Topics: Hospital Rounds; Using the Internet; Basic Training; Breakfast of Champions; Spring Forward Fitness Festival; Saving $ on Medical Care; What is a “Physical”?; Idea for Insurance Executives; RealAge.com; Blood Tests for Cancer; More on Saving $; Medical Errors; Newborn Home Visits; Charges for Missed Appointments; Sledding; New Patients; Active Vacations; Attitude; Home Exercise; Walking Program for Couch Potatoes
Thanks for the privilege of serving as your family physician. I learn so much interesting stuff from my patients that I could write a book, if I could remember the stuff. By the time I get home, all I can recall is that I had a fun day.
What’s new for 2005: Hospital Rounds In the past several years Dr. Laccheo and I have pretty much given up doing hospital work. Personally, there are several reasons for this. First and most important, the hospitalists are in a better position to do a good job because they are there all the time. If something needs to be done, it doesn’t wait for rounds the next morning. Second, rounds were never cost-effective or time-efficient when I’m on staff at two hospitals. It just takes too much time to find a parking space at St. Francis, ride the elevator several stories, track down a nurse, find the chart, talk to the patient-- then travel back to my car to start the process all over again for one patient at Stormont. This is one area where country docs have an advantage-- all the beds are close together and the staff knows who they are and what they need.
Now I’m rethinking that decision. Here’s the reason: if you have medical problem of moderate complexity (not, say, a quick in-and-out for appendicitis or a kidney infection) there is a good chance that you are in danger from a significant mistake. In recent years we have seen shocking studies of unnecessary death due to errors in the hospital. Why is this, in an era of modern medical miracles?
It’s not that there’s more stuff going on-- the number of lab tests and procedures is about the same, and they are better tests and procedures. I think the problem is a change in nursing philosophy that goes back about 25 years and is now institutionalized and uncorrectable.
When I was an orderly at St. Luke’s Hospital in 1970, I was assigned to work the day shift under the ferocious Miss Voss. She was older than God, retired from the Army, and her glare would pierce lead. We had a staff meeting every morning where we reviewed all the patients and got our specific assignments for the day, including what we needed to have ready for the doctors when they made rounds with the nurses. Mistakes and omissions were not treated lightly.
Now when I make rounds I can’t find the nurse, who is frantically busy with paperwork and the stuff I used to do, and he or she often doesn’t know the answers to my questions anyway. My impression is that, like teachers, nurses are required to spend so much time documenting what they do that there isn’t time to do what they should. They’re just flat overworked, and a lot of it isn’t nursing. It’s secretarial. Communication is not from doctor to nurse and to the next doctor; it is doctor to nurse to doctor through the chart, and this is a hazardous way of doing business. Furthermore, nurses seem to rotate from patient to patient daily, which undermines continuity of care.
Here’s what I’m going to do: Starting January 1, and for the rest of 2005, I’m going to be available to make rounds every morning at St. Francis Hospital. If it works out, in 2006 I’ll do the same at Stormont. If you want me to follow you in the hospital, that’s where you’ll have to go. It will be my job to interpret the uninterpretable for you, to clarify your options in language you understand, and to make sure something important doesn’t get lost in the confusion of modern hospital life. I may still want the hospitalist to manage your medical care if I think that is in your best interest, and of course if you have had surgery the surgeon will retain responsibility. Depending on the circumstances, insurance may not pay for my services because they are overlapping with another doctor. In that case you will have to decide if you think an out-of-pocket charge is worth it-- about the cost of a routine office visit. When it comes time for referral or hospitalization, we’ll try to remind you of this option so you can plan ahead. Again, except for deliveries and newborns, I won’t be rounding at Stormont in 2005.
Should you use the Internet to find medical information? Absolutely. Am I insulted if you run off Internet information and ask my opinion about it? Absolutely not. The Internet is an godsend, for doctors as well as patients. I need to look up stuff all the time, and the Internet is far easier to use than a library. Here’s the key: you need to use the Internet the way I do, which means distinguishing between sites run by medical authorities and those run by disease enthusiasts. If you go to a site run by a fibromyalgia enthusiast, you will find stuff ranging from sound advice to poppycock. If I go to that site, I can usually tell the difference; you probably can’t. So run it off, bring it in, and we’ll talk. On the other hand, if you Google the American Academy of Family Physicians, you will find patient information that is balanced and trustworthy, though bland. Or if you Google PubMed, you can research abstracts from the world medical literature the same way I do. Now the problem is that the information is reliable, but you may not understand the language or be able to put it in perspective. Same response: run it off and bring it in to talk about. Why don’t you just email it to me, and have me email back my answer? This is going to sound like a greedy doctor. If I were your lawyer or your accountant and you wanted me to research a problem for you, I would do the work, charge you my hourly rate, and email you the answer with my bill. But insurance companies have inserted themselves between you and me: they don’t allow billing for my research or emailing time, so I have no way to charge. And as much as I might like to spend all day corresponding with you about interesting medical problems in cyberspace, I need to generate income. So for now, that won’t work. There are experiments going on in different parts of the country along these lines, but nothing here.
Basic Training 2005: Most of you remember Basic Training from last year’s newsletter (available to read if you missed it). I’m not giving up yet, even though only six patients signed up, and none of them were my “target population”: those of you with a high risk of death and disability from obesity, high cholesterol, hypertension, poor conditioning, and/or diabetes. Despite the failure to enroll the Bill Clintons of my practice, I’m not going to give up. A few changes will be made for 2005. First, since this is NOT a diet program, I’m simplifying enrollment by eliminating the need to read Dr. Phil’s diet book. Second, I’m lowering the minimum age of participation to 40, and allowing couples to participate even if only one meets the age limits. Third, I’m lowering the cost to $150, nonrefundable, and throwing in the entry fee to the Spring Forward Fitness Festival (view on the website, doctoriliff.com) in March. Or, if you want an incentive, you can pay like last year: $500 in advance, with $400 refunded if you make every session. Fourth, You will still have to have a current database physical and treadmill EKG on file. The first meeting will Friday evening, April 8th, and then every Saturday for 12 weeks.
An article published in Circulation: Journal of the American Heart Association in September 2004 was stunning in its conclusion: masters athletes (people like you or me who had maintained a vigorous exercise habit for 25 years) at an average age of 68 (6 males, 6 females) had hearts indistinguishable from sedentary 29 year olds based on ventricular flexibility and power. Now these are not peoplewho fish, golf, and use riding lawn mowers-- but what they do is within the capability of almost all of you if you start before your body goes completely to pot.
Based on that study, I’m changing the focus of Basic Training. If I can’t get the desperate cases to sign up, I’ll happily take the rest of you and make you into walking athletes.
Breakfast ofChampions, 2005: My long-standing recommendations: Vitamin C 2000 mg, 1 good multivitamin, 1 dose of Metamucil (3 capsules first thing in the morning) or Citrucil, and 1 low-dose aspirin. What’s new? After 30 years, I’m tempted to take Vitamin E off the list. The best evidence is that it doesn’t prevent artery disease or cancer like we had always hoped; but there is good evidence for Alzheimer’s prevention, and prostate cancer studies are under way. But you need to start taking 1000 mg of fish oil in capsule form. The evidence that omega-3 fatty acids in the walls of blood vessels prevents damage is overwhelming. We have no way to directly measure intravascular omega-3 in clinical practice, and even a test for blood levels is not readily available. But my old high school classmate Dr. Bill Harris, head of the Lipid Research Clinic at St. Luke’s Hospital and a world expert on the issue, assures us that 1000 mg a day will get almost everyone into the protective range. Like Metamucil, take it first thing in the morning on an empty stomach; otherwise you’ll be tasting fish oil all day. Forget everything else in the supplement aisle unless you have an emotional attachment; there’s no evidence anything else works. Just for the record, men: nothing makes your penis longer except losing fat over your pubic bone. Just for the record, women: hormones don’t cause weight gain.
Spring Forward Fitness Festival: There are two important reasons to spend the first Saturday of spring at the Iliff Commons. First, your $25 entrance fee will support one of two good causes-- the Topeka high cross country team, or a little boy who is dear to our hearts, Luke Paine. To see a picture of Luke in his midget racer, go to http://www.kintera.org/FAF/home/default.asp?ievent=70971 A long time patient, Luke needs a lung transplant to live. Second, entering the 5K walk will give you information that could save your life-- your METs score (see METs and Me at the end of this newsletter). You can pick up information and registration materials at the office, or print it off the web site.
Emergency rooms and urgent care clinics: Managed care stopped health care inflation in its tracks in the 1990s, but Americans don’t like being managed. Now they’re spending money on health services like drunken sailors again. Don’t blame the drug companies; they’re a small part of the problem. Every time you encounter me or any other member of the profession, you ought to be thinking how can I get healthier cheaper? And you will have little or no financial incentive to do so, thanks to the craziest payment non-system a lunatic could devise. So why should you try to save a few bucks here and there? For the same reason you vote: what would happen if everyone didn’t? (That’s an application of Immanuel Kant’s categorical imperative of moral decision-making, for you philosophy majors). One way you can do this is to suffer a little inconvenience to save money. If your throat starts hurting at 1 a.m., don’t go to the emergency room! And if it starts hurting at 1 p.m., and we offer you an appointment at 3:15, don’t run to an urgent care clinic. Think about how to save money. Don’t kid yourself that the insurance company sets the price of health care; it just covers its costs, plus 10% or so. In a better system, you would shop for health care as carefully as you shop for a new car or a new washing machine-- but until that system arrives, we’ve all got to pretend that every extra dime comes out of our own pocket. When I ask you at the end of an office visit, Is there anything I can get you that will save you a trip later? I’m trying to save you money. You’ve got to help me.
What is a “physical,” and why does it matter? In 1982 Dr. Laccheo and I had visited the famed Cooper Clinic in Dallas, Texas, and were inspired to follow the practice model of the man who popularized the importance of aerobics. But we didn’t want to charge the $1500 he did for a good physical. I don’t think I have much originality; my gift seems to be copying somebody else’s good idea, only cheaper. I thought I could do a Cooper Clinic physical at 80% off, deleting only the least cost-effective items. I think we have succeeded, and to this day our database physicals are the most valuable service I provide. That’s where we find the catastrophes waiting to happen. If you let me do a database on schedule, I will pick up 100% of diabetes, high cholesterol, and high blood sugar in my practice; and 90% of cancers at a curable stage.
However, the old “yearly physical” is a waste of money. That’s why we recommend complete physicals only every 5 years from age 40 to 50, and every 2 years thereafter. We’ll continue to send you reminders at the appropriate intervals. But if you’ve been ignoring them, don’t!
Note to women: some of you apparently have misinterpreted our reminder postcards. A pap smear visit is not a database physical! The physical takes over an hour of our time in two visits to do the job right.
A Brilliant Idea for Medical Insurance Executives: Not my own, alas. In all my years of reading, writing, and thinking about what’s right and wrong with our health non-system, this one never occurred to me. It came from a letter to the editor. The author observed that health insurance companies are devising systems to reward doctors for good behavior by their patients; eye exams and blood tests for diabetics, for instance. Then she pointed out simply that this was like rewarding the trainer when a dog sat or heeled on command. Why not reward patients for the behaviors which are largely under their own control? So if Blue Cross has a list of things which all diabetics should do or be tested for, send them the list, and drop their premium if they follow through! If a doctor is derelict, an alert patient will shape him up pronto. Under the present setup, when a patient is derelict, the doctor has no recourse other than the bully pulpit.
RealAge.com: A website that is fun, educational, and motivational. Some people act younger than their age. Others don’t. RealAge helps sort out which is which. It isn’t solidly scientific, and they don’t give guarantees. But you should check it out. The survey takes about half an hour to complete. You have to know your cholesterol breakdown and your blood pressure-- ask us if you haven’t kept the labs we give you to keep, in the notebook we gave you when you first came to us (that’s a gentle reminder). According to RealAge, my habits make me closer to 45 than my 55 years on earth would indicate. My goal is to be 55 when I’m really 100. How about you?
Can I Have the Blood Test for Cancer, Doc? Would that cancer were a single disease, rather than many, and that we could test for it like diabetes or lipid disorders. Conquering cancer, I’m afraid, will take place in piecemeal fashion on many fronts. Meanwhile, doctors have to deal with the celebrity cancer syndrome. After Gilda Radnor died of ovarian cancer, the cry went up for CA-125 blood screening for healthy women. Unfortunately, the test is a very poor screening tool with very limited usefulness. Katie Couric showed the whole world the inside of her colon, and recommended colonoscopy for everyone. Colonoscopy is a good screening test for cancer, with about 95% effectiveness. So is sigmoidoscopy and stool blood screening, with the same effectiveness, at about 15% of the cost. So why choose colonoscopy? Because you don’t remember the procedure due to anesthesia (while nobody forgets their sigmoidoscopy). Why worry about an extra thousand bucks when it’s Other Peoples’ Money (also known as insurance)? Here’s another argument for Health Savings Accounts.
How to Make Health Care Affordable for your Family: 1. Make wise choices with health insurance. If your employer offers a good plan, take it. But what if that’s not the case? Don’t panic. Ask yourself an honest question: am I (or my family) at higher or lower risk than the average? Remember that commercial health insurance is not a fair deal for many people. If you are not overweight, don’t smoke, wear your seatbelts, and exercise regularly, some of your premium pays for the bad habits of your neighbors. More of it subsidizes the care of Medicare and Medicaid patients (who don’t pay their fair share for medical services by force of law) and those who fail to pay their medical bills. So buy a catastrophic policy to insulate yourself against financial ruin, and self-insure for the rest. You’ll end up ahead in the long run. If you have an unhealthy lifestyle or existing medical problems, insurance is always a good deal at any price you can afford.
2. Tell me you’re short of money. I write a lot of prescriptions, and drug reps give me a lot of samples. I am in and out of the sample closet all day. For acute problems like infections, I try to give you enough free medicine to more than pay for the cost of the visit. For problems I’m not certain that medicine will help, I try to give you enough to make sure it does before you have to buy it. And for chronic conditions, we can maintain some patients who can’t afford medicine on samples alone.
3. Take care of yourself. Go for a walk outdoors 4 days per week, working up to 3 miles in 45 minutes. Avoid crowds during the October-March cold and flu season, and get your flu shot every year. If you’re on medicine, take it as directed. Get a good night’s sleep every night. Eat regular meals with lots of fruits and vegetables and limited carbohydrates and trans-fats. Sounds kind of like your mother, doesn’t it?
Minimizing Medical Errors: Modern outpatient medicine is enormously complex. The amount of information processed by our office every day is staggering. Furthermore, insurance company policies regarding prescription plans compound the chance for error by utilizing distant wholesalers rather than your local pharmacy. For your own good, you have to help prevent errors. Know your medicines and dosages, and bring your bottles to appointments. Keep the records we give you in the notebooks we gave you.Doublecheck your prescriptions before you leave. Be an informed patient!
Newborn Home Visits: No change for 2005. See the 2004 Newsletter for details.
Charges for missed appointments: No change for 2005. To repeat: “We’ve never done it before, despite the fact that when someone cancels within 24 hours of their appointment, or forgets altogether, I’m twiddling my thumbs while the overhead rolls along at $175 per hour. With Americans becoming increasingly frantic, I’m finding that missed visits are more frequent. I hate to do it, but from now on we’ll charge $25 for failure to cancel a routine visit within 24 hours, and $50 for a physical or procedure. It won’t pay for the lost time, but may serve as an incentive to improve organization.We’ll waive the charge for really, really good excuses.”
Want to enjoy the best sledding in Topeka? My wife and I would love to have you and the kids out to the Iliff Commons on snowy weekends, if it ever snows in Kansas. We have graded a long run down a steep hill through virgin Kansas woods. It’s about a 3/4 mile walk, and you’ll be warm when you get there. Send your e-mail address to: email@example.com. Sorry, only e-mail will give us the quick notification you will need.
Are we still taking new patients? Always have, and will for a long time. We are very selective about the insurance plans we join (only Blue Cross, CIGNA, and Century this year), and so we lose patients every year because their insurance changes (and when it changes again, we hope they’ll come back). We particularly appreciate referrals from our patients, because you will have already matched your friend’s needs and expectations with the way our office works. Personal recommendations beat choosing your doctor out of the Yellow Pages every time.
Active Vacations: Here’s a good deal, if you are interested in a low-budget active family vacation that will leave you healthier than when you left Topeka: You can use my 2-bedroom, 2-bath Keystone, Colorado condo during the off season for $500 per week (less than 40% of the standard rate-- since I pay 50% to the rental agency, renting direct to you only costs me 10%, and I get a user I trust) plus a $68 cleaning fee at the end of your stay. You won’t get maid service, but I’ll supply you with a where-to/how-to list of activities to fill up every day. See the 2004 Newsletter for more details. River Run has great family dining and fast food, and within Keystone are four of the best restaurants I have ever enjoyed if you happen to be a gourmet. The kitchen of the condo is fully equipped for cooking and eating in. For simplicity, all rentals will be Sunday-in, Sunday-out. Call me at home (357-1854) if you would like to check dates for a reservation.
If attitude isn’t everything, it’s way ahead of whatever comes in second: I grew up in the Episcopal Church, reciting The General Thanksgiving every Sunday (written by English reformer and martyr Thomas Cranmer nearly five centuries ago). I don’t think it affected me much as a kid, but it sure does now. Try this once a day, and see if your attitude improves: Almighty God, Father of all mercies, We thine unworthy servants do give thee most humble and hearty thanks For all thy goodness and lovingkindness To us, and to all men; We bless thee for our creation, preservation, and all the blessings of this life; But above all for thine inestimable love in the redemption of the world by our Lord Jesus Christ; For the means of grace, And for the hope of glory. And, we beseech thee, give us that due sense of all thy mercies, That our hearts may be unfeignedly thankful, And that we show forth thy praise Not only with our lips but in our lives; By giving up ourselves to thy service, and by walking before thee in holiness and righteousness all our days; through Jesus Christ our Lord, to whom with thee and the Holy Ghost, be all honor and glory, world without end. Amen
Home exercise: I’m not a big fan of gym memberships, because most of us are too busy to use them. The following constitute a complete home gym, if you add a TV set to keep you from going nuts. A treadmill or exercise bike are reasonable substitutions for the Nordic Track , Concept2, or Air Dyne, but won’t give you upper body work at the same time. Bowflex Sport at bowflex.com, $798 and up. Nordic Track Classic Pro at nordictrack.com, $599. Concept2 Model D at concept2.com, $850. Schwinn Air Dyne Evo Comp at various online merchants, $799. Buy these specific models for the best value.
A Safe Walking Program for Couch Potatoes from the Cooper Clinic: Frequency is 4 times per week. If you have chest or abdominal pain, stop. If you feel exhausted, or can’t recover quickly, stop.