RESPECT

It's been quite awhile since I've posted here. However, there is more than a disturbance in the Force. Many within the House of Medicine are in disarray, dispirited, and ready to throw in the towel. Younger physicians are pursuing MBA's and the like as a hedge in case they have to fold up their tents and depart. Men and women enter Medicine with more debt than some houses cost. Stress and burnout are now a thing, no longer the result of ennui but from the abuse of a system which has turned professionals into data entry clerks. This cannot go on. I wrote this piece for the Medical Society of the State of New York's monthly News of New York. Given the dispirited nature of many of our colleagues, this needs a wider audience. Please accept this humble effort as a step on the road to recovery.

R-E-S-P-E-C-T

The term “provider” has bothered me for a long time. And it should bother you as well. This week, ACP President Dr. Robert McLean posted Defining our identity does not include the ‘P word’ for his September President’s message. The central theme is a reminder that the practice of Medicine is a profession. Physicians have a unique relationship with patients that is considerably more than the “Cable Guy” who comes to install your tv service. Dr. McClean writes:

… Such a fundamentally unique and sacrosanct relationship as that between patient and physician is not merely “providing” a health service. And that is why the term “health care provider” is so inappropriate. The patient-physician relationship does not consist of simple transactions where we provide and patients consume. That marketplace terminology implies that health care can be conceptualized as just another commodity.

… The primacy of this relationship has been eroded with the commoditization of aspects of the health care delivery system.

Dr. McClean is not the only physician upset by “provider creep.” Washington pediatrician, Dr. Niran Al-Agba goes one step further, writing in the Kitsap Sun: The sneaky cynicism of calling your doctor a 'provider'. She traces the history of provider as a pejorative back to 1930’s Germany:

… According to Dr. Saenger, who wrote Jewish Pediatricians in Nazi Germany: Victims of Persecution, “the 1937 issue of the Reichs Medizinal Kalender, a directory of doctors, the remaining Jewish doctors in Germany were stigmatized by a colon placed before their names. Their medical licenses were revoked in 1938. They could no longer call themselves 'Arzt' or 'doctor.' They were degraded to the term 'Behandler' or freely translated, 'provider.'

She continues:

Insulting any person on the basis of their race, ethnicity or gender is morally wrong. Using the word “provider” to describe a physician is and will always be insulting, personally and professionally; it is demeaning and devalues the education and degree conferred upon every physician. Why are physicians forced to suffer repeated use of this derogatory professional insult? And why have physicians as one professional body not risen up in anger at this injustice?

While I would not equate those who call physicians “the P word” with the Third Reich, folks should realize that Provider is insulting and demeans our noble profession.

Dr. McClean concludes:

And by the way, this terminology issue was raised through the ACP Board of Governors way back in 2008. Hence, it has been ACP policy since 2009 to eliminate use of the term “provider” and “prescriber” in lieu of “physician” in all publications and communications. Pass it on.

I leave you now with the inimitable Aretha Franklin.

The Unaffordable Insurance Act Rolls On

I received this email this morning from a physician in private practice in NYC -

The truth about being ‘insured.’

For the past three years, my small business group (less than 50 employees as per insurance status) has received a health insurance policy cancellation notice. Each one points a finger at the PPACA as a reason for the cancellation. At first, continued underwriting modifications as a result of PPACA seemed odd since the law has not been modified, to the best of my knowledge. However, the cancellations of policies developed after 1/1/14, seem to be to limit the insurance industry to components of the law that are sequentially adding into effect since its implementation. Clearly, individuals, small groups, and now medium groups are not being protected, as was the intent.

Take this coming year, for example. The PPACA, as of 1/1/16, now makes businesses with less than 100 employees lose status and forces them to enter my world of less than 50 employees. We now lose the plan at the premium we paid last year ($459/month) because, to the insurance mind-set, we are now a more significant risk as medium size groups add into the community rating. What do you do with risk? You increase the guaranteed premium, of course! To get this to fly past the NYS insurance regulators, you cancel an existing policy, that has a known risk exposure with claims made, and you create a similar, but new policy with no history only prior experience, thus masking an enormous premium increase to the eyes of the NYS regulators. Brilliant from an insurance business move. Morally unethical, however, and certainly, not in the spirit of those that created the PPACA.

Comparing my 2015 policy to the proposed 2016 policy, the only major difference is a 37.6% premium increase. NYS regulators don’t see this, of course, because the 2015 policy is cancelled. What they see is a new policy with a deductible $400.00 lower and a co-insurance 10% higher. However, most middle class workers are going to find it difficult to pay $632.00/month in premiums with a $2600.00 annual deductible applying to everything except the annual well visit and screening tests, followed by co-insurance after the deductible is met.

This hurts both the patients and the physicians caring for them. Patients are delaying care. Physician’s business volume is down and, in many cases, the account receivables are increasing due to the inability of the average middle class patient to pay such high deductibles.

We need to take to the streets with this problem. We should not be silent. The health of patients is at risk.



The Patient Protection and Affordable Care Act neither protects patients nor makes care affordable - rather, for many patients, it's actually the Unaffordable Insurance Act.

If you like your plan, you can keep your plan If you can afford your plan, you can't keep your plan.

Come senators, congressmen
Please heed the call
Don't stand in the doorway
Don't block up the hall
For he that gets hurt
Will be he who has stalled
There's a battle outside
And it is ragin'.
It'll soon shake your windows
And rattle your walls
For the times they are a-changin'.

Bob Dylan

Shameless Self-Promotion

Dr. Bob Dylan Weighs In On MOC

MOC Times Are A Changin'

Come gather 'round doctors
In your office or home
And admit that the waters
Around you have grown
And accept it that soon
You'll be drenched to the bone.
If your time to you
Is worth savin'
Then you better start swimmin'
Or you'll sink like a stone
For the times they are a-changin'.


Come Chiefs & Professors
Who prophesize with your pen
And keep your eyes wide
The chance won't come again
And don't speak too soon
For the wheel's still in spin
And there's no tellin' who
That it's namin'.
For the loser now
Will be later to win
For the times they are a-changin'.


Come EVP's, Officers
Please heed the call
Don't stand in the doorway
Don't block up the hall
For he that gets hurt
Will be he who has stalled
There's a battle outside
And it is ragin'.
It'll soon shake your windows
And rattle your walls
For the times they are a-changin'.


Come all Academics
Throughout the land
And don't criticize
What you can't understand
Your housestaff, Attendings
Are beyond your command
Your old road is
Rapidly agin'.
Please get out of the new one
If you can't lend your hand
For the times they are a-changin'.


The line it is drawn
The curse it is cast
The slow one now
Will later be fast
As the present now
Will later be past
Your old road is
Rapidly fadin'.
And the first one now
Will later be last
For the times they are a-changin'.

Angelina Jolie and Risk Reduction Surgery

You may remember the story of Angelina Jolie's decision to have her breasts removed as she was a very high risk for breast cancer. Now, she's undergone further surgery to remove her tubes and ovaries.

From the NY Times:

“Prophylactic removal of ovaries and fallopian tubes is strongly recommended in women before age 40 in BRCA1 and BRCA2 mutation carriers,” said Dr. Susan Domchek, executive director of the University of Pennsylvania’s Basser Research Center, which specializes in BRCA mutations. “There is no effective screening for ovarian cancer and too many women with advanced stage ovarian cancer die of their disease.”

Writing for The New York Times’s Op-Ed page, Ms. Jolie Pitt, 39, said she had expected to have her ovaries and fallopian tubes removed, a procedure called a laparoscopic bilateral salpingo-oophorectomy, but that a cancer scare made her decide to undergo the procedure sooner. Her mother, aunt and grandmother died of cancer.

“To my relief, I still had the option of removing my ovaries and fallopian tubes and I chose to do it,” she wrote.

Two years ago, she ignited a worldwide discussion about options for women at high risk for breast cancer when she wrote that she had had both breasts removed because BRCA1, the same genetic mutation that prompted her surgery last week, increased her risk of breast cancer.

Allow me to clear up one misconception. This is not "Prophylactic Surgery" but rather Risk Reduction Surgery. Even following removal of the tubes and ovaries, there is a small residual risk of cancer inside the abdominal cavity, histologically identical to ovarian cancer.

For more info, you can go here.

Nice Work If You Can Get It

To Commemorate NY's Silver Debacle, I've played with the lyrics to a Dire Straits Classic.

$$$ Por NADA

Look at them yo yo's - that's the way you do it
Legislators in the L.O.B.
That ain't working - that's the way you do it
Money for nothing and your trips for free.
Now that ain't working that's the way you do it
Lemme tell ya those pols ain't dumb
Maybe holding more fundraisers
Maybe give taxpayers a crumb

We gotta drain the stinking swamp
Democracy Recovery
We must remove the legislators
We owe it to our progeny

I shoulda learned to get donations
I shoulda learned to raise the funds
Look at that charmer muggin for the camera
Man we coulda had some fun
Look he's up there, makin campaign noises
Kissing babies for them all to see
That ain't working, that's the way you do it
Money for nothin and your trips for free

We gotta drain the stinking swamp
Democracy Recovery
We must remove the legislators
We owe it to our progeny

Now that ain't working, that's the way you do it
Money for nothin get your trips for free
Money for nothin and your trips for free

Term Limits Anyone?

Do Not Go Gentle Into That Good Night

Ezekiel Emanuel, MD, PhD penned a controversial opinion piece for The Atlantic on why he would hope to die at 75. This piece created a firestorm of pushback, including a resolution at the recent interim AMA meeting by MSSNY's own Greg Pinto, MD to rebuke Dr. Emanuel. While the resolution was ultimately defeated, Dr. Pinto's principled stance was not the only voice heard in opposition to Dr. Emanuel. One piece in particular by Brant Mittler MD JD was posted on MedpageToday.

My reaction to Zeke's article is one of disgust and outrage. Even if he is the smartest guy in the room, he's dumb when it comes to understanding what the average person wants. How dare he claim to know that someone over age 75 who walks slowly, has some memory lapses, and has some medical disabilities and limited resources doesn't deserve to enjoy music, sunsets, or the company of children and grandchildren?

And why will Zeke stop at age 75? When will he and his political cronies -- of both major political parties -- decide that a disabled paraplegic wounded warrior is consuming more than he is contributing?

While Emanuel claims he's only musing about his own personal decision to forgo colonoscopy after age 65 and flu shots, antibiotics, cancer care, and doctor visits after age 75, his writings are dangerous because they influence major media and national leaders.

The subtitle of this irresponsible article proves he wants to influence you to follow his lead, while he admits at the end of the article he reserves the right to change his mind. Sure, you jump off the cliff first. Zeke will follow you. Not.

Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.

Dylan Thomas