, never can replace the intimacy, attachment, and unconditional emotional and physical support of a properly operating family. Every family carries baggage. Under no circumstances can the doctor transcend the physician-patient relationship, become family, and accept that baggage like a bellhop at a five-star hotel. The physical health of an older parent is tightly entwined with her emotional well-being. So many geriatric office visits, ostensibly for a sore foot, a stiff neck, or insomnia, in fact arise from a patient’s loneliness, sense of abandonment by family, and perceived lack of respect and gratitude paid by adult children. Family dynamics, good or bad, regulate the consumption of geriatric health care. The cost of care escalates when physician replaces family as primary source of comfort, concern, and connection for the elderly. Peter Orszag, former director of the Office of Management and Budget (OMB) under the Obama administration, argues that health care costs are high because each American utilizes too much medical service. In my experience, much of what I do day to day in the office, allaying fear, offering personal presence and soothing words of comfort in a familiar setting, and reducing the strangeness of illness, are all outsourced functions, formerly the role of the family. Just as we should not expect our nation’s

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teachers to raise our children for us, we cannot expect the primary care physician to serve as surrogate son or daughter. Fostering healthy family dynamics will reduce the cost of geriatric health care. That will not be an easy prescription to fill. It is much easier to point a finger at sloppy doctoring, greedy pharmaceutical companies, or the absence of electronic health records as causes for a skyrocketing Medicare budget. The excessive utilization of medical services by geriatric patients “searching for something,” begetting ever more tests and procedures, is an expensive substitute for close filial attention. High geriatric health care costs are, to a degree, a family matter. The fault lies not just in our health care system, but in ourselves. Like Tony Soprano, fictional organized crime boss and sometime psychoanalytic subject, “I mean no disrespect to the family.” Many attentive adult children willingly and lovingly take charge, knowing instinctively what to do. Solidarity of family offers great solace. Intention, in the mind of an elderly parent, is far more important than outcome. Family is the raison d’être. It promotes survival. Grandma hangs on, waiting for a granddaughter’s wedding or a grandson’s graduation (and then, perhaps, some other future landmark event after that) to see how the story of the family unfolds. Family is a source of dignity and self-respect, two salutary intangibles for the elderly. However, today the family faces a new frontier: our pills and procedures are pushing the envelope of longevity. We are forestalling, but also prolonging, the ultimate limitations of old age on the human experience. The modern family simply may not be able to meet the challenge of a massive, superannuated Baby Boom generation, 78 million of them, all looking for filial piety plus personalized health care in their final decades. Lower birth rates among the Boomers, the first generation to utilize birth control in bulk, mean fewer adult children to take up the burden. Fractured families that recombine, single parents, nonmarried couples, and same-sex households modernize and redefine the concept of family. Will filial obligation survive the transformation? “Will they still need me, will they still feed me, when I’m eighty-four?” Who will be there to sail among the Boomers’ convoys? The story of the Baby Boom has not yet played out, but it is already clear that families and physicians have a challenging task ahead, both caring for a vast nation of elders. By necessity, we are all geriatricians now.

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PRACTICE/MALPRACTICE

A stranger enters my office. Three or four of my usual geriatric patients, contentedly marking time in the waiting room, track the stranger surreptitiously, while they pretend to read well-worn dated copies of Newsweek or People magazine. Who is this man? He is middle-aged and somber, not likely to be a pharmaceutical representative. Drug reps are young and bubbly, and they come emblazoned with drug logos and carrying goody bags of drug samples. The stranger is dressed casually, unlike the darksuited funeral director who carries a freshly typed death certificate in need of the doctor’s quick signature before burial can proceed. The stranger, however, is carrying a document. Tucked under his arm and creased in half the long way, it is wrapped in a light blue cover page characteristic of the legal profession. The stranger is a process server, and I am being sued for medical malpractice. The process server is the winged Mercury of the plaintiff’s attorney, a bearer of bad news. He quietly and respectfully asks to speak to the doctor, now. I am being “served.”1 Other than the Grim Reaper, there is no one I want less to see at my door than this man. My secretary leaves her post at the sliding-glass window and instructs the process server to follow her in from the waiting room. She knocks lightly on the door of the exam room where I stand, poised to lance a festering boil. Annoyed, I remove my sterile latex gloves, say “Excuse me” to the woman on the table, and open the door just a crack. With a worried look, the secretary says, “Uhhh, could you please come out here right away? There is someone here to see you.” She repeatedly darts her eyes and twitches her head to the right, as though she has acquired a new nervous tic, toward a person who is just out of my view. I sigh, then take a deep breath, and step out to face whatever it is that has come my way.

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Looking downward at his paperwork, rather than making eye contact with his victim, the process server perfunctorily asks my name. I respond sheepishly, like a child who knows he is about to be disciplined. Simultaneously, I experience the rapid onset of a terror-induced total-body physiologic response; I can feel every pore of my skin begin to open wide. So this is the hot flash about which menopausal women complain so bitterly! My primitive, autonomic fight-or-flight response to my predicament leans decidedly in favor of fleeing, but that is not a real option. The process server proceeds. “What is the color of your eyes?” “Brown,” I reply. “How much do you weigh?” “Two hundred and eight pounds,” I mumble, too stunned to fudge it downward by five or six pounds as I would under less stressful circumstances. Having verified that he indeed has reached his intended target, the process server hands me my summons and complaint, then bids farewell and exits briskly. His purpose with the doctor, a highly unusual happening in the quotidian life of the office, remains a mystery to those who wait for me, but there is a silent, collective sense in the waiting room that lightning has just struck the doctor. With trepidation, I begin to decipher what looks like a royal proclamation, bearing an impressed seal and written in a style of English that is both alien and arcane. “The defendant, Frederick M. Barken, MD, was a physician duly licensed to practice medicine in the State of New York.” “So far, so good,” I think to myself. I read on. “The defendant, Frederick M. Barken, MD, held himself out to the general public and, more particularly to the plaintiff herein, as a boardcertified specialist in the field of internal medicine.” “Still true,” I acknowledge. I scan down the pages of boilerplate legal verbiage until I reach the line that curses. “The defendant, Frederick M. Barken, MD, did wrongfully, carelessly, and negligently fail to diagnose . . .” After reading this allegation of personal and professional failure, my heart sinks and my eyes glaze. The remainder of the document, filled with terms like “great pain, mental and physical agony, monetary damages, and loss of consortium” adds no further sting. I am, it seems, an alleged failure. By now my full office staff gathers around me in support and defense, as though circling the wagons.

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“Who?” they ask in unison. “Which patient has done this to you?” My longtime, loyal employees express anger and indignation on my behalf. I, however, feel nothing but intense personal shame. A sense of both strangeness and estrangement takes hold over me. I have been wounded by an unexpected and forceful blow. I blush and feel faint as my limbs tingle, suddenly frozen and weak. These are the autonomic, or lizard-brain, responses to attack. Cognitively, however, my higher brain immediately begins to recalibrate my self-image: I am a failure. My inadequacies, indeed my worthlessness, have been exposed. The doctor, a pillar of the community only moments ago, stands naked in his own office. I would like to withdraw in isolation, so that I might assume the fetal position, out of the view of others. Alternatively, I would accept a large, scarlet “M” sewn to the front of my shirt, just under my stethoscope. Shame is nothing new to the practice of medicine (Lazare 1987, 1653). As patients, we all can recall the humiliation of disrobing, being poked and prodded inside and out, and even worse, being asked blunt and probing questions about our most private actions and parts, all while being addressed diminutively by first name only. Most stigmatizing is the shame that accompanies hearing a new diagnosis; it is taken as a label of imperfection, perhaps even as a moral and personal failure, a blemish on one’s soul. Obesity, alcoholism, or a sexually transmitted disease are diagnoses that commonly trigger humiliation; I have seen patients hang their heads in shame, suffering great personal despair, bankrupted of their pride and dignity, when told that their blood sugar levels remained high despite valiant efforts at maintaining proper diet. Shame, though, is not just for patients. Doctors are people too. What is remarkable, and much less appreciated by the public, is the powerful role of shame in the practice of medicine and the lifelong pursuit of shame avoidance inculcated in medical education. Whether we are a profession that preferentially selects individual students who are by nature obsessive-compulsive or we mold them that way by forcing them to run the gauntlet of clinical training, the product is a doctor who dreads the personal disgrace of a failure at diagnosis, and one who lies in bed at night, wondering and worrying, “What am I missing?” While teaching young medical trainees to think, act, and look like real doctors, instructors use the shaming process effectively, early, and often. The pedagogical style of choice on hospital rounds or in the clinic is called “pimping.”2 Superficially, it is Socratic, but in reality it is hierarchical (Brancati 1989, 89). Pimp questions are posed at the bedside by the most senior

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physician, the alpha male or female. A pecking order results among students and interns according to their ability to respond correctly and eruditely. For every correct answer, there is another question. They come faster, more staccato, and with escalating obscurity. The more arcane the question, the better the pimp. As in a rodeo, the object of the game is to stay in the saddle as long as you possibly can, but invariably each of us ultimately is thrown. Then, before his young peers, all palpably relieved that they each just dodged a bullet, the young doctor-in-training hangs his head low, as he stands corrected, even humiliated, by his superior, thus promoting shame while maintaining medical rank. If repeated often, the shame-inducing experience of being pimped, if repeated often, imprints an emotional memory akin to being tasered: something definitely to be avoided. The full and formal medical staff meetings known as Morbidity and Mortality, or M & M, further refine medical instruction by humiliation, where doctors from the top to the bottom of the hospital’s organizational pyramid meet to dissect a case gone sour and to assign blame for a “poor outcome.” Who killed Mrs. Jones, and how did he or she do it? Far harsher than a constructive critique, M & M can be an acrimonious forum for the assignment of blame, always under the guise of learning from our mistakes (Gawande 2002, 57–62; Levinson and Dunn 1989, 2252). Someone will be thrown to the lions. Ridicule by our fellow physicians, piled upon the guilt we already feel for an underlying error of clinical judgment or technical skill, is a remarkably potent source of shame and embarrassment. As a powerful moral emotion, shame hangs over physicians, interfering with our normal personal and professional lives more than we admit. An intense aversion to public humiliation and to the negative perception of others should, intuitively, drive our medical error rate remarkably low, if not to zero. Yet, it will come as no surprise that this is far from the case. Doctors make mistakes; in fact, we make a lot of mistakes. In 2000 the Institute of Medicine (IOM), in its landmark study entitled To Err Is Human, reported on the remarkably high rate of serious, often lethal, medical errors prevalent in U.S. hospitals (Kohn, Corrigan, and Donaldson 2000). The title of the book notably omitted the latter half of the quotation by Alexander Pope, “to forgive is divine.” It focused rather on medical error making as a problem of faulty system design, rather than a matter of individual blame and shame. The magnitude of the problem is staggering. A profession that reveres the principle “first do no harm,” was killing a calculated 98,000 hospitalized patients per year nationally, extrapolating from a study done by Harvard Medical School for the State of New York

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(Brennan et al. 1991, 370; Leape et al. 1991, 377). These appalling statistics were largely verified in a study done in Utah and Colorado (Thomas 1999, 255), thus indicating a national crisis of health and safety, rather than an isolated risk for New Yorkers. It was estimated that “more people die in a given year as a result of medical errors than from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516)” (Martin et al. 1999, 1). To combat an epidemic of medical errors, the IOM proposed that health care organizations “create a culture of safety and demonstrate it in their daily decisions.” Hospitals are complex organizations that run by a set of routinized activities, such as preparation of chemotherapeutic drugs by the pharmacist, counting and recounting the blood-soaked sponges by an operating room nurse, and the correct labeling of tissue samples by the pathologist in the laboratory. There are checks and double checks. Yet, from time to time, a grand conjunction of multiple synchronous but individual errors arises, and disaster strikes in the form of a horrific accident. An accident is defined by the IOM as “an event that involves damage to a defined system that disrupts the ongoing or future output of that system.” That is an operations-manager’s terminology for a sporadic but catastrophic and tragic event akin to the explosion of the space shuttle Challenger. The IOM study examines the hospital environment in the light of a new model. Individual doctors, nurses, or technicians aren’t to blame for error. The system did it. Medical staff are not nefarious evildoers, but appear more appropriately as dedicated members of a complex work team that is beneficent, humanitarian, and altruistic, even though the hospital’s system of care delivery may fail a patient miserably on occasion. The trend in recent years has been to shift medical services out of the hospital to an ambulatory care setting whenever appropriate. The busy solo physician in family practice or internal medicine is responsible for several thousand patients and must supervise their care personally, review reams of lab and X-ray reports, and prescribe with precision, all with a wildly unrealistic expectation by both physician and patient of zero errors. NASA builds a greater error tolerance into their space missions than we shame-averse physicians expect of ourselves. As a solo practitioner in my own office, I cannot assign blame for a mistake to a faulty institutional system. I am the system. I am personally responsible for each and every clinical decision, examination, laboratory report, and prescription. Perhaps I need a reproduction of President Truman’s sign for my desk: “The Buck Stops Here.” More apt to the problem of medical error making in office practice is the 1970 motto penned by Walt Kelly in Pogo, “We have met the enemy . . . and he is us.”

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Clinical errors do not occur solely at the hands of a few bad apples in medicine. By far, most slipups are not caused by demented doctors or by physicians impaired by alcohol or narcotics, although these exist. Humbling as it is, every doctor, from “Marcus Welby” to the Mayo Clinic, regularly makes mistakes of both technical skill and professional judgment. Fortunately for the patient, most of our errors are inconsequential. They cause no real or lasting harm and are easily corrected once detected. Borrowing from the airline industry, such an event is referred to as a “near miss.” An elderly woman sits in my office describing a minor ailment such as a small rash or a mildly sore knee. As we chat, I peruse her chart, scanning through prior lab data. I happen upon an electrocardiogram (EKG) tracing done six months ago. It is abnormal! The undulating electrical pattern clearly reveals a significant degree of heart block—a failure of the upper and lower chambers of the heart to beat in synchrony—that may well require the insertion of a pacemaker. Yet, the EKG is marked “Normal” and bears my signature. How could I have been so stupid? Although no serious harm has befallen her and the abnormality can be addressed by a belated referral to a cardiologist, the woman is, nevertheless, the victim of a near miss. Like asteroids, near misses in medicine streak by us all the time. Only the laws of probability save our patients from a deep impact and the fate of the dinosaurs. Charles Bosk, sociologist and author of Forgive and Remember, studied the phenomenon of medical error by shadowing surgical teams in a residency training program over a protracted period (1979). Embedded within the ranks, he was able to observe the methods of surveillance and social control in clinical training that limited errors, while professional growth, maturity, and confidence building were encouraged in resident surgeons. Most errors fall into one of two broad categories: technical errors and errors of judgment. Technical errors are common, to be expected, and usually quite evident. Surgeons leave tracks. Sloppy suturing, a wound infection, or a misguided needle that punctures something vital are all technical mishaps. According to Bosk, such “technical errors are expected to happen to everyone, but rarely.” This mirrors what I was taught by a superior in my medical residency, that “it was OK to make mistakes, as long as you don’t do it too often.” Technical errors are as common for the primary care physician as they are for the surgeon, but they are more likely to be obscured. Unlike a surgeon’s cut, the results of my faulty actions or inactions may be hard to discern from the natural downward-spiraling course of a patient’s underlying

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disease. Yet, I’d prefer not to rush the patient to a premature death either by an error of omission, as in the missed EKG abnormality above, or by an act of commission. Primary care physicians in private practice don’t do many invasive technical procedures. For us, an error of commission is more likely to result from the improper prescribing of a medication, leading perhaps to the failure of an organ such as the liver or kidneys, and to a death ahead of schedule. In this sense, the physician’s pen is as mighty as the surgeon’s scalpel. It is the technical error of omission, however, that is most haunting for me. In each year in practice, a busy primary care physician will personally review well over one hundred thousand individual lab test results, X-ray and mammogram reports, EKGs, and consultation notes from specialists. No matter how carefully I screen reports, a red flag surely will get by from time to time. Certainly, it is prudent to slow down and avoid distractions such as a beeping pager, a cell phone, or an interrupting staff member with a quick question. Of course it makes sense to review lab work only early in the day, when I am fresh and alert, and to do so in a quiet, well-lit corner of the office. An ideal environment such as that, however, is far from the real world of a busy practice that teems with complicated sick patients, where the unexpected is the daily routine, and where interruptions become nested, one upon another. As I face my large, expansive chart rack that is organized alphabetically and that contains up to three thousand active medical files, I can guess with likely accuracy that at least two or three of those charts contain some significant overlooked abnormality that demands attention. If I only knew which charts harbored a time bomb. Although better systems may come along to organize health information, such as the electronic medical records that are currently much touted and politically popular, I cannot foresee a day when my own technical error rate will ever go to zero. The constant anxiety surrounding a missed abnormality or other technical screw-up is an integral part of the practice of the medical profession. It goes with the territory. In the future, evolved electronic medical record keeping and computerized statistical analysis may quantify my own personal rate of technical error. The day soon may come when I can tell a patient, “Your test results reveal a 62 percent chance of a cancer, but there is a 0.007 percent likelihood that I have misread your report or that I inadvertently am holding some other patient’s lab test in my hand.” To err, after all, is human. Errors of judgment, unlike the punctured lung or the abnormal mammogram gone astray, are more nebulous. As in war, there is a fog of medicine.

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Critical decisions regarding diagnostic workups and interventions are made routinely, based on exiguous bits of data, and more often than not, by gestalt. Inarticulate or demented patients provide few clues. Lab work, diagnostic studies, and even physical examinations can produce ambiguous results, and false-positive and false-negative test results are a diagnostic minefield that physicians tread with trepidation on a daily basis. The trip wire most likely to snag doctor and patient is the unusual presentation of a common disease. Not all patients display the physical signs or describe the classic symptoms as appear in the medical literature. Now and then a patient with coronary artery disease will describe a backache or a facial twinge, rather than clutch his chest as would be expected. Obviously, he didn’t read an authoritative textbook of internal medicine. Physicians, though, must call them as they see them and make very consequential decisions with only the limited information at hand. As business analysts evaluating the future financial health of a corporation are apt to say, we practice our craft “going forward.” Errors of judgment, however, appear in the rearview mirror. Despite dramatic technologic advances in medicine, there is as yet no “retrospectoscope” affording the clarity of vision required to avoid missing what appears obvious only in hindsight (Shaw 1997, 1289). To be 100 percent free of errors of judgment, physicians would need to be Janus-faced, able to peer both backward and forward in real time. The routine of formulating a differential diagnosis is drilled into our heads from the first day on the hospital ward as a young medical student. Given all the facts in our possession, we must list, in rank order of probability, those maladies that best fit the puzzle of the patient’s symptoms. A patient who walks in with a bellyache may have indigestion, esophageal reflux, an ulcer, or perhaps an insidious pancreatic cancer. Components of the differential diagnosis are often presented in ascending order of gravity, but descending order of likelihood. Note that, going forward, a physician solves problems in an analog environment, or a continuum of probabilities, all to a certain degree uncertain. Dr. Jerome Groopman, in How Doctors Think (2007), refers to physicians’ decision-making practices as heuristic, a series of educated guesses, utilizing common sense, rules of thumb, and other shortcuts gained over years of experience. Remember that common things are common. We are fortunate that this is so. Otherwise, our reliance on heuristics and weighted probabilities would be an even more unsteady crutch. The view through the retrospectoscope appears, like vintage television, in black and white. The diagnosis and treatment plan were either right or

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wrong. This is the binary, or digital, world of a chart review, whether done by the quality assurance screener for a health insurer, by an aggrieved family member, or by a medical malpractice attorney. It is the imposition of a backward-looking, all-or-none, right-or-wrong legal duality on an inherently forward-looking, probabilistic, and heuristic medical practice that produces sparks. Professionally, physicians fly by the seat of their pants, but legally, our rear ends are always hanging out. I say to myself, “I am fallible. I make mistakes.” There, that wasn’t so hard to admit. What, though, do I tell my patient, or his grieving family, about my error? Whether he is the survivor of a near miss, the sufferer of a fatal direct hit, or any iatrogenic close encounter that falls in-between, it seems I have a moral obligation to disclose my mistake. I must come clean. While health care institutions may establish written policy manuals for proper disclosure of errors, there is no guideline for the private physician to follow. His only support is the strength of the physician-patient bond that has been cultivated over a protracted period. It helps if doctor and patient go way back together. In this regard, long-term care of elderly patients, even though they may require more complicated clinical management, is more comfortable for the physician. It is easier to apologize to someone with whom you have a long common history and for whom your sincere good intentions have been established firmly, perhaps over decades. The common assumption is that physicians conceal their errors and avoid apologizing for mishaps because we fear that an admission of fallibility will trigger a suit for medical malpractice, transforming patient into plaintiff. While only a small percentage of those patients victimized by physician error actually do sue, a pervasive paranoia exists among us that an admission of error will become admissible evidence one day in a court of law. Several states have adopted apology laws, designed to isolate the ethical imperative of a proper apology from any legal liability that it may establish (Wei 2006, 107), but we still worry. Further, there is the possibility that an apology, as an admission of guilt, represents noncooperation with a physician’s legal defense and may abrogate an agreement with an insurance carrier, thus voiding coverage and leaving the doctor bare. That is a compelling reason to clam up. Aside from litigation phobia and doctors’ feelings of shame and embarrassment, there is another potent reason why physicians are disinclined to apologize for our errors; we really don’t know how to do it properly (Lazare 2006, 1401; Roberts 2000). Certainly, patients want disclosure. What happened? Why did it happen? How can the error be avoided in the future

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so that others are spared? There is a natural inclination to discuss the matter in the passive voice—”Mistakes were made”—that we have come to know from Washington. William Safire referred to this form of speech as the passive-evasive, “acknowledging error while distancing the speaker from responsibility for it.”3 The major artery was nicked. Complications set in. This passive form of explanation of wrong-doing is reminiscent of the gangster thug in the 1970 novel by Jimmy Breslin, The Gang That Couldn’t Shoot Straight who “died of natural causes when someone stuck a knife in his heart.” Patients want contrition: “I truly am sorry for my error and for the pain and inconvenience that it has caused.” They want remorse, regret, penitence, and humility delivered in simple, declarative sentences in the firstperson singular. A sincere apology need not be a mea culpa, a tortured confession of guilt delivered prostrate or genuflecting before the injured party or his clan. I have had to do this a few times and it is demeaning. By the same token, the flippant and dismissive nonapology of today, “My bad,” obviously doesn’t suffice. A vague, disingenuous, or arrogant apology is no better and only rubs salt into the wound. A proper and sincere apology is more likely taught in kindergarten than medical school.4 The art form of apology, however, is a talent to be mastered in medical training, where the stakes are far higher than in grade school. It is a bedside skill to be honed, no less than auscultating the heart or palpating a tender abdomen. Our failure to apologize, I believe, reflects more a pervasive, modern decay of common courtesy and an attrition of the skills of interpersonal contact and communication of emotion, rather than true physician callousness. Disproportionately, of course, both patient and doctor hurt after “an error was made.” Although physicians do make errors, the modern world magnifies their probability. It seems that everyone can dredge up an anecdote they’ve heard about an egregious medical mistake that resulted in a disastrous outcome. As well as the reality, there is also a folklore of wrong limbs amputated, cosmetic surgery that went horribly awry and caused disfigurement, cases of flesh-eating bacterial infection detected too late, and coma-inducing narcotic dosage errors. Along with UFOs, misbehaving movie stars, and miraculous diets, this is the stuff of tabloids. Additionally, the birth of the blog and the power of the Internet search engine have given every victim of medical error the option of a virtual soapbox. Aggrieved patients or families can vent, warn others, and testify as victims of medical mistakes, all while experiencing the world wide web’s equivalent of fifteen minutes of fame.

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Most patients, however, disregard the highly publicized, morbid, and sensational stories of physician errors when they call for an appointment with their own doctor. After all, the horror stories are all about someone else: “My doctor would never do that.” When my error does befall my patient, it is likely to trigger anger and mistrust, not necessarily proportional to the severity of its clinical consequences. Responses vary with the temperament of the patient. One patient calmly might accept word from me that a one-month delay in a serious diagnosis occurred due to a paper jam on my desk. Another might go ballistic because we failed to call to remind him of his physical exam scheduled for the next day, resulting in the same one-month delay in discovery of a disease. In general, however, when a medical error is more than a near miss, undeniably iatrogenic, with or without apology, the response is shock, anger, and a loss of faith (Elder et al. 2005, 537). Some patients recoil, either by switching to another physician or by eschewing medical care entirely, as a maladaptive avoidance response. Others accommodate. They dismiss error as an unavoidable consequence of doing business in health care, and they “just deal.” More adaptive responses to physician error, albeit limited to those patients with normal cognitive function, sufficient savvy, or strong family support, include anticipation and advocacy. After an error, patients and families elect, from that point forward, to take a very personal, proactive part in their own care, henceforth doublechecking every prescription written and second-guessing each clinical decision made. Most patients who have not experienced a medical mishap personally, however, approach the physician encounter with an inherently positive outlook, perhaps naive, that everything will be just fine and that they are in good, safe, professional hands. In The Silent World of Doctor and Patient, Jay Katz wrote in 1984 about the need for more dialogue and mutuality between patient and physician in clinical decision making. The paternalistic style of practice—”father knows best”—was to be replaced by the empowerment of the patient. Three decades later, I am amazed how many patients are quick to say, “You’re the doctor, you decide” or, simply, “Just fix it.” In an age of instant access to information and sophisticated consumerism, patients remarkably still are inclined to relinquish all control to a father figure when they go to the doctor. I believe that their ready willingness to trust the physician stems from an inherent self-delusion of invincibility and immortality. “Thou wast not born for death,” wrote John Keats. Each of us, to a certain degree, adopts this as a truth, rather than face a rather unpleasant

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reality. A false sense of indestructibility is demonstrated by reckless teenagers, particularly boys, and tragically results in what actuaries observe as an adolescent male mortality spike. However, we all harbor a false illusion that, with high probability, our health will be good and, if it isn’t, the doctor will handle it and get us back on course. In my practice, I always have found remarkable the number of middle-aged patients, usually men and often highly educated, who participate in a similar self-deception when they come in for a physical examination. They assume that an unremarkable physical is some sort of factory warranty or seal of good health, and they are shocked, appalled, and angry at the doctor—if they survive— when, one month later, an unforeseeable heart attack bursts their bubble of invulnerability. As patients, we assume that the doctor will get it right because he must get it right. We are, after all, invincible. Would that it were so. Neither physician nor patient comes into the exam room properly prepared to deal with medical error. The physician, shame averse yet all too human, labors under an unachievable expectation of absolute perfection both of technique and judgment. The patient, unless previously scarred by medical mishap, is cocooned in a comfortable delusion that the doctor, unlike politicians, financial advisers, or the corporate titans of today, surely will demonstrate perfect wisdom and skill, take great care, and get it just right. It is laudable, of course, to strive perpetually for the lowest error rate achievable, but errors, to some extent, will always be with us. Both parties to the medical encounter must come to terms with this fact. It is only after we all have acknowledged the inherent fallibility of the physician that we can begin to address another problem, only vaguely related, that hangs over U.S. health care: medical malpractice. A crisis was at hand. Doctors, particularly those in western New York, where I have practiced internal medicine for a quarter of a century, suddenly had become subject to a rapid rise in litigation alleging medical malpractice. Physicians and surgeons were indignant. Tension grew swiftly between practitioners of the medical and legal professions. This malpractice crisis, not the medico-legal morass of contemporary times, was the first such crisis in the United States, and it began in the 1840s (Mohr 1993). The “contagion” of lawsuits, as doctors of that era described it, spread rapidly from upstate New York to New England and the upper Midwest at a rate of expansion that today would be called “viral.” According to James Mohr, historian of medical jurisprudence, “malpractice cases carried to state appellate courts roared ahead 950 percent between 1830 and

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1860, while the nation’s population increased 144 percent, and almost all of the increase in malpractice appeals took place after 1840” (Mohr 2000, 1731).5 A legal theory of professional malpractice had come to the colonies from English law. Sir William Blackstone, in 1768, had applied the concept to medical practitioners in his Commentaries on the Laws of England: “Injuries . . . by the neglect or unskiled management of [a person’s] physician, surgeon, or apothecary . . . because it breaks the trust which the party had placed in his physician, and tends to the patient’s destruction” (Blackstone 1768, 122). Mohr notes that, despite the presence of an established medicolegal concept of malpractice in the early 1800s, such suits were rare and that area of the law was considered arcane: “The vast majority of U.S. lawyers would not have known how to draft an action for medical malpractice.” That was a long time ago. By the mid-nineteenth century, religious fatalism was on the wane; someone, not the will of God, had to be responsible for illness, affliction, and the personal misery of a bad medical outcome. Concurrently, physicians were embarking on a new entrepreneurial modus operandi, hawking nostrums, either elixirs in a bottle or newly developed surgical procedures.6 The doctor had gone from well-meaning amateur or Good Samaritan to an established businessman and professional practitioner, with an emerging medical literature that defined a standard for his care. Once objective criteria for practice were established, it was not difficult for attorneys to target providers of evidently substandard care. An industry was born. Suits were filed, and not only against quacks and charlatans. Eminent, well-educated, and highly respected physicians of the era were suddenly the stunned recipients of their own summons and complaint, the folded blue legal document delivered by the process server of their day, who probably arrived on horseback. A medical malpractice “crisis” has been with us ever since. Beginning in the 1970s, in particular, there have been periodic flare-ups each decade or so, oscillating like sunspot cycles, tracking episodic rises in the cost of physicians’ malpractice insurance. Physicians begin to balk at rising premiums, attorneys justify their role as protectors of an injured defenseless public, and insurers plead poverty due to the rising costs of litigation and staggering multimillion-dollar jury awards. Unlike periodic solar flares, though, these cycles produce a great deal of heat but shed no light. Congress and successive presidents periodically have revisited the tired topics of tort reform and caps on noneconomic damages, pain and suffering, and other Band-Aid remedies. They propose tinkering only slightly with the legal system, through structured payouts and shorter statutes of

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limitations (Mello, Studdert, and Brennan 2003, 2281). A crisis, however, is a turning point or a decisive moment in time, not a chronic process. Crises end. The outcome may be the improvement of a situation, or not. American physicians and their patients contend instead with a “malpractice mess,” a perpetually broken system. Tort liability is our nation’s chosen method of physician oversight, quality control, and patient compensation for injurious errors (Danzon 1985). However, it is serving no one optimally and is itself a serious hazard to our public health by poisoning the core of our health care system: the physician-patient relationship. Deterrence, in addition to righting a wrong and compensating a victim fairly, is the goal of a tort action. Punishment should be instructive and commensurate with the degree of the wrong. Substandard medical care, as the Harvard Medical Practice Study demonstrated in New York and similar investigations confirmed in California, Utah, and Colorado, is in no short supply (Harvard 1990; Mills 1977; Thomas et al. 2000, 261). Yet, the victims of documented negligent care tend not to pursue legal recourse as plaintiffs. In a review of medical malpractice in the New England Journal of Medicine, David Studdert and associates reflected that only 2 percent of negligent injuries in New York resulted in claims (2004, 283). Conversely, “only 17 percent of claims appeared to involve a negligent injury.” There is scant overlap; rarely do patients who are truly wronged seek legal redress. The two alternate interpretations of this odd finding are quite polarized. How you see it depends on which rim of the medico-legal chasm you are perched. Tom Baker, a professor of law at the University of Connecticut School of Law and a legal consultant to the insurance industry, argues in The Medical Malpractice Myth that abundant negligent medical practice mandates ever more lawsuits as deterrence (2005). While it may be human to err, an error is an error. If sued into submission, sloppy doctors ultimately will straighten up and fly right. Can it truly be that the answer to the malpractice mess is more litigation?7 The alternative view is that tort litigation simply is no solution. It proceeds glacially and is exorbitantly expensive to administer, exasperating for both parties, and capricious. It is more a lottery than a well-measured compensation to the injured. A follow-up to the Harvard study ten years later demonstrated that settlement sums were proportional to the extent of plaintiffs’ disability, not to any demonstration of negligence (Brennan et al. 1996, 1963). In other words, tort litigation for medical malpractice is functioning as a no-fault means of compensation for bad clinical outcomes and not as a deterrent to negligent care. Worse, it is performing in

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a haphazard and inconsistent manner that fails to enhance the quality of medicine. Lotteries do not deter. Doctors respond to an environment of lottery litigation by adopting a siege mentality, as though under attack from any direction at any moment (Gianakos 2004, 1408). If legal action may strike from any and all patients, not just the few whom I truly have wronged, then I am a sitting duck.8 At any given moment, any one of perhaps three thousand members of my panel of patients may be “getting to a notary” to file a suit, redefining me as defendant. The result is paranoia on my part. What becomes of the patient whose doctor suspects that “they’re out to get me”? The physician is advised by the risk manager (a full-time hospital employee), his insurance carrier, his attorney, and by fallen comrades with horror stories to fortify defenses. “Document well,” we are told. The medical record, meant to be a working document charting a course of care, becomes Ground Zero in a war of the written word. “9:02 a.m. Contacted surgeon, advised patient to go directly to Emergency Room, immediately! Patient refused to go.” It was, in fact, this line that exonerated me from wrongdoing in my own malpractice case. Documentation of the precise time of the call and the patient’s refusal to seek emergency care were crucial in my defense. I had learned to document emergency surgical referrals in this manner after another patient, sent straight to the ER with acute appendicitis, elected to stop en route at the local bakery for a leisurely cup of coffee and a jelly donut, resulting in a critical delay in surgery and a ruptured appendix. Regardless of a doctor’s efforts at lawyer proofing a medical record, any chart can be pulled from the rack at random and some deficiency can be alleged. I cannot build an absolutely airtight defense by documentation alone. If I only did more tests, perhaps I would feel more secure. The extent of defensive medical practice, defined as the performance of excessive tests and procedures to bolster against legal attack, is controversial. In The Medical Malpractice Myth, Tom Baker (2005) denies the problem, citing research by Daniel Kessler and Mark McClellan (Kessler and McClellan 1996, 353) that failed to demonstrate any evidence of wasteful defensive care of elderly patients with cardiac disease. On the other hand, he does acknowledge, as others have shown (Dubay et al. 1999, 491; Localio et al. 1993, 366), that defensive medicine is alive and well in the high-risk field of obstetrics. Baker argues, however, that physicians’ fears of malpractice litigation are overblown and out of proportion to the real risk. This echoes what a local attorney once told me: “Relax. Most suits are frivolous. They are just a cost of doing business.” I contend that 1) no suit

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is frivolous if you are the defendant, and 2) the societal cost of doing business in this manner, measured in time, money, painful procedures, needless complications, and excessive radiation of patients, is astronomical. Frank Sloan and Lindsey Chepke, an economist and attorney respectively, the authors of Medical Malpractice (2008), distinguish between what they call “positive” and “negative” defensive medicine. Negative defensive responses are forms of withdrawal. Doctors stop doing high-risk procedures, refuse to see high-risk patients, pack up and leave town for another state (Jarrett 2008; Nixon 2008), or close shop and retire early. Everyone concerned would agree that these are undesirable, or negative, results. Remarkably, Sloan and Chepke define as positive “the use of diagnostic and therapeutic procedures in excess of levels that physicians would recommend solely on the basis of their professional clinical judgments” (21). There is nothing positive about an excisional biopsy that probably wasn’t necessary, a third CT scan in one year to “watch” a stable spot in the lung that almost certainly is benign, or an expensive and comprehensive blood panel ordered every six months for a healthy individual, “just to be safe.” Such practices are anything but positive for the health of my patients. The fact that Sloan and Chepke define it as such reveals a widely held, persistent, underlying fallacy that in medicine more is better. We physicians all practice defensive medicine, whether consciously or not. The patient who demands a scan, though it may be of doubtful clinical utility, gets it. The eighty-year-old woman on Medicare, an entitlement program, feels entitled to an MRI of her arthritic back. I will not stand in her way, fearing the remote possibility that a bone cancer will be missed and I will be held accountable for a delay in diagnosis. The Massachusetts Medical Society recently completed an investigation of defensive medicine as practiced in that state (Massachusetts Medical Society 2008). Based on physician-survey data, they conservatively concluded there was, at minimum, a $1.4 billion cost in that state alone, over the six-month study. We all do it. Precious health care dollars are squandered routinely on unnecessary tests, referrals, medications (such as unnecessary antibiotics), invasive procedures, and hospitalizations, all to shore up defenses and buff the charts. This is no way to practice medicine. There is a hidden cost to defensive medicine, not quantifiable in dollars, but certainly dear. The warmth and bonding of a close physician-patient relationship falls victim. As physicians, we withdraw emotionally. A strong relationship hinges on mutual trust and cannot thrive in an environment of constant suspicion, compounding the inherent high pressure of providing professional care. The physician’s demeanor under attack has been

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described as “bristling behavior” (Mello and Studdert 2006). Physicians who have reached the breaking point outwardly may bristle. They are curt and abrupt. More often, however, doctors detach emotionally, tending more to the chart as a legal document than to the patient as a person. As though suspecting the presence of a hidden video camera in the exam room, placed there for a future jury to critique her care, the disgruntled doctor performs in a manner that is technically flawless but mechanical. The trains appear to run on time, but neither the conductor nor her passengers are satisfied with the service. A physician spooked by potential litigation, feeling under siege, perhaps bristling, can derive no satisfaction from the practice of her craft. The emotional reward of a thank you note from a grateful patient or her family is diminished, knowing that any patient may be a future plaintiff in the event of a medical mistake or just a bad outcome. Furthermore, a defensive posture robs the physician by shattering self-confidence and suppressing the use of clinical intuition, a nonquantifiable art acquired over the course of a long career. A hunch is not very defensible in court; cookbook, mouse-clicked, and templated ordering of tests and procedures, however, is objective and ironclad. The real casualty of defensive medicine is an intangible. It is the lost warmth of good communication, empathy, humor, and some therapeutic hand-holding. The relationship is the victim. It is a loss of great social value, if low monetary worth. With the gradual passing of the current geriatric generation, there soon will be no patients remaining who can recall personal relational medical care as it once was. Can a defensive doctor learn to identify, with any accuracy, which patient is likely to sue for medical malpractice (Bradford 2005, 62, 66)?9 A talented physician, particularly a practitioner of primary care, has a feel for people. While there may be no scan or blood test to detect the litigious, there are subtle clues. The woman who spends the better part of her first office visit denigrating her last doctor ought to move on. The man who displays undue irritability over a small insurance co-pay or an unexpected cancellation due to an emergency probably won’t tolerate a doctor’s error with equanimity. He has flunked his “stress test.” In an individual doctor’s attempt to reduce risk, such a patient may be “turfed” or advised politely that he and the doctor do not seem to be a “good match.”10 What results is a shell game of revolving patients deemed likely to sue. This approach may protect the individual doctor who feels under siege, but from a societal standpoint, it seriously impedes overall public health. Even the litigious require access to good primary care.

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A modern, comprehensive overhaul of U.S. health care must remove the shame, blame, and paranoia that attends tort law as it is applied to the medical profession. Nothing short of a radical revision will do. We need a federally administered, universally applied system of no-fault compensation for the victims of medical mishap. There already exists a well-entrenched federal agency possessing the administrative capacity and already charged with the oversight of health care for millions of older Americans: Medicare. It is time to acknowledge that malpractice reform must come as part of a sweeping reassessment of the U.S. health care system. To promote public health, it is time to convert the matter of medical malpractice into a no-fault system under the auspices of Medicare (Sage and Kinney 2006).11 No-fault coverage for medical mishap has been utilized thus far to compensate those families struck by the birth of a severely and permanently incapacitated newborn. The assumption has been that such “bad babies” are injured by anoxic brain damage (a loss of oxygen to the brain) during delivery and that these infants consequently must be the tragic victims of obstetrical malpractice. Two states, Virginia and Florida, have initiated the option of no-fault claims, rather than traditional tort actions for these sad cases (Bovbjerg and Sloan 1998, 53; Whetten-Goldstein et al. 1999, 41). The term “no-fault,” however, is a misnomer. The regulations in Virginia and Florida prohibit a no-fault claim if the defective baby suffers from a genetic disorder or a congenital abnormality (Sloan et al. 1997, 35), a birth defect that relegates those unfortunate little patients to the category of “life isn’t fair.” Although their imperfections are nobody’s fault, they receive no compensation under no-fault. A more apt term, perhaps, would be “some-fault” insurance. In the event that a birth injury might be iatrogenic, it is quicker and cheaper to award compensation to a young family than to litigate for years, ultimately proving or disproving a doctor’s negligence. The emphasis shifts from tort litigation as a process of retribution and a roulette-style payout to a system of measured compensation for a bad outcome.12 This is, in essence, disability insurance. It is intended to help defray the enormous lifelong costs associated with the care of a baby born with cerebral palsy. Think of it as “bad-outcome compensation”: an approach readily applicable to the elderly (those on Medicare) as a way to remove the emotional, interpersonal wedge driven long ago between doctor and patient by medical malpractice tort law. Unlike the devastated parents of a newborn bad baby, the elderly patients seen in primary and geriatric care are much less inclined to sue for malpractice. Among the cohort of patients studied in Utah and Colorado,

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the elderly sufferers of negligent adverse outcomes were disinclined to sue the responsible physician (Studdert et al. 2000, 250). There seems to be a fading of litigious ire with advancing years. Perhaps the elderly lack sufficient socioeconomic status or sufficient time remaining to navigate the legal system. I would like to think, rather, that with age comes forgiveness. Seniors, however, are disenfranchised, fearful that they could alienate the doctor and wind up without access to care. When plaintiffs’ attorneys do the math, they quickly compute that a wronged octogenarian has no lost earnings and scant need for financial support in the few years remaining. Consequently, there is little contingent remuneration to be gleaned. From a purely economic perspective of the tort award (and that is how such matters are reckoned), seniors are like old cars: fully depreciated. Sage and Kinney (2006) have proposed a better way; I believe it represents a bold reform that, as both a physician and a patient, I find compelling. They argue “for the federal government to pioneer a regulatory program of administrative adjudication of malpractice claims for Medicare and encourage performance improvement.”13 As with obstetrical no-fault insurance that covers bad babies, physicians and hospitals that participate in Medicare (virtually all doctors) would have deducted from their income an annual sum that is appreciably less than their current premiums paid to private insurers. Medicare beneficiaries who believe they have suffered an adverse outcome, having waived their option to tort litigation, would apply to Medicare for adjudication. In the event of an award to a beneficiary for a bad outcome, Medicare would compute a small reduction in the responsible physician’s pay profile to adjust for the loss. This is called experience rating, something generally not part of the current system of private insurance against medical malpractice claims. Physicians repeatedly found to have been associated with bad outcomes would see progressively declining revenue and, in the most severe situations, a strong economic disincentive to continue practice. Again, per Sage and Kinney, “because Medicare is the nation’s largest health care payer, bringing malpractice policy into Medicare [also] may promote direct coverage of economic losses and more careful incorporation of liability costs into reimbursement formulas” (322). Success of such a system of compensation would hinge on establishment of standardized, reasonably computed dollar amounts for specific injuries such as organ failure, loss of limb, or death. Similar to worker’s compensation as it was conceived to compensate an injured worker, badoutcome compensation under Medicare would distribute funds more fairly and rationally, albeit as much smaller awards across the board, by

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prohibiting the jackpot payouts that are prevalent today in the tort system. Like bad babies under no-fault in Virginia and Florida, “bad grannies” (elderly victims of an adverse medical event) would get their due. Determination of compensation by Medicare would occur by chart review, a system of quality monitoring already in place at Medicare, including a process for appeal, that readily could be expanded. Medicare was created in 1965 with the limited intent of providing health insurance to those over sixty-five. In subsequent years the program gradually was expanded to guarantee an array of other benefits. It has become an instrument for achieving broader societal goals (Harris 2003, 1251). For example, the program regulates the private market for supplemental insurance (Medigap policies), subsidizes graduate medical education, and offers beneficiaries a prescription drug program. Even nonbeneficiaries receive protection through the Emergency Medical Treatment and Active Labor Act (EMTALA), which prohibits hospitals that are Medicare participants from “dumping” an indigent patient who is critically ill or in active labor. Medicare already is a tool for social change in U.S. health care. No-fault compensation for bad outcomes, a more equitable administrative approach than tort law, should be its next public goal. Physician errors and medical malpractice are matters of public health. Individuals may suffer an injury, but all Americans suffer from the consequences of an unrealistic public expectation of absolute precision and perfection from health care providers, a capricious tort system that awards windfalls haphazardly, and the slow, withering demoralization of our nation’s doctors over recent decades. This is a tragedy of the commons.14 Health care is a national resource, a common good to be shared by all. Recognition of this fundamental principle will improve the relationship between physician and patient, creating a healthier environment for both.

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YOU GET WHAT YOU PAY FOR

Accompanied by his father, a small boy comes reluctantly to see the local dermatologist for the minor management of a few warts on the back of his right hand. For the skin specialist, making the diagnosis is a trivial matter; treating the child, however, proves to be an ordeal. Blood-curdling screams fill the air as each little wart is eradicated with the brief touch of a cotton applicator laden with subzero liquid nitrogen. Kicking and screaming, the boy wiggles and writhes despite the viselike grip of his dad, who has the boy in a paternal full nelson hold, and in disregard of the soothing words of the nurse and secretary who serve as backup. Quickly, the warts are gone. The boy sobs for a moment and assesses the damage. Finding his hand still intact, he leaves the exam room with his father, and he heads for the door marked “Exit” as fast as he can go. His father, though, pauses at the front desk to pay the bill. Seeing his dad stop, wallet in hand, the little boy shouts at the top of his lungs into the crowded waiting room, “Dad, you’re not going to pay for that, are you?”1 There, in a nutshell, the young dermatologic patient had crystallized the key issue at the very heart of the financing of primary care: nobody wants to pay for that. Viewed either as a personal pocketbook issue or on the grand scale of macroeconomics, health care as a percentage of national GDP, having to “pay to be sick” only compounds the misery of illness, adding insult to injury. As a patient, my hard-earned dollars at best may restore my health to its premorbid status, giving me back what I had previously possessed before I became ill, with no net gain for my purchase and no apparent bang for my buck. Surgery, at least, is a tangible good. When LBJ crudely displayed to the press his fresh scar from gall bladder surgery, he was a celebrity endorsing

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a product and he was saying, “Look what I bought.” (More accurately, he was saying to the American taxpayer, “Look what you bought me.”) Primary medical care yields no such scar. We trade in an intangible: a relationship between doctor and patient. We educate and advise, comfort and communicate, diagnose and anticipate, while surgeons do. Policy wonks of health care differentiate between services that are cognitive, such as mine, and those that are technical, such as scopes and biopsies, shunts and stents, pacemakers and prostheses—the daily breadand-butter operations performed by my invasive and interventional colleagues. The “think or do” dichotomy at the heart of health care reimbursement, however, is fundamentally flawed. At first blush, it might seem odd that surgeons would permit their craft to be labeled “noncognitive” by default. I have no doubt that surgeons think before they cut. Yet, if the pay is good, a surgeon will be inclined to let the bureaucrats call his skills technical, rather than thoughtful. As long as the check from Medicare is made out correctly and clears the bank, call it what you will. Why do invasive procedures intuitively carry more weight, and consequently higher remuneration, than do careful consideration, diagnostic acumen, patience, communication, and management of chronic conditions? Surgery has intensity (Bodenheimer 2007, 301). It has drama. As seen on TV, the surgeon brings to the operating table a refined skill set, tireless effort, stubborn determination—”often wrong, but never in doubt”— and, of course, liability as a cost of doing business. Talk, by comparison, is cheap. Over time, though, technical procedures become routine, standardized, and rote. The job gets easier with repetition and refinement. Some years ago I was in need of a hernia repair. I saw a surgeon, a colleague to whom I regularly referred patients and in whom I had much confidence. I asked, “Are you comfortable operating on a professional colleague?” I didn’t want a nervous surgeon. The surgeon scoffed, “Fixing your hernia is, for me, like treating high blood pressure is for you. It’s no big deal.” As it was my hernia, I thought it was a big deal. My insurer must have thought so too, as the reimbursement for the surgery far exceeded what I could collect for evaluating and managing a waiting room full of elderly patients with hypertension, a task deemed of inherent low intensity (Lasker and Marquis 1999, 337). The premium paid for procedures does not go exclusively to surgeons. Among the specialists in internal medicine, there is a stratification of income based on the procedures they perform. Cardiologists are the high priests among physicians. The more invasive the cardiac procedure, the

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more lucrative the yield. Intuitively, this makes sense. The heart is the pump that is central and essential to our being. Romantically, it is the seat of our soul. Those brave fellows who maintain its plumbing—the arterial “rotorooters” who keep the pipes clear—deserve a rate of pay commensurate with the perceived relative value of that organ. Plumbers are well paid. The lowly rheumatologist, endocrinologist, or specialist in rehabilitation medicine, although they each perform an essential clinical service, is nevertheless bereft of a highly technical, gadget-dependent “acuteremunerative” procedure. They form a lower caste in the economic hierarchy of medicine. Procedure poor, they are condemned to relatively lower compensation for their work because they “think” more than they “do.” Making up the lowest echelon are the primary care physicians to the elderly, all of whose patients are beneficiaries of Medicare. The geriatrician’s patients’ needs are met, as they would be for younger and better-insured individuals, but at a markedly reduced federally established rate of pay. The primary physician has no lucrative “wallet biopsy” or “green screen” to offset the low compensation for management of a slow-motion train wreck such as a frail, elderly patient with complex problems, multiple medicines, and absent or dysfunctional family caregiving. Is it any wonder that young physicians-to-be, those on whom an avalanche of nearly geriatric Baby Boomers are counting for care, shun a career in primary medicine and head for the hills of procedure-oriented specialties, where there is gold to be found (Garibaldi, Popkave, and Bylsma 2005, 507; West et al. 2006, 774)? Medical students are told early and often by their professors that, when engaging in any diagnostic evaluation of a patient, they should follow Sutton’s law (Sutton and Linn 2004). Willie Sutton, legendary bank robber of the Great Depression era, supposedly once was asked by a reporter why he robbed banks. “That’s where the money is,” he replied. By invoking Sutton’s law, medical school professors teach students by analogy to select that test or examination that will lead most directly to a diagnosis. The take-home message, though, is more pecuniary than pragmatic. More to Sutton’s point, young doctors are drawn to procedures because that’s where the money is. Primary care is the acknowledged backbone of our nation’s health care system (American College of Physicians 2006b). Yet, its very survival is now in question. The task of providing a high volume of consistently highquality care, day in and day out, over a decades-long career, now seems unachievable (Bodenheimer 2006, 861). The relatively low reimbursement,

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when compared to that of specialists, is further demoralizing,2 leading long-established, productive practitioners of primary care to abandon ship either by “upgrading” to a specialty or by prematurely leaving the practice of medicine altogether (Sox 2006, 57). From a policy perspective, health care strategists pay lip service to primary care, but, in reality, it remains the Rodney Dangerfield of medicine: They don’t get no respect. The health economists at Medicare are well aware of the disparity in income that threatens to erode the once-solid base of primary care. They have addressed this issue before. Prior to 1984, doctors were paid by Medicare on the basis of “usual, customary, or reasonable fees” that prevailed locally. This model of physician payment was utilized by Medicare in its infancy and was adopted originally from the private Blue Shield insurance plans of the 1960s. According to Joseph Newhouse of the Department of Health Policy and Management at Harvard Medical School, “The resulting fee schedule made little sense; individual physicians were paid grossly different amounts for providing identical medical services, with large variations across different geographic areas” (Newhouse 2007, 1883). The paradigm of physician payment shifted in 1984 with the advent of the Medicare Economic Index, a mechanism that attempted to gauge physicians’ costs of practice, or overhead, on an annual basis. This was the first step toward a math-intensive, statistically derived scientifically based system of prospective payment for medical care. The relative difficulty of a case, the cost of practice overhead, and urban versus rural practice setting were all baked into a recipe for physician payment that came to pass in 1989. It was called the resource-based relative value scale(RBRVS) (Hsiao et al. 1988, 2347; Hsiao and Stason 1979, 23), and paying the doctor’s bill would never be the same. A prospective and bundled system of reimbursement to hospitals had already existed since 1983 under the heading of the diagnostic-related group, or DRG. Payment to a hospital for each admission of a patient was determined by a diagnosis or, more often, by a litany of diagnoses that added up to higher income, rather than the flat per diem rate paid for a stay in a hotel. A surgeon billed for an all-inclusive bundled package of care that included a preoperative visit, all postoperative care, and of course the surgery itself, offered like a soup-to-nuts meal on a prix fixe menu. Reimbursement for a physician’s care under RBRVS, unlike that of surgeon’s, remains à la carte. A general internist or a geriatrician, for example, provides discrete services, utilizing an arcane and Byzantine set of billing codes. (There are over seven thousand unique designations for a

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doctor’s work.) According to a current reassessment by Gail Wilensky, a health care economist and an architect and early promoter of RBRVS, “although the scale was intended to correct for a historical undervaluing of primary care and overvaluing of procedures (which it does not appear to have done very successfully) and for larger differences between urban and rural reimbursements than could be justified by differences in the costs of practice, it retained the use of a largely disaggregated fee schedule” (Wilensky 2009, 654). What ensues is a cat-and-mouse game that pits the clever physician against the wily Medicare coder in a duel of creative medical billing.3 Like lumpers versus splitters, insurers seek to bundle services and “downcode,” whereas doctors unbundle and “upcode,” all the while attempting to increase their volume of billable services. This is a bizarre way to pay for health care; it fragments and compartmentalizes care (Kesselheim and Brennan 2005, 855) and fosters quantity over quality in a system that dissatisfies patients, doctors, and taxpayers. The intent of RBRVS was to level the playing field between cognitive medical care and procedural services, giving primary care physicians and geriatricians their due; in reality, RBRVS has had the unintended consequence of hastening the decline of the generalist workforce (Goodson 2007, 2308). The problem is that the spirit of RBRVS conflicts with another congressional directive to Medicare: budget neutrality. Federal dollars apportioned for Medicare are fixed by formula to the rate of growth of the economy, defined as the Medicare sustained growth rate (SGR).4 The sum to be spent on health care for the elderly in any given year is set by government fiat. This approach is analogous to a shopper in a supermarket who fills his shopping cart with food until the bill reaches the exact amount he holds in his wallet. He may tinker with the composition of his diet, skipping the steak and opting for pasta, but he adheres to a strict food budget. When it comes to high-tech health care, however, Americans have a gourmet appetite. We are enthralled with pictures of ourselves. The remarkable explosion in computer-enhanced high-resolution medical imaging such as ultrasound, CT scans, and MRIs fosters anatomical narcissism. Like a young parent with a new camera and a first baby, we cannot stop pressing the shutter button.5 Our love affair with diagnostic imaging has not-so-subtle ramifications for the health of the public. While the budgetary pie for health care is fixed in size, the volume of high-priced high-tech imaging has exploded (Kane 2008, 9). Consequently, far less remains in the budget for traditional services like talking to patients, performing a thorough

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physical examination, and delivering thoughtful, comprehensive, and compassionate primary care. The rules of RBRVS and SGR—medical care today is dictated by acronyms—force a choice between imaging and communicating; when it comes to the cost of health care, a picture is worth a thousand words. This fact has not gone unnoticed by doctors. For a number of reasons, physicians today prefer to practice in groups rather than to go it alone. Group practice affords an economy of scale, greater clout at the negotiating table, and a better lifestyle with collegiality and cross-coverage on nights and weekends. Traditionally, groups were composed of a variety of specialty practitioners as well as a core of generalists who provided primary care and “fed” the specialists with a steady flow of patient referrals for consultations and procedures. The generalists served, in marketing terms, as wraparound loss leaders, not carrying their own weight by income, but nevertheless an essential ingredient of a profitable group practice (Sandy and Schroeder 2003, 262). Today, however, the trend is toward narrow single-specialty medical groups, so-called focused factories (Casalino, Pham, and Bazzoli 2004, 82), that invest heavily in high-tech outpatient imaging that is certain to be overutilized (Hillman, Pauly, and Kerstein 1989, 86; Mitchell 1995, 263). A money loser, the anachronistic practitioner of primary care is consequently marginalized. Nevertheless, the service provided by the generalist is essential to the smooth functioning of the entire health care industry, not to mention her contribution to the health and safety of the patient. Consider the older patient who is in need of a specialty surgical procedure. Before the surgeon will agree to operate, he will request a preoperative medical consultation to be performed by the patient’s primary care physician, the one doctor who knows the patient best. This entails a thorough history and physical examination done no more than seven days prior to the surgery. Surgeons often refer to the process as obtaining “medical clearance,” like an airplane being cleared for takeoff by the air-traffic controller. In reality, the pre-op medical exam is an opportunity to review thoroughly a patient’s overall current health status and assess the relative risk of a serious complication. Preoperative medical consultation is not meant to be a blessing, a guarantee, or a legal defense against a claim of malpractice. It is the thinking that precedes the doing. Consider this scenario: a seventy-two-year-old man with blurred vision due to dense cataracts in each eye. His eye surgeon refers him to me, his primary physician, for medical “clearance” for surgery. The man dutifully

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arrives in my office, not quite sure why this additional medical encounter is required. He just wants to be able to read and see the TV more clearly. We begin with a conversation. I obtain an update on how he is faring with several chronic conditions, and I confirm his current list of medications, allergies, and past surgeries. I note any relevant family history of disease, his lifestyle habits, and the social situation at home. I find, on careful questioning, that the man has been experiencing “blinding” headaches for six months that he has not mentioned to the ophthalmologist. I perform a headto-toe examination that reveals a new subtle heart murmur, probably indicative of the gradual narrowing of a cardiac valve by the corrosion that comes with age. This man cannot be “cleared” for surgery. I first must obtain a CT scan of his brain to evaluate his headaches and to exclude the presence of a brain tumor or life-threatening aneurysm. His murmur needs to be investigated as well. I request that he undergo an echocardiogram (an ultrasonic imaging of the heart and its valves) to exclude a critically narrowed aortic valve, a problem that might preclude elective eye surgery and that would require immediate attention. Pending the results of the two imaging studies, I postpone the cataract surgery. The echocardiogram is done in the local cardiologist’s office and is performed by a technician. The taped images are later reviewed by the cardiologist, who watches a video monitor for approximately fifteen minutes in privacy and who dictates a report to me, the referring physician. It is then my duty to disseminate the results of the echocardiogram to the patient and family, often two separate, sequential conversations. The test shows the presence of mild calcific aortic stenosis (minimal narrowing of the aortic valve from calcium buildup that has accumulated with age), but this poses no significant problem for the man. The cardiologist recommends that the echocardiogram be repeated annually. The CT scan of the patient’s brain is performed by an X-ray technician and is reviewed by a radiologist, alone in the dark, who takes perhaps ten minutes to read the X-rays on a computer screen and dictate a report. Fortunately, the CT shows no tumor or aneurysm, but it does reveal incidental generalized atrophy (shrinkage) of the brain, commensurate with advanced age. The CT report comes to me, the translator who interfaces between the specialist and the patient and family. I call the patient to explain his test results. I prefer to explain a cardiac abnormality in person with the aid of a detachable plastic model of the heart in hand. However, I give it my best shot over the phone and without props.

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“There is a thin layer of calcium buildup, like egg shells, inside a valve in your heart, but it’s not a real problem at this point.” He takes this well. “The CT scan shows no tumor or aneurysm. (The headaches therefore are probably due to tension or perhaps arthritis of the neck.) That’s very good news. The scan shows only some shrinkage of your brain.” The man becomes distraught and inconsolable. What do you mean my brain is shrinking? Is it Alzheimer’s, doc? How long do I have? My daughter will want to discuss this with you. I’ll have her call you tonight after she gets home from work.” At great length, and with carefully measured words, I explain that atrophy is a common finding on any CT scan of a geriatric brain. I comfort and reassure the man, all the while thinking to myself that I wouldn’t want a shrunken brain either. I reschedule his eye surgery. The total elapsed time for the consultation, ordering and reviewing the tests, dictating a final report, and conducting lengthy follow-up conversations with the patient and family: two hours. Now, let’s do the math. The charge to Medicare for an echocardiogram is $430, of which they pay $243.56. The charge for the CT scan is $825.25, of which the reimbursed amount is $299.03. The accepted charge for the preoperative consultation and exam done by the primary care physician is $344, of which only $175.48 will be paid. (Balances are written off as uncollectible for physicians participating in Medicare.)6 Reimbursement for coordination of care and for communication of test results and their significance: $0. The efforts of the primary care physician are the least well reimbursed yet the most labor intensive. Those services, while invaluable to the patient, are not “where the money is.” The function of the primary care physician, more so now in the age of technological medicine than ever before, is that of communicator. Patients expect rapid access to information and to their doctor. Availability is the one characteristic that virtually guarantees a doctor’s success as a generalist, even if he is otherwise quite inadequate.7 It has not always been so. The adoption of the telephone in the home in the 1870s created a new expectation that the doctor could be reached at any moment and at any hour if a question or problem arose. Drug stores served as the early answering services for physicians. According to the medical historian Paul Starr, the telephone soon surpassed the stethoscope as the physician’s chief tool of trade (Starr 1982, 69–70). With the benefits of instant access came the pitfalls of telephone medicine, which included 1) misdiagnosis due to an absence of visual observation and physical examination, 2) improper prescribing, and 3) poor documentation of calls and their consequences. It

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is difficult to assess the relative quality of telephone medicine compared to a traditional visit to the doctor’s office (Farber, Siu, and Bloom 2007, 693). However, non–face-to-face interaction, time spent on the telephone between a geriatrician and her patients, does add a calculated 7.8 hours of clinical work per week to the doctor’s already busy schedule (Hallam 1989, 47). Nevertheless, technology forges ahead. Beepers, and later cell phones and BlackBerries, have seemed to give the modern physician wireless mobility; in reality, however, the doctor is more tethered than ever. The professional service of physician availability, anywhere and anytime (now called “24/7”), is not reimbursable by Medicare or by the private insurers. While it is customary that your attorney may bill you for a phone call, your doctor may not. Like an unfunded mandate from Congress, patients expect and have come to depend on rapid, reliable access to their primary care physician. But they do not expect to pay for it. Perpetually evolving forms of electronic communication increase the expectation for physician access and further widen the disparity between the obligations of the primary doctor as communicator and his rate of pay. Performing elective procedures is a nine-to-five line of work; making phone calls is not. Furthermore, the telephone is a synchronous form of communication in which both parties to the call must be awake and conversant. No more than one call can be handled at a time. E-mail, however, is asynchronous and unbounded. E-mail messages are qualitatively quite different from conventional forms of physician-patient dialogue (Delbanco and Sands 2004, 1705). The patient who suffers from insomnia composes an e-mail to his doctor at 3 a.m. and is disgruntled when the reply is not in his in-box by 5 a.m. The extraordinary expectation of superhuman immediacy in the information age, coupled with the demand that such service be provided gratis, may hasten the demise of primary care. Ours is not a business that lends itself well to modern concepts like “outsourcing” and 24/7 free “customer support.” Will new media such as Skype, Facebook, Twitter, or whatever else the near future holds transform the practice of primary care? It must. It is hard to just say no to new technology, whether for good or ill. Google now offers patients unprecedented access to medical information, albeit sometimes unfiltered, nonrefereed, and misapplied to a particular individual’s case. Today doctors practice in an era of knowledgeable and sophisticated patients for whom medical information has been disseminated and democratized. No database or information portal, however, will replace a personal, private conversation between doctor and patient. Regardless of what technology comes along next, we must acknowledge

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that physician-patient communication, in any format, is work worthy of fair compensation. The practice of primary care medicine is under siege. Its practitioners are beleaguered by ever-increasing patient volume and the relentless demand for physician access. They feel squeezed by decades of steeply rising overhead and stagnant Medicare reimbursement. Young physicians, fresh out of medical school, avoid residency training in primary care as they observe its older practitioners burning out, demoralized, and disillusioned. The final nail in the coffin for primary care is a pay-scale structure that relegates it a distant second choice to specialty care. Geriatricians and primary care providers to the elderly, in particular, are a breed in jeopardy. The longtime absence of a coherent health policy that promotes and nourishes the growth of primary care creates a vacuum in which market forces will unleash upheaval. Disruptive innovation, as explained by Christensen, Bohmer, and Kenagy in the Harvard Business Review (2000, 102), will fill the void and find a new way to meet the needs of health care consumers. They focus on the substitution of lower-paid, less extensively trained nurse practitioners and physician’s assistants, sometimes called physician extenders, to perform many of the routine and uncomplicated tasks of primary care, leaving the complex or puzzling cases to the MD. Indeed, this trend is already established and has gained general acceptance. We need physician extenders. I fear, however, a more sinister side to the new entrepreneurial model that Christensen and colleagues anticipate: a stratification of primary medical care by economic niche (20). The particular primary care “package” a patient receives will be tied to her level of income or personal net worth. A spectrum of care will arise, like the old line of cars by General Motors that ranged from the workingman’s Chevy to the very symbol of personal prosperity, the Cadillac. The primary care provider of tomorrow will not resemble even remotely the avuncular but fictional Dr. Marcus Welby of yesterday. This will be big business. The future is already here. At the premium end of the market is “luxury primary care” (Brennan 2002, 1165). The well-heeled patient commands attention—the rich are different. As Tom Lehrer once sneered between satirical songs, there are now doctors who “specialize in diseases of the rich.” Practitioners of so-called concierge medicine opt out of Medicare participation, with its deeply discounted fee schedule, and instead offer extensive primary medical service to those select patients who can afford the high price tag that comes in the form of a hefty annual fee. “Boutique”

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physicians (Zuger 2005) are at the beck and call of their patrons, offering immediate appointments, an unlimited calling plan of 24/7 availability by telephone, and even a promise to accompany a pampered patient personally on a visit to see a specialist. The era of the designer doctor is upon us. This is primary care flaunted as fashion statement. It is no different from appearing in public with an overbred miniature dog perched in a designer handbag. The emergence of luxury medical care and the boutique physician is an entrepreneurial response to a market need. This is what the market dictates and what it will bear. It is, for better or worse, disruptive innovation at work. Clearly, the upscale health care consumer perceives the doctor’s immediate availability and personal attention as a luxury. For the physician, however, it is luxurious as well. The concierge physician is freed of the burden of seeing twenty-five to thirty patients per day, all shoe-horned into a packed waiting room, while he is perpetually harried by too many people with too many demands, too many forms to complete, and too little time in which to do a proper, thorough, and satisfying job. Like beating your head against a wall, it feels so good when you stop. That is a luxury. There are, to be sure, significant ethical concerns inherent in luxury primary care. There is the matter of resource allocation. Like food in a famine, primary care is already a maldistributed national resource. Inner-city communities, remote or rural areas, and Indian reservations go underserved, while, in a prosperous suburb or a retirement destination, the phone book’s Yellow Pages are thick with physicians’ listings. American medicine deserves a failing grade for the inequitable distribution of its services. Should we express outrage that concierge doctors are “skimming,” as they are indeed? While boutique medicine certainly is “picking the lowhanging fruit,” there is nothing illegal in catering to a wealthy clientele. Private schools for the scions of the aristocracy and high-end jewelers who display their wares privately and by appointment only are meeting the needs of a niche market. They are well within their rights to do so. Medicine, though, is by nature different. We must answer to a higher authority: the social good. Our present patchwork system of health insurance necessitates subsidy by cross-coverage. Patients with good private insurance, few medical problems, and a healthy lifestyle subsidize those with advanced age, multiple ailments, piles of pills, and poor physician reimbursement under Medicare. I need to see a steady stream of well-insured, working, younger patients—they pay the rent and keep the lights on at the office—to permit me to offer my services to the elderly. Under Medicare’s schedule of

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payment for primary care, an older patient today is what Dr. Martin Arrowsmith, Sinclair Lewis’s fictional physician of the early 1920s, would have called a “charity case.”8 The glaring ethical problem with luxury medicine is that personalized care, a physician’s availability and enthusiasm, patient advocacy, and the solid foundation of a physician-patient relationship are now deemed a luxury and not an obtainable service for a citizen of average means. Like the gradual dumbing down of curricula in our schools, there has been a subtle, gradual decline in expectations regarding primary medicine for the general public. An elderly patient is no longer shocked to learn that a physician chooses to restrict his practice by declining new patients who are Medicare “beneficiaries.” Patients come to accept that an office visit lasts no more than ten minutes and that not all their health concerns can be addressed. Like chocolate bars that seem to shrink a little bit more each Halloween, the standards of good primary care contract slowly and subtly. Substandard physician-patient exchanges become the new standard, and what was once the norm becomes deluxe.9 How will the other half receive health care? Again, in the absence of a public policy that encourages physicians to take up primary care, entrepreneurship in retail and the economics of creative destruction will find a new way. Employing the principles of draconian cost containment, convenience of time and place, and transparent “everyday low-prices,” Walmart has added an aisle for the dispensing of primary care medicine at deep discount (Sage 2007, 503). Large pharmacy chains and other big-box retailers are sure to soon follow. The niche product that Walmart offers is the immediate and affordable treatment of an array of acute, self-limited illnesses that are self-evident to the shopper, formerly known as the patient: strep throat, sinusitis, or a sprained ankle, for example, as selected from a large illuminated menu reminiscent of McDonald’s. It is not Walmart’s intention to offer cardiac catheterization in Aisle 3, nestled between housewares and sporting goods. That is not the target niche. Nor is this an attempt to unload substandard or low-quality care like day-old donuts. Ubiquitous retail clinics will be staffed by competent nurse practitioners and physician’s assistants, who, though paid substantially less than an MD, are highly skilled at the diagnosis and treatment of common but sporadic ailments. This is a consumer-driven model of care for acute illness, more like putting out the occasional small fire than sustaining a conventional, comprehensive, and continuous relationship between a patient and a provider of health care.

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Will the disruptive innovation of the retail clinic ultimately capture the broader market for comprehensive primary care? Will it dislodge the doctor altogether? It is possible, but not likely. Big-box retail clinics face a practical problem: they generally lack space for private rooms, toilets, and sinks, making disrobing and fluid collection problematic, a matter of “plumbing and privacy” (Scott 2006). More important, retail managers quickly will come upon the same stumbling block that trips the internist and the geriatrician: complicated, time-consuming cases at low rates of reimbursement. The fast-food model of service meets its nemesis when it greets its first customer who is eighty-nine, has a litany of medical complaints, lacks adequate social support, and has more than a touch of forgetfulness. Walmart will be quick to tell that customer, “You really need to see a doctor.” Treating a patient for a sore throat is not comprehensive primary care, and medicine, arguably, is not fast food (Schell 2006). The patient who pays full fare and has a quick and uncomplicated problem like a back strain or a touch of gout, while not the medical equivalent of a Big Mac with fries, is essential to the current business model of a physician’s practice (Bohmer 2007, 756). Strip away that element of the business, along with the members of the upper crust who jump ship for concierge care, and the traditional provider of adult primary care or geriatrics can start to pack his doctor’s bag. He retains only a vast sea of money-losing older patients, all in need of complicated and comprehensive counseling and care at low-budget Medicare rates. At current prices, and with the loss of the easy-case subsidy, the geriatrician will not be able to make it up in volume. There will be no safety net for older Boomers, soon to be caught in the middle. While luxury medicine, delivered by an attentive concierge physician to the well heeled, is hardly egalitarian, it does adhere to the tenets of good primary care: communication, compassion, continuity, and care that is comprehensive and coordinated. This is good doctoring, albeit only for the fortunate few.10 Walmartization of medicine, on the other hand, is insidious. A big-box retail clinic is a corporate liquidator, teasing out profitable healthprovider services like treatment of a sore throat or administration of a vaccine. Such “clinics” strip primary care of its viable component assets and discard those services that are not profitable, such as the care of complex patients with multiple chronic illnesses. Their business plan maximizes return on shareholders’ equity but is highly detrimental to the survival of primary care and to the prospect of any reorganized overall national health care plan. No physician endures the rigors and costs of prolonged medical education with the goal of one day becoming a loss leader.

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Complexity is a relative term. As such, it is remarkably difficult to quantify. RBRVS, Medicare’s relative value scale, was a well-intentioned but failed attempt in the 1980s to do just that. Yet, it is still with us. Under RBRVS, a physician-patient encounter is graded on a numerical score based on the complexity of the case ( Jensen 2005, 52). Minimally complex decision making entails one self-limited minor problem such as a cold or an insect bite. That sounds easy. Low-intensity care requires a bit more “cognitive labor” and carries commensurate risk, thus it deserves a higher rate of pay. Two or more self-limited problems or one stable chronic illness makes the grade. Moderate complexity is justified if there are one or more chronic illnesses, an undiagnosed new problem, or one acute complicated injury such as head trauma; but who’s keeping score? As in the game of Scrabble, the physician-player tallies his total, noting any extra credit as he would for using uncommon letters or for well-placed words of doubled or tripled value, and he submits his bill to Medicare. The board game metaphor of physician reimbursement is bizarre but accurate. RBRVS is fundamentally flawed because it defines and measures complexity as a property of an illness or illnesses, rather than as a particular trait of a patient. The complex patient, from the standpoint of physician payment, is the one who is unusually demanding or difficult to deal with, not necessarily the one who is seriously or multiply ill. Physicians are well trained and adept at diagnosis and disease management; we are not particularly good handlers of those people who require extraordinary amounts of our time: the demented, slow, hearing impaired, inadequate, lonely, anxious, neurotic or obsessive-compulsive, and the depressed or disconsolate. All require and indeed demand extra time with the doctor. However, the primary care physician, like any other service provider, is the proprietor of a business. Even the most altruistic, compassionate, and understanding doctor has an office to run and bills to pay. Time is money. How shall we compensate the practitioner of primary care for an intangible, a strong and enduring relationship and the willingness to take the extra time to listen to a patient? Unlike a colonoscopy, a catheterization, or a liver biopsy, a service that is ill-defined, difficult to quantify, and nebulous is remarkably difficult to price. Patients desire good primary care, even if they cannot describe accurately what it entails (Green et al. 2004). We may appreciate the value of a good primary physician’s care, but we are not able or willing to establish a fair market price for the service; we just don’t want to pay for that. We focus on the tangible components of health care. That which is directly measurable is worthy of compensation, as though we pay for it by

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the pound. An ounce of prevention is worth a pound of cure. But is it? We really don’t know (Cohen, Neumann, and Weinstein 2008, 661). We do know, however, that there is a significant regional variation in the cost of health care throughout the United States. Why should management of a heart attack in Cleveland cost substantially less than treatment of the same ailment in Los Angeles? Medicare, as well as third-party insurers, seek to be smarter shoppers. For the government, accustomed to procurement of goods and services by awarding contracts to the lowest bidder, a large regional variability of health care costs doesn’t sit well. It is an unaccountable finding somewhere on a federal accountant’s spreadsheet. For insurance executives, it is an anomaly that holds the allure of cost containment, or “found money.” The alliterative term for physician reimbursement commensurate with clinical outcome is pay for performance, or P4P (Fisher 2006, 1845). From Medicare’s perspective, or a private insurer’s, what exactly does a dollar’s worth of health care buy, and are they getting what they pay for? Is quality primary care delivered uniformly, efficiently, and at lowest cost across the country? A prudent purchaser needs to know. How does P4P measure good primary care provided to frail and elderly patients with multiple chronic illnesses? Insurers do so by demanding rigid adherence to strict clinical guidelines, by incorrectly attributing health outcomes to the primary physician when a cadre of specialists plays a role in care, and by breaking down complicated, comprehensive, and relational patient care into the sum of its parts, a checklist form of care that resembles more an automobile maintenance schedule than a personal dialogue and working relationship between doctor and patient. This is primary care as defined by committee. Clinical practice guidelines distill good primary care into quantifiable bite-sized units. Did the patient receive a pneumonia vaccine? Did the doctor do a blood test, called a Hemoglobin A1C, to confirm proper control of diabetes? Did she tell the patient to stop smoking and to start getting some exercise? I cannot deny that, taken individually, these are all important questions. Yet, good primary care is more than simply the sum of its parts. Lost in the translation, or the deconstruction, is the essence of the physician-patient relationship, the je ne sais quoi of medicine that defies quantifiable measure and that rates one practitioner over another, even when both have “checked all the boxes.” An elderly patient is well aware that her doctor either “has it,” or not. However, our rudimentary methodology of measurement, focused strictly on the technical, is not sufficiently sensitive to detect those subtle nuances of sentient and sustained doctoring. How do we pay for that under P4P?

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We do not. Clinical practice guidelines, applied as a carrot-and-stick means to alter physician behavior, are the reductio ad absurdum of cost containment in health care. Like the cubists, Braque or Picasso, they fragment the portrait of the patient into a clutter of misaligned component boxes that barely resemble the fully intact subject. In a study published in the Journal of the American Medical Association (2005, 716), Cynthia Boyd and her associates examined the care that would be rendered to a hypothetical seventy-nine-year-old woman with chronic emphysema, adultonset diabetes, osteoporosis, hypertension, and arthritis if existing clinical practice guidelines were applied. Their faux patient, at least on paper, is illustrative of a typical geriatric patient with multiple medical matters. Highly atypical, however, is the investigators’ intentional exclusion of confounding neuro-psychiatric diagnoses like depression or dementia, which, in reality, complicate so many geriatric cases. Rather, the authors simply applied existing narrow practice guidelines to each isolated component, or “box,” of the woman’s care, a contrived hypothetical that bears no remote resemblance to reality. Were they to have placed under the microscope of their study a genuine older lady, forgetful, perhaps a little paranoid, still driving though she cannot see over the steering wheel, and repeatedly refusing a much-needed move to assisted care, they would have demonstrated that clinical practice guidelines are far too crude to reflect the real duties and challenges of geriatric primary care. Under the clinical practice guidelines, the poor woman, were she real, would have received prescriptions for twelve different medications at a computed cost of $406 per month and at great risk of a medication error, a drug side effect, or, more likely, noncompliance. This study highlights the fallacy and impracticality of the application of rigid one-size-fits-all clinical regimens to very complicated older patients: garbage in, garbage out. Clinical guidelines have no context; they are based on the analysis of single ailments considered in isolation and examined in nongeriatric uncomplicated cases. Real medical care of the elderly is far murkier. Clinical practice guidelines distort the picture of good primary care, paradoxically promoting quantity over quality. As a measuring stick for physicians’ remuneration under P4P, rigid guidelines are misguided. Despite the clumsiness of cookie-cutter protocols as a grading template, P4P nevertheless retains a certain appeal among those who write the checks for health care. Medicare already has begun implementing elements of P4P reimbursement for care of hospital inpatients, and the concept will be extended to outpatient services. It will be coming soon to a doctor’s office near you. P4P has its proponents. The Leapfrog Group (Hospital Rewards

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Program 2009), a private consortium of employers and industry leaders, strives to increase health care purchasing power and achieve high customer value—they want to “get what they pay for”—while also achieving great leaps in patient safety and quality of care. Nobody would argue against greater patient safety or better outcomes, but the evidence supporting P4P as a new and improved form of reimbursement for primary care is exiguous at best. Payment reform for primary care, though, is an issue critical to the success of any new and sweeping health care reform; we must get it right. The supply of current and future primary physicians is dwindling. An ill-conceived payment reform, the wrong medicine at the wrong time, will make matters worse, hastening the demise of the practice of primary care. A look at the experience with P4P contracts in Massachusetts is instructive. A study published in Health Affairs by Steven Pearson and colleagues examined the impact on quality of P4P reimbursement plans introduced into physician group contracts in Massachusetts from 2001 to 2003 (2008, 1167). Quality criteria were derived from the Health Plan Employer Data and Information Set (HEDIS), designed by the National Committee for Quality Assurance (HEDIS and quality measurement 2009). HEDIS criteria include, for example, targets of care such as breast and cervical cancer screening for women, proper dispensing of asthma medication as they define it, comprehensive diabetes care, and cholesterol screening. The study excluded physicians in solo practice or two-physician groups, due to small patient sample sizes and confusion in determining a group affiliation for coding purposes. This leaves a somewhat arbitrarily constricted view of primary care in Massachusetts. Nevertheless, the findings of Pearson and colleagues do not lend credence to the argument for P4P. During the study period there was an across-the-board improvement in quality of care in Massachusetts as measured under HEDIS, regardless of mode of physician payment, conventional fee-for-service or P4P. That improvement, while welcomed, remains unexplained. Perhaps, awareness of an ongoing quality study alerted doctors in the Bay State that they were being watched and that they should get their act together and take better care of their patients. That seems unlikely. More plausibly, well-informed patients, steadily gaining a sophistication that comes with unprecedented access to medical information, demanded and received better care. Performance, as it is narrowly defined, improved because patients demanded that it do so, not because of P4P. Crucial to the impact of any financial incentive for physician reimbursement is the magnitude of any bonus or penalty. How sweet is the carrot

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and how big is the stick? In the Massachusetts study the incentive did not exceed two thousand dollars per physician. That is a pretax figure; a doctor practicing in a high-tax state such as Massachusetts might receive no more than one thousand dollars after taxes as reward for a major effort at documentation of compliance with established protocols and laborious data entry. In other words, P4P in Massachusetts had no “teeth.” The stakes were too low. If P4P for primary care is to succeed here in the United States, we should examine the efforts of the National Health Service in the United Kingdom. In 2004 the NHS initiated a P4P program for reimbursement of family practitioners. A review of results in the UK published by Doran and associates in the New England Journal of Medicine examined achievement of clinical quality indicators, similar in concept to HEDIS (2006, 375). They graded practitioners on performance by automated clinical data entry from over eight thousand medical practices in England. The British added one intriguing factor: real money. Typical salaries for family practitioners ranged from ₤70,000 to ₤75,000 ($122,000 to $131,000). The P4P incentive bonus increased the average gross income of a family practitioner by ₤23,000 ($40,200), or approximately 32 percent of base pay. Now, that’s a carrot. As the authors of the study noted, “The UK program was costly and was funded with substantial additional monies rather than by restructuring existing payment systems.” This was no zero-sum game like Medicare’s SGR here in the United States. The British correctly recognized that a budget-neutral payment reform would gain no traction with primary care physicians, many of whom would incur extra financial burdens of implementation of the information technology needed to monitor their performance. Did the British “get what they paid for”? The answer, as with so many matters of health care policy, depends on how we pose the question. Well-paid family practitioners under P4P in the United Kingdom achieved generally high marks for achieving selected clinical criteria: diabetic monitoring, cholesterol screening, and vaccination against influenza. However, quality of care also correlated with the status of the patient. Quality suffered among patients who lived in a single-parent or low-income household or who were sixty-five or older. Low socioeconomic status is a powerful predictor of poor health, as was demonstrated dramatically in the Whitehall study, also from the United Kingdom (Brunner and Marmot 2006). P4P won’t fix that. Most crippling to the validity of the UK’s P4P experience is the fact that physicians were permitted to declare an exception for any patient, typically the chronically ill and elderly, deemed by their doctors to be too

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complicated and labor-intensive to fit the rigid mold of the study. British family practitioners quickly learned to “game” the system. They invoked an escape clause by declaring exceptions. Doran and associates (2006) concluded their discussion of the UK experience: “Whatever the case, financial incentives should be aligned to physicians’ professional values to avoid serious distortions of care.” In other words, formulaic practice guidelines under P4P, even if better compensated, are all well and good until someone comes along who is old, time-intensive, or falls outside the box of rigid “quantized care.” That is when P4P defaults and we must defer to the doctor. There is no doubt that, if adopted universally, P4P will have unintended consequences, as do all modifications of public policy. The rules will change. An efficient market will achieve a new equilibrium. Somebody will suffer. Those patients at the top of the socioeconomic ladder will fare well. Medically sophisticated and motivated to stay well, they will enjoy healthier and longer lives than those on the bottom rung. If I am to be paid for performance, as measured by clinical results, then I will be compelled to avoid treating those who are sick and poor, socially predestined for a bad outcome. The sick will get sicker under P4P. Consider, if you will, my former patient from years ago, Mrs. K. Mrs. K was in her late fifties with a long history of poorly controlled diabetes complicated by severe obesity and poverty that qualified her for benefits that included disability income under Social Security and health coverage under Medicare and Medicaid. She was under my care back in the early 1980s, long predating the current epidemic of morbid obesity and the consequent prevalence of adult-onset diabetes. She was ahead of her time. I admitted Mrs. K to the hospital when her blood sugar topped 500 (normal < 105) and she began to suffer from the blurred vision, excessive thirst, and frequent urination indicative of diabetes seriously out of control. She was placed on a strict proper diet and was attended by a dedicated but perplexed young nutritionist who measured every mouthful and carefully counted calories. Nurses poked Mrs. K’s fingers round-the-clock, measuring blood sugar levels, as I prescribed steadily rising doses of injected insulin, all to no avail. We were all committed to the cause: doctor, patient, nurses, and nutritionist. Yet, despite our valiant effort, Mrs. K’s sky-high blood sugar would not yield. It was not until I heard from an unlikely member of the health care team that Mrs. K’s case was cracked. I received a phone call from one of the janitors at the hospital. Sweeping the floor in Mrs. K’s room that morning, he discovered, beneath Mrs. K’s

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hospital bed, two large boxes of partially eaten glazed donuts. He wondered if this information might be helpful in her care. It was indeed. The donuts were seized, as were a large block of cheese and other perishables found perched on the outside window ledge, chilling for later consumption. Mrs. K’s blood sugar rapidly improved and her symptoms subsided. For the moment, under “house arrest” and subject to search, Mrs. K was healthier and all was right with the world. That was twenty-five years ago. Medicare and Medicaid paid me to take care of Mrs. K, and I billed them for daily hospital visits on a fee-forservice basis. Noncompliance with a diabetic diet and the concealment of contraband foods, while frustrating, were not a pocketbook issue for me. Today, however, P4P assumes that I and Mrs. K are members of a team, each shooting for a common goal: improvement of her blood sugar and her health. Like a college football coach, my income under P4P depends on the number of games we win. I had better choose my team members very carefully.11 Mrs. K would be no physician’s first-draft pick. Her heart was not in the game. Patient noncompliance, in one form or another, is ubiquitous in primary care. A man may feign weakness or forget medication to enjoy the secondary gain of a daughter’s close attention, a disability check, or a handicapped-parking sticker. That will come out of my pocket. Poor people do poorly; they will be the last players picked for the team, as I was for all sports through junior high school. P4P will, by economic necessity, limit access to care for some and foster skimming of those patients likely to do well and avoiding the “losers.” P4P is a social experiment in the making (Epstein 2007, 515). We do not yet know the outcome of our tinkering, but the odds are that the impoverished, the complicated, the noncompliant, and those disenfranchised by bad health habits, poor protoplasm, or complex psychosocial twists and turns will suffer the consequences. The “team” will be forced to leave them behind. If not P4P, then by what yardstick shall we measure and reimburse primary care of the complex elderly patient? Coordination of care is a worthy goal (Bodenheimer 2007, 730). Geriatric patients with multiple ailments are adrift in a sea of specialists, hospitals, pharmacies, therapists, and local agencies. Nobody seems to be running the show. It seems logical that the primary care physician, the one professional who best knows the patient, should be crowned as clinical coordinator, the doctor who will ride herd. Conceived as a sort of human router, the primary care physician’s reimbursable role expands to include much of what she already does for free: steering patients through the labyrinth of modern medicine, comforting,

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collaborating, and smoothing the way as patients navigate toward comprehensive, continuous, and compassionate care. Were we to determine a fair rate of pay for such a service and then post the job on Craigslist—call it “pay for coordination”—we might be disappointed with the physician response to the ad. Medical schools do not teach subjects like management or human resources. Under managed care, nurses and nurse practitioners—who were taught a more holistic approach to care than physicians were—hoped to achieve the role of care coordinator, but few have the time actually to do much coordinating. Institutions don’t budget for care coordination, and busy NPs aren’t reimbursed for that service. Coordinated care demands adequate time and reimbursement, regardless of who performs the task. Perhaps we need a new nonphysician middleman, the case manager or patient advocate. Broadly trained in social work, gerontology, management, and information technology, a new cadre of health specialists would coordinate consults, relay information, accompany patients on visits, and carefully chart the cumulative care, status, and progress of the older patient. At non-MD fees, the care coordinator approximates concierge care without the luxury price tag. In fact, one of the appeals of the medical home, a patient-centered, multifaceted source of personal primary health care (Rosenthal 2008, 427), is that it incorporates a care team that includes a case manager. Recently, a new term was coined in the measure of physician performance: “connectedness.” In a study by Steven Atlas and colleagues (2009, 325) they defined the word as “the closeness of the relationship between a patient and an individual physician on the basis of a model indicating how likely a physician is to identify a patient as ’my patient’.” The authors hypothesized that patients with a strong physician-patient relationship, or “connectedness,” would fare better and enjoy a higher quality of health than those who are unconnected. Indeed, they found that “patients without a close relationship with a specific physician were less likely to complete recommended testing for preventative and chronic illness care.”12 It is good to be connected. At last we have come to the heart of the matter of physician payment reform for primary care: it is all about a relationship. Just as our eyes register only visible light but fail to detect the longer and shorter wavelengths of the spectrum, P4P and pay for connectedness (P4C) measure only a narrow band of primary care. The full spectrum encompasses a physicianpatient relationship and is not amenable to the metrics currently employed in the study of health care economics.

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The time has come for pay for connectedness. Having defined only recently this new term, we do not yet know whether doctors can be motivated or taught to connect with their patients. It seems likely, however, that a revised reimbursement model for primary care of the elderly, if it incorporates P4C, will remunerate doctors more fairly, enhance patient access to primary physicians, foster a relationship, and lead to a higher satisfaction and quality of health for the elderly. The relationship between a patient and a personal physician finally has been acknowledged to have real value (Bindman 2009, 351). Pay for connectedness is pay for performance (P4C = P4P). Many years ago, a tiny wisp of a young woman arrived in my office for a checkup. She felt fine when she came in. She had no complaints, and I could find no physical abnormalities. Before she dressed to go, the nurse drew a few tubes of blood with one needle and administered a tetanus booster by a poke in the arm with another. Although terribly squeamish about needles, she bravely endured the jabs and made way for my secretary’s desk to pay her bill, not indicating that she felt lightheaded and “fuzzy.” The thin, now ashen-grey woman stepped up to the payment window, took a look at the charge for medical services rendered, and at that moment slumped in a dramatic swoon. The kind man standing behind her grabbed the young lady as she toppled and lowered her gracefully to the floor, whereupon he stood and said to the secretary, “That must have been some bill!” It wasn’t. Now, decades later, as that same woman and 78 million others in her Baby Boom cohort reach old age and Medicare, the collective doctor’s bill truly is cause to faint. Staggering health care costs for the elderly, for the next two to three decades, are inevitable and inexorable as the Boomers transit their golden years like a rat through a snake. This is the delayed culmination of a demographic event that occurred sixty-five years ago: World War II GIs returned from Europe and the Pacific and immediately started families, making babies at a high rate of production. No adoption of modern electronic medical records, pontification by government economists and efficiency experts, or smoke-and-mirrors models of physician payment reform can undo what has been done. The bill for the Boomers is due. Properly compensated primary care physicians are the key to a rational and successful formula for care of a geriatric Baby Boom. If primary care doctors are well paid and well respected in their profession, the field will attract and retain highly qualified, compassionate, and caring young doctors. If you pay them, they will come. However, we must reprioritize and

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flip the medical totem pole on its head to “get what we pay for” in health care. Primary care is principal care (Showstack, Rothman, and Hassmiller 2003, 242), but are we willing to pay for it as though our lives depended on it? Time spent with my doctor, with whom I feel a personal connection, warmth of character and confidence, a sense of security, and a homelike comfort should remain the cornerstone of care in this century, as it was in the past. We must be prepared to pay for that.

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EPILOGUE

The year: 2030. Twenty years have elapsed since former president Barack Obama’s speech to Congress in which he vowed, alas unsuccessfully, to be the last American president to take up the cause of health care for all, a political tradition inaugurated by Teddy Roosevelt a full century before.1 For the Obama administration, addressing health care meant tackling health insurance. They grappled with a well-entrenched private insurance industry, recalcitrant Republicans who championed laissez-fare and the status quo, and righteous liberals who demanded universal coverage as a national moral imperative. They confronted physicians who bristled when chastised for achieving less-than-stellar outcomes for astronomical fees. It was a time of much rancor, a “great disturbance in the force” of U.S. domestic policy. Here, from a vantage point two decades hence, I can look back and reflect on the evolution of the practice of medicine. Twenty-three years have passed since I last hung a stethoscope around my neck and called myself “doctor.” It is nearly a quarter of a century since I last practiced my craft, performing a physical examination, delivering a difficult diagnosis, or pronouncing a man dead. Now, like 350 million other Americans, I experience health care from the other end of the stethoscope; I am a customer, a consumer, a patient. A good relationship between me and my primary care physician, still very much in demand but hard to come by, is a personal need, yet universal. To be sure, there were technical improvements in the delivery of health care that came to pass in the first two decades of the twenty-first century. The electronic medical record indeed became the lingua franca of medicine. It suffered a rocky start and an initially less-than-lukewarm physician

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reception. The early software and hardware compatibility problems, rivaling the nonuniform track gauge of early nineteenth century railroads, finally were ironed out. Plagued early on by clumsy, counterintuitive, and user-unfriendly systems, the computer ultimately evolved to find its place in the practice of medicine, as an intuitive and enabling physician’s assistant. It no longer required an information technologist or an advanced degree in computer science to promptly report to a patient the result of a simple blood test. Some things got better. Fiscally, however, all was not well. As the leading edge of 78 million Baby Boomers became Medicare beneficiaries, the National Debt Clock tolled $14 trillion. Steadily rising health care costs were a natural and predictable consequence of a population that was aging and enlarging, both in number and in girth. The cost explosion was to be expected, dictated by demography. However, the true and fundamental driver of change in American medicine in those years was a slow but inexorable slide in our national standard of living, something we all felt but no politician seeking re-election ever dared utter. A debtor nation could not pay the doctors’ bills. The only “solution” was the shifting premise; the problem, it was argued, lay not with an impecunious payer, but with the “producers” of health care. The practice of medicine was pegged as an anachronism, predating the cotton gin. Doctors, for that matter, were an unruly bunch. Each possessed a stubbornly unique approach to the utilization of diagnostics and expensive, uneven prescribing habits formed by personal clinical experience rather than by standardized rigid guidelines. The government was determined to achieve order, to herd cats. The “solution” for health care beyond our national means was to establish uniformity, a turn from the qualitative to the quantitative, less art, more math. The new math of medicine was evidence based, therefore irrefutable. Boilerplate templates assured even implementation, albeit by regression to the mean. Uniform care was measurable and, consequently, reimbursable. Pay for performance became the tail that wagged the dog of doctors’ care. More than measurable and reimbursable, formulaic care was defensible in court. “I was just following orders,” the defense that failed miserably at Nuremberg, held up well enough for a physician charged with professional negligence. (Medical malpractice liability, the eight hundred–pound gorilla in the exam room, had not been tamed.) Bland, paint-by-number care fit the format of the spreadsheet, but contained an insidious and sinister side effect not initially appreciated: the deprofessionalization of our nation’s principal providers of care, primary care physicians. A seemingly

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subtle shift in equilibrium, from relationship to transaction, drove a reaction that ultimately broke the bond between physician and patient. The change was not outwardly apparent. A doctor’s office still looked like a doctor’s office, with the same white coats and waits. The doctor, however, seemed different. Less a compassionate counselor and source of comfort, she had become a proctor, there to administer health care evenly under an institutional “uniform medical code.” I do not mean to be melodramatic; the morphing of the modern physician was not like a scene from the 1950s sci-fi movie Invasion of the Body Snatchers. Yet, the hollowness of the health care provider was evident to his patients. Dispassionate and disconnected, the doctor now dispensed by menu in a “take it or leave it” style devoid of professional pride, integrity, and personal commitment. It seemed the lights were on but nobody was home. The Post Office felt warmer. We had sacrificed the true function of the primary care physician, while preserving only the form. We had, in fact, made a grievous error. As with the little Vietnamese village Ben Tre, in a war long ago, for some reason we felt we had to destroy primary care “in order to save it.” This is somber stuff, rather gloomy conjecture on my part, I admit. Not an Orwellian prediction of doctoring in dystopia or a Dickensian vision of the Ghost of Physician Future, it is nonetheless my considered estimation of where primary care is headed on its present course. But wait, my story need not end so sadly. We still can fix this. First, we need to recognize that there is nothing inherently wrong with a cottage industry. Bigger is not necessarily better. The small, nimble, wellmanaged, and autonomous medical office delivers good care, individually tailored and appreciated, more effectively than has been acknowledged. It is managed locally, close to home. The entrepreneurial spirit of the physician small-business operator intertwines with competent, compassionate, clinical professionalism to form an effective combination, not so easily surpassed by a large organizational structure or tweaked by government fiat. Second, unless there is an ultimate, frank resolution to the matter of medical malpractice liability, there will never be sufficient incentive to sway young physicians-in-training toward adopting a career in primary care. The net of liability, cast broadly across a panel of several thousand primary care patients, is guaranteed to dredge up plaintiffs periodically. As long as malpractice exposure risk exceeds physician financial reward, there will be far too few primary care doctors to go around. Primary care does not show well in the specialty beauty contest put on for medical students in their final year of training, when each is shopping for a

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lifetime career while grappling with the enormous personal debt incurred for their medical school education that is not adequately funded by the government. Whether through tort reform, reality-based award caps, or (as I favor) establishment of a no-fault format administered through Medicare, we must do something. I left practice partly because I came to realize, as I entered my sixth decade, that malpractice liability reform probably was not going to arrive during my career, and perhaps not in my lifetime. Allowing this matter to drag on year after year and decade after decade meets Einstein’s definition of insanity: doing the same thing over and over, yet expecting different results. Health care reform without meaningful malpractice liability reform is nonviable. The applicable medical term, adopted by Congress to describe legislation that holds no hope of passage, is DOA (Dead on Arrival). Third, we need to recognize a conflict that exists: patients long for the close relational quality of primary care that they had in a slower, simpler time, while they simultaneously demand speed, precision, and errorfree efficiency from a field now collapsing under the weight of modern complexity. Primary care in the twenty-first century is much more than hand-holding and relatively simple remedies. Today’s patients are the beneficiaries of an extraordinary pharmacopoeia, powerful pills that demand deft titration. The accumulation of chronic ailments, now an expected part of the late phase of the life cycle, mandates a cadre of specialists whose care requires careful coordination and effective communication. Far more than relational, primary care today is by necessity also managerial. There is a limit. How much care can a doctor ever hope to pack into an office visit? A primary care physician cannot be all things to all people, day in and day out. How many patients can he stuff into the waiting room, where there already is no space to add any more folding chairs? Insuring 40 million more Americans, while noble, is meaningless if those newly insured will be hanging from the rafters in the waiting room. We need to recruit, even draft, primary care doctors and create proper incentives that will promote the growth of primary care medicine. If primary care truly is the backbone of U.S. health care, then we need to support it. We must put our money where our mouth is. Finally, we need to appreciate what primary care is not. It is not, and can never be, a surrogate for a warm and caring, functional family. It is not an anchor for modern, mobile family members who are isolated and adrift, emotionally and geographically. Attachment and family connection are essential to human health. The primary care doctor cannot raise your

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child, re-establish your ruined relationship with your mother, or cure the loneliness of later life within a dysfunctional family. Like charity, primary care really begins at home. Leaving my busy practice behind, I have had an opportunity to ponder the state of my profession. Disconnected from the serial service and round-the-clock responsibilities of practice, where the workdays blend one into the next, I can reflect on what I had that is now gone: the relationship I enjoyed with my patients. That, I can confirm, truly is the force that drives the primary care physician. It is the core of U.S. health care. Physicians, like their patients, crave the human relational aspect of medicine. To foster primary care, that personal relationship must become our focus, for the benefit of a nation of patients, their doctors, and today’s young students drawn to medicine as a calling. If we build that, a foundation of primary care based on a strong physician-patient relationship, they will come.

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NOTES

1. A First Visit with the Doctor 1. Epidemiologists and specialists in immunization refer to “herd” immunity. A term perhaps first borrowed from our veterinary colleagues, it indicates that a sufficient majority of a group have been vaccinated for a given disease and that the risk of that illness is thereby reduced for all, including those few who elected not to receive the vaccine. The term is not flattering, but expresses well the concept of shared, or communal, health. 2. I paraphrase Martin Luther King Jr., who said, “The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy.” Strength to Love, speech written in early 1963 for his Birmingham, Alabama, campaign.

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2. “Tell Him Not to Drive” 1. In recent years, with steadily rising operating costs, the responsibilities of business management heaped on top of clinical duties and stagnant insurance reimbursement rates, the entrepreneurial model of the private practice of medicine has joined the endangered species list and is at risk of extinction. The new business model will be the ownership and management of the small office practice by a health care corporation or by the local hospital. The office practice likely will operate at an actual loss. The hospital, however, will make out well, with a steady revenue stream from the lab work, X-rays, colonoscopies, and surgeries funneled from each practice that it owns.

3. Polypharmacy 1. Nineteenth-century saloons offered patrons a “free” lunch, as long as they bought one drink. Mid-twentieth century economists codified the concept as an economic principle. The science fiction writer Robert Heinlein ultimately reduced it to the acronym TANSTAAFL in his novel The Moon Is a Harsh Mistress. 2. I thank Professor Paul W. Sherman of the Department of Neurobiology and Behavior at Cornell University for his insight on the self-medicating tendencies of nonhuman primates and on the importance of Darwinian medicine for the practicing physician.

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3. To appreciate the magnitude of the problem, watch any old black-and-white era movie and then turn to a few minutes of a current TV show or commercials. Note the dramatic, pervasive change in American body morphology that passes today as “normal.” 4. Trans-fatting is the use of chemically synthesized artificial fat that enhances food taste, texture, and shelf life, but that is correlated positively with coronary artery disease. New York City has banned trans-fat (Okie 2007, 2017). 5. Grace Slick’s “White Rabbit” 6. The Federal Trade Commission also shares responsibility for regulation of deceptive advertising and should play a role here as well. 7. This would prevent certain awkward situations such as when I once prescribed Coumadin, a blood thinner, for an elderly man. The prescription was filled generically, with the label correctly reading “warfarin.” He happened to notice that his medicine bottle read the same as his box of rat poison, and he called to accuse me of attempted murder. 8. NB: Don’t try this at home! Review of the Material Safety Data Sheet (MSDS) indicates that WD-40 is a blend of petroleum distillates. These could be absorbed systemically through the skin leading to undetermined ill effects. WD-40 is not a treatment for achy joints. As they say, “Ask your doctor.”

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4. Poly-Doctoring 1. Note that the other meaning of “special,” which definitely does not apply here, is a reduced price, as in “the K-Mart Blue Light Special.” 2. The specialist very well may have done an excellent job at communicating with the patient and family. Somehow, though, they still need to “hear it” from somebody with whom they have had a long and trusting relationship. 3. This is a common play on the initials MGH, which, in fact, stand for Massachusetts General Hospital. 4. Alternatively, the records already have arrived electronically, in an ideal world of compatible electronic medical records, or, for the old-fashioned, by snail mail. I personally prefer to have the patient hand carry his records, so that I am sure that they reach the intended destination. Mailed paper records for a new patient who has not yet arrived have a way of getting misplaced, since there does not yet exist a physical chart in which they can be placed. The secretary at the specialist’s office then calls my office, with the irate patient fuming at the window overlooking her desk, complaining that the patient can’t be seen without records. 5. CT scans, utilizing undesirable X-radiation, have become commonplace today. MRIs (magnetic resonance imaging) avoid the radiation and are higher-resolution studies, but they are much more expensive. PET (positron-emission tomograms) are the current “Cadillac” study for looking for a tumor, but they are prohibitively expensive and require prior approval by insurers that is difficult to obtain. 6. Given the current climate of high malpractice liability, physicians fear the accusation of “failure to diagnose.” Why take any risks? It is easier and safer to simply order one more scan or do whatever other study the radiologist advises. Note that, for a hypothetical unscrupulous radiologist, the “Recommend” comment in the report can become a license to print money perpetually. 7. General anesthesia carries far more risk for an elderly, ill patient than do local, regional, spinal, or other types of anesthetic. To render an opinion about the patient’s chance of surviving the procedure, I really need to know which will be used. 8. I was an early and strong proponent of the hospitalist movement, and I was most grateful when freed from the once onerous and superhuman burden of being in two places, office and hospital, at the same time. 9. A more proper term in Greek would be perittiatric, meaning stemming from, or caused by, too many doctors. I thank Professor Alan Nussbaum of the Classics Department at Cornell University for his help in synthesizing this new term. It is Greek to me.

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10. The above case was not assigned an identifying code, such as Mrs. E, because it is in fact the sad story of my own mother, to whom, along with my father who also died after a difficult struggle with cancer, this book is dedicated. I have recounted this personally troubling story because I cannot emphasize strongly enough the importance of coordinated, rational medical care for the elderly and the pivotal role to be played by a good primary care physician as captain of the team. 11. Policy Monograph of the American College of Physicians, January 22, 2006, p. 7, http://www.acponline.org/advocacy/where_we_stand/policy/adv_med.pdf. 12. In chapter 7 I present a proposal for a physician draft that will populate the ranks of generalists while giving specialists-in-training two years of much-needed experience in the relational nature of patient care.

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5. A Bubble Off 1. “Dementia” is a carefully chosen, nonjudgmental, noninferential, clinical term indicating a loss of previously possessed cognitive skills. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (American Psychiatric Association 1994) dictates that, to be demented, a patient must demonstrate cognitive loss in two or more domains, such as memory, language, calculations, orientation, and judgment. The demented are, without question, functionally impaired at work or at home (Kawas 2003, 1056). 2. Inhibition, a higher cognitive function attributed to the frontal lobes of the brain, is what permits us to participate in a civilized society. With the loss of inhibition, we lose refined self-control, saying or doing what comes to us in the immediate moment, without a formerly held regard for social rules or for the feelings of others. Imagine a coming world in which a new majority composed of quirky, disinhibited elderly people will alter our established norms of interactive behavior. 3. We are not alone. A United Nations study done in 1996 estimated that by 2050 there will be 36.7 million individuals with dementia in the developed countries. Estimation of the future prevalence of dementia in the less-well-developed countries is a more difficult task. However, if life expectancies increase there, the number of demented worldwide would increase by an additional 65 million people by 2050 (13). This will be a global pandemic. 4. Sadly, for those older Americans who are truly alone in the world or who are neglected by family, the doctor’s office may feel more like home than home itself. 5. Incompetence, or the lack of capacity, is a legal term, not a medical one. A person who lacks capacity cannot be held to a signed contract or other legal document. A physician may be called on by a court to render an opinion about a patient’s competency, based on a history of dementia and a neurological examination, but she doesn’t make a diagnosis of incompetence. 6. This is where common sense must prevail over federal forms. Of course I will speak to a daughter whose mother lies dying in the hospital. I think few doctors would invoke HIPAA as a reason to refuse to take that phone call regardless of federal regulations. I do worry about it, though—the fines for HIPAA violations are hefty. 7. The term “Alzheimer’s disease” is a specific pathologic diagnosis, made on examination of brain tissue postmortem. It was originally described by Dr. Alois Alzheimer, a German psychologist turned neuropathologist, in 1906. Microscopically, the brains of its victims demonstrate characteristic plaques and tangles of deposited material. The prevailing paradigm is that the material, called amyloid, is laid down in the brain over many years, leading to a slow cognitive decline. There is another common cause of dementia. The accumulation of many small strokes that look to pathologists like lakes, or lacunae, leads to multi-infarct dementia and to a brain that appears grossly like Swiss cheese. Less common causes of dementia include those stemming from a life of chronic alcoholism, as well as much rarer disorders that are of great interest to researchers in the field of neuroscience. For the purpose of discussion of the primary care of the patient with dementia, I may use the term Alzheimer’s disease, but keep in mind that there are other reasons why people become demented.

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8. For a remarkably insightful portrayal of the process of becoming demented, I refer you to the short novel, Out of Mind, written by Dutch author J. Bernlef and published in the United States in 1989. The novel charts the narrator’s course from rationality to fears and fragmented memories and finally to a disjointed clutter of words without cohesive thought. It captures well in fiction the essence of the loss of self that is experienced by patients with advanced AD. 9. Amyotrophic Lateral Sclerosis (ALS), also referred to as Lou Gehrig’s disease, results in progressive deterioration of nerve cells that control muscles and movement. Cognitive function remains completely intact. The cause of ALS is uncertain, and there is no cure. The course of the disease is quite variable, but often it is long enough for there to be time to form an enduring relationship between a patient and a doctor that, thus far, remains the physician’s only meaningful therapeutic contribution. 10. See The Caregiver: A Life with Alzheimer’s (Alterra 2008). 11. Alternatively, the driver is a teenager, not even of legal age, who is paid under the table by the family to get grandma where she needs to go. The teenager sits quietly during the office visit, chewing gum and listening to her mp3 player, while I try to make some attempt at a medical assessment of the old woman’s clinical status, absent any useful information from the young woman who accompanies her.

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6. On the Road Again 1. It was not until 1884 that microbiologist Robert Koch firmly established a causal link between a bacterium and a particular disease. Prior to Koch’s postulates of bacterial infection, the cause of tuberculosis was thought to be “diathetic,” a hereditary or constitutional predisposition to disease, rather than due to a malevolent microbial invader made airborne by a cough in close quarters. Susan Sontag wrote eloquently of our past inclination to ascribe a “tubercular” character. She chided us not to make the same mistake today when we think of a “cancer-prone type” or “AIDS-prone individual” (Sontag 1989). 2. This is a critical question for health care policymakers. A tenet of the Obama administration’s approach to revision of U.S. health care is that great cost savings can be achieved through preventive measures and by the general promotion of health. That may be wishful thinking. 3. In the interest of complete disclosure, I currently serve as vice president of the board of trustees at Longview. 4. A meta-analysis pools data from multiple smaller studies to obtain a larger picture. It suffers from potential misinterpretation due to subtle differences among study designs, clinical criteria, and measurement endpoints. Seemingly simple questions can prove remarkably difficult to answer with any degree of certainty. 5. Attributed to the late Senator Paul Tsongas (D-Massachusetts).

7. The Supply Side 1. Per the 18th Report of the Council, “COGME was authorized by Congress in 1986 to provide an ongoing assessment of physician workforce trends, training issues, and financing policies and to recommend appropriate Federal and private-sector efforts to address identified needs.” The purpose of COGME, under Title VII of the Public Health Service Act, as amended, is to provide advice and recommendations to the Secretary of DHHS and Congress on issues, including 1) supply and distribution of physicians in the United States, 2) current and future shortages or surpluses of physicians or surgeons by specialty, 3) issues relating to international medical graduates, 4) federal policies pertaining to financing graduate medical education, and 5) establishment and maintenance of databases concerning the supply and distribution of doctors in the United States.

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2. The floodgates regulating the flow of physician training can be placed at several different points in the course of medical education. The number of medical school seats and acceptances offered to premedical applicants is one dam in the river. Another is the control of the number of positions available for GME, which includes internship and residency training that follows medical school, plus any additional training in remarkably narrow, superspecialized fields. For example, consider the neuro-ophthalmologist, who deals only with disorders of the nerve cells that run from the back of the eye to the back of the brain, or the craniofacial surgeon who, after a seeming lifetime of schooling, artfully reconstructs the faces of patients who have suffered disfiguring accidents of nature or man. 3. Note the terminology. Historically, Medicaid has been a form of charitable health care handout, or dole, to its poor recipients. The elderly are the beneficiaries of Medicare, a program of entitlement. The distinction, however, will be moot when no primary care physician will be there to see either group. 4. I cannot leave the subject of physician training without recalling a personal anecdote about my own application to medical school. The fear in the mid-1970s was that doctors were becoming jargon-speaking, soulless science nerds with no appreciation for the arts. What was sought was the true Renaissance man, who was scientifically savvy, yet “wellrounded.” After submitting twenty-five individual applications to medical schools across the country, I was offered an interview at Hahnemann University in Philadelphia. It was the first nibble. I arrived in jacket and tie, sat in the reception area with twenty other young students who looked equally uncomfortable, each waiting for their fifteen-minute shot at admission. The interview went well enough, with a measured dose of information offered about the school, the admission process, and the poor statistical likelihood that I might ever gain entrance. There were a few softball questions thrown at me about my life experiences at the ripe age of twenty-one, and I fielded them well enough. I was ready to grab my coat and go when the interviewer said, “I just have one more question—who is Jascha Heifetz?” Oh no, I give up! I had been shot down by the “well-rounded” question. There would be no MD for me. My failure to recognize a famous violin virtuoso and the terror that it invoked in me seems silly now, but it highlights how subjective and fickle the process is by which we select our nation’s future physicians. I was accepted to Hahnemann one week after the interview. 5. The medical economics of physician reimbursement is such a critical topic that I devote a full chapter of this book to its exploration. See chapter 10. 6. By its very nature, however, primary care, and particularly geriatric care, is a local job that is not amenable to the outsourcing seen in the manufacturing sector. While well-heeled consumers of health care today may opt to have a specialty surgery or a refined procedure done in a foreign country such as India—so-called medical tourism—on returning home, they promptly call their family physician to book a follow-up appointment. Like politics, all primary care is local. 7. However, regulations pertaining to health insurance companies and medical malpractice insurers currently are also subject to the actions of state insurance boards in all fifty states. 8. From “To a Louse” by Robert Burns. 9. President John F. Kennedy, inaugural address, January 20, 1961.

8. All in the Family 1. It commands a behavior, not necessarily an emotional bond. Take care of your parents to avoid them shame. Just do it.

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I thank Rabbi Scott Glass of Temple Beth El in Ithaca, New York, for his thoughts on this subject. 2. Historically, landline telephone rates were cheaper on Sundays, as well as on Mother’s Day and Father’s Day. I don’t know whether adult children call their parents on Sundays to be thrifty or because calling is the last item to be addressed on a busy, weekly To Do list. It would be interesting to see if the pattern of filial phone calls holds in the era of cell phones and national calling plans. I suspect it will. 3. The term “successful aging” has been utilized in diverse fields of science from cellular biology to sociology and psychology. While biologists probe the lowly nematode worm for clues to the causes of cellular senescence, social scientists strive to characterize optimal aging of the individual. Physical and cognitive health is essential. The “compression of morbidity” is medicine’s attempt to delay disease and dysfunction until very late in the game (Fries 1984, 354). Successful aging, however, is not just the absence of disease. Independence, security, control, and a purposeful, productive later life, filled with social engagement are the real goals. Studies of the social determinants of health in the United Kingdom refer to a “third age” in later life, when fortunate individuals experience the self-fulfillment that may come after career and child rearing are completed (McMunn et al. 2006). 4. This is the term used by hospice workers and thanatologists (specialists in death and dying) to describe patients who have begun their final descent down the slippery slope of illness and whose health status is deteriorating rapidly. It is an odd term, as it attempts to distinguish those who face impending death at an accelerated rate from the rest of us who are merely dying “passively.” 5. John Maynard Keynes. This is one prediction by an economist that is irrefutable. 6. Nobody wants to hear any of this. The only geriatric affordance readily and gratefully accepted is a signed authorization for a handicapped-parking sticker. As long as I have that letter, I will never be lonely.

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9. Practice/Malpractice 1. To his credit, the process server, who may very well be a nice guy at heart, is providing me a true service by notifying me of a legal proceeding against me, thus guaranteeing my right to due process under the Fifth and Fourteenth Amendments of the Constitution. Regardless, I still would rather he never appear. 2. I am not referring here to the far more common usage of the word pimp: a business manager of prostitution. To my knowledge, other than this word, the two professions share nothing in common. 3. President Ronald Reagan used the phrase in his January 27, 1987, State of the Union address while discussing an arms-for-hostages plan that came to be known as the IranContra affair. He is not the only prominent political figure to have used this construction. See Safire’s Political Dictionary (Safire 2008). 4. Future CEOs receive some advice in business school on how to make a proper public apology for a high-profile corporate mishap, but they also are taught to gauge the relative economic benefits of doing so or not (Kellerman 2006, 72, 148). A private and personal apology, however, is not something readily taught in the classroom. 5. Proceedings of lower courts no longer survive, but appellate court documents remain intact. 6. Mohr provides a dramatic example of the effect of surgical advance on the incidence of malpractice litigation. In the 1850s, patients with a compound fracture of the leg, previously managed by amputation, came to be treated by fixation of the broken bone, thus preserving the limb but likely resulting in a permanent discrepancy of leg length and a noticeable limp. The difference in limb length, easily measurable, became a readily demonstrable cause of legal action. Two-legged patients, albeit lacking a perfect surgical result, were suing their doctors, whereas a decade earlier, a one-legged patient would have been a satisfied customer. Here, in the mid-nineteenth century, was an early example of the bizarre

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and unexpected consequences of the application of tort law to differentiate practice from malpractice in the profession of medicine. 7. Recall from chapter 4 that, with specialist consultants, who you see determines what you get. Every consultant sees a solution to a problem through the tunnel vision of his or her own narrow field of expertise. Lawyers are no exception. 8. At the introduction to this chapter, when I received my summons and complaint from the process server, my staff gathered quickly to see who among our long list of patients had filed suit. If the tort system truly worked, they easily should have been able to take a good guess and predict the plaintiff. The fact that the lawsuit and the litigant came as a total surprise indicates the randomized, lotterylike nature of the medical malpractice tort. 9. Readers may not be aware that on the Internet there exists a National Practitioner Data Bank (NPDB) located at http://www.npdb-hipdb.hrsa.gov/ (Brentnall 2008; Studdert et al. 2000, 250). It is a massive electronic repository of data regarding physicians’ past experiences as defendants in malpractice litigation. Verdicts against the doctor, sums awarded, although not private settlements, are accessible by health care institutions. Although individual patients are not intended to have access to this information, the NPDB serves effectively as a virtual public pillory. Doctors disgraced by the Data Bank may find it difficult to find a job with an HMO or other corporate employer, once they are pegged as high risk. I must point out that the reverse repository does not exist: a National Patient Data Bank to flag those patients most inclined to sue. 10. “Turfed” is an unflattering term from the days of my medical training that refers to the disposition of a patient through the transfer of care to another doctor, another hospital, or some other facility such as a nursing home. 11. In the event that the United States ever moves to a single-payer universal form of health care coverage, it is likely that the plan will evolve as an expansion of Medicare coverage to all Americans, young and old. A standardized, national no-fault system of compensation for medical error would then be in place for all. 12. This is vividly portrayed in the book Damages, by Barry Werth, which chronicles in detail the proceedings of a nonfictional “bad baby” tort case and the agony experienced by both plaintiffs and defendant (Werth 1998). 13. The legal argument for this, per Sage and Kinney, is that Congressional law supersedes state tort law under the Supremacy Clause (Article VI, Clause 2) of the United States Constitution. While the legal arguments are beyond the scope of this chapter, note that there is precedent in the Employee Retirement Income Security Act of 1974 (ERISA), which established federal law regarding adjudication of claims against employer-sponsored benefit plans (Sage and Kinney 2006). As with ERISA, newly crafted federal law could supplant the present dysfunctional system of state tort law as it has been applied to medical malpractice. 14. The “tragedy of the commons” is a concept originated by Garrett Hardin regarding population growth and the exploitation of common resources (Hardin 1968, 1243). Individuals naturally pursue their own interests for personal gain, ultimately depleting resources and degrading the quality of life for all. It is a myopic approach.

10. You Get What You Pay For 1. I thank my dermatologist and friend, Dr. Robert Horn, for his amusing story. 2. Job satisfaction correlates with income level relative to a comparison or reference level. The fact that primary care physicians are paid substantially less than specialists damages their morale far more than does the absolute dollar amount paid for their services. Economists Andrew Clark and Andrew Oswald (1996, 359) demonstrated this psychological phenomenon in a study of five thousand British workers. I believe that it is equally applicable to career professionals in adult primary care and geriatrics. It is poor policy, and indeed naive, to expect that the primary care needs of 78 million soon-to-be decrepit Baby Boomers will be met by a cadre of demoralized and dissatisfied primary care physicians. It

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behooves us all to ensure that certain professionals, such as doctors and airline pilots, are happy in their work. It is in our best interest. 3. Accusations of physician overbilling versus insurer down-coding are not limited to doctors’ participation in Medicare. There has been a flurry of class-action lawsuits filed by physicians against private insurers for alleged systematic obstruction and delay of payment. In a case against Humana, a federal appeals court judge described the case as “almost all doctors versus almost all major health maintenance organizations” (Kesselheim and Brennan 2005). According to Kesselheim and Brennan, writing in the New England Journal of Medicine (855, citing Klay v. Humana, Inc. 2004), “[Physicians] invoked the federal Racketeer Influenced and Corrupt Organizations (RICO) Act, which prohibited racketeering— including extortion, bribery, and mail fraud—in conducting the affairs of any enterprise that affects interstate commerce.” Damages under RICO are tripled. Although private insurers such as Aetna and Cigna settled, the awards per physician-plaintiff in the class action were trivial ($142 per physician in the case of Aetna). Nevertheless, the settlement was a moral victory for downtrodden doctors. 4. Since 2002 Medicare periodically announces its intention to roll back physician reimbursement to abide by SGR. Physicians’ groups then protest the fee cuts and threaten that they will refuse to accept new patients on Medicare. The elderly are pawns. At the eleventh hour, Congress rescinds the pay cuts, and a crisis is deferred for another year. Those doctors with the lowest profit margins, however, are most vulnerable to the whims of Congress. At a time when electronic medical records, or health information systems, are touted as an efficient improvement that saves money and improves the quality of care, doctors are reluctant to shell out the large capital outlay to shift over, while Medicare reimbursement remains uncertain from year to year. Defense contractors, never knowing whether Congress will scrap appropriations for the latest rocket or helicopter, are accustomed to doing business this way. Physicians, as sole proprietors or in small groups, cannot tolerate annual payment cliff-hangers (Orszag and Ellis 2007, 1793). 5. In fact, today the first baby picture placed in a scrapbook often is a grainy ultrasound image of a large-headed eight-week-old fetus doing the backstroke. 6. Fees and Medicare reimbursements quoted are for upstate New York in April 2009. 7. There are the “four As” of medical practice, predictors of a doctor’s success, which I rank in ascending order of importance: ability, affability, affordability, and availability. 8. See Sinclair Lewis, Arrowsmith, 1925. 9. From a systems-analysis perspective, this is called normalization of deviance (Kohn et al. 2000). What was once considered to be unacceptable quality, with the passage of time and habituation, becomes passably acceptable, if not the new norm. Nobody notices the latent problem of substandard care until disaster strikes. Normalization of deviance is at least partially to blame for the tragic loss of the space shuttle Columbia and its crew. 10. I do think that personally driving a patient to her appointment with a specialist is obsequious, over the top, and above and beyond the call of duty of the physician. Hippocrates makes no mention of this in his oath. 11. Sufferers of an illness called Munchausen syndrome represent the antithesis of the sort of patient a doctor would want to see under P4P. Munchausen’s is a psychiatric disorder in which patients feign symptoms or even self-inflict illness by causing an infection, contaminating a clean wound, or undergoing multiple unnecessary surgeries for vague symptoms. How shall I be reimbursed under P4P for the care of a patient with Munchausen’s? Fortunately, it is a condition infrequently seen in primary care. 12. Atlas et al. do note that patients who were determined to be connected were also more likely to be insured, speak English, and be non-Hispanic white. They suggest that it is the underlying lack of connectedness that causes the disparity of care by race or ethnicity.

Epilogue 1. President Obama’s Health Care Speech to Congress, September 9, 2009.

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INDEX

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AIDS, 25, 52, 174 allergic reactions, 50 Alzheimer’s Disease (AD), 45, 94, 98, 101–104, 106, 110, 165, 197 ambulance, 13, 124 American College of Physicians (ACP), 90 – 91 Americans with Disabilities Act (ADA), 98 anthrax, 150 antibiotic, 68, 85, 89, 107, 112, 164 antidepressants, 25, 47, 55 anxiety, 15, 24, 31, 46 – 48, 65, 76, 90, 100, 153–154, 156, 176 arthritis, 11, 31, 57, 66, 71, 77, 167, 197, 205 attorney, 1, 8, 70, 87, 161, 170, 178, 182, 184 –185, 188, 198 Baby Boomers, 2–3, 5– 6, 11, 27, 34, 55, 90, 94, 97– 98, 101, 109, 119 –120, 123, 125, 130, 132, 137, 141, 143, 152–153, 155, 166 –167, 192, 202, 211, 214 Beers criteria, 65 biopsy, 18, 80 –81, 84, 88, 185, 191–192, 203 Bowlby, John, 154 brain, 10, 20, 31, 64 – 65, 82, 96, 172, 187, 196 –197 breast cancer, 35, 174 Bruenn, Dr. Howard G., 53 bursitis, 66 – 67 calories, 208 cancer, 20, 39, 45–46, 52, 54, 61, 71, 75, 81–83, 87–88, 114, 133, 160, 164, 167, 176–177, 185, 206

cardiologist, 53, 63, 73, 75, 87, 88, 175, 191, 196 caregiver, 95, 103–106, 109, 112, 119, 121, 126, 129, 154, 161 catheterizations, 81 centenarian, 33, 104 chemotherapy, 25, 62, 83, 88, 89, 122, 159 cholesterol, 18, 54 –55, 66, 139, 206 –207 Christensen, Clayton, 3, 199 clinics, 125, 141–142, 146, 201–202 colonoscopy, 18, 203 computerized tomography (CT ), 20, 27, 39, 80 –83, 92, 185, 194, 196 –197 customer, 9, 11, 43, 48, 68, 77, 81, 127, 132, 136, 198, 202, 206, 213 databases, 39 defibrillator, 31, 99 dementia, 14, 31, 45, 62, 90, 94 – 95, 97– 98, 100 –110, 114, 120 –122, 161, 166, 175, 177, 203, 205 depression, 45– 47, 65, 95, 112, 122, 133, 151, 155–156, 192, 205 dermatologist, 74 –75, 190 Descartes, René, 47 diabetes, 31, 35, 50, 54, 66, 70, 204 –206, 208 diagnosis, 11, 15, 20, 43, 45, 74, 76 –77, 79, 102–103, 112, 172, 177, 180, 185, 190, 192–193, 201, 203, 213 diet, 9, 53, 57, 80, 95, 121, 133, 172, 194, 208–209 Dietary Supplement Health and Education Act (DSHEA), 61– 62 disability, 128, 183, 187, 208–209

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Index

disease, 7, 9 –10, 26, 44 – 46, 54 –55, 58, 62, 72, 74 –76, 78, 80 –81, 87, 89, 98, 101–102, 106 –107, 110, 119, 126, 133–134, 157, 165, 167–168, 172, 175, 177, 180, 184, 196, 203 driving, 29, 31, 32, 33, 34, 48, 66, 67, 105, 157, 214 drug reps, 7, 59, 170 drug therapy, 23, 25, 31, 35, 48, 49, 50, 51, 52, 53, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 67, 68, 69, 70, 71, 75, 85, 87, 89, 110, 128, 170, 174, 189, 205

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echocardiogram, 196 –197 egalitarian, 12, 202 electrocardiogram (EKG), 11, 42, 44, 175, 176 electronic medical record (EMR), 37–38 emergency care, 11–13, 29, 42, 85, 123, 184, 186 endocrinologist, 76 –78, 192 evidence-based medicine (EBM), 39 – 42 examination, physical, 7, 32, 40, 48, 53, 72–73, 79, 92, 139–140, 174, 181, 192, 194–197, 213

hospice, 88–89, 121, 129, 165–166 hospital, 1, 13, 24, 26–27, 29, 74, 84–86, 96, 103, 107, 112–113, 115, 118, 121, 124, 128–129, 131, 141, 146, 149, 152, 164, 172–174, 177, 184, 193, 205, 208–209 hospitalist, 85–86 house call, 73, 109, 111–117, 121–126, 128–129 hypertension, 40, 48, 54, 66, 70, 191, 205 hysterectomy, 88 injury, 13, 17, 94, 118, 183, 187, 189, 190, 203 insurance, 1–2, 7–8, 10, 12, 15–17, 23, 25, 34, 36, 47, 54, 59 – 60, 63, 68–71, 74, 77, 85, 94, 99 –100, 113, 115, 138–139, 142, 147, 149, 165, 178, 182–184, 186 –189, 191, 193–194, 198, 200, 204, 213 internal medicine, 1, 2, 73, 132, 143, 146, 171, 174, 177, 181, 191 internists, 27, 91, 113–114, 141, 143, 193, 202 interns, 26–27, 111, 137, 145–146, 148–149, 172 Institute of Medicine (IOM), 173–174

Flexner, Abraham, 131–132 flu (influenza), 12, 14, 36, 115, 150, 160, 164 Food and Drug Administration (FDA), 44, 51–52, 57– 62, 64, 66 – 67 full-time equivalent (FTE), 135, 138

Just for Us, 124

genes, 14 geriatric care, 3, 31, 34 –35, 39, 43– 44, 47– 48, 50, 55, 64 – 65, 74, 83, 91, 95, 97– 99, 103, 105, 109 –110, 115, 120 –123, 125–127, 143, 149, 152, 156, 159 –161, 167–168, 170, 186 –187, 192, 197, 202, 205, 209, 211 Google, 40, 198 Groopman, Dr. Jerome, 43, 177 Guglielmo, Wayne, 143

laboratory, 11–12, 22, 30, 79, 110, 115, 128, 174 Lee, Thomas, 26 –27 libertarian, 12 litigation, 77, 142, 178, 181–184, 186 –188 living will, 108, 166

Harvard Business School, 3– 4 Health Insurance Portability and Accounting Act (HIPAA), 13, 18, 30, 100–101, 157–158, 161–162 health maintenance organizations (HMOs), 2, 7, 46 heart attack, 32, 35, 44, 61, 99, 151, 181, 204 hepatologist, 80 –81 herbal medicine, 44, 50, 60 hernia, 3, 18, 75, 191 Hippocratic Oath, 137, 157 home visits, 107, 109 –119, 121–125, 127, 129

Kahn, Robert, 156 Katz, Jay, 157, 180 Keats, John, 180

magnetic resonance imaging (MRI), 2, 15, 80, 185, 194 malaria, 51 malpractice, 1, 5, 8, 23, 75, 77, 115, 138, 141–142, 146, 164, 170, 178, 181–189, 195, 214 –216 mammogram, 20, 37, 176 Maslow, Abraham, 156 McDonald’s, 201 Medicaid, 1, 2, 10, 118, 124 –125, 135, 208–209 medical history, 11, 38, 44, 139 medical records, 36, 79, 86, 163, 176, 211 medical school, 39 – 40, 44, 50, 55, 72, 76, 79, 88, 103, 132, 136 –138, 146, 179, 192, 199, 215

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Index medical therapy, 53, 67, 121, 165 Medicare, 1–3, 7, 10, 16 –17, 22, 30, 34 –35, 38, 43, 47, 70, 74, 77, 85, 95– 96, 100, 106, 115– 116, 118, 121, 125, 128, 133, 135, 138, 141, 147–149, 156, 159, 165, 167, 185, 187–189, 191–194, 197–205, 207–209, 211, 214, 216 medication, 10, 12–13, 15, 19, 30 –32, 40, 49, 50, 52–55, 59, 60, 62–70, 80, 84 –86, 95– 96, 100, 121–122, 152, 161, 176, 185, 196, 205–206, 209 migraines, 66 mild cognitive impairment (MCI), 93–100 Miller, Phil, 143 Millis, John, 134 Mohr, James, 181 Mongan, James, 24, 26 –27 Moynihan, Senator Daniel Patrick, 39

243

polypharmacy, 5, 49, 50, 53–56, 60–64, 66–67, 75, 95, 121 prescriptions, 11, 37, 46, 48, 52, 62–63, 67–68, 205 private practice, 1, 3, 9, 43, 46–47, 50, 88, 136, 176 process server, 170 –171, 182 professionalism, 118, 130, 215 Program of All-Inclusive Care for the Elderly (PACE), 125 Prozac, 47– 48 psychiatry, 47, 73 public health, 13, 57, 70 –71, 119, 131, 137, 140, 147, 150, 160, 183, 186 –187, 189 pulmonologist, 80, 82 Putnam, Robert, 117, 160 quinine, 51

No Child Left Behind Act of 2001 (NCLB), 36 no-fault, 183, 187–189, 216 nursing home, 22, 114, 120, 122, 125, 127, 153, 155, 165

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Obama, President Barack, 4, 37, 133, 168, 213 obesity, 4, 9, 54, 133, 208 Occupational Safety and Health Administration (OSHA), 34, 119 occupational therapist, 22, 126 octogenarians, 30, 33, 90, 105, 107, 156, 188 oncologist, 35, 88–89, 103 ophthalmologist, 196 Orszag, Peter, 4, 168 orthopedist, 79 osteoporosis, 55, 205 over-the-counter (OTC) drugs, 31, 44, 49, 58, 61 pacemaker, 31, 110, 175 parasites, 18 pathology, 72 Pearson, Steven, 206 penicillin, 34, 48 pharmaceutical representatives, 7, 59, 170 pharmaceuticals, 44, 49 –52, 54, 56 – 61, 63– 65, 67–71, 81, 138, 148, 170 pharmacology, 49, 50, 53, 56, 60, 73 physical therapist, 22, 126 placebo, placebo effect, 51, 61, 66 – 67 pneumonia, 89, 103–104, 107, 204 poly-doctoring, 5, 63, 77–78, 81

radiologist, 20, 80, 82–83, 196 residency, 2, 25–26, 40, 73, 79, 115, 134, 137, 143–149, 175, 199 rheumatologist, 63, 76 –77, 192 Rockefeller, John D., 132 Roosevelt, President Franklin D., 53 scheduling, 10 –11, 23, 94 scopes, 74, 81, 191 secretary, 9, 10, 15, 17–19, 95– 96, 105, 144, 170, 190, 211 selective serotonin reuptake inhibitors (SSRIs), 48, 55 solo practitioner, 1–2, 174 stool collection, 18 stroke, 22–23, 37, 54, 101, 133 Stuck, A. E., 127 student, 2, 26–27, 36, 55, 111, 119, 132, 164, 177 suicide, 46 surgery, 32, 38, 42, 66, 71, 73–75, 79, 82–84, 88–89, 91, 121, 132, 144, 153, 161, 166, 175, 179, 182, 184, 191, 193, 195–197 Theophrastus, 50 –51 Timed Up and Go (TUG), 126 tort, 182–183, 187–189, 216 triage, 13 tuberculosis, 13 tumor, 10, 71, 83, 88–89, 196 –197 urine, 11, 25, 107 utilitarian, 12, 159

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vaccination, 14, 36, 166, 202, 204, 207 Valium, 65 Viagra, 55, 71 Virchow, Rudolf, 72 vitamins, 44, 60, 62

X-ray, 2, 10, 18, 20, 24, 37, 42, 53, 79, 80 –82, 174, 176, 196 Zion, Libby, 137

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waiting room, 3, 8–14, 19, 21, 43, 59, 85, 90, 94, 99 –100, 105, 116, 136, 170 –171, 190 –191, 200, 216

Walmart, 3, 94, 201–202 weight loss, 44, 47, 53 Welby, Marcus, 2, 42, 175, 199 workers’ compensation, 12

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