Concierge Medicine, Social Justice & Sex at 100

Some of my medical colleagues who champion the cause of “social justice” bristle when they learn that I practice concierge medicine. 

They fervently believe that it is somehow more noble to practice Soviet-style medicine in America than it is to take professional responsibility for delivering excellent, individualized medical care to their patients.  One of the benefits of being sanctimonious about private doctors who practice in a capitalist model is that you can blame some of the crappy medicine you deliver on your benevolent, utopian system, which claims to be “fair” to everyone.  How convenient.  But what are the consequences of focusing on clinical algorithms, electronic medical records, and the forced “fairness” that comes down from the Politburo?

Today I saw a 99-year-old patient in my office who is on my indigent medical care program.  She pays me $5 per visit, just so that she’s got some skin in the game.  (Quiet…I don’t want my social justice critics to know that I actually see people who can’t afford to pay my concierge fees.)  This elderly woman has diabetes and has been in the ICU twice over the past year with urosepsis, on the sepsis protocol.  Last week she was taken to a local ER at a hospital where I do not practice.  She had a recurrent kidney infection, despite receiving rotating prophylactic antibiotics and intravesicular gentamycin given to her by an expert urologist.  I was never called by the ER physician, because I am merely the patient’s attending physician – a point that is irrelevant to most ER physicians, given that virtually every patient in the ER is now admitted to the “hospitalist team.” 

Instead of admitting this frail, 99-year-old diabetic for IV antibiotics and careful monitoring, the ER physician opted to treat her as an outpatient with generic Keflex.  This would not have been my approach, but I have to agree that it certainly was “cost effective.”  Fortunately, my patient survived this “UTI algorithm.”  The doctor also opted to treat her hyperkalemia with equal efficiency, giving her a single dose of oral Kayexalate, which she promptly vomited after arriving at home.  Luckily, she did not have a cardiac arrest from her hyperkalemia, especially in light of the fact that they did not bother to hold her ACE-inhibitor, which was contributing to her elevated potassium.

As my patient left the ER, the medical team dutifully handed her the ubiquitous, and always helpful, discharge instruction sheet.  This document no doubt met all hospital and governmental regulations for educating people about pyelonephritis and hyperkalemia.  Although my patient is legally blind and cannot read standard print, I’m sure she found this 4 page document very comforting.  More importantly, the purveyors of social justice can rest assured that they followed all of the guidelines set forth by the Politburo and did their duty to deliver the same level of care to everyone, regardless of income, ethnicity or social standing.   

Had my 99-year-old patient been able to read this information sheet, I’m sure she would have found it helpful to know that she should “refrain from having sexual intercourse until after all of her kidney infection symptoms had resolved.”  I don’t know about you, but there is nothing that irritates me more than seeing a non-compliant, centenarian who continues to have sex while being treated for an active pyelonephritis.  The only way to prevent these elderly nymphomaniacs from reseeding their genitourinary tracts is to put it in writing!

What we are now seeing is just the beginning of medicine by administrative committee.  If you think I am misusing the term “Politburo”, just wait until you see what happens under the Department of Health and Human Services in the name of ObamaCare.

Patient Protection & Affordable Care Act, A British Perspective

By Dr. Diego Fox

Patient Protection and Affordable Care Act, a British perspective

It has long been a commonly held British view that falling ill in the United States of America can be a very expensive business for the patient. When President Obama declared his intention to address this problem, many here naturally assumed he intended to introduce an American version of our NHS. We also naturally assumed that this idea would be almost universally welcomed by Americans. The subsequent bitter and sustained opposition is something few Brits can understand, particularly when it is seen that the proposed changes are, to us, just a tiny step towards what we were perhaps expecting.

To understand our perception you first would have to understand a little of our system of healthcare.

At the beginning of the twentieth century in the coal mining communities of the Welsh valleys a new means of health provision was being tried. Every employee would contribute a small part of his wages into a central fund. This fund was used to enable the community to employ one or more doctors, who would then provide health care to the miners and their families. No payment was required for treatment, but only those who paid into the scheme could benefit. Some schemes were even able to provide for a hospital, such as the one at Tredegar, which opened in 1904.

These schemes were run by trustees, one of whom was Aneurin Bevan, who subsequently became government Minister for Health, just after the second world war. In 1948 he applied exactly this scheme on a national scale as the National Health Service. Literally overnight, on July 5 1948, almost every hospital in Britain became state owned and run, and almost every hospital doctor became a state employee. General practitioners, although supposedly independent, were nonetheless paid by the state also. The system is paid for by a specific tax, “National Insurance”, paid by all employees, and there is also an employer contribution for each worker. This contribution is compulsory.

Despite 15 major reorganisations since 1948 these principles remain. Most hospitals remain state owned, and virtually all doctors are employed, directly or indirectly by the state. To this day no patient is ever asked for money for NHS treatment. The medical profession, who in 1948, bitterly opposed the inception of the NHS are now almost to a man totally committed to it. Any perceived threat to the NHS arouses the most bitter and universal opposition from doctors and the general population alike.

Compared to the creation of the NHS, the US reforms are modest indeed. In essence there is to be some extension in eligibility for the already existing medicare and medicaid. There is also to be improvement in affordability of health insurance, and assistance with premiums for those of low/moderate income. These are hardly ground shaking changes. Also firms are to be encouraged to make provision for employee’s healthcare, something better employers do already.

So what the objectors are so angry about is difficult to understand, certainly to us in the UK. I have had a good look at a web site called obamacaretruth.org  where many of the arguments are cited to try and get a feel for the objections and I am still really none the wiser. I was particularly interested that they cited the Stafford scandal, implying that the entire NHS is like that. Now the NHS has many imperfections and if I were to go into them this article would double in length. But In fact although one or two places have caused serious concern the vast majority of our patients in the UK view their experiences of NHS care in a very positive light. Most are grateful and appreciative. Particularly those who have had expensive treatment of life threatening conditions, without having to worry about paying for it.

I am left with the impression that the objections boil down to a perception that those who will get free healthcare are somehow “freeloading”, as if they get deliberately ill in order to get free treatment.

So should the American medical profession have anything to fear from the reforms? I can’t see that they should. Unlike the NHS, American  hospitals are not about to be taken over by the government, and doctors are not about to be forced to work for the state. As far as doctors are concerned it should be very much business as usual.

It has long been a source of puzzlement to Europeans that the richest country in the world should be so reluctant to provide decent health cover for it’s poor. Is this because in Europe decent healthcare is considered a right, whereas in the US it is considered a commodity? It is my view that one of the hallmarks of a truly civilised nation is that it looks after it’s sick. Aneurin Bevan thought exactly the same when he said, “We ought to take pride in the fact that, despite our financial and economic anxieties, we are still able to do the most civilised thing in the world - put the welfare of the sick in front of every other consideration.”

The US healthcare reforms are a long way short of providing this ideal, but they are a small step in that direction. If even this small step fails the rest of the civilised world will simply not understand.

About: Dr. Diego Fox (Dr Zorro) is a full time NHS Consultant in his late 50s. He blogs at http://vulpesmax.blogspot.com

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A Typical Medical Device Company

CEO's are scared.

I asked a friend of mine , the CEO of a medical device company enjoying a dominant market position , if he was considering hiring any additional sales and marketing people. Having recently made the decision to relocate his manufacturing from one European location to another in Asia, I thought he might be in need of some international sales talent.

Not only was the answer NO. It was damned NO. He responded  that "I think we are a typical company right now. Our revenues actually jumped over 15% this year, but we're sitting on the biggest cash position we've ever been in since the companies start. BUT...we have no idea about the unknowns. Obamacare scares us. The possibility of a falling dollar or inflation  not only scares us...it has hurt us and costs us more to manufacture  at our European facility. So, we simply sit tight"

Reading about the 9.8% jobless rate, the flat economy, the budget deficit and other bad news is one thing. The human impact is another. My experienced, very talented unemployed friends continue to crank out resumes and network incessantly, while American competitiveness in the global bioscience innovation community continues to deteriorate.

A recently released report, "FDA Impact on US Medical Device Innovation" reinforces the point and notes that the average medical device company responding to their survey of 204/1023 device companies spent $31 M to get a 510(k) device approved by the FDA and $94 M to get pre-market approval. In addition,while it took 54 months to get PMA approval in the US, it took 11 months in the EU.

That said, keep in mind that the best time to innovate is during hard times like these. Great companies emerge from recessions. Talent is available, people are willing to take risks, suppliers are eager to cut deals, and there is always a need for a better mousetrap.

The Need For Concierge Medicine

Concierge Medicine & The Lion King: “Simba, it is time…”

It is indeed a dark time in medicine. Nature is out of balance. The wrong species are in charge. The pride lands – once ruled by medical giants – are now barren. Internists are now nonexistent in the hospitals, a place where they once roamed free. Similarly, the strong and proud general surgeons are all but extinct. In their place is a group of complacent, demoralized, cubs – the emasculated sons of warriors - who willingly accept the rule of the hyenas. 

I was a pioneer in the concierge medicine movement. I opened one of the first concierge medicine practices 10 years ago. I could not accept the mandates of the bureaucrats of Medicare, the pack predators of the HMOs or the crony-capitalism of big insurance and big government. I opted out. 

The weak and politically correct lions in my medical community were initially very critical of my independence and autonomy. I was publicly scolded for “pandering to the rich”, as they participated with unethical third-party payers to ration care for their patients, lining the pockets of the HMOs…all to protect a guaranteed income stream. I was described as mercenary and selfish for contracting directly with my patients, as if this were somehow violating the ethical gold standard set by United Healthcare, Humana or Senator Pete Stark. I was assailed by one academic physician on the front page of the Arizona Daily Star stating that what I was doing was, “boutique medicine at its mercenary worst.” 

In my opinion, much of the destruction of medicine has been due to an epidemic of acquired hypogonadism among doctors. Perhaps more accurately, it has been a peculiarly, voluntary castration. The present distortion in the medical food chain is due, in large part, to the complacency of doctors.

Many physicians share the same pitiful attitude of Simba in Disney’s The Lion King. Just listen to the whining that goes on in every doctor’s lounge across the country. Instead of taking their rightful place as medical leaders in the circle of life, they have indulged in self-pity, viewed themselves as victims, and hidden behind a false pretense of “humanitarianism” – as if it is somehow humanitarian to cede control of their profession to others. Somehow, it is “caring” to accept the absurdities of ObamaCare, work for Medicare or Medicaid or have a clerk at an HMO tell you that the MRI of the brain that you ordered for your patient is unnecessary.   

The future of the pride lands is now at stake. Clearly, ObamaCare will not save medicine; it will only hasten its demise. However, ObamaCare may have the unintended consequence of causing physicians to wake up. In this current landscape, dominated by medical hyenas, I would argue that Mr. Obama is very much the “Scar” figure. He is an agitator and a manipulator, who has overpromised to his opportunistic pack. He has no skill set upon which to turn his words into reality. He has promised all the hyenas – the trial lawyers, the insurance companies, the big unions – that he will create great prosperity for them all. And yet his most transparent act of “audacity” has been to pretend that you can “reform” healthcare, without even considering tort reform. Obamacare will ultimately fail, but it will cause much suffering until it is repealed. 

To the disenfranchised, Obama has demonized those of us who have given countless hours of free medical care to the poor during our careers. He has said that he will wrestle power from the greedy doctors…you know…those surgeons who would rather “amputate a leg for $50,000 than prevent the diabetic foot ulcer from occurring in the first place.” (Remember that gem?) 

As medical care and resources become rationed and scarce, all of the hyenas –even those who put Mr. Obama in power - will become disenchanted. Obama will ultimately share the fate of Scar.  He will be eaten by his own…the pack-predator brethren who put him in power. This is the nature of the rise and fall of the Scars of this world. It is all a part of the circle of life. It is a simple enough concept for Disney to explain to small children. 

When that day of reckoning comes, and the medical pride lands have been completely scorched, it will be time to rebuild. It will be then that doctors should heed the words of the wise Rafiki: “Simba, it is time.”   The only people who will have the expertise to rebuild medicine will be the doctors. Time will tell if they will be up to the task. To do so, they will need to find the strength to be leaders, and if necessary, they will need to find the strength to become warriors. 

The best method to restore the doctor-patient relationship and physician autonomy will be a movement toward private practice. Medicare and Medicaid will ultimately perish. In truth, they are already dead.  There is no Medicare trust fund. All of the money that was supposed to be put into the fund has been spent. Medicare is now just part of the mounting national deficit. 

The hyenas of the HMOs and insurance giants must get a clear and consistent message from physicians.  This message should be contained within a single, powerful word: “NO!”  No, you will not dictate the nature of my practice. No, you will not be the unwelcome middleman any longer. No, you will not tell me what tests to order, how to practice medicine or how much I will be paid for my services. Go back to your pack or be killed. Tell the other hyenas that your reign of terror is over. You may sell insurance plans to patients if they desire to purchase them in a free market, but that will be a relationship between you and the consumer. It will not involve us. If you choose to challenge us for control of medicine again, there will be no negotiations. The lions have returned to their rightful place in medicine. And we will do whatever is necessary to protect ourselves, our patients and our freedom. 

There is no contradiction in a healer being a warrior. Many famous physicians throughout the ages have also been martial artists. There are times where war – be it literal war or political warfare – is the only solution. Leadership, by its very nature, sometimes involves going to war. Leadership, by its nature, cannot be founded on pacifism.