The chronicle of a lonely do-gooder family doctor who survived.

Saturday, September 20, 2008

New patients

I work 80% full time seeing patients, the rest being various administrative and teaching responsibilities. The average American goes to the doctor 2.3 times per year (yeah, lots of you never go to the doctor but there are a special few who go like 20 times a year, so it averages out). Doing some math, my practice should be full at about 1600 patients, a number I surpassed like 6 months into my career (you know, primary care shortage). However, thanks to the magic of cost sharing, under insurance, and general lack of concern for their health problems on the part of my patients, I can't keep my schedule full at 1600 patients; periodically I have to open the practice back up to new patients, agonizing over the decision each time. There are currently about 2300 people who consider me their primary care physician.

In July of this year, as we were looking at empty schedules and rising expenses, we had to bite the bullet and open up again. Though I like not losing money and laying off employees, I still protested hard. Not that I mind being busy, what I mind is being exposed to the circulating pool of crazies.

"What do you mean by 'circulating pool of crazies,' Dr. Sour Puss" my nurse asked.

"There's this population of patients, chronic patients with unfixable problems who burn out their doctors pretty quickly and once it's clear that doctor cannot help them, they jump to the next doctor-victim" I said. Because they go to the doctor a lot, and because they are always looking for a new doctor, they represent a disproportionate amount of the new patients calling to schedule an appointment. Just ask any doctor who just recently hung out his or her shingle.

"You're just being negative like always, you need to relax."

"Oh really, you don't believe me, eh?"

There's a white board in my office and we've been keeping a track. Here is the current tally as of today.

Since July 19, 2008

Number of new patients, establishing care: 44
Number of new patients with a pain complaint requiring narcotics of > 3 months' duration: 23
Number of new patients with very severe uncompensated mental illness: 9

Saturday, September 13, 2008

Obama talks like a fag

“Joe stated his case logically and passionately, but his perceived effeminate voice only drew big gales of stupid laughter.”

Marc Fisher wrote an interesting op-ed in the Washington Post this week.

For Working Moms, 'Flawed' Palin is the Perfect Choice

In it, he makes the typical argument that Palin resonates with people because she's one of the common people. But what I think is interesting is what it actually says about the other side. Here's the money quote:

"She's just as flawed as we are," Tweddle said. "It's not the fact that she's a woman but the way she does it all. And let me tell you: There're more American parents with unwed pregnant teenaged children than American parents with Harvard grads. She's real."

Things have gotten pretty twisted when going to Harvard and raising children who don't get pregnant has become a political liability.

There was another fantastic article linked to on Metafilter this week by Jonathan Haidt, a professor of psychology at University of Virginia who researches morality and emotion:

What Makes People Vote Republican?

It's a fairly dense essay, but one well worth reading. In it, one of the arguments he makes is that the moral structure that motivates Republicans can be divided into ingroup/loyalty, purity/sanctity, and authority/respect. He urges Democrats to understand how these themes motivate people to vote Republican and offers a prescription for how Democrats can turn them to their advantage.

The ingroup/loyalty foundation supports virtues of patriotism and self-sacrifice that can lead to dangerous nationalism, but in moderate doses a sense that "we are all one" is a recipe for high social capital and civic well-being. A recent study by Robert Putnam (titled E Pluribus Unum) found that ethnic diversity increases anomie and social isolation by decreasing people's sense of belonging to a shared community. Democrats should think carefully, therefore, about why they celebrate diversity. If the purpose of diversity programs is to fight racism and discrimination (worthy goals based on fairness concerns), then these goals might be better served by encouraging assimilation and a sense of shared identity.

The purity/sanctity foundation is used heavily by the Christian right to condemn hedonism and sexual "deviance," but it can also be harnessed for progressive causes. Sanctity does not have to come from God; the psychology of this system is about overcoming our lower, grasping, carnal selves in order to live in a way that is higher, nobler, and more spiritual. Many liberals criticize the crassness and ugliness that our unrestrained free-market society has created. There is a long tradition of liberal anti-materialism often linked to a reverence for nature. Environmental and animal welfare issues are easily promoted using the language of harm/care, but such appeals might be more effective when supplemented with hints of purity/sanctity.

The authority/respect foundation will be the hardest for Democrats to use. But even as liberal bumper stickers urge us to "question authority" and assert that "dissent is patriotic," Democrats can ask what needs this foundation serves, and then look for other ways to meet them. The authority foundation is all about maintaining social order, so any candidate seen to be "soft on crime" has disqualified himself, for many Americans, from being entrusted with the ultimate authority. Democrats would do well to read Durkheim and think about the quasi-religious importance of the criminal justice system. The miracle of turning individuals into groups can only be performed by groups that impose costs on cheaters and slackers. You can do this the authoritarian way (with strict rules and harsh penalties) or you can do it using the fairness/reciprocity foundation by stressing personal responsibility and the beneficence of the nation towards those who "work hard and play by the rules." But if you don't do it at all—if you seem to tolerate or enable cheaters and slackers -- then you are committing a kind of sacrilege.

Unity is not the great need of the hour, it is the eternal struggle of our immigrant nation. The three Durkheimian foundations of ingroup, authority, and purity are powerful tools in that struggle. Until Democrats understand this point, they will be vulnerable to the seductive but false belief that Americans vote for Republicans primarily because they have been duped into doing so.

I would state it even more simply. For Republicans, morality is about what unifies us. It's about circling the wagons. For Democrats, morality is about what we aspire to. And actually, if you try and separate the historical context from each model of morality, neither way of thinking is necessarily superior. Haidt makes the point that Democrats aren't winning because, recently, they don't understand what's motivating people to vote Republican. I think Obama does it better than most Democrats (who do you relate better to, Obama or Pelosi?) but McCain and Palin (in the last couple weeks at least) are outdoing them. If the Democrats want to win, they need to play up the fact that they are basically normal people who have more in common with working stiffs than old "7 houses" McCain, while still trying to explain why it's okay to vote for the smarter candidate.

But how exactly do you show middle America that being smart is a good thing that makes you a better leader while not alienating those who don't self-identify as educated? As the right holds on to power by demonizing smart people with new ideas ("The Liberal Elite" I suppose), the more I believe this nation's survival depends on answering this question; Haidt offers a pretty good answer to this question.

The most dangerous element in American society today, more than the military buildup, the suspension of civil rights, the encroachment of religion into government, the failure of the mortgage industry, or the lack of affordable health care, is this disdain for intellectualism. Being a nationalistic flag waver doesn't lead to fascism nearly as fast as demonizing ideas does.

Thursday, September 4, 2008

Patriots and Nationalists

It's a fine line between patriotism and nationalism. According to Webster's dictionary, the only distinction between the two is degree, that nationalism is an "extreme" form of patriotism. In my mind, a patriot is someone who loves his or her country, someone who is willing to serve his or her country, and someone who sees his or her country for what it is, warts and all, and still wants to be here. A nationalist is someone whose love has become fanatic, contingent almost on being number one. Someone who believes that no matter what happens, fidelity to the motherland is more important than anything else. To a nationalist, it is more important to win than to be right.

If it weren't so bloody clear that McCain is going to get trounced in November, last night at the Republican convention would have given me an ulcer. While the Democratic party convention (to my surprise actually) was filled with speeches about what we, the patriots who love this country, can do to serve and make it better, last night the Republican convention was filled with statements that demonize anyone who dares point out the things that aren't going so well, and they're willing to lie outright to do it. I almost threw up when I heard Sarah Palin say "There's only one man in this campaign who has actually fought for this country," referring to McCain's military service and implying that dropping bombs on people is somehow more virtuous than any other public work.

It reminded me of the words of another great American, who hit the nail right on the head:

Tell me who's the real patriots
The Archie Bunker slobs waving flags?
Or the people with the guts to work
For some real change
Rednecks and bombs don't make us strong
We loot the world, yet we can't even feed ourselves
Our real test of strength is caring
Not the toys of war we sell the world
Just carry on, thankful to be farmed like worms
Old glory for a blanket
As you suck on your thumbs

Real freedom scares you
'Cos it means responsibility

So you chicken out and threaten me

Saying, "Love it or leave it"
I'll get beat up if I criticize it
You say you'll fight to the death
To save your worthless flag

If you want a banana republic that bad
Why don't
you go move to one?

-Jello Biafra, The Stars and Stripes of Corruption, 1985

Monday, September 1, 2008

Obama, McCain, and health care.

With health care reform being such an obvious issue on the minds of American voters this year, it’s surprising to me that we don’t hear more from the candidates about it. I suspect it has to do with the fact that any real, durable solution is going to be controversial. It will be good for some, bad for others, and will involve a great deal of compromise. Not exactly the kind of issue you want to build your campaign around. And so the public debate is limited to the usual meaningless sound bites. “Affordable health care.” “Access to the highest quality medicine.” “Coverage you won’t lose when you change jobs.”

As a doctor, people do ask me about the candidates’ positions and sometimes they even want to know my opinion who has the better plan. Those who know me have heard me say over and over again that the best, most cost effective, comprehensive, highest quality system is a single payer plan. I am under no illusions about the chances of this coming to pass in the U.S. But I do see it as a starting point for the debate, a model that we will need to move towards eventually.


John McCain’s health care reform ideas are largely influenced by John Goodman, an economist and president of the conservative think tank The National Center for Policy Analysis (he's the father of the Health Savings Account! Which nobody uses!). He has an amusing, little blog over here where he just sort of rants about things he appears to know a tiny bit about. The National Center for Policy Analysis describes its mission as finding “private sector solutions to public policy problems.” In addition to solving the health care problem, the NCPA also manages to find time to have position statements on affirmative action, crime, the economy, education, social security, terrorism, and welfare (these guys must be Really Smart!) Mr. Goodman’s health care credentials seem limited to a book he wrote criticizing single payer health care and he apparently has no direct experience in actual government health policy. McCain's chief domestic policy advisor is Douglas Holtz-Eakin who is said to favor free market solutions to the health care problem. And for good measure, we also have Tom Miller, resident fellow of the American Enterprise Institute, the Bush Administration's cactus league where new "talent" is developed. What's astounding to me is I could find no evidence of any actual health care experts, physicians, or patient advocates informing McCain’s health care plan.

McCain’s plan depends on market forces and individually purchased insurance to drive down costs, with government setting policies that would reward care providers on outcomes. Currently, employers who buy health insurance for their employees get to deduct the premiums they pay from the their corporate tax bill. McCain wants to eliminate this tax deduction and then use that extra tax revenue to give money to individuals in the form of tax credits, which they can then use to buy their own insurance. He expects such a credit would be $2500 for an individual, or $5000 for families.

Now, everyone knows that health insurance on the open market costs way, way more than this, at least $6000 a year for an individual and about $12000 for a family. His solution? Deregulate the industry so that individuals are encouraged to purchase much less comprehensive insurance with high deductibles and allow them to purchase insurance from any company willing to insure them, anywhere in the country.

And what about the people with complex, expensive medical problems to whom insurance companies will simply refuse to sell? He plans to create a large government-run insurance pool for those that the health care industry calls “uninsurable.”

The plan also pays lip service to improving the speed with which generic drugs are brought to market (although, one presumes not by limiting the current patent laws that protect pharmaceutical companies), improved health care technology (whatever that means), and reform of medical malpractice.

As I see it, there are several problems with this that illustrate how poorly informed McCain really is about the health care system:

1. Companies that are already doing the right thing by providing health care for their workers will be forced to subsidize those companies that aren’t. It won’t take long for most smaller employers to simply stop providing health care altogether, which is what I suspect is the idea all along. But then what happens to the revenue that is supposed to fund these tax credits?

2. It doesn’t fully fund health care. As an individual, you will still, conservatively need to cough up $3500 and the bill will still go up 5 to 10 percent a year. And most people who are uninsured now will simply remain uninsured because the cost is still far too high for them. Many of those who use the tax credit will likely purchase inexpensive bare bones policies with super high deductibles, which is little better (from a primary care perspective) than no insurance. I can tell you, it is extremely difficult to treat something as simple as hypertension when your patient tells you “Doc, I can only afford to come see you once a year.”

3. For the most difficult, costly patients who have the greatest need, he’s basically proposing a government administered single payer program, which absolutely blows my mind. I mean, god forbid we have government involved in health care, unless of course you are actually sick and need health care, then it's fine. Now, a normal person might think if it’s good enough for the people who are going to use it the most, why not make it more cost effective by including more healthy people? Hell, you could even prevent some of those cheap healthy people from becoming expensive sick people by getting them steady access to primary care. I guess you'd have to be a normal person to think like that.

4. The “cost savings” of the plan relies on competition within the individual insurance market even though that is typically the most expensive segment of the health insurance market, one that involves individual underwriting and exclusion of pre-existing conditions.

5. The single biggest piece of most physicians’ overhead is that which is devoted to administering the insurance system. I contract with 15 different insurance plans and it requires almost 2 full time employees to send those bills, chase after bills that get denied, collect co-pays, change prescriptions every time one of those insurance companies gets a new formulary, and make sure my credentialing is current with each company. I shudder to think what would happen in a deregulated insurance market, where patients come to me with hundreds of different insurance plans, each with their own package of benefits. Certainly, many primary care physicians would choose to abandon insurance contracts at all and go to a strictly cash out of pocket business. Again, this may be the plan all along.


Obama’s top health care advisors include David Cutler, a professor of applied economics at Harvard who has years of health policy experience and who helped craft Bill Clinton’s health care reform plan, David Blumenthal, a practicing physician, professor of medicine at Harvard, former vice president of Brigham and Women's Hospital, former director of the Center for Health Policy at the Kennedy School of Government (his resume includes minor things like correspondant for the New England Journal of Medicine, sitting on the advisory committee for the National Academy of Sciences), a man who has more than 20 years’ experience writing about health policy and reform, and Stuart Altman, a health care economist who helped develop health policy for Richard Nixon, Bill Clinton, and John Kerry. 2 of the three are from Massachusetts, a state that has implemented its own, generally successful, universal health plan. Say what you want about Clinton's reform attempt or the Massachusetts plan, but these are people who are well known and respected in the health care field who have spent their careers researching and thinking about this stuff.

Obama’s plan is a standard “play or pay” plan. Employers would be required to provide health insurance or they would pay into a fund that would create a new national health plan, similar to Medicare. In addition, for those that would prefer private insurance to a government-run plan, he would establish a new national health exchange that would allow small businesses and individuals to purchase insurance as part of a large pool, similar to what several states are doing successfully now.

Under Obama’s plan, there would be a mandate that all parents must purchase insurance for their children but it stops short of mandating all adults participate for the time being (this was the key difference between Obama and Clinton’s proposal).

Obama also plans to increase regulation of the insurance industry to end risk rating based on health status and to create a new system of reinsurance whereby the federal government would subsidize employers for costs incurred by catastrophic medical cases, protecting the remaining pool of insured persons from these cases.

Like McCain, Obama’s plan also has statements about driving down costs but his proposals are much more specifically friendly to primary care. He would do this through the adoption of electronic records, promotion of chronic disease management, emphasis on prevention and public health, payment to providers on the basis of performance and outcomes, all ideas that bring us closer to achieving the Future of Family Medicine’s proposed medical home.

It is not entirely clear how Obama’s system is going to be funded. He proposes a combination of allowing certain tax cuts to expire, reduced administrative expenses, and savings from improved prevention and disease management. I think we are likely to get a system that costs as much as what we are currently paying, but one that is much more comprehensive, leaves fewer uninsured, and serves the needs of ordinary people much better that what we currently have. Employers want to get out of the business of providing health care and this proposal will give them a path to do exactly that. And this may move us all much closer to a single payer system. For the time being it preserves the health insurance industry and maximizes individual choice.

It would be na├»ve to think that either candidate is simply going to pass whatever reform plan they want in their first days in office; our political system simply doesn’t work like that. The president merely dictates the direction and tone of the debate. When you read the candidates’ health care proposals, it doesn’t tell you so much about what they really are going to do, rather it gives you insight into how the candidate and his advisors think about the problem and their vision for the future.

With that in mind, I’m throwing my lot in with Obama’s team. His plan prioritizes the needs of patients and primary care over that of insurance companies and employers. He’s listening to the right people, and his plan builds on previous successes. McCain recklessly proposes that the entire country adopt an untested insurance paradigm, one that seems guided by conservative economic ideology and not actual real-world experience. I am convinced that there will be another real attempt at health care reform during an Obama presidency, hopefully this time with real results.

Reagan speaks out against health care reform and the fact that it will inevitably lead to a communist takeover of America.