Reader feedback.

Dear Editor:

I just read Dr. Washburn's article in The Physician Executive (volume 25, issue # 1) and must commend him on hitting all the relevant nails directly on their respective heads. He clearly articulated what many of us have increasingly (and uncomfortably) felt over the past few years. I do not believe the word "apocalypse" overstates the coming meltdown in clinical medicine in this country. As an industry, we are impossibly constrained between mandated rising costs and an inability to raise our prices. We are also constrained between the reality that managed care often means less care, and the malpractice standard that we provide only the best outcomes and are liable regardless of managed care requirements.

Several years ago I entered an MBA program. so that I might be more favorably positioned to remain In clinical medicine. I am nearly through the program now, and instead fear my business degree will end up having to provide me with an exit from clinical practice, and maybe medicine altogether.

In the past four to five years I have had an increasing sense that the overall quality of medical students has declined significantly. This is not based on any data--I don't know if there is any data--but the medical students I see do not appear to be of the same caliber as they were five to ten years back. There are others at my institution who agree. It certainly makes some sense: If you are 20 years old and among the best and brightest with many career options open to you, choosing to enter a profession under siege is not especially attractive. Clearly, many will (and do so) Out of a commitment to clinical care, However, I wonder just how much of our deteriorating situation has filtered down to the premedical student level and nudged some of them away from medicine, For example, how many physicians now encourage their children to pursue a medical career compared with ten years ago? If true, this is rather frightening for the future.

In the end, I think the answer will come only when our society as a whole--government and populace--can make the conscious choice between "affordable health care" and "the best health care." To have both is not possible.

Although a depressing subject, it was nice to read Dr. Washburn's article and somewhat reassuring that physicians in positions of authority understand and can possibly influence the course of "the coming medical apocalypse." Don't stop articulating the message!

Rick Ohanesian, MD

Farmington Obstetrics & Gynecology Group Avon, Connecticut [e-mail]

In the "mush"

Earl Washburn's article, "The Coming Medical Apocalypse" (volume 25, issue # 1), could have several other major trends that threaten medicine added to it. For instance, not only is there major provider angst, but there also exists major patient angst. Patients are disillusioned with medical care, which may be curing but not necessarily healing. Some evidence of this trend is that out-of-pocket expenses for alternative and complimentary care are increasing; patients are willing to pay for relatively unproven treatments themselves, perhaps because these providers seem more caring than physicians in general.

Other evidence is the continued compromising of the patient-doctor relationship by thoughts of liability and defensive medicine. Another trend is that from the point of view of larger society, the costs of care are continuing to increase at an unsustainable rate. More and more expensive technology and polypharmacy cannot substitute for true healing. Dr. Washburn touched on the spiritual loss as well; what has happened to the appreciation of the sacred nature of the work, the privilege of caring for the life of another human being? If physicians are not in touch with gratitude within themselves for the privilege of practicing medicine, it's no wonder both physicians and patients are in angst.

I would like to suggest that, in the face of the crisis, we in medicine ask ourselves several questions, such as: "What really matters In medicine? What is its essence?" "In what ways can I truly be of service?" "How can I live my life in integrity with my deeper values, regardless of circumstances?" The state of mind of the medical profession is the answer to the problems of medicine. Mucking around in the problems will not solve them. We as physicians have to quiet our personal thinking (let go of "what about me'ing"), and collectively look in the direction of what we don't yet know, to see something new. What we already know about the problems is not helping us solve them.

One point of Joe Flower's caterpillar/butterfly mush, "In the Mush" (ibid), is that we don't need to try to figure it Out, we need to relax our thinking into knowing that the answers are in a quiet mind. We can stop anguishing over what we don't know. If we are not distracted by anguished thinking. we will see with clarity and insight. If we continue to analyze what we know about the existing situation, and try to figure Out what to do from that, we will use up a lot of energy that would be better spent in responding when necessary to the obvious--and we'll miss the obvious in the process. Together we can go into the "mush," and see beyond our present situation to a new view of medicine that returns us to our sacred healing profession. Thanks once again for pointing us in the direction of opportunity.

Marsha Milburn Madigan, MD, MPH

Executive Consultant

Associate Clinical Professor, MSU-CHM

Laingsburg, MI

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Chinese pictogram for crisis

I have just read Earl Washburn's article, "The Coming Medical Apocalypse" (volume 25, issue # 1). It is a great article with a very thorough analysis and forceful argument. He has my 200 percent vote.

A small reason that I write to you is that there was a mistake on the Chinese character for "crisis" in the article illustration. The one printed means, "something belongs to something or someone, or something related," for example. this is your paper. I do not have a dictionary with me, but this certainly has no meaning related to crisis. The correct two Chinese characters for "crisis" are:

Again, I really enjoyed reading Dr. Washburn's article. Like him, I am also very seriously concerned about where American medicine is heading, and what we can do about it as a group for the sake of our society, our profession, and our own living.

Best regards,

Jim Jian Zhao, MD, PhD, MBA

Director of Diagnostic Molecular Pathology 

Department of Pathology and Clinical Laboratories

Orlando Regional Healthcare System

Orlando, Florida 

Crisis--danger and opportunity

It has become a famous quotation that the Chinese pictogram for "crisis" consists of two words--the first meaning "danger" and the second meaning "opportunity." In his article, "The Coming Medical Apocalypse," Dr. Washburn used this quotation to alert us to a potential tsunami that we may be facing. Unfortunately, the Chinese pictogram used as an illustration is incorrect. I remember seeing the same error somewhere once before, and would hope that further misquotation can be avoided. Shown below, from left to right are three Chinese words with their approximate pronunciation above: danger, opportunity, and goal. The first two words together would mean "crisis." The third word, used as the illustration, has two correct uses-one, as a suffix to make a possessive case of a noun ("der"); two, as a word to mean "goal" ("dee"). It is realized that different dialects and different ways of mimicking the sound with English letters exist.

"wei" "gee" "der" or "dee"

Chingmuh Lee, MD, CPE 

Professor, UCLA School of Medicine

Department of Anesthesiology 

Harbor-UCLA Medical Center 

Torrance, California

Most revealing

I write to congratulate Dr. Washburn on his magnificent article in the January/February issue of The Physician Executive. It is masterful, and accurately portrays (to this reader's mind) the challenges we face together. Thank you for the illumination he has provided. I do have one question. On page 38, Dr. Washburn seems to suggest that the Clinton health plan of '93-94 would have brought "peaceful change" to the health care system, that the "opportunity" was "squandered," and the consequence of the "failure" is increased risk. This seems a fair hypothesis, but it created for me a cognitive discontinuity as I reflected on his first dangerous trend, namely that the practice of medicine is becoming too complex from a business and legal perspective. Specifically, he rightly alluded to increasing legal risks to providers.

As I am sure Dr Washburn is aware, the proposal's roughly 1,600 pages used the words "crime, sanction, penalty, fine, and jail" more than 100 times in reference to enforcing provisions that would have applied to physicians. My dilemma is that my impressions of the risks he described, and with which I agree, may not have been assuaged by the proposal. Did I miss the point? In any case, congratulations again on a fine article. Most revealing.

Sincerely,

George R. Beauchamp, MD

President Healthcare Values Alliance

Dallas, Texas 

[e-mail]

Squandered opportunity

Thank you for your kind comments. I had some hesitancy in writing an "end of the world as we know it article, but I did it anyway. I hope that it gets some people thinking.

My comment on the squandered opportunity of the Clinton Health Plan probably should have been further developed. My feeling is that in 1993-94 we had a rare situation where the politicians and the people and those of us in health care were ready to sit down and work out some really tough issues about the health care of our country in the coming decades. I would not hire 500 MDs to reform our legal system; too bad that Clinton hired 500 lawyers to propose a revamp of health care. He hired the wrong people and ignored the providers of health care. The result was a mess and got the response it deserved. I still think that we had a real chance to do something much better, but the effort needed to be much different right from the start.

Thanks again for your kind response to my article.

Earl R. Washburn, MD, FAAP 

Administrative Physician

El Dorado Pediatric Medical Group, Inc.

Placerville, California

[e-mail]

Reconnecting with the business

I wanted to let you know how much I enjoyed John Goldener's article on "Twenty Steps to Survive Managed Care" (volume 25, issue # 1). He hit on a couple of my favorite issues with the group practice model. I feel that, as a group grows, the individual members become removed from the operations of the business. His emphasis on monitoring the health of the practice Is right on. Small groups tend to be intimately familiar with these things because they are closer to the revenue and expenses. Group practices need to find a way to reconnect the individual members with the business. I had a couple of additional thoughts. The first involves the schizophrenia many of us feel when payment comes from both FFS and capitation. The incentives are often in conflict and the ideal of practicing the same regardless of payer can disadvantage the group with one or the other payer class. This often requires a shift in incentive at the individual level to something other than charges. We have used panel size (managed care member ship plus FFS patients seen in the past two years) in primary care as a method for compensation. Specialists are harder and we have used RVUs, recognizing that we may be incenting over-utilization on the capitated population. Our next model will involve subcapitation. I also wanted to put a plug in for accurate coding. Goldener alludes to this in discussing claim errors. We want to make sure our coding is accurate so that we optimize the FFS reimbursement for our services and to document the work we are doing on the capitated group. His caution about overbilling (upcoding) is important, given the current focus on "fraud and abuse." Anyway, nice job.

Richard A. Boss Jr., MD

Hitchcock Clinic

Concord, New Hampshire 

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Improving health or making money?

While I have changed my own perspective on alternative medicine over the years, Dr. Berndtson's and Mr. Weber's articles in The Physician Executive (volume 24, issue # 6) did contain areas that concerned me. Allergic sensitivities due to kidney yin deficiency along with liver chi stagnation and chiropractic treatment for asthma is difficult for this Occidental to understand. When I read "Cash. It's a whole new bankroll that can be tapped," I wonder whether this is all about improving health or making money.

I recognize that much of traditional Western medicine is unproved. But we at least try to prove or disprove treatments, even if we are slow to adopt the former and to eliminate the latter. Will the proponents of alternative medicine do the same? I have no problems with trying new approaches. We need to, and we need to keep our minds open. But I hope we will not go down the path of giving people what they want solely because they want it, because we can make money from it, and because somewhere, somebody said it worked. The fact that a patient improves with a treatment does not imply causality. Let us always try to understand why, and let us assume the null hypothesis until the evidence causes us to reject it.

In Carl Sagan's last book. The Demon Haunted World, he wrote of the magical thinking that has always been present in man's approach to the world. Many people believe in astrology, but that doesn't make it right. Quackery has never been far below the surface in medicine. Sick, desperate, or unhappy patients will pay for anything that somebody in authority says will work. Let us not misuse our authority; at the same time, let us not be blind to the fact that new, seemingly bizarre ideas may in fact be right. Let us also remember that those in authority in both mainstream and alternative medicine may be wrong. It's not the forcefulness with which the evidence is presented. It is the evidence itself.

Sincerely yours,

Michael S. Smith, MD

Las Cruces, New Mexico 

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Their own worst enemies

I thought I'd share my experiences on the paucity of physicians in rural areas in response to Dr. Weil's article series, "Attracting Qualified Physicians to Underserved Areas" (volume 24, # 6 and volume 25. # 1).

I am a board-certified obstetrician/gynecologist who has practiced in four rural areas (population less than 18,000) and one medium-sized city since leaving my residency in 1983. All but one practice was in Michigan; the last one was in rural New Mexico.

While I have no experience with inner city patients, there are similarities to rural patients. Many are on Medicaid and have psychosocial problems that cannot be easily solved. I can imagine that many physicians would have little sense of accomplishment in either setting. Indeed, it seems ludicrous to expect physicians to practice in inner cities whose governments are unable to effect any substantial changes and, in some cases, wish they would simply go away. It would also explain why many IMGs do not want to return to the abject poverty of their countries of origin.

However, rural areas also have some peculiarities, not the least of which is they tend to be their own worst enemies. The local power structure, often a "good ol' boy" network, runs the town like Hooterville. They are big fish in a very small pond who wouldn't amount to plankton in a larger community. The local physicians have often been established for 20 to 30 years and are hostile to newcomers and new ideas, while barely tolerating each other. I've attended raucous medical staff meetings at two rural hospitals in which I expected the staff to start shooting.

All of the hospitals were managed by large companies that were hundreds, or, in one case, thousands of miles away. The CEOs picked for rural hospitals are often not the brightest or most experienced individuals and are put in a place where they supposedly can't get into too much trouble. I've had more business sense than all of the CEOs for whom I've worked and I am merely a physician, with no formal training.

The physicians generally hate the CEO, since he dances to a tune from afar and is usually expected to ride shotgun on an unruly bunch who've managed to chase away most of the well-insured. They don't want anyone telling them what to do, seeing themselves as the last bastion of freedom in the health care system.

Practice in rural areas comes with a harsh fiscal reality. Most of the patients are on Medicaid or are private pay, usually meaning no pay. (The hospital in New Mexico was 30 miles from the border; we received poor Mexican patients who could never pay.) Medicaid reimbursement is much lower than commercial insurance and is often delayed for months, as the state usually has a shortfall a few months into the fiscal year. Obstetrics is particularly vulnerable, as one is not paid until months after the delivery. One can either try to be the kind of physician the patients want and risk bankruptcy or try to survive on volume, running a mill. I did the former and went belly up in seven months. A family physician who did OB in the same town ran on volume--his patients didn't like him, but he was solvent.

Practice set-up costs vary by specialty and location. As internist needs very little office equipment to get started. A general surgeon needs even less, since he does most of the work in the hospital. By contrast, setting up an OB office can be costly. Equipment can come at premium prices when there are no local distributors. The income 'guarantee" also comes with the expectation that the hospital will be able to quickly recoup the investment, In my experience, an OB practice in a rural area will barely break even in two or three years.

I've been recruited by hospitals three times with grandiose promises that fall short on follow through. All of them wanted to establish credible obstetric services to attract the insured patients seeking care elsewhere, but none of them were willing or able to provide the necessary resources. They figured hiring a competent physician would be enough, and were sorely disappointed when the masses didn't beat a path to their doors. None of them wanted to confront their poor reputations in their respective communities.

Solo practice for an obstetrician in a rural area can be insane. One does not function well being chronically sleep-deprived and instead becomes a liability. I recall one run of ten nights in a row with little or no sleep. The obvious solution is to hire two OB physicians, but most budgets can barely accommodate one. When I read ads for "1 in 7 call" next to "a unique opportunity" (read: solo practice), it isn't hard to figure out which one is more attractive.

Finally, a rural area is a cultural shock to most city folk. The physician replacing me in New Mexico had recently finished her residency in the Bronx. The nearest perinatal center accepting Medicaid patients was 220 miles away in Albuquerque. The patient rooms were made of cinder block and had no built-in oxygen or suction. The nursery did not have a compressed air source to run a ventilator-we had to do that in one of the birthing rooms.

It will take a lot more than money to attract good physicians to rural areas.

* Income incentives will likely have to be subsidized in areas with largely indigent populations if the practice is to remain viable.

* In the absence of any oversight, physicians learn to play the game" in rural areas, which is usually not in the patients' best interest. Even well-intentioned physicians may be required to make unpleasant choices or leave the area. A state or federal agency may be required to monitor rural hospitals to avoid the mischief of which Columbia/HCA and Quorum have been accused.

* Physicians may require a limited release from liability. Rural hospitals cannot maintain the levels of service of their metropolitan counterparts and should not be expected to operate as such. They cannot provide 24-hour in-house anesthesia for VBACs, Cesarean sections in 30 minutes, neonatal intensive care, or immediate access to MRIs. Even air transport can be delayed several hours. That is not to excuse shoddy practice. but we often have to play the hand we are dealt on short notice, incurring gut-wrenching liability in the process.

Sincerely,

David A. Rivera, MD, FACOG 

Lombard. Illinois

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RELATED ARTICLE: The Dance of Anger

DEAR READER:

The American College of Physician Executives sent a flashmail to members asking them whether physician anger, fear, and resentment was a phenomenon they were dealing with and if it needed to be addressed by the College. Yes was the overwhelming response. Here's what members told us:

Angst and disenfranchisement are sentiments that characterize American medicine, The practice of medicine has changed, and physicians decry the loss of autonomy even more than the decrease in income. Long endowed by society with a great deal of independence and control, many physicians now find themselves employees of health care systems that dictate much of what they do. Faced with reduced compensation and decreased autonomy physicians feel devalued. Their frustration is manifested in decreased productivity behavioral problems, and even leaving the profession.

By becoming compassionate leaders of change, physician executives can provide the support their medical staffs need to cope and thrive in the new health care environment. The articles in this issue of The Physician Executive address physician responses to changes in practice and explore leadership beyond the era of managed cost. They describe how physician executives can help physicians cope with the changing industry, from providing opportunities for meaningful physician participation to proactively becoming involved in the future of their profession by offering a better model of health, medicine, and the community. Physician executives need to work with physicians to orchestrate this effort to create a new vision of health in the 21st century

A program on dealing with anger, fear, and resentment will be offered at the Senior Executive Focus at the Spring Institute on May 12 - 14 in Las Vegas. Presentations by Charles Dwyer, PhD, from the Wharton School of the University of Pennsylvania, Robert Kuttner, economist and Business Week columnist, and interactive networking sessions will provide real solutions for changing the perceptions of today's beleaguered physicians. Dr Dwyer will also be facilitating a cyberforum on physician anger and resentment--please log onto ACPE's website at www.acpe.org to participate in this discussion.