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POLICY: Hmmm….Docs are always docs

So Krugman writes about Cleaning Up the Health Care Mess and the NY Times publishes a bunch of  letters. Krugman basically said that we’d eventually need some kind of government-regulated health care system, and that limits would have to be put on what’s done. Despite the fact that the crisis in our health care system is to the point that even General Motors has noticed and wants out, 5 out of 7 letters are from doctors, and almost all of them are going on and on about government interfering with patients choice, their autonomy, etc, etc, etc.

Perhaps we are just back in 1936 after all. But isn’t it about time the collective physicians of America moved on and realized that they’d better start positioning for a world in which they have to cut a better deal?

Otherwise they’ll be moaning about how it all went wrong when they took on the hospitals, as does this guy. Unlucky for him that he bought at the top, and not on the way up like his colleague in North Dakota.

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Stuart Gitlow MDSteve Coulter, MDmarcus newberryGreg Hinson, MDKelly Clark Recent comment authors
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Stuart Gitlow MD
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Stuart Gitlow MD

Dr. Coulter’s statements are interesting. Yes, of course, long-term abstinence requires short-term abstinence, but Naltrexone has not been demonstrated to be “highly effective” at reducing relapse, nor has it been demonstrated to be useful in ongoing treatment of alcoholism. The major studies in the field have had inclusion errors in which they failed to study alcoholics (rather, they studied alcoholics who had been drinking heavily — not the usual group one would see in an outpatient setting). They had outcome measure design flaws by not looking for abstinence; some looked at days before return to HEAVY drinking, while others looked… Read more »

Steve Coulter, MD
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Steve Coulter, MD

Stuart Gitlow writes about Naltrexone: “This drug [Naltrexone] was recently approved for use for alcohol dependence. But a close review of the literature indicates that while naltrexone leads to short-term abstinence, there is no evidence that either naltrexone or short-term abstinence lead to recovery from the illness or long term sobriety. In fact, the drug has essentially no place in the treatment of alcoholism…” This is bizarre. Long-term abstinence requires first achieving short-term abstinence. Naltrexone has consistently been demonstrated to be an extremely safe and highly effective treatment in reducing relapse to active alcoholism. Unique among available treatments, those who… Read more »

Stuart Gitlow MD
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Stuart Gitlow MD

Tom, your comments make a number of assumptions, the most important of which is that guidelines are developed by what we’re both calling the Best in the Field. I think we’d both agree that the Best in the Field is the doctor who has the greatest success in reducing morbidity and mortality for a given disease. There are obviously other factors, but that’s the most important one. When I think of the doctors to whom I refer my patients with given illnesses, the docs that we docs think of as best in a given field, they’re not the docs developing… Read more »

Tom Leith
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Tom Leith

> Who would you want as your MD? Someone who > follows the guidelines? Or someone who questions > everything and would follow a guideline only once > he or she is convinced of its value? Dr. Gitlow hinted at this, but I myself have some (possibly misplaced) trust that the process of vetting guidelines produces diagnosis and treatment plans on average better than a randomly-chosen physician will come up with on his own. So, if I must choose a doctor at random (and basically I must because useful information about doctors is well-nigh impossible to come by even for… Read more »

Stuart Gitlow MD
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Stuart Gitlow MD

A number of comments have been made concerning standardization. The basis of medical training, and really what differentiates it from training for PA’s, nurses, and other allied healthcare professionals, is the education in basic sciences that we receive such that we’re able to theorize and speculate with intelligence rather than guesswork. That’s why physicians do not follow protocols, guidelines, or other similar processes very well. If a patient comes to my office suffering from an illness, I may use my knowledge of the patient, the literature, the pharmacology, and the epidemiology of the illness to select the treatment. Why, you… Read more »

Tom Leith
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Tom Leith

> I often wonder what the boards of trustees > are doing to maintain the interests of the > community. Unfortunately, not enough, IMNSHO. This should be another thread, but I’ll tell two little stories here, and maybe Matthew or somebody else will look for POLICY/GOVERNANCE articles to blog. I would like to further explore this aspect of the industry. I was fortunate to speak with the COO of the SSM Health System, Bill Schoenhard, about a month ago after a talk he gave on SSM’s pursuit of the Baldridge Award. He said that just recently he was wandering around… Read more »

marcus newberry
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It is difficult to sympathize with the cardiologist about his speciality hospital. They do tend to aggravate the problems. But, it is not all about money. Everyone likes their own space when they can get it and security, or the perception of it, is such a comfort.
Now that they have CEO’s, hospitals have become imperialistic and want to control everything in sight. I often wonder what the boards of trustees are doing to maintain the interests of the community. Just a thought.

Greg Hinson, MD
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Greg Hinson, MD

I don’t think I will leave medicine. You never know. I have been doing it for 8 years and, although I make a comfortable living, it is LESS then what I made 8 years ago. The cost of living is climbing and so my relative value is falling and that just does not feel good, when you continue to work just as hard if not harder. I think it is also important for everyone to realize that there is a huge disparity between what some doctors are making and what those of us in primary care are making. The average… Read more »

Tom Leith
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Tom Leith

Well, Dr. Hinson, I hope it does not come to leaving primary care or medicine altogether for you. And yes, the benefits of EBM, metrics, IT, and the rest flow 90% to patients, and maybe 10% doctors. This is a problem: we want big organization capabilities from a small organization industry, and the transition is going to be very painful.

Greg Hinson, MD
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Greg Hinson, MD

Elliot, Dr. Gitlow is not saying that he is smarter then you. You seem to have some insecurities about MD’s thinking they’re smarter then you. I am not smarter then a lot of my friends, but I am smarter then the average Joe. And I did dedicate myself to make it through medical training to do what I do because this is what I want to do. Would I want to do this if it lead to me making less then my plumber? Guess what, he already makes more then me and his income is actually climbing year to year!… Read more »

Tom Leith
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Tom Leith

> “Cancer care as individualized as you”
If I thought that a randomly-chosen oncologist knew enough about molecular biology to tailor a treatment “just for me” in time to do me any good, I might be moved by something like this. As it is, this is only a marketing slogan, and means about as much as any other marketing slogan.

Kelly Clark
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Kelly Clark

No, the public appropriately does not accept “standardization of medicine” in the way it is too often conceptualized. For those driven by “consumer focused” care, a billboard in my community advertising a local hospital is worth contemplating – a row of bright flowers with the line “Cancer care as individualized as you”.

elliottg
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elliottg

With all due respect to Drs. Gitlow and Clark, the idea that medicine should not be standardized is one of things standing in the way of higher quality, lower cost medicine. I would have thought that if there was any evidence that foreign doctors or physician stand-ins had worse outcomes, then someone would be trumpetting it to the heavens. Perhaps I have missed the studies; any pointers? The practice of medicine in this country is so much more costly because of variability of care (see Dartmouth, see Stanford). That variability is tolerated because doctors (and the public) won’t accept any… Read more »

Kelly Clark
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Kelly Clark

I agree with Dr. Gitlow that US physicians are not going to work at our jobs with any further significant pay cuts. We are a talented and smart bunch and can indeed change careers. The issue then becomes who will be practicing medicine. The two most likely applicant pools are physicians from other countries, and non-physicians (prescribing nurses, physician assistants, and organ-specific providers such as dentists, podiatrists, psychologists, optometrists). International medical graduates are currently providing a significant percentage of family practice trainees in the US, and non-physicians are gaining prescribing powers and procedural powers in many states. Many people bemoan… Read more »

Eric Novack
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Tom- touche — but you have not seen my kitchen. I happen to agree with you that the future will not likely hold across the board income increases for physicians. Your scenario of doctors as employees is what the major hospitals and bureaucrats would like. Both groups really do not like the idea of doctors working for cash outside of the system (I am not sure if Matthew does either). By helping to establish the current medicare system, doctors have added some of the worst features of unions — monolithic lobbying, meritless pay increases, and the ability to scream when… Read more »