Sunday, June 30, 2019

Why I Left Private Practice

After 20 years, I have left private practice and joined with the Cleveland Clinic.  To those who know me and this blog, this development may seem surprising, if not shocking.  On many levels, I’m shocked at this unexpected denouement of my career.   Let me explain.

First, these past two decades in private practice have been fabulous.  Our amazing staff and my partner worked hard every day to provide concierge level care to our patients.  We survived only because we provided a level of service that the surrounding competitors simply could not rival.  We provided customized and personal attention.  Our patients were happy and satisfied.  And, so were we.  So, why did we make a change?

Over the past few years, my partner and I had become uneasy about our practice’s ongoing viability.  The economics of a 2-person private practice are increasingly challenging.  Consider the math.  There is ongoing downward pressure on reimbursement with inexorable upward movement on expenses.  We cut every expense that we could – including the physicians’ salaries.  The only expense that remained sacred was our staff’s compensation.  We knew that if we didn’t retain our outstanding medical and administrative staff- the crown jewels of the practice - that the enterprise would decay.  

The math was against us.

Additionally, my partner and I were on-call for hospital work and emergencies every other weekend and every other holiday.  And, this schedule became more burdensome when one of us was on vacation.  This was our situation for years and we were unable to solve it.

And finally, we worried that if our still independent community hospitals were acquired by a larger entity – which we think will happen – that this could herald the abrupt demise of our practice. 
So, this was our mindset when the Cleveland Clinic approached us and expressed interest in our practice.  Twenty meetings or so later, here we are.  My new office is just down the street from my prior practice and I am honored that my former patients are following me.  Of course, it’s a transition from being president of my practice to becoming an employee of a large medical enterprise, but my partner and I correctly judged that this was the right decision at a most propitious moment in the life cycle of our practice.   Frankly, we got lucky.  We saved our practice and much of our staff have joined us.

Our staff and us had some sad goodbye moments.  But, there were some joyful goodbyes as well.  Imagine my mirth and euphoria in saying goodbye to working on weekends, nights and holidays!  Yes, I deserve a lighter load after nearly 3 decades of hard core specialty care; but life isn’t fair and we don’t always get the fair shake we merit.   Conversely, sometimes we catch a break that we didn’t earn.

If the Clinic and I remain happy with each other – and so far we are – then this will be my final gig. I’ll keep you posted, from time to time.

Sunday, June 23, 2019

Is My Doctor Any Good?

When I meet patients in the office, our conversations do not focus exclusively on the medical issue at hand.  Of course, if you come to see me with a stomach ache, at some point I will direct the dialogue toward your abdomen.  Often, our conversations are far removed from livers and pancreases, and deal with more personal vignettes and anecdotes.   Why does this happen?  First, I enjoy it; and secondly, it helps me to understand the patient better as a human being.  I won’t give this up, despite the many forces – Electronic Medical Records in particular – that conspire to dehumanize the medical experience. 

I am a trained typist and had several secretarial jobs in my younger days.   The tool of the trade then was a contraption unknown to the generation whom are now soldered to their smart phones.  It was called a typewriter.  For those curious, you might actually be able to palpate one of these dust covered devices in your grandmother’s attic.  My favorite was the IBM Selectric, which had a sphere covered with raised letters and characters which rotated with each key stroke before striking the paper.  Oh, the simple world devoid of Google, cut & paste, Instagram and Wikipedia.  Kids today would never give up their technology, and they have no clue what they have given up in exchange for 

The IBM Selectric Typeball

When a new patient arrives, I always ask how they came to see me in particular.  Sometimes, I am gratified to learn that a satisfied family member referred them.  On other occasions, they have selected me at random, a seemingly chancy method of selecting a physician.  These folks likely would do more due diligence in purchasing a washing machine. 

If they have a primary care physician (PCP), I always ask if they are satisfied with the care there.  These have been extremely valuable inquiries and are unique opportunities for me to learn of patients’ views on their PCPs.   Of course, their review may not be the full story.  And, I would not allow one bad review to change my impression of a doctor.  But over time, I accumulate more data on individual physicians.  For example, if nearly every patient cared for by a Dr. Kildare offers a glowing tribute, this will weigh heavily when I form an opinion.  Similarly, when we read reviews on line for various products and services, they carry more weight if there are a large number of reviews, rather than one or two, leaving aside for a moment the pitfalls of relying upon on-line product and service 'reviews'. 

The truth is that doctors have little clue about what actually goes on in our colleagues’ offices. Physicians and their offices may treat medical colleagues differently than they do their patients.  I’m amazed how often a patient’s experience differs from my impression of a physician who may be quite cordial with me in the elevator.  And, it goes both ways.  I’ve met doctors who seem to me to deficient in social skills and yet, patients love them.

If primary care physicians are smart and seasoned, they will ask their patients about us - the specialists.  Are we as nice to their patients as we are to them?

So, when you come to see me in the office to discuss your heartburn and your hemorrhoids, don't worry.  We''ll get around to it.  First, we may reminisce about milk bottles, fountain pens, paper road maps, Encyclopedia Britannica and my beloved IBM Selectric.

Sunday, June 16, 2019

Medical Risks and Benefits - Shades of Gray

Readers know how strongly I feel that my profession is suffering from the twin chronic diseases of Overdiagnosis and Overtreatment.  Here's a primer on how physicians make medical recommendations to our patients.

Take a look at this grid I prepared, which is worth a full year of medical school.

                                    Low Benefit                   High Benefit

Low Risk                                                           Medical Sweet Spot!


High Risk                DANGER ZONE!

When we physicians are contemplating a treatment, or are weighing one treatment against another, we are aiming for the Medical  Sweet Spot highlighted in blue above.  We want low risk and high reward for our patients.   Would we ever consider a treatment within the DANGER ZONE?  We would if the patient’s medical circumstance were dire and there were no superior options.  For example, if a patient was under a serious threat of a severe outcome, we might consider a treatment with considerable risk that had limited evidence of efficacy.  Of course, it may be that an informed patient might decline the treatment. 

There are times when the Danger Zone is reasonable.

Obviously, medicine is a murky discipline and most treatments do not fall neatly into one of the 4 quadrants of this grid.  Moreover, medical experts often disagree to the extent that a treatment is safe or effective.  In other words, different physicians may place the same treatment in different regions of the grid.  This is one reason why pursuing a second opinion can become more bewildering than clarifying.   Just because a second opinion is different from the original, doesn’t make it right.  To further confuse you, two differing medical opinions can both be right!

How does an average patient make sense out of this morass?  By asking the right questions.
  • What are my reasonable treatment options?
  • What is the scientific evidence supporting each of these options?
  • What is the scientific evidence of the risks?
  • Does my personal medical situation favor one option over another?  (For example, if a medical option’s risk is to suppress the immune system, and you already have a diminished immune system, then this option may not be suitable for you.)
  • How will I be monitored for adverse drug reactions? 
  • Is no treatment an option?  Where would this choice fall on 'grid'?
In my view, the 'no treatment' option should be considered much more often.  Why do so many patients and physicians move this option ‘off the grid’?

Sunday, June 9, 2019

Medicare for All - Bad Medicine for the Country

Last week, I presented my discerning readers with arguments supporting Medicare for All.  Here in Part II, I will offer a few rejoinders and caveats to those proposals.  

Senator Bernie Sanders deserves credit for advancing this issue into our national conversations.  And, many of his 22 rivals who are angling for the Democratic nomination for president in 2020, have embraced the position in their collective leftward migration.  Indeed, if this leftward drift persists, we may soon be regarding Comrade Bernie as a moderate!

First of all, the Medicare for All being proposed now should be renamed as it goes far beyond our current Medicare system.  The New & Improved Medicare for All promises the following additional benefits which are not included in conventional Medicare.
  • Vision coverage
  • Dental coverage
  • Hearing Aids
  • Long Term Care
  • Medical Care for Illegal Aliens
  • Minimal cost sharing, meaning no copays or deductibles

I’m surprised that the generous proposed benefits do not include coverage for pets, plants and backyard animals.  Doesn’t an ailing rose bush deserve healing?  Do you really want to be seen as campaigning against roses, lilacs and lilies?  Do you want to be labeled as a puppy hater?

Medicare for All supporters
Please come home.

And, how do we pay for all this?  The standard bromide is to tax the wealthy, but will there be enough left from the greedy 5% after they have funded the Green New Deal, Free College For All, Refinancing Student Debt and raising teacher salaries by $13,500?  Incidentally, the European nations who have nationalized their health care provide fewer benefits to their populace than do our Medicare for All proponents, a fact that is omitted from the presidential candidates' stump speeches.   The strategy is to promise everything, claim that we can afford it or may even save us money, and when the cold reality emerges years later, blame someone else. 

Look, I agree that health care reform is necessary, overdue and very complicated.  And, we all know how the dysfunctional process is tainted by dozens of well-heeled constituents who think of their own interests and not the greater good.  Feel free to peruse my postings under the Health Care Reform Quality category on this blog for additional rants.   I’m also skeptical that the Medicare for All crowd is focused on our interests rather than their own political interests.  For many of them, the notion of taking down the corporate framework of our medical system dovetails perfectly with their anti-Wall Street mission.   If Medicare for All is such great idea, then let’s pilot it in a few regions of the country and let us measure the medical and financial outcomes.  When we have a new medical treatment that we think might work, we study it on a small group for obvious reasons.  We don't open it up to the entire country and hope for the best.

There may be a planet out there where every individual can enjoy every conceivable benefit at low cost, or better yet, at a cost borne by others.  But, we live on planet Earth.  Hopefully, the Medicare for All space travelers can return back home so we can have a more down to earth discussion on how to make progress.

Sunday, June 2, 2019

Medicare for All - A Moral Imperative

Brace yourselves.  Over the coming months and longer, you will be hearing presidential candidates and their acolytes proclaiming the moral imperative of a Medicare for All program.  Is this just an electioneering slogan or is this really the Holy Grail of health care reform? 

Nearly all Whistleblower posts are stand alone essays.  This Medicare for All entry, will be a rare departure from this tradition and will be a two-parter.  If you like Part I today, then you will have strong incentive to visit this site next week.  And, if you find today’s post to be disappointing, then I invite you back next week with the hope that you will find the conclusion to be more captivating and riveting than this post.  How's my salesmanship?

Let’s try to agree on one thing before we disagree over everything else.  Conceptually, we all support any health care system that provides high quality medical care, with reasonable access into the health care arena and is cost effective.   We do not have these 3 pillars uniformly presently today.  More accurately, these 3 pillars are in place for many of us, but this is not a universal phenomenon.  Obamacare promised progress on all 3 of these fronts, but most of us agree that it did not deliver.  We all are aware of the ‘if you like your doctor, you can keep your doctor’ falsehood.  Additionally, most of us have not found that Obamacare has resulted in better or cheaper health care.  I agree that Obamacare did increase access, mostly with Medicaid expansion in various states, but the access improvement is less than you might think.  Prior to Obamacare, about 15% of us lacked medical insurance and now it is closer to about 10%.  Yes, this is real improvement, but it represented incremental improvement.  Seems like it is costing the nation years of turmoil and division for insuring another 5 or 6% of us.

Young George Washington Knew You Needed 3 Pillars To Keep It Steady.

Medicare for All proponents offer these arguments.
  • Health care for all is a human right and a moral imperative.
  • We are the only industrialized nation that does not provide this benefit to its people.
  • We need to cut down Big Pharma and the Insurance Companies who are gouging all of us.
  • We need a standardized benefit package across the board so no one is left behind.
  • We will save a fortune by cutting administrative costs.
  • We will enjoy better health by emphasizing preventive care and treating active medical issues sooner.
  • Current spending at about 18% of our GDP and is not sustainable.
These arguments seem meritorious.  Don't be swayed yet.  There's a reason in our system of jurisprudence and debate that judgement is reserved until the other side has been heard. 

Next week, if you will kindly return, I’ll offer some ripostes to the Medicare for All arguments.