The Cost of Health Care : Are Doctors Complicit?

photo by Phillip Toledano from the New Yorker

from New York Times Editorial June 13, 2009

Doctors and the Cost of Care

Published: June 13, 2009

As the debate over health care reform unfolds, policy makers and the public need to focus more attention on doctors and the huge role they play in determining the cost of medical care — costs that are rising relentlessly.

Doctors largely decide what medical or surgical treatments are needed, whether it will be delivered in a hospital, what tests will be performed, and what drugs will be prescribed or medical devices implanted.

There is disturbing evidence that many do a lot more than is medically useful — and often reap financial benefits from over-treating their patients. No doubt a vast majority of doctors strive to do the best for their patients. But many are influenced by fee-for-service financial incentives and some are unabashed profiteers.

All Americans are affected. Those with insurance are struggling to pay ever higher premiums, as are their employers. If the government is going to help subsidize coverage for the millions of uninsured, it will need to find significant savings in Medicare spending, at least some of which should come from reducing over-treatment. In the long run, if doctors can’t be induced to rein themselves in, there is little hope of lasting reform….

A glaring example of profligate physician behavior was described by Atul Gawande in the June 1 issue of The New Yorker. (His article has become must reading at the White House.)

None of the usual rationalizations put forth by doctors held up. The population, though poor, is not sicker than average; the quality of care people get is not superior. Malpractice suits have practically disappeared due to a tough state malpractice law, leaving no rationale for defensive medicine. The reason for McAllen’s soaring costs, some doctors finally admitted, is over-treatment. Doctors perform extra tests, surgeries and other procedures to increase their incomes….

Dr. Gawande’s reporting tracks pioneering studies by researchers at Dartmouth into the reasons for large regional and institutional variations in Medicare costs. Why should medical care in Miami or McAllen be far more expensive than in San Francisco? Why should care provided at the U.C.L.A. medical center be far more costly than care at the renowned Mayo Clinic?

When President Obama speaks at the annual meeting of the American Medical Association on Monday he will need all of his persuasive powers to bring doctors into the campaign for health care reform. Doctors have been complicit in driving up health care costs. They need to become part of the solution.

The Cost Conundrum by Atul Gawande in the New Yorker

Fostering healing through mindfulness in the context of medical practice

P.L. Dobkin, PhD from: Curr Oncol. 2009 March; 16(2): 4–6.

Keywords: Healing, mindfulness, medicine

Correspondence to: Patricia L. Dobkin, Department of Medicine, McGill Programs in Whole Person Care, McGill University, 546 Pine Avenue West, Montreal, Quebec H2W1S6. E-mail:patricia.dobkin@mcgill.ca

 

Suffering is an affective experience of unpleasantness and aversion associated with harm or threat of harm. Suffering may be physical or mental (or both), depending on whether it is linked primarily to the body or the mind. Often it is precipitated by illness, especially when patients feel a threat to personal identity. Patients may experience isolation, a sense of loss of control and predictability in their lives. Mount and colleagues¹ identified themes revealed by palliative care patients: Those who suffered and faced anguish felt a sense of disconnection from self, others, and the phenomenal world; they had a crisis of meaning with an inability to find solace; they were preoccupied with the future or the past; they maintained a sense of victimization; and they needed to be in control.

Many physicians practicing Western medicine have mastered skills aimed at diagnosing and curing diseases, and yet they may be at a loss when it comes to relieving suffering. With the advent of specialization, physicians have tended to focus on physical data (for example, test results) or on particular systems (cardiovascular, for instance) rather than on the whole person. Even though they acknowledge that psychosocial (and spiritual) factors may influence patients’ outcomes, physicians may have qualms about using that knowledge, perhaps because they consider it to be outside their realm of expertise—or more practically, because they think it too time consuming.

DISTINGUISHING “CURING” AND “HEALING”

Hutchinson and colleagues ² distinguish “curing” from “healing”—the former being an action carried out by a health care practitioner to eradicate disease; the latter being a process leading to wholeness and relief of suffering in response to injury or disease. The roles of physicians and patients differ considerably for curing and healing to occur. A physician draws upon expertise concerning disease to bring about a cure (when possible), but must shift positions when healing is the aim.

Healing is a process involving movement toward an experience of integrity and wholeness in response to injury or disease. It depends on an innate potential within a patient ¹. Hutchinson et al. ² observe that healing may occur upon acceptance of things as they are, including the fact that change is a constant factor in life. Mount et al.¹ note that acceptance of self and personal situation is not a form of resignation; instead, it is an active integration of reality that frees a person to discern and opt for that which is possible given the constraints of the circumstances. For example, a woman who has been treated successfully for early-stage breast cancer needs to make choices about how to resume activities even though she is anxious about recurrence. By acknowledging and facing her fears (rather than repressing or escaping them), she can strengthen her resolve to live the rest of her life fully.

Egnew ³ conducted a qualitative study that involved an inquiry by Drs. Cassell, Hammerschlag, Inui, Kubler–Ross, Saunders, Siegel, and Stephens about the meaning of healing. A distillation of the interview data led to the statement “Healing is the personal experience of the transcendence of suffering” (p. 258). These well-respected allopathic physicians agreed that the healing process takes place within a trusting relationship. This assertion is consistent with the qualitative data reported by Hsu et al.⁴ , who conducted, with patients, physicians, and other health care professionals, focus groups pertaining to healing. A consensus that healing is both a personal and an interpersonal experience emerged. Emphasis was placed on communication, information sharing, support, empathy, and compassion. For instance, when a relapse occurs, the words spoken by the physician, the tone of voice used, the manner in which the patient is invited to integrate undesired news, the ability of both parties to explore their respective reactions, and the respect shown for the patient’s preferences and needs will influence the healing process.

Kearney ⁵ posits that providing a safe place in which patients can regain a sense of integrity and wholeness is part of the health care mandate. This place is more than a hospital corridor or an examining room; it encompasses the space in which expressions of doubts, dread, and hope can be heard. Mount ⁶ emphasizes the importance of inviting a meaningful exchange between two equal individuals, one who happens to be a doctor, and the other, a patient. For example, by being present to and accepting personal sorrow when communicating bad news about recurrence, the physician (sometimes called the “wounded healer”⁷ ) may be able to contain the patient’s grief.

Because suffering is magnified by a personal perception of being separate and alone, suffering may be alleviated by the presence of another who is able to be with and to bear the distress. A physician can be one such person. The physician may acknowledge the patient’s suffering verbally or otherwise, and may encourage the patient to deal with that which perpetuates it. Fricchione⁸ refers to this situation as the physician’s willingness to provide care by stepping into the “intermediate area” between separation and attachment.

HOW MIGHT MINDFULNESS REDUCE SUFFERING AND FOSTER HEALING?

Brown and Ryan⁹ consider mindfulness to be an attribute of consciousness; they propose that consciousness encompasses both awareness and attention. When purposefully cultivated, mindfulness results in heightened awareness of inner and outer experiences through focused attention in the present moment.

In the late 1990s, Epstein ¹⁰ published an article in JAMA titled “Mindful Practice.” That article elaborates on how mindfulness can be brought into the clinical encounter. Epstein says, “Mindful practitioners attend in a nonjudgmental way to their own physical and mental processes during ordinary, everyday tasks” (p. 833). By taking this stance, the physician can be open to the whole person who presents as a patient and can skilfully treat that patient. According to Epstein, the goal of mindfulness is informed compassionate action incorporating relevant information, making correct decisions, and empathizing with the patient as a means of relieving suffering.

In line with the importance of relating to patients in this manner, Stewart¹¹ showed the link between effective physician–patient communication and patient health outcomes (that is, emotional health, symptom resolution, functional status, and pain control). He maintained that, for optimal communication to occur, physicians must be “mindful” of themselves, the patient, and the context.

CAN MINDFULNESS BE LEARNED?

Epstein answered the question of whether mindfulness can be learned in the affirmative. Mindfulness is characterized by learned mental habits: attentive observation of self, patient, and context; critical curiosity; beginner’s mind (that is, viewing the situation free of preconceptions); and presence. Presence is defined as “connection between the knower and the known, undistracted attention on the task and the person, and compassion based on insight rather than sympathy” ¹².

Epstein proposed an eight-fold method for teaching mindful medical practice¹³: priming, availability, asking reflective questions, active engagement, modeling while “thinking out loud,” practice, praxis (consolidation of knowing through experience), and assessment and confirmation. The method can be integrated directly into medical training by a mentor who also engages in the relevant mental habits when working with patients.

It is recommended that mindfulness be introduced early in medical education¹⁴ given that Shapiro and colleagues¹⁵ found that the level of empathy significantly declined in medical students during the period between entry into medical school and the end of the first year. To counter this trend of decline, a program titled “Mindfulness-based Stress Reduction” has been provided, with positive results, to medical students and physicians in various medical schools around the world. In a randomized clinical trial for health care professionals, Shapiro et al.¹⁶ found that following the program, participants reported reduced stress levels, increased quality of life, and more self-compassion. In a study with a larger sample size of medical students, Rosenzweig and colleagues¹⁷ reported similar results.

Being a physician is both a privilege and responsibility. Mindfulness enhances the physician’s ability to bring awareness to the treatment of another human being¹⁸ . It is not what is done, but how it is done that matters most. It is not how much time is spent with a patient, but rather what transpires within that time. Physicians need to be as comfortable “being” as “doing”—that is, being fully present to the patient and to their own internal processes.

What might this “full presence” look like in the context of a medical encounter?

The physician would be an effective communicator, who listens actively, provides emotional support, relates with compassion, and is flexible. The physician would encourage the patient to explore the meaning of illness and to grow from the experience, no matter the physical condition or prognosis³ . The physician would be committed to the patient, offering generosity and patience. The importance of continuity of care would be recognized and acted upon¹⁸ .

CONCLUSIONS

To practice medicine in this way—that is, to cure when possible and to foster healing even in the absence of cure—the physician needs to add the form of consciousness called mindfulness to the traditional “black bag.” This state of consciousness can be taught and learned through practice. Numerous medical schools around the world have recognized the need to broaden training such that curing and caring are equally valued and simultaneously provided in the best interest of the patient. Outcomes may depend upon it.

LINKS:

Opening to Our Lives: Jon Kabat-Zinn’s Science of Mindfulness

Center for Mindfulness in Medicine, Health Care, and Society

Brief Instructions for sitting Meditation

Mindfulness Instructions

NY State Amendment to Limit Recognition of “Board Certified” Physicians

 

New York State Senator Suzi Oppenheimer recently introduced an amendment to the Education Law (Bill no. S3964), which would prohibit a medical doctor from stating that he or she is “board certified” unless:

1)      the board or association is a member of the ABMS (American Board of Medical Specialties) or AOA (American Osteopathic Association) or

2)      the board is approved by that physician and surgeon’s licensing board or

3)       is a board with an ACGME approved postgraduate training program that provides complete training in that specialty or subspecialty.

 

 

The claimed justification for the bill, is “to eliminate bogus boards and provide truth in advertising protection for patients.” The only state with similar legislation is California, which was enacted in 1990.

 

If passed, this bill places serious and unnecessary restraints on physicians who are members of boards or associations who are not members of ABMS or AOA such as the American Board of Cosmetic Surgery, the American Board of Facial Plastic and Reconstructive Surgery, the American Board of Sleep Medicine, the American Board of Physician Specialties, and the American Board of Spine Surgery. 

 

One wonders why Senator Oppenheimer feels this bill is necessary right now, almost 20 years after the California bill was enacted. Is there a sudden epidemic of “bogus boards” in New York state requiring this bill to protect the public? Or rather, is this a reaction to rumored settlement talks in the lawsuit filed by the American Association of Physician Specialists vs. the NY Department of Health on the use of the term “board certified” on the NY-DOH physician website for physicians.

 

Title of Bill: An act to amend the education law, in relation to statements of specialist by a physician.

 

Text of Bill S3964:

 

State of New York

In Senate

April 7, 2009

Introduced by Sen. Oppenheimer– read twice and ordered printed, and when printed to be committed to the Committee on Higher education

An ACT to amend the education law, in relation to statements of specialty by a physician

The People of the State of New York, represented in Senate and Assembly, do enact as follows:

1 section 1. Section 6527 of the education law is amended by adding a new

2 subdivision 8 to read as follows:

3  8. A licensed physician may include a statement that he or she limits

4  his or her practice to specific fields, but may only include a statement

5  that he or she is certified or eligible for certification by a private

6  or public board or parent association if that board or association is an

7  American Board of Medical Specialties member board or a member board

8  the American Osteopathic Association, a board or assocation with equiv-

9 alent requirements approved by that physician and surgeon’s licensing

10  board, or a board or association with an Accreditation Council for grad-

11  uate Medical Education approved postgraduate training program that

12  provides complete training in that specialty or subspecialty.

13.  S  2. this act shall take effect on the sixtieth day after it shall

14   have become a law.

Justification:

This bill is aimed at those physicians who have claimed to be “Board Certified” by so-called “boards” that require a large payment and send a diploma by return mail.  It would help to eliminate bogus boards and provide truth in advertising protection for patients.  California has enacted similar legislation.

LINKS:

Contact Sen. Suzi Oppenheimer

News from AAPS vs. NY-DOH

EM Group Recruiting Letter Riles ACEP/ AAEM

(from Emergency Medicine News Volume XXXI, Number 2 February 2009)

 By Ruth SoRelle, MPH

 

 

 

 

 

A recruiting letter from Team- Health has raised the hackles of leaders in Vanderbilt University Medical Center’s emergency medicine residency program, and has even drawn a demur from the president of the American College of Emergency Physicians.“It was sent out by one of those big agencies,” said Keith Wrenn, MD, the director of the emergency medicine residency program at Vanderbilt University School of Medicine in Nashville. “By recruiting people who have not been trained in emergency medicine, they are undermining the whole board certification process.”

 

 

 

In the letter that began “Dear Primary Care Resident,” Dr. Dukes wrote: “Physicians who are trained in primary care specialties such as Family Practice and Internal Medicine are in a position to take advantage of the opportunities available in Emergency Medicine.” He noted that only 1,100 doctors graduate from emergency medicine residencies in the United States each year, a number that falls short of meeting the demand.

“Therefore, primary care physicians will be needed in the foreseeable future to staff the nation’s Emergency Departments,” Dr. Dukes wrote. “ECC’s experience over the past 27 years reveals that Primary Care trained physicians are well equipped to perform superbly in the Emergency Department,” noting that they have the “people skills”needed to “get along with patients, hospital staff, and attending physicians.”

The letter continued: “We have immediate opportunities available in several of our departments for Primary Care Residents to work directly with an experienced Emergency Medicine Physician. Residents are compensated while receiving on the job training.”

David Lawhorn, MD, the president of the Tennessee chapter of American Academy of Emergency Medicine, did not dispute that more emergency physicians are needed, and he said the number of emergency medicine residency slots should be examined. “But he said one of the significant differences between primary care and emergency medicine is that primary care physicians begin to lose many of their procedural skills, such as intubations or central lines, due to the demands of the office-based practice. “It is in these critical care areas that the emergency medicine-trained physician stands out and performs confidently, knowledgeably, and routinely. In the United States today, we are like a hybrid of primary care, office surgery, and critical care intensivist. It is clearly very disheartening for the trained emergency medicine physician who loses his emergency medicine job to someone trained in another specialty,” Dr. Lawhorn said.

Yet he acknowledged Dr. Dukes’ dilemma. “It is absolutely true that we in the United States will need physicians other than EM residency-trained physicians to continue to staff emergency departments across the country for several years to come. Even if EM residency programs were able … to fill all the slots, the problem would still exist with the many, many rural hospitals,” he said. “I suspect that ECC of TeamHealth has a significant number of these small rural EDs with which they have contracted to provide services, and thus put themselves in a position to fill the EM slots with any viable physician they can find.”

The reluctance of many emergency medicine-trained physicians to work with contract management groups also constrains supply, Dr. Lawhorn said. He noted that the letter implied contract management’s difficulty in filling EM slots with residency trained, board certified emergency specialists, adding that this will persist because of the contract management companies’ “necessary strategy for survival of getting the contract first and then figuring out how to fill the positions needed for coverage.”

But beyond the recruitment message of the letter is a bigger issue for the future of emergency medicine, Dr. Lawhorn said. “It is so close and obvious that it can be hard to see. Step back a bit, and you will see a large corporation in the business of selling the highest quality, lowest cost emergency care to the hospitals with which they contract. And now they are looking to other specialties to fulfill that role. What other board specialty in the United States has large business-run corporations that sell themselves as the leaders in that specialty that then turn around and recruit the residents from other specialties to fill their needs so that they can maintain contracts and keep their revenue streams?” Dr. Dukes said he sees no proble with recruiting primary care residents.“If you look at emergency medicine, what makes an emergency physician? A core of knowledge and technical skills,” he said. “I think these physicians have been proven to do as good a job as anyone in the emergency department. For these physicians to start in emergency medicine, they need to have the ability to work in the department along with another experienced physician. Once they get trained in family practice or internal medicine, they need some orientation in an emergency department along with training in advanced life support and other programs to work a solo shift. The letter was for primary care residents to offer them a position as a second physician usually working in the fast track alongside an experienced emergency physician.”Acknowledging that a Dec. 2, 2008, Institute of Medicine report (http://www.iom.edu/cms/3809/48553/60449.

aspx) on residency hours would include moonlighting in the numbers of hours resident is allowed to work, Dr. Dukes said ECC is open in its dealings with residency programs. “We usually take a few people in the third year with the knowledge of the program director. We also work with some physicians in emergency medicine fellowships,” he said.

Dr. Dukes said he recognized the controversy over this issue in emergency medicine. “I know AAEM does not recognize the AAPS board,” he said. “That is kind of bad. How are we ever going to get board certified physicians in all these hospitals if they are not graduating enough emergency medicine-trained physicians each year? For physicians who don’t have the same training but have excellent training in primary care and are doing the same rotations as emergency residents, how can they get certified?”

Dr. Wrenn of the Vanderbilt residency program said Dr. Dukes is seeking to employ physicians who completed primary care training but now want to practice another specialty. Such people can seek retraining and board certification through the American Board of Emergency Medicine, he said, although no federal funds support it.

 

“I am not sure as a specialty that we have done the best we can to send emergency physicians to the rural areas,” said Dr. Wrenn, also the vice chairman and a professor of emergency medicine at Vanderbilt. “We need to address that, but it needs to be addressed by board certified people, not those who have not been trained.”

Excerpt from AAPS letter to EM News:

” BCEM, along with Team Health and others, recognizes that there are too few emergency medicine residency trained physicians to meet the growing needs of our nation’s communities, particularly rural emergency departments. The 1,100 physicians who graduate from Emergency Medicine residencies each year in the U.S. falls short of meeting the need which exists…

AAPS’ Board of Certification in Emergency Medicine (BCEM) provides primary care residency trained physicians practicing full time in Emergency Medicine, a valid and critical option to demonstrate that they can perform confidently, knowledgeably and safely.  BCEM has certified and recertified thousands of well qualified Primary Care residency trained physicians working in Emergency Medicine. BCEM Diplomates continue to increase in numbers…

At no time is BCEM’s option to board certification in Emergency Medicine designed to diminish Emergency Medicine residency training. Instead, BCEM’s focus is to provide a legitimate and recognized option for Primary Care residency trained physicians to demonstrate competency and to become certified in the specialty of Emergency Medicine.

BCEM has, and continues to, welcome the opportunity to meet and discuss effective methods that EM residency trained and non-EM residency trained physicians, including Primary Care residency trained physicians, can employ and engage to work together to provide care to the Moms, Dads, and families who present themselves each year to our nation’s ERs..”

Robert J. Geller, D.O., FAAEP

Chairman, BCEM

 Link: Supply of Board Certified EM Physicians Unlikely to Meet Country’s   Needs

 

 

 

 

 

 

 

 

The Truth About “Daniel et al. vs. ABEM”

Misconceptions in the Emergency Medicine community regarding the now legendary case of “Daniel, et al. vs. ABEM” have been running rampant. Chief among these are:
1. that Dr. Daniel and AAPS were working together in this case
2. that the end of the Daniel case vindicates ABEM and that no antitrust violation occurred
3. that the end of the Daniel case means that for now and the future, only EM residency trained physicians can practice Emergency Medicine

Before explaining why these are misconceptions, let us first read what actually happened in “Daniel et al. vs. ABEM”
(Excerpted from “Antitrust: Emergency Medicine Physicians Lack Standing to Bring Antitrust Action” by Sarah Gasper in American Journal of Law and Medicine)
Background:
Dr. Gregory Daniel and 175 other named plaintiffs, along with approximately 14,000 members of the proposed plaintiff class were physicians who currently practice or who have practiced emergency medicine and who would be eligible to take the ABEM exam if the practice track still existed.18 Plaintiffs alleged that by closing the practice track and placing a premium on ABEM certification, ABEM, CORD, numerous hospitals, and various individuals associated with these organizations unlawfully restrained trade and monopolized the market for ABEM-certified and ABEM-eligible physicians.19 Specifically, plaintiffs argued that the defendants conspired to limit the pool of eligible applicants, thus creating an artificial shortage of ABEM-certified and ABEM-eligible physicians, with the end goal of demanding super-competitive pay.20 While other boards certify physicians in emergency medicine,21 the plaintiffs asserted that the ABEM certification is the most prestigious, that some hospitals only hire ABEM-certified physicians, and that some hospitals base compensation and promotion decisions on ABEM certification. As a result, plaintiffs asserted they receive “substantially less remuneration than ABEM-certified physicians” and that they continue to suffer loss of income.23 Furthermore, plaintiffs assert that they have been denied positions solely by reason of not being ABEM-certified or ABEM-eligible and that some were discharged, demoted, and assigned to undesirable work situations due to the lack of ABEM certification.24 Finally, plaintiffs claimed that CORD had a specific interest in keeping the formal residency training as the required path to ABEM certification.25

Court Decision:
In declaring that the plaintiffs lacked antitrust standing, the Court noted that even if a private party is injured by a violation of antitrust laws, the party must still have standing to bring a claim.37 The Court identified four relevant factors for determining antitrust standing38 and focused on two: the alleged antitrust injury and efficient enforcement of these claims.39 The plaintiffs here alleged financial injury due to ABEM restricting the number of eligible physicians that take the certification exam, which in turn limits the number of such doctors and allows the certified doctors to charge higher costs.40 However, as the Court summarized, the plaintiffs’ “theory of injury is not simply that ABEM-certified doctors command supercompetitive remuneration; their injury is the inability to do likewise.”41 The plaintiffs did not attempt to remove the residency track requirement, nor did they allege that they would have received the same pay but for ABEM’s domination of the market.42 Rather, the plaintiffs sued “only to restore-temporarily-the practice track as an alternative to residency training so that they can qualify for the ABEM exam, after which they are satisfied to have the certification door shut on any other test applicants.”43 The Court noted that the plaintiffs could not state an antitrust injury “when their purpose is to join the cartel rather than disband it.”44
In addition, the Court noted that even if the plaintiffs did have a viable antitrust injury, these plaintiffs are not the best enforcers for the alleged antitrust violation.45 As the District Court below found, these plaintiffs “have no natural economic self-interest in reducing the cost of emergency medical care.” 46 The Court emphasized that the relief pursued by the plaintiffs here is to gain entry into an exclusive arrangement that they otherwise seek to maintain in order to share in the supercompetitive remuneration allegedly made possible by ABEM exclusivity.47 Furthermore, the Court noted that both the individual emergency care patients, who rarely choose their emergency doctors, and the hospitals, who act both as consumers who pay for the emergency care and as suppliers of the residency training, are an unrealistic class of plaintiffs.48 On the other hand, the government and private health care insurers, who compensate hospitals for most emergency care, do have a direct and undivided economic interest in reducing the costs of emergency medical care as well as the necessary legal sophistication to challenge an antitrust violation.49 Ultimately the Court concluded that health care insurers would be the best enforcer of this antitrust challenge.50

Judge Katzmann concurred in part and dissented in part with the majority’s holding. While he agreed with the majority’s conclusions on personal jurisdiction, he believed plaintiffs had antitrust standing and would thus transfer the case.51 Katzmann found plaintiffs allegations sufficient to “allege losses stemming from a competition-reducing aspect or effect of the defendant’s behavior” because they allege that the defendants unreasonably restrained them from competing in the ABEM-certified market of physicians and consequently, the plaintiffs suffered financial losses.52 In addition, he argued that the plaintiffs’ remedy would actually benefit consumers because an increase in the number of ABEM-certified doctors could result in lower salaries for those doctors in general and thus lower costs for the consumers.53 Katzmann also disagreed with the majority’s conclusion that plaintiffs only want the practice track to be an option temporarily, indicating that the plaintiffs stated that they wanted the exam to be open to all class members, who, presently or with passage of time, would meet the practice track criteria.54 In sum, the plaintiffs did not seek to earn “super-competitive” wages, nor was their request for relief “inconsistent with their allegations that (1) prohibiting practice-track physicians from taking the certification exam is illegally anti-competitive and (2) the plaintiffs have suffered antitrust injury as a consequence.”55

***While this case does not rule affirmatively either way as to the allegation that closing the practice track was an antitrust violation,the second Circuit speculates that health care insurers, and not doctors, would be efficient enforcers of such an allegation.

It should be obvious from the above that misconception #1, that “Dr. Daniel was working with AAPS in the case” is completely untrue. In fact, AAPS had absolutely nothing to do with “Daniel et al. vs. ABEM”. Statements made by persons such as Dr. Antoine Kazzi, former president of the California Chapter and AAEM Board Director in EM News (”AAEM: Board Certification Under Attack in Florida” Emergency Medicine News:Volume 26(9)September 2004pp 1,46) and others stating this association reveal at the very least careless ignorance of the facts.
Misconception #2:
It should also be clear from the above that the decision in “Daniel et al. vs. ABEM” in no way, shape, or form vindicates ABEM’s actions. In fact, the decision states that upon reviewing the evidence, ABEM may very well be guilty of antitrust violations, however health care insurers, and not doctors should be the ones who should bring that claim to court. Judge Katzmann, who dissented in the opinion, argued that the plaintiffs’ remedy (allowing career EM physicians to take the ABEM certification exam) would actually benefit consumers because an increase in the number of ABEM-certified doctors could result in lower salaries for those doctors in general and thus lower costs for the consumers.

Misconception #3
that the end of the Daniel case means that for now and the future, only EM residency trained physicians can practice Emergency Medicine

New version of patient triage aims to cope with spiraling costs and long waits for treatment

(Tribune photo by E. Jason Wambsgans / February 9, 2009)

from Chicago Tribune.com (click for full story)

U. of C. emergency room to get more selective

By Bruce Japsen|Tribune reporter

February 10, 2009

The University of Chicago Medical Center announced a major restructuring in which it would eliminate 450 jobs.The emergency room of the University of Chicago Medical Center may no longer be for every illness or injury. Have a severe injury from a car accident? Head to the ER. Have pneumonia that can be treated with antibiotics? You may be led elsewhere. That’s because the hospital is changing the way it admits emergency room patients as part of its effort to deal with the worsening economy, a move underscored by Monday’s announcement of 450 layoffs, or 5 percent of its workforce. The U. of C.’s decision to introduce what amounts to a new version of patient triage represents an aggressive and unusual move by one of the city’s premier hospitals to cope with spiraling costs and the long waits for emergency treatment.  Some don’t like the plan, but the U. of C. says it has no choice. The academic medical center in the Hyde Park neighborhood said 40 percent of the 80,000 patients who go to its emergency room each year do not need to be there. These visits cost the hospital tens of millions of dollars a year in time spent by staff and specialists whose attention is redirected to cuts, bruises and other less severe conditions that can be treated at community hospitals or through prescriptions.

In addition, the hospital has been dealing with the rising numbers of uninsured, as well as patients covered by Medicaid, which pays low rates and has been months behind on payments to doctors and hospitals in Illinois. So the hospital is escalating steps to direct these consumers elsewhere, which it says will allow it to focus on treating the sickest of patients, as well as conduct research and train doctors. The U. of C. says its costs are 30 percent to 40 percent higher than community hospitals, which are better positioned to treat a variety of patients. “We are trying to get the right patients to the right doctor at the right time for their disease and disorder,” medical center Chief Executive Dr. James Madara said.

The hospital’s effort to manage patient care began as the Urban Health Initiative with a group of executives that included First Lady Michelle Obama, who was involved in early efforts to educate patients on the best use of the emergency room. Under the escalated program, the emergency department will be reorganized to provide more evaluations from doctors and nurses before care is provided. In the past, the U. of C. treated the patients and then educated them about health clinics, setting appointments at doctor’s offices and community centers for follow-up care. The medical center found in a poll that 60 percent of its patients did not know these community health centers were an option, said Dr. Eric Whitaker, who took over Obama’s duties as executive vice president for strategic affiliations and external affairs in January. Some analysts say the shift in strategy could be risky, particularly if a patient who had a condition that needed the medical center’s attention were to be turned away. “This is tricky,” said Jim Unland, president of The Health Capital Group, a consulting firm based in Chicago. “If patients really need to be in an ER and the U. of C. is turning them away, I have a problem with that. “But if patients can be better served at a primary care clinic or urgent care center, it is a good idea as long as they can get there.” Whitaker said the U. of C. has criteria that nurses and doctors use to make their best judgment—evaluations that routinely are done in emergency departments nationwide. There are times, he said, in any emergency situation where a person is treated and advised to go home only to find out they need to return for more care. “At the end of the day, we want to have quality care and be sure the people are treated in the right place,” Whitaker said.

In some cases, patients will be referred to any of about two dozen health centers throughout the South Side or to either of two community hospitals, Mercy Hospital and Medical Center and Holy Cross Hospital, which have agreed to be partners in the initiative. For some patients, The U. of C. will provide transportation or schedule appointments. “We are trying to streamline the process so that patients get seen at our nearby partners in a much shorter time frame,” Whitaker said.

But it can be confusing for patients who feel they should be able to come to the hospital and get the care they need, particularly from a place like U. of C., which is known for state-of-the-art care. Take Mary Darden, who was rushed to the medical center by ambulance around 8 a.m. Monday and diagnosed with pneumonia. By mid-afternoon, U. of C. doctors recommended that she be transferred to Mercy Hospital, her family said. “Why would you keep moving a 92-year-old woman with pneumonia?” said her daughter, Carol Thomas. Joshua Darden questioned the hospital’s judgment in not admitting his grandmother. “That’s what a hospital is for,” he said. The medical center would not comment on the case, but said pneumonia is a common condition that has resulted in many patients being referred elsewhere.

Supply of board-certified emergency physicians unlikely to meet projected needs across the U.S.

from: Mass Gen Hospital Press Release:

MGH-led study supports the need for alternate staffing strategies

17/Dec/2008

BOSTON – The number of physicians with board certification in emergency medicine is unlikely to meet the staffing needs of U.S. emergency departments in the foreseeable future, if ever; according to a study from a research team based at Massachusetts General Hospital (MGH). In the December issue of Academic Emergency Medicine, the investigators report finding that staffing every emergency department with board-certified emergency physicians does not appear to be feasible, given their projections for the field.

“Thousands of emergency departments are not currently staffed by physicians with this type of training,” explains Carlos Camargo, MD, DrPH, of the MGH Department of Emergency Medicine, who led the study. “We questioned whether staffing every department with residency-trained, board-certified emergency physicians – which some individuals have advocated for decades – was a realistic goal. So we set out to estimate emergency physician workforce needs, taking into account the diversity of hospitals across the country and projections about the future physician supply and demand.”

The researchers analyzed data from the 2005 National Emergency Department Inventories–USA database to determine the number of emergency departments in the country and their patient volumes. Based on the approximately 22,000 board-certified emergency physicians in practice and the 1,350 who became newly certified during 2005, the team developed three scenarios for physician supply, all of which assumed the same number of new board-certified physicians each year. The best-case scenario, which was intentionally unrealistic, assumed that no board-certified emergency physician died or retired; the worst case assumed an annual attrition rate of 12 percent; and the intermediate scenario assumed 2.5 percent attrition each year.

Having at least one board-certified emergency physician present in all U.S. hospital emergency departments at all times would require 40,000 physicians with such training, indicating that only 55 percent of 2005 demand was being met. Under the intermediate-scenario projection, it would not be possible to meet the goal until 2038, and under the worst-case scenario, the goal could never be met.
*** Even if no board-certified emergency physician ever died or retired, 100 percent staffing of all emergency departments with board-certified emergency physicians would not happen for more than a decade. ***

“The mismatch between the supply and demand for residency-trained, board-certified emergency physicians is a longstanding problem,” Camargo says. “The need for emergency services is large and growing; and even if existing programs graduated more physicians, there is little reason to think more of those graduates would move to the rural areas that are particularly short on physicians with this specialized training. We probably should explore alternatives, such as giving the family physicians who currently staff many U.S. emergency departments extra training in key emergency procedures. We might also increase our reliance on nurse practitioners and physicians assistants, who can help emergency physicians of any training background better handle the continually rising number of patients.” Camargo is an associate professor of Emergency Medicine at Harvard Medical School.

Co-authors of the Academic Emergency Medicine report are Janice Espinola, MPH; Ashley Sullivan, MS, MPH, and John Pearson, MGH Department of Emergency Medicine; Adit Ginde, MD, MPH, University of Colorado Denver School of Medicine; and Ayellete Singer, MA, and Adam Singer, MD, Stony Brook University Medical Center, New York.

Note:
THANK YOU! Now, who will step up and do something about it? It is obvious that the leadership of EM organizations are too preoccupied with protecting their turf, to care whether good emergency care is actually being delivered to the US population. Board certification, which has been used as a “merit badge” of quality, is instead being used to exclude other competent medical professionals from working in Emergency Departments regardless of the detrimental effects on communities.
It would seem that other agencies, perhaps the government (Health and Human Services?) or even the courts will have to come in and act, and their solutions will probably be something that the EM residency trained/ “board certified” docs will not like. But you know what? It will be their own fault for not seeing the big picture. -DW

Comment:
There are numerous physicians likely more skilled than those having completed a residency in emergency medicine, that could be absorbed in the ER workforce and fulfill the nations needs virtually instantaneously. Those docs are methodically being eliminated by restraints on trade that quite frankly echo the charges in ANTITRUST made by Daniel v. ABEM. Imagine, the powers that be would rather have a P.A. or a N.P. [nothing against the care provided by these practitioners] supervised by one residency trained ER physician, than have an experienced, higly trained ER physician certified by AAPS, who in some instances, trained the ER residency trained physician. Thus, this ER “residency” has become manna. But not so fast. The need for this residency was not called for unanimously, far from it. I heard it once said that life imitates art and that the TV show ER probably had more to do with legitimizing ER medicine than any politial sleight of hand that brought it about.

It has become obvious to me that this “ER residency” has been fought for tooth and nail and has become a holy grail so to speak. At the heart of things, the demigods in ER medicine sold the nation, or at least got it passed when no one was looking or even cared, on the need for a “residency” in ER medicine. Note that many specialties disagreed with such a need and opposed the creation of ER medicine as a separate specialty. Initially it was suggested it be a fellowship of general surgery, internal medicine or family practice. As such, training costs would be minimized and manpower issues would be less severe or there would be none. Saved money would be spent on improving 911 care so to speak so that out of hospital care would be improved and not as dismal as some reports now charge.

ER is not like general surgery where one would have to learn operations. So even cross training would not be a problem. Thus, if there was a national emergency there are many physicians that could walk into an emergency room and independently and successfully care for patients. Not so in surgery.

Yet still, the demigods, by attrition, or because of oppositon apathy, won the battle to create what was felt by important medical authorities to be, a relatively insignificant residency. And then the first thing they did was arbitrarily close their practice track eliminating thousands of excellent ER physicians/colleagues from the workforce, resulting in Daniel V. ABEM. I should say, Daniel v. ABEM 1, since the way the ER workforce is controlled by all the outsourced ER service providers [another issue], we will soon see much more litigation, and Daniel v. ABEM 2. We are already poised for a dramatic court case in AAPS V. NYSDOH, wherin AAPS is very likely to win under the legal standard that the NYSDOH lacked rational basis. You may know that under the legal theory of rational basis, States can legislate that a caveman may practice emergency medicine and win, but not so in this current AAPS case.

In AAPS V. NYSDOH case, really a natural outflow of Daniel 1, the opposers to the broader, more inclusive practice of emergency medicine, of course i mean, ABEM, ACEP, AAEM, AMA, ETC…have gone as far as to put their own grandfathered physicians on the line. Because in this case, the grandfathered physicians would have to be removed from the State’s website and unable to call themselves Board Certified in New York State. OR, they permit BCEM certified physicians to be listed on the website.

Dr. Collman in a recent rant on your site, is perfectly right. It is about patient care. And you are right in part, it isn’t a turf war, it is an attempt at monopolizing a market.

The United States would see dramatic reduction in costs, and I am certain an increase in quality of care if they open up the ER market and expand not shrink the workforce. This issue will need to be removed from the hands of physicians, especially those with strong self interest in eliminating equally qualified physicians. Let’s face it, ER medicine is such that just because a physician trained in ER medicine doesn’t make him better than a physician with practice experience that did not. The “residency” should not have gone forward.

Richard Davis ESQ.
Litigation Logistics

Links:
Disposable Doctors 1
Disposable Doctors 2
American Board of Physician Specialties
PUMA MD
US Alliance of Emergency Medicine
Fighting to Level the Playing Field for AAPS docs in NY
News from AAPS vs. NY-DOH
Florida ACEP: “Only EM Residency Trained Docs Should Work in ERs”
Response to Florida ACEP

Study: Doctors Still Too Tired When Treating Patients

Report Recommends Increasing Rest Among Residents

from The Boston Channel.com

POSTED: 3:46 pm EST December 2, 2008

BOSTON — Doctors-in-training are still too exhausted, says a new report by the Institute of Medicine. Five years ago, the IOM capped how long residents can work, 80 hours per week.

But as NewsCenter 5’s Ed Harding reported Tuesday, the IOM is calling for hospitals to allow doctors to get more rest.

For young doctors fresh out of medical school, on-the-job training can be grueling.

“Everyone realizes that resident fatigue is something that we have to deal with,” said Dr. Matthew Eisenberg, a senior resident of pediatrics at Children’s Hospital Boston. “Thirty hours is the longest shift I’ve ever worked,” he said.

Five years ago, the Institute of Medicine capped how long residents could work, up to 80 hours per week.

“About 75 percent of residents before the 80 hour rule were burnt out. They were not feeling good about their job. About 25 percent were depressed,” said Dr. Ted Sectish, the program director for the Boston Combined Residency Program in Pediatrics.

Sectish admits that sleep deprivation can also lead to medical mistakes, putting patients at risk.

A new report by the IOM found young doctors are still too tired, despite the 80 hour a week limit issued by the IOM. It has recommended easing the workload a bit more, so doctors can get more rest.

“In those 30 hour shifts they recommend they only care for new patients for the first 16 hours, and they recommended there be a five-hour period of sleep,” Sectish explained about the IOMs recommendations.

The report also calls for:

- Experienced physicians to more closely supervise residents

- A better overlap of schedules during shifts to reduce errors

- An increase in the number of mandatory days off each month, and extend hours off between shifts depending on how long the resident working, during day or night.

“So they’ve asked that the string of nights be no more than five nights. And that when you go from four night shifts to day shifts, you should have 24 hours to catch up on some sleep,” Sectish said.

The accreditation council did not immediately say if it would follow the recommendations. However, Sectish said the recommendations are taken very seriously by hospitals.

Links:
IOM Report: Resident Duty Hours
Sleepy Heads
Neurosurgeons Raise Concerns About IOM Resident Work Report

Many U.S. Doctors Plan to Quit or Cut Back: Survey

from Medscape

WASHINGTON (Reuters) Nov 18 – Primary care doctors in the United States feel overworked, and nearly half plan to either cut back on how many patients they see or quit medicine entirely, according to a survey released on Tuesday.

More than half — 60% — of 12,000 general practice physicians would not recommend medicine as a career.

“The whole thing has spun out of control. I plan to retire early even though I still love seeing patients. The process has just become too burdensome,” the Physicians’ Foundation, which conducted the survey, quoted one of the doctors as saying.

The survey adds to building evidence that not enough internal medicine or family practice doctors are trained or practicing in the United States, although there are plenty of specialist physicians.

Health care reform is near the top of the list of priorities for both Congress and president-elect Barack Obama, and doctor’s groups are lobbying for action to reduce their workload and hold the line on payments for treating Medicare, Medicaid and other patients with federal or state health insurance.

The Physicians’ Foundation, founded in 2003 as part of a settlement in an anti-racketeering lawsuit among physicians, medical societies, and insurer Aetna, Inc., mailed surveys to 270,000 primary care doctors and 50,000 practicing specialists.

The 12,000 answers are considered representative of doctors as a whole, the group said, with a margin of error of about 1%. It found that 78% of those who answered believe there is a shortage of primary care doctors.

More than 90% said the time they devote to nonclinical paperwork has increased in the last 3 years and 63% said this has caused them to spend less time with each patient.

Eleven percent said they plan to retire soon and 13% said they plan to seek a job that removes them from active patient care. Twenty percent said they will cut back on the number of patients they see and 10% plan to move to part-time work.

Seventy-six percent of physicians said they are working at “full capacity” or “overextended and overworked.”

Many of the health plans proposed by members of Congress, insurers and employers’ groups, as well as Obama’s, suggest that electronic medical records would go a long way to saving time and reducing costs.

Obama Wins: Why All Americans Have a Reason to Celebrate

by Arianna Huffington
excerpted from The Huffington Post

Even if your candidate didn’t win tonight, you have reason to celebrate. We all do.

Ten months ago, when Obama won in Iowa, we had a glimpse of what was possible and what became real tonight. What I wrote then about one state is now true for the whole country:

Barack Obama’s impressive victory says a lot about America, and also about the current mindset of the American voter.

Because tonight voters decided that they didn’t want to look back. They wanted to step into the future — as if a country exhausted by the last seven-plus years wanted to recapture its youth.

And they turned out in unprecedented numbers today to make sure that no amount of scrubbed rolls, malfunctioning machines, endless lines, or polling places running out of ballots would block the way.

The history of America is studded with great breakthroughs — propelled by leaders such as Lincoln, Teddy Roosevelt, FDR, and Martin Luther King – followed by decades of consolidation and occasional regression.

The Bush years have clearly been in a period of regression. The repudiation of those years is now almost universal. Even conservatives are admitting it; over the course of today, I’ve received numerous emails from conservatives ending with some variation on “Go Obama!”

In America’s journey toward a more just and truly democratic society, tonight is another milestone. And not just because the son of a Kenyan father and a mother from Kansas is now President-Elect. But also because tonight’s outcome is a declaration that we are once again a nation more driven by hope and promise than a nation driven by fear.

Bush’s re-election in 2004 was a monument to the power of fear. And McCain, his staff stocked with Karl Rove disciples, followed the Bush blueprint and played the fear card again and again.

Be afraid of Obama, the GOP warned us. Be afraid of something new, something different. He would meet with our enemies. His middle name is Hussein. He “pals around with terrorists,” consorts with the radicals at Acorn (which is “destroying the fabric of democracy”), and doesn’t see America “like you and I see America.” A vote for Obama would be “dangerous” and “too risky for America.”

The people of America listened, but chose to take the risk. So even if you voted for John McCain; even if you love Sarah Palin, who is still in search of the “pro-American areas of this great nation”; even if are Joe the Plumber – or, hell, even if you are Michele Bachmann – tonight is a night to be proud of America.

Obama’s victory holds up a mirror, reflecting the country we are. And it turns out to be the kind of country we’ve always imagined ourselves being — even if in the last seven-plus years we fell horribly short: a young country, an optimistic country, a forward-looking country, a country not afraid to take risks or to dream big.

Of course, it will take more than big dreams to help America dig out from the many crises we face. From the global economic crisis to the wars in Iraq and Afghanistan, the day of reckoning is upon us.

But these challenging times also will provide the new president with the opportunity to really transform America. As Gary Hart points out, “Great presidents do not emerge form quiet times; they arise in times of chaos and crisis.”

This is an idea that has animated Obama’s candidacy from the beginning. As he put it on the stump many times last week:

We began this journey in the depths of winter nearly two years ago, on the steps of the Old State Capitol in Springfield, Illinois. Back then, we didn’t have much money or many endorsements. We weren’t given much of a chance by the polls or the pundits, and we knew how steep our climb would be. But I also knew this. I knew that the size of our challenges had outgrown the smallness of our politics.

Since that time, the size of our challenges has grown even bigger — and the smallness of our politics has even downsized McCain from a noble hero to a hack fearmonger.

But over the course of this long and arduous campaign, Obama has repeatedly demonstrated the ability to inspire us to tap into the better angels of our nature — to stir the American people to expect more of themselves than they otherwise would.

It’s a theme Michelle Obama touched on many times on the campaign trail. “Barack Obama will require that you work,” she said at a rally on the eve of Super Tuesday. “He is going to demand that you shed your cynicism; that you put down your divisions; that you come out of your isolation; that you move out of your comfort zones; that you push yourself to be better; and that you engage.”

This call echoed something that historian and presidential biographer David McCullough had once said about JFK. “The great thing about Kennedy,” he told me, “is that he didn’t say I’m going to make it easier for you. He said it’s going to be harder. And he wasn’t pandering to the less noble side of human nature. He was calling on us to give our best.”

See the rest of this article on The Huffington Post