Wednesday, January 31, 2007

Your Doctor and You – Looking for Answers Outside of Traditional Medicine, Thirteen in a Series, The Great Debate, Fraudulent Practitioners, A Realist

The Great Debate

In 1999, the alternative vs. traditional medicine debate reached a defining moment when the doctor hero of the alternative movement, Andrew Weil, MD, debated Arnold Relman, MD, staunch defender of scientific medicine.

Dan Rutz, Senior medical correspondent at CNN refereed the debate, which was held at the University of Arizona medical center. The debater’s credentials were presented to the audience.

In one corner was Andrew Weil, MD, an international authority on integrative medicine and director of the University of Arizona Program in Integrative Medicine. He was author of many scientific and popular articles and seven books. Named by Time magazine as one of the nation's most influential people of 1997, Dr. Weil was a recognized expert on alternative medicine, medicinal plants, and reforming medical education. He was a member of the American Academy of Achievement and earned degrees in botany and medicine at Harvard University.

In the other corner was, Arnold Relman M.D., outspoken critic of integrative medicine (New Republic cover story, Dec. 14, 1998). He had served as editor-in-chief emeritus of the New England Journal of Medicine and professor emeritus of medicine at Harvard Medical School. Dr. Relman was a Fellow of the American Academy of Arts and Sciences, and a former president of the American Federation for Clinical Research, the American Society of Clinical Investigation and the Association of American Physicians.

To give you the flavor of the debate, here were Relman’s and Weil’s opening remarks.
Doctor Relman: “Integrating alternative medicine with mainstream medicine, as things stand now, would not be an advance, but a return to the past, an interruption of the remarkable progress achieved by science-based medicine over the past century.”

“I can't see how such integration, even if it were possible, would improve medical care or further the cause of human health. Most alternative systems of treatment are based on irrational or fanciful thinking, and false or unproven factual claims.”

“Their theories often violate basic scientific principles and are at odds, not only with each other, but with modern knowledge of the structure and function of the human body as now taught in our medical schools.”

“It could not be woven into the fabric of the medical curriculum without confusion, contradiction, and an undermining of the scientific foundation upon which modern medicine rests.”

Doctor Weil: “In this country and throughout the world, patients in unprecedented numbers are going outside of conventional medicine to look for help.”

“Why are people doing this? Clearly, there is dissatisfaction with conventional medicine. There is a large and growing gulf in this country between what patients expect of doctors and what medical schools are training them to do.”

“Patients want physicians who can take the time to sit down with them and listen and explain to them, in language they can understand, the nature of their problem; who are aware of nutritional influences on health; who will not push just drugs and surgery as the only approach to treating illness; who can answer intelligently questions about dietary supplements; who are sensitive to mind-body interactions; who will not laugh in your face if you ask questions about Chinese medicine; who are willing to look at you as more than just a physical body. I think those are very reasonable requests.“

Who Won?

Among the scientific community, Relman won the debate. The alternative community and the public felt Weil won hands down. Both sides remained unconvinced of the other’s position.

As time has passed, Relman’s position has been largely validated by government-sponsored double-blind, controlled scientific studies, which show most alternative products have no scientific value in relieving symptoms or curing disease.

On the other hand, Weil’s stature has gained widespread legitimacy in the public’s eyes and among some academic centers and mainstream practitioners, who know reality of alternative medicine’s popularity when they see it.

Beware of Fraudulent Alternative Practitioners

Unfortunately with legitimacy has come a rise in unprofessional, fraudulent practitioners (“Life and Death on Fringes of Medicine, Los Angeles Times, February 5, 2006).

Using the Internet and word-of-mouth promotion, peddlers of unproven cures offer hope to desperately sick people in imaginative new ways.

I had a friend with terminal pancreatic cancer who paid $10,000 for caffeine enemas and massive doses of multivitamins to treat his disease. Another friend, with advanced congestive heart failure, was told by a health food clerk that she had 20 proven remedies to treat heart failure. To doctors, thoughts of health food personnel dispensing medical advice can endanger and mislead patients.

The Case of Coretta Scott King

Some fatally ill patients forgo traditional care; others burn through their savings. Diagnosed with ovarian cancer, Coretta Scott King recently sought care at a Mexico clinic, Santa Monica Health Institute, known for its fringe medical treatments. She died there, and it was shut down by Mexican health authorities. Many patients merge conventional care with alternative practices without telling their doctors, risking dangerous side effects or drug interactions.

A Realistic Approach to Alternative Medicine by Doctors

For doctors, what is a reasonable approach to patients who are true believers in alternative medicine but whose health may be endangered through drug interactions or avoidance of proven traditional medicine?

As the editor of a monthly newsletter, Physician Practice Options, which reaches 100,000 practicing physicians, I endorse the approach of Doctor Neil Baum, a well-known urologist and medical marketing expert.

Baum advises doctors to learn from the effective humanistic techniques of alternative practitioners, ask patients about alternative drugs that may interact with prescribed drugs, show neutrality and understanding, and form relationships and develop referral relationships with legitimate alternative practitioners (“Clinicians Can Learn from Alternative Practitioners,” Physician Practice Options, October, 2004).”

In other words, don’t denounce alternative medicine practitioners, learn from them. When necessary protect your patients from potentially harmful products, but show understanding.

Wrapping Up

Alternative and complementary medicine is here to stay. Recognizing this, the National Institute of Health is studying it; academic medical centers and hospital systems are setting up programs and accepting patients. The America public continues to embrace alternative practitioners’ hands-on, naturalistic, spiritual, and compassionate approaches. But on its fringes, danger lurks in thee form of untoward drug interactions, worthless and costly procedures engendering false hopes, and fraudulent practitioner.

Your Doctor and You.— Looking for Answers Outside of Traditional Medicine: Twelfth in a Series

Unconventional treatments often seem to make people feel more comfortable, even when their accompanying theories are silly.”

Edward Champion, MD, New England Journal of Medicine, 1993

You're weary of seeing MDs. They usually prescribe drugs, dismiss your theories of self-care, and don’t have the time or interest to discuss vitamins, supplements or herbs or other things you consider good for your health.

For you, the time has come to talk of other things, herbs, acupuncture, chiropractic, naturopathic, and even exotic, quixotic procedures that may help, once everything else has been tried.

Your friends, the clerks at the local health food store, and multiple folks on TV, radio, and the Internet are telling you there’s relief to be found outside of traditional medicine.

After all, Chinese and other Oriental cultures believe in remedies outside of American scientific medicine. Surely thousands of years of experience mean something. These remedies have worked for them, why not for you?

Besides, alternative treatments are inexpensive, natural, and devoid of side-effects. You can choose which one works for you. You don’t have to argue about the bill with the insurance company. Control of your own health, in your own way, is important to you.

You and millions of other Americans have accepted complementary medicine as a legitimate “alternative” and “supplement” to conventional scientific medicine. The medical establishment is now grudgingly “integrating” alternative medicine into mainstream practices. Traditional doctors are aware alternative practitioners are on to something. They know practitioners outside of mainsteam medicine have succeeded in winning new patients by emphasizing humanistic, spiritual, natural, self-healing, and hope-engendering approaches to health.

Defining Alternative and Complementary Medicine

You might be interested in how The National Institute of Health, the most influential scientific establishment in America, defines alternative and complementary medicine(SOURCE: National Institute of Health, Division of Alternative and Complementary Medicine).

“Complementary and alternative medicine is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. While some scientific evidence exists regarding some CAM therapies, for most there are key questions that are yet to be answered through well-designed scientific studies--questions such as whether these therapies are safe and whether they work for the diseases or medical conditions for which they are used.”

Proponents and Opponents Not Swayed by Each Other

Alternative medicine vs. scientific medicine is one of those debates in which neither side is swayed by the others’ arguments. Recently a spate of articles in the scientific literature using double blind techniques to remove bias have shown Palmetto for prostate overgrowth, glucosamine and chondroitin for arthritis, Echinacea for the common cold, and St. John’s Wort may not be worth the bottles they come in.

About the only thing conventional medicine will admit is that chiropractic medicine has some benefits for back pain, ditto for acupuncture for migraine, and the placebo effect. The placebo effect is powerful, i.e., if you think something is going to make you feel better, it will.

Loyalists of Alternative Medicine

Loyalists of alternative products are by scientific studies discrediting their beliefs. unimpressed (“Natural Remedy Users Loyal, Studies or Not,” Associated Press, February 27, 2006. Loyalists say they will keep accepting alternative nostrums, undergoing its procedures, and downing its pills as long as they make they make them feel better.

The debate is unlikely to reach any definitive conclusion. While the medical establishment denounces alternative medicine, patients embrace it. According to a February 3, 2006, New York Times article “When Trust in Doctors Erodes, Other Treatments Fill the Void.” consumers spend $27 billion a year on alternative medicine. Nearly half of adults used alternative therapy in 2004, up from 42 percent a decade before.

Favorite Remedies

Millions of patients now venture outside mainstream medicine. They are taking herbs for colds, depression, headaches, arthritis, and backaches; getting their spines manipulated; desperately seeking cancer cures with massive doses of multivitamins, enduring caffeine enemas to flush out toxins, and undergoing intravenous therapies to leach out calcium from atherosclerotic plaques to unclog their arteries.

Why You Like Alternative Practitioners

You like alternative practitioners because they spend time with you, give hands on therapy, promise results, and don’t “poison” you with expensive dangerous drugs. Besides, you don’t have to haggle with insurers or worry about drug or surgical side effects. Herbs, supplements, and acupuncture needles appeal psychologically because they are either “natural” or rooted in traditions of Eastern medicine.

Grudging Respect from the Medical Establishment

Let there be no doubt. Alternative medicine (also sometimes referred to complementary, integrative, holistic, or natural medicine) has gained a foothold in today's medical world.

Alternative medicine has garnered respect from many mainstream physicians and researchers. Medical centers such as UCLA and Memorial Sloan-Kettering Cancer Center in New York City have created integrative programs, and medical schools increasingly offer courses in the field.

Even the vaunted National Institutes of Health, the government’s premier scientific arm, has gotten into the act. In 1998, the NIH established the National Center for Alternative fro Complementary and Alternative Medicine, or CAM.

Next: Your Doctor and You – Looking for Answers Outside of Traditional Medicine, Thirteen in a Series, The Great Debate, Fraudulent Practitioners, A Realistic Approach to Alternative Medicine by Doctors

Tuesday, January 30, 2007

Clinical trials - Your Doctor and You – What You Know and Might Not Know, The Money Problem, Hope Better Than Hopelessness, Eleventh in a Series

What You Know

One thing’s for sure. You know you want to live. As a transplant surgeon, John Najarian of the University of Minnesota, once said to me,

“I have never met a patient who didn’t want to live another day.”

From your research, you know clinical trials out there might yield a miracle drug. You know heretofore incurable cancers – childhood leukemia, Hodgkin’s disease, testicular malignancies, stromal tumors of the stomach, myeloid leukemia in adults and other cancers treated early and aggressively – are often cured.

You know about Lance Armstrong. You know today there are more cancer survivors than ever, 10 million of them (American Cancer Society).

What You Might Not Know

But, alas, you might not know most new drugs may are marginally effective, only occasionally curative. What you might not know is that 80 percent of oncologists are willing to try a drug if it prolongs life by two months (American Cancer Society survey). Oncologists want you to survive as long as you can, and they are willing to try any drug to prolong your survival.

These new drugs include.

• Avastin for colon, breast, .lung, and pancreatic cancers.
• Erbituz for advanced colon cancer
• Gleevec for chronic myeloid leukemia
• Herceptin for breast cancer
• Rituxan for B-cell non-Hodgkin’s lymphoma
• Tarceva for non-small cell lung caners and pancreatic cancer
• Thalomid for plasma cell myeloma

The Money Problem

These drugs may cost from $25,000 to $100,000 for a year’s treatment. Critics question the ethics of pharmaceutical companies in charging “outrageous prices.” (“Cancer Drugs Offer Hope, but Expense Worries Doctors and Patients,” New York Times, July 12, 2005).

Yet, even in the face of these criticisms, doctors and patients are reluctant to confront the pharmaceutical companies, perhaps because it is unseemly to put a value on human life. Some fear drug firms will stop research into newer more effective cancer drugs, and they hope, against all odds, the money will come from somewhere in this vast affluent nation.

Hope Better than Hopelessness

And so hope lives on that somewhere out there a cure lurks, a cure that may be just around the corner. We always have hope we will be one who wins the “battle against cancer.”

According to a New York Times piece “ The Ethics of Hope: Doctors' Delicate Balance of Keeping Hope Alive,” Meg Gaines, director of the Center for Patient Partnerships, a patient advocacy program at the University of Wisconsin, Madison, false hopelessness is worse than false hope.

"I tell people to ask the doctor, 'Have you ever known anyone with this disease who has gotten better?' If the answer is yes, just say, 'So let's quit talking about death and talk about what we can try!' "

Some patients beat the odds; others succumb even when the odds are piled in their favor. But total ignorance about the odds, she cautions, can be dangerous.
She says,

"People should know about prognosis to the extent that it's necessary to make good decisions about monitoring your health care,"

"You can't be an ostrich in the sand. When the stampeding rhinoceros is coming, you have to be able to get out of the way.”

Wrapping Up

Cancer remains a feared disease. Detected early, many cancer victims are cured. More than 50 percent of cancer patients now survive. There are now more than 10 million survivors. Although chances for cure are greater than ever, new more effective cancer drugs may cost $25.000 to $100,000 each year. Doctors who treat cancer patients will treat advanced cases with drugs if data shows these drugs will prolong live by two months or more. Cancer doctors must combine realism with hope, and if all hope evaporates, they can comfort patients by saying they will be with them until the end.

Monday, January 29, 2007

doctor patient relationships - Your Doctor and You - With Cancer, With Hope, Tenth in a Series

While there are several chronic diseases more destructive to life than cancer, none is more feared.”

Charles Mayo, MD, Annals of Surgery, 1926

You passed your 50th birthday sometime ago. You were looking forward to a prosperous middle age and secure retirement. But suddenly you were diagnosed with cancer. The very word “cancer” filled you with dread.

But you have hope. Your cancer can be cured with chemotherapy drugs, and more people are surviving cancer. A report from the American Cancer Society on January 18, 2007, reported cancer deaths have dropped for the second year in a row in 2004, the latest statistics available. That's the first time that has happened in 70 years. Cancer deaths fell by 3014, but there were still 553,888 deaths so these numbers may not mean much for you. But some hope is better than no hope at all. You know more than 50 percent of all cancer victims now survive, and there are more than 10 million cancer survivors out there.

But then you are shocked to find how much cancer drugs cost, to learn that most health plans don’t cover full drug costs of treating your cancer, that the new Medicare Part D bill requires a $4800 co-payment for certain expensive drugs, and that your prognosis remains unpredictable, making planning difficult.

The psychological and emotional impacts of the disease are devastating, and you may turn to prayer and support groups to prop up hope. You learn there is still a long way to go for ultimate answers – biological, psychological, ethical, and economical – and for converting cancer from unmanageable malignancy into a manageable chronic disease.

You will search for the best care medicine can offer and for compassionate doctors. You hope and pray you will beat the odds with the money and support needed to survive.

America’s Top Doctors for Cancer

I sit on the advisory board of a publication America’s Top Doctors for Cancer (A Castle Connolly Guide, New York City, 2005). The publisher and the Board have evaluated and selected 2000 of the nation are leading cancer specialists engaged in preventing, diagnosing, and treating cancers in children and adults.

Friends, relatives, colleagues, and others frequently consult board members about whom we would suggest as the best specialist and the best medical center for a particular cancer. These top doctors, and the latest drug or radiation therapy, may give you your best shot at cure.

Many cancers are potentially curable if caught early. More than 10 million cancer patients have been completely cured (Source; American Cancer Society), and most survivors can cope with their cancer like any other chronic disease. That said, it is important to say no cancer specialists or institution devoted to cancer is perfect. Cancer remains a disease calling for Art, Science, and Hope.

Cancer a Disease of Hope

Perhaps my son, Spencer, who is a nationally known poet because of his book The Clerk’s Tale (Houghton-Mifflin, 2004) ought to be writing this chapter rather than myself.\

Because, when chances for a cure dim, cancer is primarily a disease of hope. You hope against all odds you will survive. Cancer becomes a disease of the soul, mind, and spirit as well as the body. Cancer evokes the language of hope, and poetry lends itself to that language.

Maybe that’s why lists 100 books of poems by cancer victims. Emily Dickinson (1830-1886) penned these lines "Hope is the thing with feathers that perches in the soul,” and John Keats, a medical student at the time, composed the following poem with these opening and closing verses.

To Hope, by John Keats, 1795-1821

When by my solitary hearth I sit,
And hateful thoughts enwrap my soul in gloom;
When no fair dreams before my "mind's eye" flit,
And the bare heath of life presents no bloom;
Sweet Hope, ethereal balm upon me shed,
And wave thy silver pinions o'er my head!

And as, in sparkling majesty, a star
Gilds the bright summit of some gloomy cloud;
Brightening the half veil'd face of heaven afar:
So, when dark thoughts my boding spirit shroud,
Sweet Hope, celestial influence round me shed,
Waving thy silver pinions o'er my head!

The Medical Ethics of Offering Hope to Cancer Victims

For cancer doctors, offering hope, particularly false hope, can be a tricky and cruel ethical exercise.

• Should doctors offer false hope by placing a terminal patient on a ventilator, or should they give morphine or some other powerful pain killer to soothe the passage?

• Should doctors give a precise prognosis, because the law says patients have a right to be realistically informed about their prognosis? Prognosis estimates are based on statistical aggregates, but patients die individually, long before and long after any statistical mean.

• Should doctors passively issue a bleak prognosis, or should they aggressively encourage the patient to pursue unproven cutting edge treatment?

• Should they subject the patient the toxic therapy when, in your heart of hearts and in their experience, they know it will likely fail?

• Should they admit to the patient and family that no doctor knows how long the patient will live – that cancer survival statistics are notoriously imprecise?

• Should and when should they recommend the patient enter a hospice, a tacit admission that the end is near?

Answering any of these questions entails the Art of Medicine, rather than blind belief in the Science of Medicine. Doctors can’t always say precisely when and how things will turn out, but they try can do the best they can and offer emotional support.

When The End Nears

There comes a time when everybody knows – the patient, the family, and the doctor – the end is near. What does the doctor do then?

In Oregon, the patient can consider euthanasia. For most states, hospice is a more realistic option.

I have a friend and colleague, Dr. John Burns, an internist, who has something important to say about terminal care. When confronted by a hopeless situation, Dr. Burns said to patients, “I will always be with you. I will never abandon you, and we will face the end together.” This message, he says, always comforts patients.

Next: Your Doctor and You – With Cancer, With Hope, What You Know and Might Not Know, the Money Problem, Hope Better Than Hopelessnes

Sunday, January 28, 2007

Blogging, general - Grand Rounds of Blogging Competition Entry*

The Grand Rounds of Blogging have requested I enter a blog to compete for the best blog on the importance and status of the consumer healthcare movement.

Here’s my entry.
I’ve been asked to comment on the healthcare consumer movement; whether it will solve economic, treatment, and societal healthcare problems; and on my personal experiences with the consumer movement.

Here goes.
1. The consumer movement will prevail. Why? Because everything else has failed to stem costs and to rationalize care. Medicare has failed. Managed care has failed. Self-funded employers have failed. The only alternatives left are cost-conscious consumers spending their own money, or a government single payer system. Our culture is not likely to accept the latter.

2. Will consumerism solve healthcare problems? Not all at once, but perhaps in the long run. Market-based solutions lurch forward in incremental, experimental bursts and reverses. An HSA, HRA, and FSA here. A high deductible or high co-pay there. A tax system tweak here. A tax subsidy there. A specific comprehensive consumer-oriented website here. Inexhaustible Internet-rich health information lore there. A technological innovation here. A political setback there. But always forward the market will go.

3. My personal experience? As a practicing physician in Minneapolis, I was present at the creation at one of the centers of the HMO movement and of United Healthcare. I predicted physician-punishing and patient-depriving HMOs would ultimately fail (And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota, Media Medicus, 1988). Doctors and patients, I said, would rebel. I saw first hand how powerful market forces could be — how they forced Mayo to set up satellite sites in Jacksonville and Scottsdale, closed multiple Twin Cities hospitals, force Minnesota doctors into economic servitude, pushed the University of Minnesota hospital into economic retreat and into an unwelcome acquisition by a community health system.

Based on these and subsequent experiences, I believe market-based innovations - HSAs, high deductible health plans, technological innovations, and cost-sensitive consumers — will, for better or worse, be stronger change agents for lowering costs and rationalizing care than government.

Our capitalistic culture demands individual freedom and choice. The market is more likely to provide these attributes than government.

This submission argues healthcare market forces are more powerful and more likely to prevail than a government single-payer system. My blog is http;//
Comment by Richard L. Reece, MD — January 27, 2007 @ 11:43 am

* Grace Marie Turner, founder of the Galen Institute sends this correction and clarifying comment on my last blog which implied that a national single payer might be illegal,

“ I have a quibble with your blog: You say that “Three of the Democratic candidates for President – John Edwards, Barak Osama, and Hillary Clinton – don’t share the Journal’s views” and are pressing forward with universal health coverage. The Journal is writing about the illegality of state-based universal coverage schemes. But ERISA preemptions wouldn’t apply if the federal government creates a new, national single-payer health care system. ERISA only is there to protect companies from having to comply with 50 different state regulatory schemes.

I worry even more about the risk that Sen. Kennedy will prevail with his Medicare-For-All plan than I do about the attempts by the states, which are failing of their own weight.”

Saturday, January 27, 2007

Universal coverage - State Universal Coverage Plans May be Illegal

Periodically I will bring you up to date on the credibility of my January 11 blog predictions for 2007.

Prediction #2 for 2007

“The Universal Health Care movement will take shallow roots in states at the edge of the continent – California, Massachusetts, Maine, and Vermont.”

Prediction Progress

When I used the term “shallow roots,” I may have been prescient. According to a January 23 Wall Street Journal editorial, “Illegal Health Care,” California and Massachusetts “pay or play” plans may be illegal. The WSJ editors base this illegality on a ruling by Judge J. Frederick Motz of the Fourth Circuit of Appeals, who ruled that Maryland’s Law forcing Wal-Mart to” pay” 8% of its payroll for health benefits if it were going to “play” as a Maryland business was illegal.

The judge ruled that the “Wal-Mart tax” violated Erisa, the federal law permitting multi-state employers to maintain nationwide benefits and uniform administration from state-to-state. The Journal editorializes, ”We’re all for state policy experiments, but these ballyhooed health care reforms are policy blunders that won’t stand scrutiny in court, much less in the marketplace.”

We shall see. Three of the Democratic candidates for President – John Edwards, Barak Osama, and Hilliary Clinton – don’t share the Journal’s views. All have put their variations of universal coverage on the table (Mike Dorning, “Healthcare coverage gains political steam: candidate embrace universal coverage,” Chicago Tribune, January 26, 2007). Only one thing is for sure. No state or the nation as a whole can afford first-dollar universal coverage. Somebody, probably everybody, will have “to pay to play” the universal game.

Friday, January 26, 2007

Your Doctor and You -- Tired and Sick of Waiting – Times Vary in U.S., Are Longer in Canada, Can Endanger Your Health, and Require Time Management,

Waiting times for appointments to see specialists vary across the United States. Waiting times are a demand-supply problem. The greater a given specialist shortage, the greater the number of patients, the longer the wait times.

Take cardiologists. Heart disease is the most common disease in America, and by far the greatest killer.

Here are cardiologist waiting times Merritt Hawkins, a national physician recruiting firm in Irving, Texas, found in various metropolitan areas across the country in a 2004 survey. If you’re a Medicaid patient with a heart problem, it’s the most difficult to get a cardiologist appointment in Dallas, New York City, or Seattle.

City Shortest time Longest time Average time Accept Medicaid
Boston 18.7 days 120 days 37 days 11%
Philadelphia 20.1 days 136 days 27 days 80%
Portland 20.2 days 128 days 25 days 100%
Denver 20.2 days 128 days 23 days 30%
New York 20.2 days 26 days 20 days 0%
Miami 15.3 days 45 days 21 days 40%
Detroit 17.7 days 42 days 20 days 65%
San Diego 19.9 days 72 days 17 days 68%
Atlanta 20.3 days 28 days 17 days 80%
Minneapolis 20.2 days 105 days 15 days 80%
Los Angeles 18.1 days 23 days 13 days 22%
Washington, D.C. 16.0 days 23 days 12 days 100%
Houston 20.2 days 43 days 11 days 85%
Dallas 17.2 days 16 days 10 days 0%
Seattle 18.1 days 24 days 9 days 0%

Source: Merritt Hawkins Associates, 2004 Survey

Waiting Times in Canada

Waiting times for a specialty appointment are longer, on average, in Canada than in the United States.

In Canada, the median wait time between a referral by a family doctor and an appointment with a specialist increased to 58 days in 2005 from 25 days in 1993, according to a recent study by The Fraser Institute, a conservative research group.
Meanwhile the median wait between appointment with a specialist and treatment has increased to 66 days from 39 days over the same period.

Average wait times between referral by a family doctor and treatment range from 39 days for oncology to 280 days for orthopedic surgery.

Some Canadians die while waiting for an appointment, others have radiation treatments delayed, and still others cross the U.S. border for treatment.
In June, 2005, the Canadian Supreme Court struck down a provincial law banning private medical insurance and ordered the province to initiate a reform program within a year.

The decision ruled that long waits for various medical procedures in Quebec violated patients' "life and personal security, inviolability and freedom," and that prohibition of private health insurance was unconstitutional when the public health system did not deliver "reasonable services."

In February 2006, Quebec proposed to lift a ban on private health insurance for several elective surgical procedures, and announced it would pay for such surgeries at private clinics when waiting times at public facilities were unreasonable.
Nationalizing a health system may not solve the waiting problem. It often exaggerates it.

Indeed, in most nations with centralized government systems, more waiting is the rule rather than the exception. Universal government coverage prolongs waiting, for there no economic incentive to please patients.

Dying While Waiting

In the United States, patients can die while awaiting an organ transplant. The same goes for severely ill or injured patients in emergency rooms. Some doctors double-book appointments to make up for patient cancellations. And doctors say they are pulled in so many directions – phone calls, emergencies, interruptions, meetings, unexpectedly complicated patients.

Some Waits Unavoidable

In some cases, long waits may be unavoidable. Add to this that medicine is unpredictable and the fact that Medicare, Medicaid, and insurance companies are reimbursing doctors at such low rates that doctors feel compelled to see more patients. Consequently doctors may over-schedule and fall further behind as the day progresses. It may pay for you to schedule appointments early in the day.

Managing Time, The Inelastic Asset

For doctors shortening waiting times for you is all about managing time while showing you the courtesies you deserve. In the larger scheme of things, these goals require increased physician productivity (Marshall Zaslove, MD, The Successful Physician: A Productivity Handbook for Practitioners, An Aspen Publication, 1998).
For increased productivity, which translates to more time for patients, doctors can go to open access scheduling, delegate tasks to nurse practitioners and physician assistants, manage patients through email communications, conduct “virtual office visits, “encourage you to come bearing specific questions.

But in the end doctors cannot change the doctoring process – history, review of systems, physical, and treatment.

And doctors can’t create more time. Time is inelastic, irreplaceable, and unique, and they cannot make more of it. And everything a doctor does take time.

Wrapping Up

Doctors are shortening waiting times through open-access scheduling. This permits them to see patients on the day they call. Still doctors may not see you on time because of the unpredictable nature of medicine and increased demand for services in the face of a national doctor shortage.

Thursday, January 25, 2007

Doctro pateints relationships - Your Doctor and You - Sick and Tired of Waiting, Eighth in a Series

“I am ready any time. Do not keep me waiting.”

John Mason Brown, 1900-1969

Most patients are satisfied with their doctors, but there are complaints, particularly about time spent in the waiting room, according to a survey of about 39,000 patients and 335 primary care doctors that appears in the February edition of Consumer Reports….. Patients' top complaint about doctors was time spent in the waiting room. Nearly one in four patients (24%) said they waited 30 minutes or longer.“

Sources: WebMD, Inc, January 8, 2007, News Release, Consumer Reports, Re: Consumer Reports, February 2007 issue pages 32-36

You’re sick and tired of waiting -- waiting to get an appointment, waiting in the doctor’s waiting room, waiting to get the procedure done, waiting to get test results, waiting to see the specialist to whom you were referred, waiting in the hospital admitting suite, waiting in the emergency room, waiting to have your operation.

Why can’t doctors and hospital be more efficient?

Don’t they understand your time is just as valuable as theirs?

For patients tired of waiting, there is good news and bad news.

The good news is:

Doctors are working to shorten waiting times.

The bad news is:

Waiting lines are growing longer. The best advice: call ahead and insist on being seen on time.

Doctors are as concerned as you are about long waiting lines in their offices. They are keenly aware of new assertive “health care consumers,” who will be spending more of their own money, and will want to be seen promptly on time. So doctors are doing something about shortening or even eliminating waiting times for appointments. They want to please health care consumers and please patients.

Doctors and practice managers across the land are diligently introducing “open access scheduling,” or other forms of “wave” scheduling, in their clinics.

The “open access” concept is simple enough – leave slots open daily in the doctors’ schedules so you can be seen on the day you call.

“Wave” scheduling is based on the fact that patients come in “waves,” e.g., on Monday mornings and Friday afternoons, and you can more efficiently arrange your schedules to anticipate patient waves.

Switching from the present way of doing things, tight schedules with no openings, to seeing patients on the day they call or anticipating and planning for waves in which they appear, doesn't happen overnight.

Doctors must readjust practice habits. Open-access scheduling involves "doing today's work today," i.e. physicians going home with all work done, immediately dictating or otherwise entering their findings, eliminating appointment backlogs, and seeing patients on the day they call for an appointment.

Meanwhile, in the Short Run

Meanwhile, in the short run, waiting problems have grown worse.

Advances in technology have created more tests and procedures to wait for, and new drugs and treatments mean more people need more doctor visits.

Over the last ten years, the National Center for Health Statistics says doctors' appointments for people over 45 increased by more than 20 percent and emergency room visits went up by 23 percent.

Doctor Shortage

And then there’s the complicating factor of the doctor shortage. In the February, 2002 edition of Health Affairs, Richard Cooper, M.D. of the University of Wisconsin in Milwaukee projected a shortfall of 50,000 physicians in the U.S. by 2010 and 200,000 by 2020. At a 2005 national conference on the physician workforce sponsored by the Association of American Medical Colleges, most leading physician supply analysts agreed physician shortages will be serious and sustained.

This shortfallof physicians and lengthening waiting times for seniors may be greatly exaggerated by government policies calling for continuing cuts in Medicare fees for the next five years. According to a new AMA survey, nearly half of physicians plan either fewer new Medicare patients or will stop seeing new Medicare patient’s altogether if Medicare physician payments continue to be reduced.

Next : Tired and Sick of Waiting, Waiting Times Vary in U.S., are longer in Canada, can Endanger Your Health, Require Time Management, Ninth in a Series

Wednesday, January 24, 2007

blogging, general - Three Duties of A Medical Blogger

As a medical blogger. I have three essential duties:

1) To access accurately healthcare trends, to make predictions that matter, and to remind you occasionally when those predictions are coming to pass.1.

In my January 11, 2007 blog, Twelve Predictions for 2007, I predicted:

"Taking care of health problems of employees, both on an acute and chronic basis, at the worksite will become a growth industry. American HealthWays has made a science of reaching chronically ill clients both at home and work with protocol-bearing nurse extenders. Their evidence-based programs provide specific and personalized interventions for each individual in a population, irrespective of age or health status, and are delivered to consumers by phone, mail, Internet and face-to-face interactions. American HealthWays is contracting with a number of Blues plans and large employer grous. Niche companies, led by physicians and often using Internet technologies, are springing up at the edge to supply workplace health services... These include and These various efforts could be characterized as disease management at work."

On January 14, three days later, the New York Times carried an article entitled: "Company Clinics Cut Health Costs," with these opening two paragraphs.

“Frustrated by runaway health costs, the nation’s largest employers are moving rapidly to open more primary care medical centers in their offices and factories as a way to offer convenient service and free or low-cost health care.
Within the last two years, companies including Toyota, Sprint Nextel, Florida Power and Light, Credit Suisse and Pepsi Bottling Group have opened or expanded on-site clinics. And many employers are adding or planning to add even more clinics, which were experimented with about 30 years ago but fell out of favor amid questions about their cost-effectiveness.”

2) To write of how patients and doctors can create clinical partnerships, communicate with each other better, and strengthen the patient-doctor relationship. I have done this with a 20 part series on “Building Patient-Doctor Trust” and a current series on “Your Doctor and You.”

3) To direct you to the work of other bloggers who are contributing significant insights into the inside workings of the healthcare system.

That said, I bring your attention to this January 23 blog, http:/// “Improving Patient Communication Often Leads to Improved Healthcare,” by Shadid N. Shah, CEO of Netpective, a software consultancy delivering in-house, outsourced, and offshore solutions.
Here’s an excerpt.

What I liked about Emmi was that it facilitates physician-patient communication by providing “prescription-strength” multimedia programs to help patients understand what to expect before, during, and after a surgical or invasive medical procedure. As most of us who’ve been in this industry for a while intuitively get, the more a patient knows and understands about their care providers, their diagnoses, and their procedures, the better the patient’s overall health is likely to be

And this January 22 bog, www:// by Matthew Holt, a noted healthcare analyst and astute observer operating out of San Francisco., This particular blog, “A Nice Conversation with Brent James,” features an interview with Brent James, M.D., Dr. Brent James at Intermountain Health Care in Salt Lake City, is a giant in health care, a physician who has provided national leadership on the quality, safety and industrial processes movements. He is executive directors of the Intermountain Institute for Health Delivery Research in Salt Lake City. He's been active at the Institute of Medicine, and recently served as a panelist on the Citizen's Working Group in Healthcare. At 11,956 words, this may be the longest blog on recent record, but it’s worth the read if you are a thoughtful observer of the American healthcare scene.

Tuesday, January 23, 2007

Blogging, doggerel - A Limerick Medical Blogging Challenge

A doctor turned literary critic
challenged me to blog a medical limerick.
I thought for a while,
Then with a smile,
A dozen limericks I blogged double quick.

A medical blogger thought his blogs bright,
He considered them faster than light,
Until he sent one out one day
in a relative way
and it returned the previous night.

John Donne said no man is an atoll,
Expression is the need of our soul,
Now we start blogs,
To better our nogs.
And sit atop the literary honor roll.

There once was a blogger named Reece
Who thought his blogs should be for lease.
A blog reader told him off,
with a sneer and a scoff,
But Reece still blogs on without surcease.

For years it has been an end of mine
To write a blog for a friend of mine.
This man is a medic
(a genus pathogenic)
Who else would be a friend of mine?

Your blogger is a bald-headed male
Who writes comic poems without fail.
This Prince of the Grin
To whom Fun is Next of Kin
Now grips the health system by the tale.

Among the computer cognoscenti
Especially those on EHRs hellbenti,
It is widely held
And often yelled
The future belongs to digital literati.

In these limericks every line has been clean
not a word that’s profane or obscene
Or spelled by four letters
That might pain my health betters
Or demean them – if you know what I mean.

There’s a old blogger in Old Saybrook,
Who believes the health world he has shook,
But, why do you think?
To his blogs they link,
It’s because they link by mistook.

A health blogger should cultivate brevity,
With a suitable leaven of levity.
In short, be terse,
For nothing is worse
Than interminable verbal longevity.

A blogger is like a rare old pelican
His bill holds more than his belican
He can take in his beak
Enough words for a week
I’m darned if I know how the helican.

Not all of these limericks are original,
Some may even strike you as aboriginal,
But whatever your take,
Whatever criticisms you make,
Blogging a dozen is not trivial.

Sunday, January 21, 2007

Clinial innovations - Health Care Innovations for 2007 - Presentation before Comprehensive Health Solutions, Inc, Tuesday, January 23, 2007

A Coffee-Pot Theory of Health Care:
Boil It up from the Bottom Before
Percolating It Down from the Top

This talk will turn 180 degrees away from what other speakers are saying. These speakers are top health care lawyers, officials from the Department of Justice, the Office of Inspector General, the Centers of Medicare and Medicaid, and compliance experts. Other speakers work at the health care summit. I work in the trenches of care. I’m a bottom-up boiler, not a top-down percolator.

Government’s Role

In my view, the government’s should not only rule and regulate. Government should create a nourishing environment for health care innovators. The U.S. government doesn't create the health care economy. Entrepreneurs, innovators, and companies do. For the U.S. economic and physical health, we must balance the energy of entrepreneurs against the stagnation of regulation.

I champion private innovation and entrepreneurship. The U.S. health system’s success, and that of the economy as a whole, depends on vibrant innovation, health care decentralization and creative use of information technologies– not on government regulation. What happens in the field, not what occurs in Washington. D.C., is what matters.

Oh, I know government is the 800 pound gorilla at the Top of the Summit, the King Kong of Payers, and the Sheriff of the System. But government isn’t innovative. It makes the rules, but it doesn’t provide innovative tools.

If you provide care on the ground, innovation is within your control; policy decisions from the top-down aren’t.

One Workable Idea

If you carry away one workable idea from this talk, I will have succeeded, and you may further you success too. Here are four innovation examples.

• Create a Chief Innovation Officer for your organization.
• Delegate a nurse to manage a preventive program for uninsured ER “frequent fliers.”
• Install video and audio bedside modules for homebound patients.
• Organize an innovation team to brainstorm new ventures.

Action This Year

This year Democrats will push universal child coverage, government negotiation of Medicare drug prices, information technology incentives, and policies for covering the uninsured. Republican governors from Massachusetts and California have leaped upon the universal coverage bandwagon.

Not only government is engaged. On January 18, a broad coalition of business and consumer groups, doctors, hospitals, and drug companies unveiled a major proposal to provide health coverage to more than half of the nation’s 47 million uninsured. The coalition proposed expanding federal benefit programs and offering new tax credits to individuals and families.

The proposal, released after more than two years of work, was endorsed by 16 groups including AARP, the American Hospital Association, the American Medical Association, the Blue Cross and Blue Shield Association, Johnson & Johnson, Kaiser Permanente, Pfizer and the Chamber of Commerce of the United States.

“This is a proposal not for mandates but for incentives,” said Dr. Reed V. Tuckson, senior vice president of UnitedHealth Group, one of the nation’s largest insurers. “It’s a careful balance of public and private solutions.”The two key words here are “incentives’ and “balance.”

As we go through our political process, we should heed warnings from Europe. Stephen Pollard, Center for the New Europe Conference, says: “It would be the ultimate irony if the U.S. were to embrace single payer at the very time when Europeans are discovering competition and choice.”

As John Naisbitt points out in new book, Mind Set! in a chapter “Mutually Assured Decline,” Europe beats with two hearts – one offering comprehensive social welfare benefits and the other promising economic supremacy. You cannot have both. These two incompatible hearts, which beat in different rhythms, will likely result in mutually assured economic decline, and turn Europe into a historic theme park for well-off Americans.

My Purpose and Message Today

My purpose today is not so speak of universal coverage but to speak of incremental marketplace innovations you may see in 2007.

I define innovation as doing things better, quicker, differently, and more cost-effectively, even if it disrupts the usual way of doing things.

My message? Innovate and control your destiny, and someone else will.

Start of Road Show

Think of this talk as a road show. The show starts with my article in the August 2006 There I described five major new directions for 2006.

1. Information technology tools for consumers to better manage and pay for care.
2. Consumer-driven healthcare.
3. Chronic care management.
4. Public-private partnerships to manage Medicare and Medicaid recipients’ care.
5. Customized ambulatory care centers and retail health chains.

In my healthleaders article, I outlined this consensus for 2006 of top ten innovations among 100 national health care experts whom I polled.

1) Pay-for-performance programs.
2) Introduction of electronic health records into medical practices.
3) Add-ons to EHRs--instant medical histories, coding devices, prescription-enabling modules, or Web sites that permit registration, virtual visits, prescription refills and open-access scheduling.
4) Software facilitating prescribing from office.
5) New practice business models (concierge, cash and retail).
6) High tech/high touch remote patient monitoring with patient interactive capacity.
7) Personal health records with and without EHRs.
8) Disease management programs.
9) Transparency as part of the consumer-driven care movement.
10) Software enabling self-care, self-service and self-empowerment of consumers.


When asked to talk, I was writing the following book.

Innovation-Driven Health Care: 34 Key Concepts for Transformation
Richard L. Reece, MD,
ISBN 10: 0763746819
Price: $64.95 (Suggested US List Price)
Cover: Cloth
Pages: 400
Copyright: 2007
Bartlett and Jones will publish: 03/29/2007

2007 Expectations

From that book and other sources, here’s what I expect in 2007.

• Employer emphasis on HSAs, Consumer-Driven High Deductible Plans, consumerism, and workplace wellness.
• A web-based consumer revolution, backed by $500 million from Steve Case of AOL fame being a prime example.
• Call for government negotiation of Medicare drug costs and closure of the donut hole.
• Efforts to expand coverage at state and federal levels.
• A gradual policy shift will occur from illness to wellness– with greatest payments still on the disease side of the ledger.

Preventing disease and encouraging wellness is still more talk than action. Diseases are tangible and concrete; wellness is intangible and abstract.

At a more abstract level, we all know, or think we do, what the main lever for change will be – sweeping transparency and accountability reform through local, regional, and national data-sharing. This also is more rhetoric than reality.

Web-Based Innovations

Web-based innovations will flourish in 2007. For one thing, spreading the word by the Web is efficient. The Web lends itself to creativity and standardization across the enterprise and across the nation. For another, computers are becoming ubiquitous.
Web solutions will,

. help patients actively control their health;
• educate patients to understand their condition so they can comply with medical instructions;
• intervene at every medical interaction, communicate, and document exactly what to expect and what to do;
• aggregate and use captured documented exchange data to enhance care, improve outcomes, save time, and reduce risk.

Two countervailing realities, however, keep raising their heads.

• One, consumers lack real-time, relevant, and understandable information to comply with provider instructions or to change behavior.
• Two, many non-preventable diseases – Parkinsonism, Alzheimer's, ALS, MS, and non-smoking related cancers – are beyond consumer power to control.

What I Consider Innovative

What do I consider “innovative”?
• Emmi Solutions, Inc, Chicago, Ill: because it effectively educates patients with a pleasing voice, plain language, and precise illustrations of what to expect from the health system.
• Jewett Orthopedic Clinics, Orlando – because it has decentralized and gone out to patients by setting up seven outlets for minor orthopedic problems.
• MedAI, Inc, Orlando – because it has developed artificial intelligence techniques to help health care organizations make sound business decisions.
• Connextions, Inc, Orlando – because it has effectively used nurse callers and information technologies to manage health consumers in health plans of large corporations.
• Archimedes Project, Kaiser, Oakland, California – because it has used predictive modeling to manage major chronic disease decisions and to run drug clinical trials.
• Pavilion Healthcare, Wilmington, N.C. – because it has reached out to patients by setting up nine multispecialty ambulatory clinics in medically underserved North Carolina.
• Instant Medical History, Columbia, S.C.- because its founder has created easy-to-use software allowing patients to create their medical history before seeing their doctors.
• Bundled Bills, Oklahoma City, OK – because bundled bills combine hospital and physician costs for most hospital procedures and allow consumers to predict in advance what total procedural costs would be.
• SHAPE (Superior Heart and Pulmonary Evaluation), Mayo, Rochester, MN – because its developers modified existing cardiac and pulmonary tests to predict fitness and future chances of hospitalization and death.
• MinuteClinic, Inc, Minneapolis, MN, because it led the charge to bring affordable care for minor procedures in retail outlets.
• Big Boxes, Duluth, MN, and elsewhere – because it shows hospitals and doctors can work together and invest together in large one-stop facilities of benefit to all concerned.
• MedDirect, Inc., Grand Rapids, MI, a web-based company that offers convenient lines of credit and financing for patients and corporations at the point of care.

Five Road Stops

Now let’s visit five stops along the innovation road.

Software City
Consumer City
Chronic Disease City
Retail City
Capital City

Destination One, IT City, Home of Software Developers

1) Emmi Solutions, Chicago, step-by-step, encounter-by-encounter, documented instructions of what’s about to expect and what to do.
2) Artificial intelligence and predictive modeling, MedAI (Orlando) Archimedes (Kaiser), SHAPE (Mayo).
3) “Transparent” health plan websites, e.g. doctors and hospital fees and Rx calculator, Aetna leading charge, United Health and Humana not far behind.
4) You Take Control, Inc,, a company for consumers to protect sensitive information, Richard Dick, PhD.
5) Hospitals revealing prices in advance. St. Lukes Health System, Kansas City, Missouri,
6) Physician websites for scheduling, Rx refills, email messaging, patient education,
7) Medfusion, Inc., Raleigh, N.C
8) Connextions, Inc., a customer management company, headquartered right here in Orlando.
9) Hospital-physician bundled billing, particularly for elective high-tech procedures, personal experience.
10) Integrated community records aligning 7 hospitals and 4 doctor groups in Northwest and Alaska, PeaceHealth, Bellevue, Wa

Destination Two, Consumer City, Where Consumer Empowerment People Live

1) Health Savings Accounts and High Deductible Health Plans Growth, destined to capture ¼ to ½ of health plan markets by 2011.
2) Employers and their perception that consumer-driven care is only practical alternative short of single payer.
3) Health plans’ positive experiences (so far) with high deductible plans, e.g., Aetna’s report on first 1.6 million since 2001 12% preventive services growth, 70% rollover of unspent funds, cost rise,1% per year for HRA and HSA holders.
4) On economic front, Steve Case’s comprehensive website, and his acquisition of multiple health companies, backed by $500 million and his support, with intent of “revolutionizing” health care by empowering consumers.
5) On political front, Newt Gingrich, Center for Health Care Transformation, a feeding center of the media.

Destination Three, The Biggest Megapolis of Them All --Where Old Folks and Chronic Disease People Live

1) Aging population, “Demographics is destiny, a future that has already happened”
2) 150 million with chronic disease
3) 70 to 90 percent of present costs
4) Medicaid (53 million) and Medicare (42 million) populations
5) Private-public partnerships to handle problem, American Healthways, Pfizer Health Solutions, Medicaid HMOs with Medicare and Medicaid the prize markets up for grabs.
6) Shift to preventive side of market for the chronically ill -- in Medicare & Medicaid, in health plans, and among employers.

Destination Four, Mall City, Where You Can Get It Retail – and Wholesale

1. Walk-in specialty clinics, e.g. the Jewett Orthopedic Clinics here in greater Orlando area
2. MinuteClinics, acquisition by CVS with 6150 stores, acquisition of Red Clinics by Revolution Health, and other players, with plans for hundreds, probably thousands of retail clinics in Walgreens, Walmarts, and national drug stores, grocery chains, and national discount stores.
3) ProHealth Physicians, Inc., entry by physician into retail clinic market, a signal that doctors are ready and willing to join the competitive fray.
4) Urgent care centers, Urgent Care Association of America, 15,000 strong, expanding and ambitious
5), – doctor-led companies expanding outside physician offices
6) Big Boxes and Big MACCs, with and without hospital ties.
7) “Focused Factories,” Herzlinger, focusing on diseases like diabetes and AIDs, not yet viable because they lose money on sick patients.
8) “In-house clinics” in many national corporations.

Destination Five, Capital City, Where Money Lenders Reside

1) Venture capitalists have gravitated back to health care after physician management firm and collapses. They recognize health care is economic engine driving most communities, and nation as a whole.
2) Real estate developers and construction firms are providing capital because unprecedented hospital, outpatient, rehab, and other health facilities building boom underway – spurred in part by medical technology wars and by expanding population, 300 million +, 12.3% over 65.
3) Capital needed for large cancer and heart centers with two hospitals collaborating as partners in many communities. 50 heart centers in U.S, at least 5 two-hospital partnerships, Springfield, Ill., Waterbury, CT
4) Capital in the form of lines of credit for patients at the point of care, Meddirect, In, ( in Grand Rapids, MI
5) To repeat, new capital partners, e.g., construction firms and real estate developers, DeWitt Healthcare, Raleigh, N.C,
6) New practices and new startups capital sources, ,, Cain brothers, and others.

Things to Watch for on Your Journey

On your journey, watch for:
• New practice vehicles
• Toll booths
• Big Ideas
• Speed Bumps
• Megatrends

As you tool along, watch for these new practice vehicles

1) New practice models, concierge, group visits, cash-only (direct pay) practices, retail clinics, (Society for Innovative Practice Design) in search of physician satisfaction.
2) Consolidated large practice models – single and multispecialty – in search of infrastructure and efficiency.
3) Integration models based on Mayo model or other forms of integration, Carilion Clinic, Roanoke, in search of cutting cost.
4) Practices centered around Big Boxes,, Daniel Zismer, in search hospital-physician joint equity.
5) Big MACCs (Multispecialty Ambulatory Care Centers), in search of new markets and more physician control.
6) Academic-Faculty joint ventures, Beth Israel, Boston, in search of new revenues (125 medical schools).
7) Competing hospital cancer and heart joint venture centers, too costly to go alone, in search of ½ a pie or none at all.
8) Remote care models, home-based, in search of patient independence, better outcomes, few re-admissions.
9) “Integrative” Care Centers, Duke University, and chains of cancer centers, in search of more holistic care and patient satisfaction

Smart Card Tollbooth and Big Ideas

To pass through the tollbooth, just swipe your smart card containing your HSA and personal history,

As you near your final destination, keep these big ideas in mind.

1) Predictive models based on large databases, watch for battles of databases.
2) Decentralization outside of hospitals, off-site ERs and clinics, and often in rehab facilities or home care, doctor-owned ambulatory care.
3) Going where paying consumers work, play, and retire – exurbs and rural areas,” “hit ‘em where they ain’t.”
4) Card-swiping of smart cards containing HSA and personal health information, with prompt payment at the point of care.
5) Aggregation of data to estimate costs of episodes of care, which may vary by factors of 5 to 20.
6) Consolidated consumer databases reflecting “wisdom of crowds,” the google-factor.
7) Consumers as free and willing data entry clerks– examples: ATM, gas stations, super markets, airports, instant medical histories, personal health records, HSA smart cards.

Really Big Ideas

“The Biggie,” Systems Engineering – “Science and process engineering will help bring health care per capita costs down before we reach the breaking point.” George Halvorson, CEO, Kaiser, Personal Communication.

A) SOP Care ( Systematic, Organized, and Purposeful Care) by big organizations (Kaiser, Mayo, VA, other integrated systems, health plans, and big IT companies)

B) SOAPWare for small practices (SOAP stands for Simple Object Access Protocol) , a computer communication platform that might be better called Systematic Organization of Assessments, and Plans (AllScripts, NexGen, GE, SOAPWARE, Inc, eclinicalworks, doctor notes, and 100 other vendors, large and small.

Speed Bumps along the Way

1) Viability and workability of Regional Health Organizations (RHIOs), competitors reluctant to share data.
2) EHRs and PHRs without subsidies, only 15-25 % of doctors now have EHRs, fierce resistance and skepticism by many doctors.
who see nothing to gain by radically changed practice flow and patterns without economic gain.
3) Pay-for-Performance without adequate bonuses, favor large practices, but 80% of docs in small practices.
4) Transparency across the system seems doubtful.
5) Pay-for-Performance as outcome-improving and cost-cutting tool.
6) Regulation reduction or elimination not easy, the Stark truths.
To Stay on the Road
1) Focus on health and consumers.
2) Create new consumer options.
3) Decentralize,
4) Partner with physicians.
5) Ramp up IT.
6) Explore transparency.
7) Seek new capital partners.
8) Combine health-focused with disease-focused care.
9) Innovate: it’s never too late.

Churchillian Conclusions

As Winston Churchill observed:

1) “The inherent vice of capitalism is the unequal sharing of blessings. The inherent virtue of socialism is the equal sharing of miseries.”

2) “In the end, Americans will always do the right thing, after they have exhausted all the other possibilities.”

The future system will not be perfect but it will be kinetic, free-flowing, and full of winners – and losers.

Next: Because you’ve been so patient slogging through this long blog, I will give you and me a rest for the next three days while I’m in Florida giving this presentation. I will resume blogging with an off-beat piece called “A Limerick Challenge.”

Saturday, January 20, 2007

Electronic medical records - Digital Doubts -- More Perverse Verse

I have lingering deep-down digital doubts,
computers can storm all human redoubts.
can watch-over, make-over, and take-over
all patient-provider check-ups and fallouts.
No matter what the software rendition,
you cannot program the human condition.
In the end, I suppose you could say,
If dogmatic digital doggerel is okay,
You cannot out-google,
Every human boon-doogle.

Hickory Clickety Doc.
Hickory Clickety Doc.
The computer mouse ran up the clock.
The mouse rang up $’s on the clock.
Every step of the way,
every minute of every day,
the Doc had to pay,
despite practice flow disarrays,
staff training, and other delays,
and no clear or obvious
returns for financial outlays.

Next: Presentation before the National Summitt on Quality/Performance, Management& Compliance in Healthcare, Comprehensive Health Solutions, Inc., Orlando, Florida, January 23, 2007

doctor patient relationships, seeking a high on prescription drugs, Your Doctor and You - Seventh in a Series

Young, Healthy, Single, and Seeking a High
What Can Doctors Do?

What can doctors do about prescription drug “borrowing” and “prescribing” by one young person to another, or for that matter, obtaining these drugs over the Net?
Not much. But doctors can be alert to misuse symptoms – deterioration of school performance, lassitude, agitation, inappropriate behavior.

Multiple Drug Misuse in Heroine Users

They can also recognize that “doctor shopping” leads to “polypharmacy,” the use of multiple drugs. This is common among heroin users. In fatal deaths from heroin, multiple drug use is reported in 90 percent of toxicology reports. Prescription drugs were present in 80 percent of subjects. Subjects aged 14 to 24 years dying of overdoses use medical services six times more frequently than the general population. More than half of prescribed drugs were those prone to misuse, such as benzodiazepines and opioid analgesics.

A pattern of increasing drug -seeking behavior in the years before death was identified, with doctor-visitation rates, increased number of different doctors seen. Prescriptions peaked in the year before death (Data cited above from various Oregon studies, of heroin deaths, including Heroine Overdose Deaths --- Multnomah County, Oregon, 1993—1999).

Drug Access Techniques

Young adults trade unused prescription drugs, get medications without prescriptions from the Internet, and, in some cases, deceive doctors to obtain medications they think they need. It’s illegal to give prescription medication to another person, but the offense is rarely prosecuted.

Moving to the Beat of a Different Drug Drummer

Present practices of young adults giving mood-altering drugs to peers have a different goal than use of marijuana, cocaine, or powerful painkillers. These young adults don’t want to get high. They want to feel better - less depressed, less stressed out, more focused, better rested. The quickest route to this blissful happiness that end often seems to be medications for which they do not have a prescription.

A Pill for Regulating Every Mood

Some seek to regulate every minor mood; some want to enhance their performance at school or work; some simply want to find the best drug to treat a genuine mental illness.

Young people say many general practitioners, pressed for time and unfamiliar with the ever-growing inventory of psychiatric drugs, are happy to take their suggestions. Young prescription abusers have learned it pays to be informed. You can use your expertise to influence or manipulate primary care doctors.

Health Officials Worry
Health officials say they worry that as prescription pills get passed around in small batches, information about risks and dosage aren’t included. Even careful self-mediators, they say, may not realize the harmful interaction that drugs can have when used together or may react unpredictably to a drug.

Reflecting the Culture

Young people mirror America’s culture – a culture largely devoid of formal rites of passage and often unobservant of the few that exist.

Consequently, young people may make up their own rites of passage. These include feeling good at all times through drinking, drugging, and prescription drug use.

Contributing to Medicalization

These behaviors may well be a carry-over from the “medicalization” of untoward behaviors when young adults were going through school. Doctors may unwittingly contribute to this later behavior by prescribing mood-altering drugs to students referred to them by school authorities or parents. Drug prescriptions among the young meant to counter depression, anxiety, and mood or attention disorders went up 250 percent from 1994 to 2001 (Brandeis University Study).

Targeting Boys

Prescriptions for hyperactivity, attention deficit syndrome, and bad behavior most often target boys. One of every ten boys who visited a doctor during this time period left the doctor’s office with a prescription.

Of this phenomenon, conservative commentator Thomas Sowell commented,

“The motto used to be ‘Boys will be boys.’ Now it is ‘Boys will be medicated.’ The 3Rs have become Repression, Re-education, and Ritalin.”
The doctor culture may have created a counter-culture.

Wrapping Up

Doctors can't control swapping of information on prescription drugs or giving of these drugs to friends. The Internet has changed our culture. The young can now go directly to the Internet to learn about the psychopharmacology of these drugs. Many feel they know just as much as doctors, who are hard pressed to keep up with new drugs pouring out of pharmaceutical company pipelines. Also these young people can learn from Internet support groups, like, and they are perfectly capable and competent of using the Internet to order drugs from Canadian pharmacies and other sites. Also, through email and one-to-one relationships, the young are accustomed to exchanging highly personal information, an unthinkable behavior in previous generations.

Friday, January 19, 2007

doctor patient relationship, prescription drug users, Your Doctor and You - Sixth in a Series


The weller you are the more drugs you can take without getting sick.”

Eugene Stead, MD, “Aphorisms from Eugene Stead, Jr.,” Annals of Internal Medicine, 1968

You’re under 25. You’ve rarely been sick in your life, except for a bad cold or perhaps a bout of mononucleosis or an athletic injury.

You don’t worry much about health insurance. Why spend money on health care premiums, when you have electronic toys, clothes, and cars to buy; boys or girls to chase; places to travel; events to attend, parties to go to; and pleasures to pursue.

Speaking of pleasures, you’re in the fun phase of your life. You’re healthy. The world’s your oyster. You have new things to try, new things to do, new experiments to undertake– before age and reality force you to settle down.

Occasionally, at parties with your friends, you try a drug or two, a new drink, a drag of marijuana, or a street drug.

You’ve heard prescription drugs alter your mood and give you a high. You can get prescription drugs and don’t ever have to see a doctor. You have friends whose parents are addicted to pills, and you borrow from them. You have other friends who take drugs for their ailments. They get lots of pills and sell them cheap. You don’t worry. As long as prescription drugs are taken right, they’re much safer than street drugs.

You’re an Internet browser. There you learn about mood and mind altering drugs and their main and side effects. You can even order drugs online.

In a democracy, you’re free to exercise choices, to do what you want to do. You’re bent on pursuing happiness, no matter what the risks. Life, Liberty, and the Pursuit of Happiness. Isn’t that what it’s all about?

The Doctor’s Role

Doctors are the only ones who can legally prescribe drugs. They tend to think you’ll follow their directions. You know better. In fact, you may know more about these drugs than they do. Besides, you can always google and bring up this kind of information from the Boston Consulting Group and Harris Interactive.

Imperfect Patients

Many patients say they do not follow doctors’ orders. They cite a number of reasons for not taking their prescribed drugs.

In the past 12 months have you…

not filled a prescription 18 percent

sometimes forgot to use or refill 24 percent

delayed filling a prescription 26 percent

didn’t want the side effects 20 percent

taken a medication in smaller doses than prescribed 14 percent

the drug costs too much
17 percent

taken a medication less often 30 percent

don’t think you need the drug 14 percent

stopped taking a medication sooner than prescribed 21 percent

couldn’t get the prescription 1o percent
filled, picked up, or delivered

If doctors can’t control how their own patients follow prescriptions, how can they expect young people like you to follow doctors' instructions? Doctors can’t. That’s why you experiment. You occasionally use drugs like Vicodin and Ritalin. Why not? They’re easy to get. And you can mix them with alcohol or marijuana – anything for a high.

Sure, you hear occasionally about overdoses, even deaths, but that’s what happens to others – not to you. After all, you’re young and healthy. You have no where to go but up.

Thursday, January 18, 2007

Doctro patient relationships, fending for yourself, Your Doctor and You - Fifth in a Series

Fending for Yourself with Help

Most seniors, even those with chronic disease, are independent. You prefer to fend for themselves. But if you’re 75 or older, chances are you will need help. According to the National Council on Aging, most communities have centers for the aging offering help to improve the quality life, involve seniors in the community, and offer resources to aid independent living.

Senior Center with Expanding Services

Most seniors, given their druthers, prefer to remain in their homes. In Old Saybrook, Connecticut, where I live, the Estuary Council of Seniors, Inc. serves nine communities along the Connecticut shoreline.

Among other things, the Estuary provides nutritional counseling and low cost meals at its headquarters, has nutritionists who visit homes, and sponsors active daily meals-on-wheels programs staffed by volunteers.

The Estuary also offers health and support services, including talks by visiting doctors and other health professionals and other program for patients and caregivers of victims of emphysema, diabetes, Alzheimer’s, and spousal loss.

Senior services support exercise classes, weight lifting programs, book clubs, income tax preparation, and computers. Most recently, the Estuary has expanded its transportation services to include ferrying patients to doctors, hospitals, radiation and chemotherapy sites, in the immediate community and throughout the state.

The Estuary prides itself as a center where you can meet, greet, socialize, and learn. If you’re ill, of course, you may need medical services in your home. This is often supplied by home care providers or by visiting nurses associations. There are also agencies that will supply caregivers to stay in homes during the day or 24 hours a day.

Best Care by Doctors Who Know You

Many doctors feel the best care is care provided by a doctor familiar with the patient’s history. This is the position of the American Board of Clinical Medicine and an organization called Bridges to Excellence, a bonus program for doctors supported by multiple businesses including GE.

Francois de Brantes, who oversees Bridges to Excellence and who manages GE health programs, says, “We pay disease managers to coordinate care because no one else is doing it, but all the evidence says care coordination is better if done by a doctor. “

Doctors Feeling Less Chained to Offices

This may be, for many doctors feel chained to their offices. That’s where they receive their income, keep their equipment, provide ancillary services, and maintain their staff. Those are among the many reasons; they don’t make house calls anymore. But that is changing. A survey by the American Association of Family Physicians indicate 19 percent of their active members make house calls.

Doctors are feeling a financial pinch. They’re now less reluctant to venture outside their offices into homes and workplaces for disease management. Reimbursement is low, and they’re losing money in their offices. They're beginning to welcome information systems linking them to home-bound patients and to employees in the workplace and to nurses. Additional compensation for coordinating care would also be appreciated.

Gray Panther Political Power

Seniors vote. They swing elections. Therein lies the power of the over 65 crowd. If you doubt this power, I invite you to look at the Medicare Prescription drug bill passed in December of 2004. Senior anger forced Republicans and Democrats to pass “some bill” – even though it meant an unprecedented increase in Medicare spending, from $300 billion to $400 billion in 2006. With 78 million baby boomers starting to turn 60 this year, gray panther power will intensify.

Summing Up

It isn’t a bowl of cherries to be elderly, sick, and alone. But there is help out there.

• Senior centers are expanding transportation, educational, food, and educational services.
• Caregivers are going to homes.
• Doctors are devoting their time exclusively to the elderly.
• Health plans, independent firms, and health systems are developing disease management services.
• Companies are creating and installing remote technologies, i.e., telemedicine devices your home to keep you constantly in touch with the outside world.

If you’re still unhappy with the system, you always have the option of exercising your political power. When AARP (The American Association of Retired People), 40 million strong, speaks, politicians listen.

Wednesday, January 17, 2007

doctor patient relationship, when you;re old and blue, no one to tell your troubles too, Your Doctor and You -- Fourth in a Series


“Old age is not for sissies.”

Betty Davis

You’re over 75. Your friends are dying off. You’re divorced or widowed. You live alone. You’re one of 150 million Americans with one or more chronic diseases – arthritis, depression, hypertension, diabetes, coronary artery disease, heart failure, emphysema, Alzheimer’s.

You're frightened and confused about the new Medicare drug plan. Will you fall in the dreaded “Donut Hole,” or won’t you?

Your kids have moved and live in a distant warm weather state, most likely Florida, California, Texas, or a Southeastern state with a moderate climate. People are questioning your ability to drive, your last vestige of independence (“Older Drivers Fight to Stay on the Road,” Wall Street Journal, March 25, 2006).

You do not know quite what to do with the time you have left.

Should You or Shouldn’t You

Should you try to stay in your current home? That would be best. You want to maintain your dignity and independence. But it isn’t easy. It’s the simple things that are hard to do – cooking, shopping, and doing the laundry. Sometimes you need help dressing, bathing, and even doing ordinary toiletry. Where can you turn for help for these seemingly simple chores?

Should you sell the big house? Should you move into a condo? Should you consider an assisted living facility? Should you move closer to your children for family support? Should you get rid of your assets so you can qualify for Medicaid-assisted nursing homes?

These are scenarios and questions you face everyday. Doctors qualified to address problems of the elderly may not be available. A huge shortage of geriatricians exists in this country. The government is concerned. Chronic disease and long term care is costing a lot of money. Twenty percent of patients with chronic disease generate 80 percent of all health costs (in the management and economic worlds, this is known as Pareto’s Law – 20 percent of problems cause 80 percent of results).

Patients with Five or More Chronic Diseases

The Centers for Medicare and Medicare Services, says patients with five or more chronic conditions accounts for 23 percent of its beneficiaries but 68 percent of spending. These patients see an average of 13 different doctors each year and fill 50 prescriptions. By 2020, 25 percent of Americans will be living with multiple chronic conditions, and costs for managing them will reach $1.07 trillion (Source: Center for Medicare and Medicaid Services)

Medical Records, Medical Homes, and Home Monitoring

Some health plans are offering financial incentives to primary care doctors to invest in electronic medical records to improve care for patients with multiple ailments. With these records, doctors can coordinate care among multiple doctors and nurses.

The American College of Physicians, representing internists, the American Association of Family Practice, and the Academy of Pediatrics are asking to be paid more to establish a “medical home” in their offices.

The Centers of Medicare and Medicaid (CMS) have launched a pilot program covering 100,000 beneficiaries. CMS will pay eight companies, including Healthways, Aetna, CIGNA, and Health Dialogue to coordinate care.

Electronic Monitoring of Home-Bound Patients

One rapidly evolving trend is remote electronic monitoring of home-bound patients with small bedside video and audio units though. Through these units, chronically ill patients can initiate conversations with nurses and doctors and signal distress. Doctors and nurses, in turn, can see you, talk to you, listen to your heart and lungs through a remote stethoscope, and monitor your vital signs, your weight, and even your blood oxygen.

Next Episode of Your Doctor and You. Old, Sick and Alone. Fending for Yourself.

Tuesday, January 16, 2007

doctor patient relationships, poetic doggerel, Your Doctor and You -- A Poetic Interlude

My recent outburst of three episodes of Your Doctor and You, you deserve a break. As John Asberry, the Pulitzer Prize winning poet observed in last Sunday's New York Time Magazine, "It doesn’t take so long to read a poem, and if you need a quick fix or consolation, you can get it. ”You will be interested to know that, the most popular physician blog, and, destined to be the be the world's most comprehensive health are website, will mention my blog.

Prose and Cons of Blog Poetry:
More Pros than Cons, I Trust

To my astonishment and conceited great satisfaction,
My blog is finally gaining much needed gratis traction.

Traction is coming in the form of complimentary e-mails.
More often emails come from males rather than females.

As examples of these responses, still too few,
I offer as evidence these recent precious two.

One comes from one of America’s top health leaders,
The other comes from one of my anonymous readers.

From George Halvorson, Kaiser’s Chief Executive,
came this message in a series of sentences consecutive.

He is giving me personal thanks,
And saying with him rhyme ranks.

“Thanks for the blog.
Are you getting responses?
I love the idea of rhyme.
I wrote a few rhyming pieces in college.
We could be the Twin Poet Laureates
of health care blogging.
Just a thought.”

George, please note, chose to converse
in a poetic medium known as blank verse,

His mind is not blank, just his poetic prose.
He’s a frustrated poet to the tips of his toes.
Let us hope in rhyme he will now compose.

The other comment sprang from an unknown source,
too shy to let his or her identity be known, of course.

He or she has his or her likes and dislikes,
It depends on which gender mood strikes.

“Twas a dual of two poets..
I personally liked Richard Reece's poem
over Richard Brautigan's piece.”

Mame or Sir, whoever, you have your opinion,
even if it falls outside your literary dominion.

Choosing my poem over Brautigan’s piece,
is an amusing case of undeserved noblesse.

Now I am no Ogden Nash,
But I am making a splash.

Before you know it,
I will be a real poet.

It was the late poet Ogden Nash,
for those old enough to remember,

with a still intact memory cache,
who said one frigid day in December.

“I test my bath before I sit,
and I'm always moved to wonderment

that what chills the finger not a bit,
is so frigid upon the fundament.”

There you have it,
Before you know it,

I will be a poetic dandelion,
a widely known literary lion.

The following verse was written
For my fans who are poetically smitten.

Some call this dogmatic doggerel,
I proclaim it as fulsome folderol.

Roses are red.
Violets are blue.

Dandelions do,
what they want to do.

Monday, January 15, 2007

doctor patient relationships, ending information limbo, Your Doctor and You - Third in a Series

Ending Information Limbo

Here are your options for ending information limbo.

• Simply seek out a doctor with credentials on the wall with whom you feel comfortable and trust.

• Find your doctor through word of mouth, referrals from other doctors, asking your friends and relatives, calling your local hospital or medical society, or by leafing through the yellow pages.

• Go to to find if doctors have been disciplined.

• Visit to see how the federal government rates hospitals for their treatments and outcomes of certain common diseases.

• Call your local hospital to see how many nurses they have on staff, and what the nurse/patient ratio is (the ideal NPR ratio varies from 1:1 in trauma units and operating rooms to 1:5 on general medical or surgical wards)

• Go right to the top by consulting America’s Top Doctors book or a referral service like America’s Best Doctors (

• Proceed directly to a nearby well-known clinic or hospital with a good reputation. Hospital systems and academic medical centers pride themselves on having the best doctors and providing the best care.

• Look at your health plan’s website. It will have information on doctors and hospitals in its network, the website may compare costs of brand name and generic drugs, and it may even list the prices charged by its participating physicians.

• Gravitate to doctors who have practice websites. Most businesses across America now have websites. Why not doctors, too? Ideally practice websites will tell you how to get to the doctor’s office, the hours of operation, the credentials of the doctors, and will help you refill prescriptions, schedule appointments, educate you about disease, and allow you to consult with your doctor by email for minor non-emergency illnesses.

• Study your disease over the Internet, download relevant references, compile your questions, and then go to the doctor with your concerns. Doctors vary in how they react to Internet-savvy patients. Some doctors welcome well-informed patients; others regard them as misinformed. You may want to call ahead to see how the doctor might react.

• Tell your doctor you want to create an equal partnership with equal sharing of information, guidance to the best evidence, open-ended access, and economic mentoring about best values in health care.

Another Possibility

Another possibility is slowly evolving – patronizing doctors whose offices have electronic health record systems. Government, corporations, health plans, and consumers are pressuring doctors to install computer systems to generate electronic medical and health records. These electronic records, it is said, will make you safer, separate good doctors from mediocre doctors, and coordinate your care as you go from doctors’ offices to another, to hospitals, to rehab units, to your home.

Another Tack - Interviewing the Doctor

You may want to interview doctors before considering their services. That way, you can judge the personal chemistry and see if you can work with this person. You can ask them about their results, how many procedures they have done, and how their quality ranks among their peers.

This approach may work best if you are considering undergoing a major operative procedure. It may require confidence and an assertive personality.
I have a friend, the former CEO of a major company. He knew he had to have both knees replaced. He did not go to the Internet to find the best doctor.

Instead he personally visited four orthopedic surgeons, assessed the compatibility of their personalities, and asked how many bilateral knees that had done and what their results had been. The operation succeeded, and he is now walking without pain.

My friend says if had he had it to do over again, he would still go the interview route. Nothing, he says, can replace talking to a doctor in person before what needs to be done is done.

Sunday, January 14, 2007

Doctor patient relationships,, information limbo, -Your Doctor and You - Second in a Series

Information Limbo

Limbo is not a good place to be.”

Bill Joy (1954- ), Chief Scientist and Co-Founder in 1982 of Sun Microsystems

• You’re confused.

• You have a chronic disease, not curable but controllable.

• You’re taking a drug to treat the diseas.and you have read the long list of side effects.

• You have seen the drug advertised on TV.

• You have googled the disease and the drug.

• You have joined an Internet disease support chat group.

• You remain befuddled about what to do.

Things aren’t going well. You’re still feeling ill. You’ve seen multiple doctors, each of whom has a slightly different opinion and who may have prescribed another drug. You’ve obtained a second, third, and fourth opinion.

You’re in disease information limbo.

Information Overload

You’re suffering from information overload. It’s nobody’s fault in particular. You’re doing the best you can to find straight answers. You want to understand the options. Your friends, spouses, and relatives are trying to help, but there is simply too much information to absorb and digest.

You’d like to trust the drug companies, but those long lists of side effects frighten you, and drug costs are becoming prohibitive. And even though drugs are field-tested and marketed at considerable expense and are Federal Drug Administration approved, you’re aware drugs like Vioxx harbor unexpected complications.

Your doctors are doing their best to prescribe the right drug, which to the best of their knowledge, works. But the media is telling you drug companies are unduly influencing doctors with luncheons, gifts, and consulting fees.

The Internet web sites – some containing neutral information, some biased with information relating to their product, much of it unfiltered by editors or experts – are trying to keep you informed – or to sell you something.

Parts of the Information Limbo Problem

Parts of your limbo problem are,

• No precise “scientific” answer exists for each individual patient for every problem. Everybody has a different set of genes and reacts differently.

• Much medical knowledge lies in the “gray zone.” Anecdotal stories may say something works, but solid unequivocal scientific evidence is lacking or conflicting.

• A subtle and sometime profound interaction exists between mind, body and spirit. This is the “placebo effect.” If you trust doctors, you respond better. If you believe a drug is helping, it will. Prayer may work but sometimes not(“Long-Awaited Medical Study Questions the Power of Prayer, New York Times, March 31, 2006).

• Then there is Internet misinformation. Internet vendors have a product to sell an ax to grind, and they grind it – whether it holds scientific weight or not. Infomercials hype products with “antioxidant” powers to destroy those “dangerous free radicals,” and you wonder if this is too good to be true.

• The “fragmentation” of the system contributes to your problem. Medicine is divided into 50 or so different specialties. Many specialties function apart from one another, and some specialists do not know what other specialists are recommending or prescribing. Presently no common patient record is accessible to all doctors that keeps all caregivers across the health care spectrum coordinated and informed.

• You may not be complying with the doctors’ instructions. As many as 30 percent of patients never fill their prescriptions, stop taking the medicine, fail to follow the dosage schedule, or randomly take the pills of spouses.

Next blog -- Ending information limbo

Saturday, January 13, 2007

Doctor Patient, Relationships Your Doctor and You- First of a Series

Navigating the System

This series will consist of excerpts of chapters from my unpublished book Your Doctor and You. These entries may be a trifle long for instant news-seeking and quick-reacting blog readers. Forgive me. I prefer depth to one-liners and balance to sensational revelations or late-breaking news. I am not the Jack be Nimble, Jack be Quick, Jack Jump over the Candlestick type. I don’t look for current greedy villains. I prefer quiet innovative heroes, many of whom I describe in my upcoming book, Innovation-Driven Care: 34 Key Transformations (Jones and Bartlett, 2007). I will occasionally break up the longevity by inserting a poem or two.

For many of you patients navigating the health system – finding the best specialists, avoiding the worst, selecting the right cosmetic surgeon, choosing a cancer doctor who knows most about your particular malignancy, picking the right health coverage, unearthing care you can afford, and finding help in settling disputed claims – has become an exercise in futility because of the overwhelming complexity of the system.

To whom can you turn? Your employer, your insurance agent, your doctor, your local hospital, your local medical society, or, Internet search engines, such as Google, Yahoo, Netstar, or soon, These sources may help, but in the end you must help yourself as an informed consumer. In desperation, you may even want to turn to this blog.

Human Help Needed\

As good as the Web is for ferreting out health information, it is not enough. Human help is needed. I have tried to provide that help by writing this book for patients in different, sometimes difficult, economic, disease, and cultural circumstances.

This book seeks to instruct patients how to get the best care depending on your situation. i.e., whether you are healthy, sick, old, young, wealthy, foreign-speaking, poor, insured, uninsured, happy, unhappy, neglected by doctors, cultivated by doctors, afflicted with cancer or other dread disease, going to alternative practitioners, or just plain frustrated with the system.

Americans Generally Satisfied with Quality of Doctors, Nurses, and Hospitals

Surveys indicate most Americans are satisfied with quality of their health care: 86 percent are happy with their doctors and nurses, and 74 percent rate the quality of their local hospital as good or excellent.1

Furthermore, Americans are living longer than ever and are approaching an overall longevity of 80 years. Cardiovascular death rates have dropped by two-thirds since 1960.
We have the most advanced medical technology and medial science in the world.

• America has more Nobel Prize winners in medicine than the rest of the world combined.

• Eight of the ten of the world’s most important medical innovations over the last thirty years have been from America.2

• Companies selling eight of ten of the world’s top selling drugs are headquartered in the United States.3

Americans Dissatisfied with Costs, Uninsurance, and Inefficiencies

While Americans like their doctors and approve of the quality of care, they are not happy with the cost. In 2001, 71 percent said they unhappy with health care costs.1

This was higher than your dissatisfaction with crime or poor education. Moreover, according to a recent New York Times series, many of you are unhappy with various pitfalls, bear traps, and potholes in the system (see

Health care defects include high prescription drug costs, long waiting lines, growing uninsurance, information overload, inefficiencies, and spotty quality. A host of critics have suggested how to reform the system. Some recommend government take-over. Others advocate a shift to a consumer-driven, market based system. 4-6


I am a pathologist, writer, editor, speaker, and author of nine books, eight on health care, and one on my beloved French bulldog, Paris
This current book consists of my opinions and observations, refined and cultivated over the last 40 years, on patients and their doctors.

For the last seven years, I have served at historian for The Center for Practical Health Reform in Jacksonville, Florida. The Center espouses structural reform with private-public partnerships and wider coverage.

For the last decade, I have been on the Advisory Board of America’s Top Doctors (A Castle-Connolly Guide, New York City, 2005). America’s Top Doctors is an 1133 page volume containing lists, addresses, phone numbers, and credentials of more than 3000 top specialists nominated by peers and investigated by the Top Doctors staff.

Emmi Solutions, Inc

More recently, I have served on the industrial advisory board of a company called Emmi Solutions, Inc, in Chicago. Emmi stands for Expectation Medical Management Information. Emmi is in the business of educating patients about what to teaching patient what to expect from surgical procedures and chronic disease.

Emmi has come up with an elegant solution, - web-based programs featuring vivid videos guiding people through a soothing empathic conversational voice, plain language, and beautiful medical illustrations. A big part of our health system’s problem is that doctors and others have not taken the time to look and listen and teach – from the patient’s point of view with the right information patients understand at the right time presented in the right way.

Americans need to be more informed health consumers. But is up to we doctors to provide the information you need -- relevant, real time, at the right time when you need it the most.


1. “Survey Results on the Cost of Health Care and Health Insurance,“Market Strategies,: Livonia, Michigan, 2004.
2. Victor Fuchs and Harold Sox, “Physicians Views of the Relative Importance of Thirty Medical Innovations, “Health Affairs, 20 (2001), pages 30 to 42.
3. U.S. Council of Economic Advisors, Economic Report of the President, Washington, D.C., U.S. Government Printing Office, 2004.
4. John F. Cogan, R. Glenn Hubbard, Daniel P; Kessler, Healthy, Wealthy, & Wise: Five Steps to a Better Health System, The AEI Press, Publisher for the American Enterprise Institute, Washington, D.C, and the Hoover Institute, Stanford University, Stanford, California.
5. Richard L. Reece, MD, Voices of Health Reform, Interviews of Leading Health Care Stakeholders at Work, Options for Repackage American Health Care, Practice Support Resources, Inc, Independence, Missouri, 2005.
6. Rashid Fein and Julius Richmond, The Health Care Mess: How We Got Into It and How We Get Out, Harvard University Press, Cambridge, Massachusetts, 2005.