White Coat Wisdom

Fix Healthcare by Slowing the Gravy Train

2009-09-12T11:13:00.000-07:00

The U.S. healthcare system is stuck a financial quagmire, and everybody knows it. “I provide the service, he gets it, and you pay,” deadpanned anesthesiologist Saied Assef, MD, during the well-attended health forum I moderated September first in Green Bay. Doctor Assef rightly pointed out that any commodity traded this way would lead to spiraling cost increases. Well, our country pays almost 50 percent more per person on health care than the next most expensive nation, according to President Obama. And there are plenty of reasons for that.

Much of America’s financial healthcare ails are rooted in our insurance system, both for health and medical liability coverage. Let’s talk medical malpractice insurance first. Just as drivers of automobiles are required to have licenses, those trained to practice medicine must be licensed, as well. As part of licensure, physicians must buy insurance in case any of their patients sue them for malpractice. At the health forum, John Gallagher, MD, told us he and his employer have paid about $2 million in liability insurance premiums over his 30-year career as an obstetrician/gynecologist. And he’s never been sued!

Well, where is that money going? Here’s one answer. In 2006, a Dane County jury awarded $8.4 million to a 33-year-old patient who suffered from what the proceeding determined was malpractice. Four million, two hundred fifty thousand dollars of that award was for pain and suffering. Will those millions eliminate the pain?

Here’s something even more excruciating. The lawyers in these cases end up getting a disproportionate amount of such massive awards. As evidence, the winning trial attorney in the above-mentioned case lives in a mansion near Madison’s Lake Mendota. In 2009, it had an estimated fair market value of just under $5.4 million.

If that’s not high-octane enough for you, how about this one: In 2006, the Wall Street Journal reported that the then CEO of UnitedHealth earned $8 million per year in salary. But Dr. William McGuire’s unrealized stock options totaled a staggering $1.6 billion! That’s for one human being. Now, this is a company whose main business is to offer health plans to businesses, and seniors on Medicare. And it’s just one company among many in this industry.

Here’s one more example, especially for those who fear a government takeover of health care, because it demonstrates how an insurance industry coup already has taken place. Green Bay’s Doctor Nicky Plementosh told the health forum how a patient’s insurance company “cancelled an operation” by saying they wouldn’t pay for it after it had been previously approved. Why? Because the patient required another day of intravenous therapy, according to Dr. Plementosh, an OB/GYN. The doctor simply rescheduled for one day later because the underlying reason for the surgery hadn’t changed. “I needed to start the pre-certification process all over again,” she explained. That took six hours of costly staff time. When asked how unusual this situation was, she replied, “Very, very common.”

So the first step in reforming our healthcare system is to address the lunacy. No person, certainly not the leader of a health insurance company, needs to earn $1 billion. Doctors, not insurance companies, need to be the ones calling the shots on what treatment is necessary. Trial attorneys should not be siphoning millions of dollars out of the system when patients suffer a devastating loss. Injured patients deserve full compensation to cover their care, but not millions for intangible losses like pain and suffering. And, as consumers of healthcare, we need a system that gives us a financial incentive to make smart choices. We need to care about how much we are paying when we visit the doctor.

We get there by creating real competition among insurance companies, requiring all of them to offer a “standard health insurance plan,” which a government-appointed panel would develop. That way, consumers and businesses can make an apples-to-apples comparison of what is offered, and force companies to offer competitive products nationally.

We get there by dismantling our medical malpractice system and directly compensate losses by bypassing the trial lawyers.

We get there by doing what the President suggests, and require every citizen to buy health insurance. If we’re all in the pool, including the young and healthy, we can mitigate the damage for those who suffer expensive illnesses and hopefully, catch many more earlier on.

Yes, heath reform presents a myriad of mind-boggling issues, but many of them will become less onerous when we pick the low hanging fruit.

To watch the entire Green Bay health forum, see http://tinyurl.com/mjgl7a and click on the picture of the physician panel.

One ER Doctor Speaks

2009-08-17T13:42:00.000-07:00

"In America, we're dialyzing ninety-two year-year-old people. We spend the final resources on every life until we've squeezed every possible life out of it. We save life and we tangle ourselves up in all sorts of ethical dilemmas, but there's a lot to talk about what we're doing.

"I find it abominable that we take people who have horrible disabilities, like with a stroke, and their brain is destoryed and they're ninety years old. They can't recognize anybody around them and they put gastric feeding tubes in those foks, so that the GI doctor can get paid for doing that. Then, we send them to the ER doctor, so we can work on their fever. We spend thousands of dollars taking care of people who have no meaningful chance of return. And we don't have the resources to give a measles shot to a baby? That's perverse."

John Whitcomb, MD
Excerpt, End-of-Life Matters, by Stephen J. Busalacchi

End-of-Life preparation makes good sense

2009-08-14T07:11:00.000-07:00

The U.S. Senate Finance Committee’s decision to drop end-of-life provisions from health reform legislation is plain dumb. It’s really unfortunate that the part which would give people the option of getting Medicare-covered counseling regarding pain management, power of attorney for healthcare and hospice care would get nixed from a health reform bill. It’s dumb because end-of-life counseling leads to decision-making that honors each person’s wishes, provides more compassionate care and may well do so at much less expense than simply doing everything medically possible, whether the patient would want that or not.

End-of-life care is not the scary prospect portrayed in some political circles. In fact, hospice, pain control and consultations with a palliative care specialist make one's life better! What a shame that the Democrats' health reform proposal that would have paid doctors to make such consultations fell victim to fear mongering.The irony is that end-of-life care is all about options. It is not about telling people they have to die a certain way. The whole point is that the patient's wishes are carried out, after he or she is aware of the medical options. Unfortunately, a great many people find the whole topic too taboo and never discuss it, leaving their families in the lurch when some catastrophic illness strikes and mom or dad isn't able to make decisions anymore. To me, that's the scariest position to be in.

So, what tends to happen, according to many physicians I know, is that all medical care is given, whether the person has a reasonable hope for recovery or not. Think about that one for a moment. Medical technology can keep people alive for a very long time, even if they have no cognition and little prospect for regaining it. Look at the case of Martha "Sunny" von Bulow. She lived for almost three decades in an unconscious state, before dying last December. Imagine the medical expense associated with such choices!

The good news is that anybody wanting to make smart decisions regarding his or her health can do so right now by filling out the Power of Attorney for Healthcare form. In addition, speak to loved ones about your wishes, should you become unable to make your own healthcare decisions. Our population is aging to the point where those 65 and over will triple by mid century. Equally daunting, there will be fewer workers to support these retirees.

The fact is it will be impossible to do everything for everybody, and we might as well address that reality right now, as President Obama so wisely has. It's my belief that most people who are informed, will choose a pain-free, quicker death when there is really no hope for recovery, rather than live on indefinitely connected to tubes with no recognition of who they or anybody else is. How could the latter be a moral choice when so many lack basic health needs, especially children who may not even have access to immunizations?

Anybody who wants to die with dignity, pain-free and according to his or her own wishes, can do so right now! We don't need the permission of those who would rather bury their heads in the sand. The doctors in End-of-Life Matters clearly explain better than I can why this makes sense and why it will be less expensive, to boot.

Why Dying in America is Just Killing Us

Thoughtful physicians whose long experience shapes their insights, offer hope and wisdom for making end-of-life care a natural part of the life process. Death is not the enemy. Rather, it's something to prepare for. Read it via Google Books

This 72-page primer on end-of-life care may well be the most important investment you ever make. What could be more important than avoiding a death that does not honor your wishes?

"End-of-Life Matters is an outstanding collection of stories from physicians on the front line of practice, who've helped dying patients with heavy decisions."

William Rock, MD, Medical Director, Emeritus, HospiceCare, Inc.

Fulfillment-Physician Style

2009-08-05T14:35:00.000-07:00

If one thing stood out after having spent 56 hours interviewing dozens of accomplished physicians, it was the fact that these doctors love what they do. As I worked on the White Coat Wisdom manuscript, I started to become a bit envious. What gives them such great job satisfaction?

First of all, many of them don’t tend to consider what they do work, per se. More than one doc described medicine as more of a calling than an occupation.But this level of satisfaction isn’t limited to medicine. I’m convinced each of us can learn something from those who take great joy in how they spend their professional or occupational time. These physicians exemplify that fulfillment comes after commitment to something bigger than yourself, sacrifice and knowing you’ve done something important for others.

Take Doctor Sandra Osborn. She is a 2006 graduate of the University of Wisconsin School of Medicine and Public Health. Late bloomer? Quite the opposite. She’s more like a re-bloomer. She first graduated from UW med school in 1973. Yes, she’s a double-dipper. Doctor Osborn retired after three decades as a pediatrician and then immediately re-enrolled in medical school to mentor the next generation of doctors. Yes, she took those classes all over again, year after year. Sandy Osborn did it because she wanted to do it. Osborn, like most of her colleagues, is a lifelong learner. “Med School 2” was just an extension of that penchant for learning and contributing. Doctor Osborn also volunteers for what has to be one of the most demanding and important positions around: service on Wisconsin’s Medical Examining Board. People who don’t have time to formally retire tend to be long-lived. Remember that.

Like Osborn, Dr. John Riesch is a past president of the Wisconsin Medical Society. Riesch is a general surgeon with an unmatched passion for medicine. I wanted to know he developed that, working 100-hour weeks into his 70s. Doctor Riesch told me his perfect way of leaving this life would be to fall over after completing a procedure. Now that’s commitment.

Part of commitment is to care about those you interact with. The lesson from doctors is to get to know those you’re helping. It’s not just about making a contribution or volunteering at an event. Real satisfaction results when we get to know those we’re assisting. Doctor Mark Timmerman, a family medicine physician, told me the most rewarding part of medicine for him, was the broad exposure he had to the population. It makes him a deeper human being to get to know so many different kinds of patients.

Doctor Adam Dachman is another physician who finds great satisfaction in establishing rapport with patients. That may be unusual for a surgeon because their interactions with patients are often episodic. But as a musician and composer, Dachman finds inspiration in the individual stories that play out in his office. He writes songs about patients who inspire him and then gives them CDs. But medicine can be depressing at times, too.

Early in his family medicine career, Dr. Alan Schwartzstein internalized the fact that doctors can’t save everybody. In fact, they have to try hard not to view that reality as a personal failure, though many still do.Perhaps fulfillment comes when we’re able to both appreciate the good and accept the realities of life, even when they’re particularly unpleasant or even painful. So if we want a fulfilled life:

• Find your passion
• Volunteer
• Get to know the people you’re helping and empathize with their plight
• Appreciate the good aspects of your work, and
• Share a bit of yourself and your interests in the process• Recognize that we’re not all in control of what happens in life

I couldn’t help but be affected by these physician stories. They inspired me to keep writing. You don’t rise at 5 a.m. every day for three years while working full-time unless you’re really into something. For me, writing this book was without question, the most rewarding professional venture of my life. And it’s affected me in other ways, too. Shortly after completing the manuscript, I quit a stable job and started my own business. These physician stories inspired me to push myself. In two and half years on my own, I’ve had the opportunity to edit a dying UW-Oshkosh professor’s book manuscript, deliver the keynote address for young physicians from the California Medical Association, and co-present a day-long media training workshop for physician leaders at the University of Wisconsin Medical Foundation, among many other activities.But it took me a long time to begin the process of writing White Coat Wisdom, which led to this new chapter in my life.

For 15 years, I only talked about writing this oral history. And then a member of your Rotary Club showed enthusiastic interest in the idea. He was the first to really endorse the concept and instructed me to just do it. “I’d read that! You have to do it.” So I did it.

I needed a nudge and Ed Fink gave me a kick. Helping others succeed is rewarding, too.

Stephen J. Busalacchi is author of White Coat Wisdom: Extraordinary doctors talk about what they do, how they got there and why medicine is so much more than a job. See http://www.whitecoatwisdom.com/.

Managing Death

2008-07-02T07:00:00.000-07:00

With more people living into their 90s and longer these days, perhaps that’s one explanation for why it’s so hard for physicians to let go of dying patients.

“It’s difficult, at times, to know when to put the brakes on,” says Philip Dougherty, MD, an expert in palliative care who participates in the ethics program at Milwaukee’s Medical College of Wisconsin.

“Doctors are never trained to quit. They are trained to prolong life as much as possible,” says Dougherty, a semi-retired internist who has practiced medicine for more than three decades.

When he was fully active in medical practice, Dougherty was medical director for three nursing homes and was responsible for dozens of elderly patients. He recalls a revelation he had one day as he was doing rounds: “Of the 89 people, 11 of them could hold a conversation with me. Now to me, that’s a tragedy,” says Dr. Dougherty, an outspoken advocate for end-of-life care, which includes comfort care. Such examples are likely to become even more common, as the number of U.S. nursing home residents is slated to grow exponentially with the aging baby boom generation.

“The institution, just by keeping the person there, is treating them,” Dr. Dougherty points out. Injections of medicine, intravenous fluids, and feeding tubes are not necessarily required or in the best interest of these elderly patients. There is also reason to suspect that dying patients are not being cared for as well as they could be in their last weeks of life.

“The data indicate that as many as 50% of dying persons with cancer or other chronic illnesses experience unrelieved symptoms during their final days,” states the U.S. Centers for Disease Control and Prevention on its website, www.cdc.gov. But that’s exactly the kind of compassionate care physicians must provide to their patients, according to Dr. Dougherty.

“Do the things necessary to keep the patient comfortable and do nothing to interfere with the death process,” Dr. Dougherty advises, when patients are very old and have no chance for a meaningful recovery.

“Doctors are part of the problem,” agrees Kay Heggestad, MD, a veteran family physician who became a hospice specialist in recent years. She has spent the last few years of her long family medicine practice caring for dying patients in Madison, Wisconsin.

“Physicians don’t want to tell people they have six months or less to live,” says Dr. Heggestad, which is essentially the definition for who qualifies for hospice care. “Oncologists are probably the worst,” adds Heggestad. “I’ve had people who are hanging on by a shoestring and the doc is still talking about chemotherapy.”

However, Alan Schwartzstein, MD says if he’s sick and his life is on the line, he wants a surgeon who’s confident and maybe even a little cocky. And that’s exactly the kind of physician Schwartzstein and his family dealt with on the East Coast when his 85 year old mother fell seriously ill from a bowel obstruction. It was the latest of many health ills she suffered later in life.

Schwartzstein’s mother had stated emphatically that she didn’t want any extraordinary life-support and feared having doctors pound on her chest if she flat-lined during surgery. Nevertheless, the surgeon insisted the operation had a good likelihood of success and he wanted the chance to save her life, as she would surely die if nothing were done. But the patient’s family wasn’t completely convinced the surgery was the right course and wanted to talk privately about their options.

“(The surgeon) essentially refused to leave the room, so I could talk to my sister and dad,” recalls Dr. Schwartzstein. “He continued to try to convince us that this was the right way to proceed. I don’t know if I hadn’t been a physician whether I could have diplomatically insisted that he leave the room, so I could talk to my sister and dad.”

Ultimately, they decided against the surgery and Schwartzstein’s mother died a short time later with all her loved ones at her side.

These are always gut-wrenching decisions, but doctors like Heggestad and Dougherty say planning ahead by filling out a relatively simple power of attorney for health care form, as well as discussing one’s end of life wishes, can make these decisions much easier for family to make should you become incapacitated.

Doctor Dougherty is optimistic that physicians will become more comfortable with helping patients better manage the end of their lives because he says every medical school in the country now finally has a palliative care program in place.

“Once we have all these young physicians who’ve been better trained about kindness and humility, then we’ll see much greater strides being made in handling death and long illnesses that accompany it,” says Dr. Dougherty.

Doctors Get a Little Help from Above

2008-04-16T15:19:00.000-07:00

A patient dies on the operating table, but surgeon John Riesch of Menomonee Falls, Wisconsin, is able to revive him. When he regains consciousness, the doctor asks whether he remembers anything.

“I had the nicest visit with Tommy,” the patient replies.

‘“Tommy. Who’s that?’” the doctor inquires.

“‘You don’t know him. We lost our son so many years ago. He said, ‘Dad, I’ve been waiting for you for so long. It’s nice to see you.’”

Doctor Riesch says he’s had lots of patients who’ve reported out of body experiences during his four decades of surgical experience. “That’s exciting and it really makes you believe. No matter how smart you become in your field of medicine or whatever, there’s something else controlling all of this,” asserts Dr. Riesch.

Another surgeon from half a world away has reached a similar conclusion. Munci Kalayoglu, MD, Chairman of the Department of Surgery, Memorial Hospital, Istanbul, Turkey, recalls a patient whose heart stopped five times during the helicopter trip from a rural area in Wisconsin to the hospital in Madison where he practiced for many years. Her liver shut down and she was in need of an immediate transplant.

“On the way from the intensive care unit to the operating room, the patient’s heart stopped again,” recalls Kalayoglu. He says the anesthesiologist thought he was crazy to even try transplanting this patient because she was already dead! “No,” he says. “We did it.” Within 11 days, the patient went home. “You call it coincidence or miracle or God. I say it’s God,” states Dr. Kalayoglu.

Another surgeon, a former colleague of Kalayoglu’s, also bows to a higher power. “Packing off some bleeding, closing your eyes, saying a quick prayer and asking for a little bit of help to get bailed out of a difficult situation, has happened to me on more than one occasion,” says Layton Rikkers, MD, Chairman, Department of Surgery at the University of Wisconsin Hospital. “I don’ pretend to understand all of this, but certainly there are forces much greater than ourselves that must be at work,” adds Rikkers, who’s also editor of the Annals of Surgery.

Surgeons may be the ones who are confronted most directly with these life and death situations, but they’re not the only ones who are convinced spirituality plays a role in survival. Plenty of other physicians also report experiences that they cannot explain in scientific terms, either.

“Many physicians and nurses have intuitive and anecdotal impressions that the beliefs and religious practices of patients have a profound affect upon their experiences with illness and the threat of dying,” according to the Ethics in Medicine from the University of Washington School of Medicine’s website. “It is generally accepted that religious affiliation is correlated with a reduction in the incidence of some diseases such as cancer and coronary artery disease.”

Michael Miller, MD, president of the American Society of Addiction Medicine, is a believer in the power of faith. Miller is a psychiatrist who practices in Madison, Wisconsin.

“She should have died a million times,” Dr. Miller says of an alcoholic patient he treated over many years. “I detoxed her a million times. It was one of those cases where you can’t help but be humbled because you know that it isn’t up to you. God was keeping this lady alive,” says Dr. Miller, who notes that this patient eventually did succumb to the many health problems linked to alcoholism.

“All of us in medicine need to be grateful for the experience and the opportunity, and to realize what we can do and what we can’t do. There is stuff that’s bigger than us,” adds Miller.
In spite of all their rigorous, evidence-based training and experience, it may seem odd that these men of science would be open to the notion of God’s influence. But Dr. John Riesch says man’s knowledge can only take us so far.

“With medicine, people think it’s a science. It’s not,” says Riesch. “There are so many things we don’t know, that it boggles the mind. You learn that you are not all in control.”

Yes, doctors play a significant role in a patient’s recovery, but Riesch says there are times he knows that he had nothing to do with a person’s revival.

“You see people come back from death’s bed, not from me. I may push a button here or there to make sure they get the electrolytes correct, blood counts, but man…”