The End...starting from the Beginning

As of June 30th, 2012, my practice will cease to exist.  For those who did not know, in short, I am a family physician practicing in Portland, Oregon for the past 10 years.  My practice was unique in that I  had no ancillary support staff.  It was just me and the patient.  When the patient calls, it is me who speaks with them.  When a patient walks in the door, it is me who greets them and sees them from start to finish.  Most times, I spend 30 minutes with each patient, sometimes up to an hour.  I've been using electronic medical records ever since I started.  I use technology to cut through the clutter and to efficiently get the tasks I needed to get done for my patients.  The technology was nearly invisible to my patient...the primary value of the visit is the face-to-face time that I spent with my patients, the eye contact, listening to them, provide education, and help them.  It was my dream to practice this way...the way I thought the practice of medicine should be.  I left what was the status quo of hamster-wheel medicine to pursue my dream nearly 10 years ago and I spent 10 years perfecting and maintaining this dream.

Only to see my dream be on permanent life support with no end in sight.

Due to circumstances beyond my control.

Like making a heart wrenching decision to pull a patient off life support, I had to do what was right for me and for my patients.

What happened?  I will explain in the next few posts....

A canary in the coal mine

It's been another year and I'm just getting back to this dusty blog which has been on the backburner. To make a long story short, a lot of changes in circumstances have occurred since I last wrote here.

1. My practice has been altered to adjust for changes in my personal life (new addition to the family!). I'm still practicing 3 days a week and 2 of those days I'm working for a child abuse assessment center as its medical director. I'm doing evening clinics now so I can spend one day a week being available to do errands and life-important things in the daytime.
2. For the past year, I've been secretly (it's no secret now) working on a soon-to-be released open source electronic medical record, programmed in PHP, MYSQL, and works under the Apache web server system. I've gotten so fed up with the recent changes with my existing electronic medical record system Amazing Charts. I'm making constant changes and additions for myself, that finally I said to myself, "What the heck?! I've got to re-invent the wheel because the wheel is broken!!" I then starting looking into using OpenEMR but again, I came across the problem of a broken foundation - just didn't fit the needs of my practice and what I think most doctors and other health professionals really feel would be user friendly; I said to myself again, "Another broken wheel, might as well re-invent another one." So, here I am, announcing that my stubborn, perfectionist attitude has, yet again, resulted in the birth of a new monstrous creation. My first creation, if you didn't catch it was my solo practice, much sooner than I anticipated to have done in my lifetime.
   
3. Sooner or later, it was going to happen, and it happened this year; my computer server failed and I eventually migrated to Ubuntu Linux for my new quad-core server and mostly ditching Microsoft for good. I couldn't tell you how many times I've had to deal with corrupt registries, frequent unexplained freezes resulting in numerous reboots, and crazy stuff like daylight savings time stupidness. Besides, Microsoft Windows 2000, the most stable (I think) of the Microsoft operating systems, is no longer supported by Microsoft anymore, uh, like 3 years ago... Oh, and being a geek for building my computers from scratch, I finally bit the bullet and got a pre-configured system only to find out I can't buy one at a big-box store because Windows Vista was being retired for the transition to Windows 7; so I ended up having to go underground to find a system that had Vista so I could just wipe it out to put on Ubuntu. Sheech...
   
4. Health Care Reform - or more like, Health Insurance Reform, only that the reform doesn't mean anything for another 3 years, and we still have millions of uninsured despite the reform, and well, "what kind of reform are we talking about" reform? Sounds like the storyline to the Wizard of Oz to me too...
   

So on the subject of reform, I have waited and watched to see the events unfold only to see that the health insurance and pharmaceutical industry is going to do very well after all that is said and done. If you read my other postings, you know where I stand about this. And my concerns about my specific specialty, my profession, continue to go on. I got to watch Michael Moore's Sicko a few weeks ago (a couple of years since it's initial release) and it's just sobering how far away we are from reaching any kind of meaningful consensus that health care is a right for everyone. It's so sad that other industrialized nations and some third-world countries already figured this out and we are so behind. In some ways, living in Portland, Oregon has insulated me because there are a lot of like-minded people who feel the same way I do; however, I'm reminded every now and then that the rest of the country is living in fear and paralyzed by the threats of socialism, evoking and inflaming racial and social class tensions.

So as I see the end result of this reform in the short term; I see that my ability to sustain my practice in it's current form will come to an end. There has been no effort to change in the bills to address the reimbursement formula to increase pay for primary care physicians which will continue the hemorrhaging of prospective, highly qualified, medical students into the field. I see no immediate change in the bill that will address the byzantine and labyrinthine billing/prior authorizations/pre-existing conditions/eligibility procedures for all these different companies with different contact information. In fact, it appears with the entrenchment of the insurance companies in this current reform, not only do I not see this changing dramatically anytime soon (I fear, not in my lifetime), I see a very distinct possibility that things will get much, much worse.

I recently read an opinion by Dr. James Kibbe, MD, MBA who had expressed concern about some of the problems with enticing doctors to adopt EMRs without address the foundational problems of the current US system. I wholeheartedly agree - our foundation that we stand on is the wrong approach, unsustainable, unethical, and an anathema to common decency. Insult upon injury, it also is punitive to doctors who are trying to do the right thing and we are now further pushed to go into a system that rewards profits over care, rewards being a production man machine (NOT a doctor) feeding the ravenous insurance-drug-procedure industrial complex.

Furthermore, Dr. Kibbe coined the concept of some of these smaller/solo doctors as the canaries in the coal mine. As a solo family practice doc in a low-overhead model where I get exposure to all of these different aspects of navigating the health-care maze; I instantly understood what he meant. Of course, I wouldn't be writing all these concerns in this blog had I not experienced first hand what it was all about. And now, as the canary seeing a dark end of a tunnel that goes nowhere and meaning certain death, I am now making a critical decision so that I can try to survive; knowing that the direction of this country's health care policy is veering towards certain destruction. It's never an easy decision; it's always nice to have everything you want and in the idealized way. Certain dreams have to be laid to rest until another day. It's just that sometimes each one of us has to decide when to step off that moving train going towards a cliff.

Just as we all hope that someone else will solve our problems; once again, I am destined to solve these problems my own way. Just like when change happens in the grassroots, at the local level, I will need to make changes both personally and from where I can influence change...my own practice. I can no longer wait for salvation.

Just to add my icing to my depression cake, I would like to point out a new film made by a young emergency room doc called "The Vanishing Oath" which talks about the tolls and tribulations of primary care physicians and where it all comes from. The "why" highlighted in the film is not so surprising if you have followed my blog...it's all the same stuff. The "where do we go from here" remains, unfortunately, unanswered; I think we're just skimming the surface.

So, in my next post, I will talk more about my plans for change in my practice...

If health insurance companies ran the postal service...

This is what it would look like...

It's "Burn Your Health Insurance Bill Day!"

Today, March 11, is the day to voice out your support for single payer health care. I would certainly like to burn my health insurance bills; unfortunately, my clinic operations depend on it (for now), and I would be creating a large amount of carbon emissions with the bonfire. But, in spirit, I have copies of PDFs on my laptop that I plan to stuff in the recycle bin and vaporize with a button, repetitively. The word needs to get out and Obama needs to hear what the majority of Americans and physicians and nurses all desperately want to see change.

Oh...the drug companies!

You can definitely where things go from here, and the true motives of pharmaceutical companies, when all is on the line on the stimulus package. The drug companies are insistent that government funding for research to see if the drugs really work is a bad idea. We're probably going to see a lot more this as we are finally bringing up issues that really matter.

Muffled

I recently read an interesting article about a BBC documentary that was only shown outside of the US about the state of the US health care system. Pretty shocking stuff, but I'm not actually surprised.

The tube

Wow...on January 14, 2009; while I was flipping channels on my TV (local stations with ABC, CBS, and NBC), literally every single commercial break was filled with at least one pharmaceutical direct-to-consumer advertisement...Crestor, Viagra, Humira (for rhematoid arthritis), Boniva, and others.

I admit, I don't watch TV every day so I may not have noticed the trend; I know at least 5 years ago that's when it began...but every single commercial break??!

All I can say is..."wow".

Like my observation that health insurance is starting to pinch pennies mercilessly over the past year; I'm beginning to wonder if the pharmaceutical industries are doing their last "hail Mary" before their Golden Age is overwhen Obama takes office...if and when that happens.

Of course, I just giggle at the absurdity of these commericials - 90% of the time devoted to it is talking in quick talk about all the potential side effects these medications have - like if someone was really listening in, they would really want to get sick from all of these medications! Literally, who are the marketing geniuses for these companies?!

Recommended viewing

I have included a link to a recently made video that wonderfully and explicitly details the issues surrounding the American health care system today. The ideas presented obviously coincide with my sentiments and my views and hopefully, more and more get to learn and hopefully assist in a political change to make single payer health care a reality.

A good primer

This document is actually a very condensed and informative primer on the American Health Care System, how it came to be and where we go from here. Happy holidays!

Measuring happiness

Now this is a cool idea.

Squashed

As we wait, if and when health care reform is a reality (or what it would look like), I can't help but notice the external forces that are affecting the landscape for solo practitioners like me, currently, and in the future as the wheels keep turning and time is ticking. Below are some examples that highlight some of what I'm worried about.

1. CCHIT, also known as Certification Commission for Healthcare Information Technology (who comes up with these acronyms, I don't know...but as you'll see later, it's quite fitting for what kind of mess this is). It was a great idea on paper...to have an agency that sets standards for electronic medical records with the aim for interoperability and allow secure exchange of medical information. However, as it quickly evolved, it has become a sore spot for me as the $COST$ of being certified as a CCHIT product no longer becomes reasonable, especially for us smaller doctors that don't that have much overhead to negotiate without affecting our day to day operations. What bothers me is...why do they (CCHIT) have to be some agency that requires that an EMR company to pay them a substantial amount (I believe it's around $30,000 for the initial 3-year cert and then $5000 every year in the 2nd and 3rd years to cover licensing fees). That's a HUGE burden and that cost gets passed down to the physicians/hospitals/etc who are purchasing these products! As someone who also dabbles with computer software/programming (I'm actually a supporter of open-source projects), I see "standards" as a set of guidelines that in order for other systems to work or connect or to meet a minimum level of acceptability for user-friendliness...a good example is the W3C (World Wide Web Consortium) that determines the standards for HTML code for website that get translated by Web browsers like Mozilla Firefox...there's NO huge cost layout to make these standards established and for other computer software companies to comply if they want to be competitive. This is yet another example of how the cost of *anything* that is related to health care is so absurdidly high for no real, substantiative reason other than the profit motive. I mean, to get a "medical" stool costs 5 times as much from a medical vendor than it is to get from Costco (just a different color). What's the reason for that?! (and I hope it's not that the dyes for vinyl covering for the medical stools comes from some special factory that uses gold screws).

Anyways, pretty soon, Medicare has plans to make sure that doctors are using these certified EMRs and electronic prescribing. That too, on paper, sounds like a good idea...it would be great if health care finally uses electronic methods to input, store, and analyze data...like the banking system has been doing for, what, 40 something-odd years? But who's gonna pay for this? Why pay for some "standards" that have no benefit for me when I pay the EMR company who has to shell out this money to this agency to create the standards? Does it help me in any way?

I'd rather pay an EMR company to create a excellent product on its own merits and not have to up their price just to be certified. Oh, by the way, I do have that right now. I use Amazing Charts...but the bad news is that they held out for so long not having to be pressured to be certified. However, with the inevitablity of Medicare mandates, they have now made the decision to become certified, and (guess what?), the cost of their EMR is now 10 times more than when I purchased it including the annual fees for updates. YIKES! So I'm actually trying to shore up a way to create some HTML/PHP templates for OpenEMR...that's what I do in my spare time these days...at least the EMR is free.

I don't really know what I would offer as a solution; I think there's definitely a developed culture of "If it's medically-related, it's gotta be expensive. Let's offer a product to doctors and because they have lots of money, we can up our charge for the same product that we sell to others, but let's don't tell them that." Yeah, well I'm rowing up CCHIT creek because I'm not one of those well-paid doctors.

2. Vaccinations - a nightmare of epic proportions for me. Let's say you're a clothing store and you order your merchandise from the manufacturer for $10 an item. As a store, you need to increase the charge cover the cost of your operations, so you bring the total to $20 and that's the asking price to the customer.

OK, so now let's say that instead of the customer paying for $20 item, he/she uses their grandmother to pay for the item and the grandmother says, "I'm not going to pay for this item for $20, I'll pay you $5". What would the store do at this point? The store would say, "I'm sorry, that's how much we charge".

OK, so now let's say the vaccine manufacturer is our manufactuer in this example. The store is the doctor's office, the customer is the patient, and the grandmother is the insurance company (I mean no insult to grandmothers). Right now, the store would say, "OK...I'll give you the item, you pay me $5 dollars, and that's that."

I don't know how medical doctors and offices got into this (I think I know, we're probably too nice or maybe back in the day, we didn't read the fine print) but no self-respecting business person would even consider this a fair deal. It's a raw deal.

So you've got these mandates (again). I'm generally a believer in vaccines (but there are some caviats to some of the more recent ones, but I'll discuss that later) and there's a huge public health benefit for vaccinations. It sounds good on paper but the devil is in the details. The system is rigged so that in the end, doctors are losing money to give them. This is highly magnified in a smaller practice, hence the argument that to absorb the loss, you have to be in a bigger group. But why does it have to come to this? All that I ask is that the cost burden be fair, starting from whether the cost of the vaccine is justified, to making sure the insurance companies are actually paying the cost of the vaccine if the manufacturer is asking for that cost so that us doctors aren't left with the bill.

There are victims I see amongst some of my colleagues, too numerous to count, that have been so frustrated with this system and dealing with programs (Vaccine for Children's programs for the uninsured or on Medicaid) that try to aid because it's so unfair. We're literally at the mercy of money-hungry entities that believe you're well off and can be bought off and sold off; but there are no alternatives; no regulations.

3. A very well-written blog about the concept of "overtreatment." I second all the statements!

Perhaps a little light from a long tunnel...

What a difference an election makes - it's all about dumping far-right, far-left ideologies and really address the issues that affects everybody today and now insurance companies are wanting to play ball as along as everyone is covered!

Speaking of which, this is an excellent summary on the plight of primary care. Again, more of the same but highlights the struggles and obstacles to improving our health care system. As I read this, I was reminded of my experience as a 1st year family practice resident at Hennepin County Medical Center in Minneapolis, Minnesota nearly 8 years ago and one of my esteemed preceptors, the now retired Dr. Harley Racer, talked to me about how I only get 15-20 minutes with a patient after I had spent nearly an hour talking to a patient who had diabetes, hypertension, liver disease, and tobacco use and managing the myriad of issues (sound familiar to other family physicians?); I certainly understood his position that we were working within a confines of a messed up system, but he encouraged me not to give up hope; that we went into medicine for noble, selfless reasons. I saw in his aged eyes, knowing that he participated in being a general physician since the 1940's, that he'd seen a world that has changed before him. I never forgot that lesson and I carry it with me to this day. Perhaps, with perseverence, there can be a light at the end of the tunnel.

Grumblings

As I scan through the various medical blogs since the election, I see an emerging civil war between specialists and generalists erupting from various proposals from policymakers, such as Senator Max Baucus from Montana. In order to fix the U.S. health care system, addressing the plight of primary care physicians is absolutely essential. What does that mean? For some, it's "spreading the wealth" in regards to income distributions between specialists and generalists and that strikes fear into the hearts of specialists who have depended on the decades long payment system that favors procedures versus investment in prevention. There's also stuff of sorts that primary care physicians don't work hard enough and we have to see more to make ends meet. Heard that before. When we cut through the spin and fear-mongering; the essential question is this:

Are we as a society going to understand and redefine what it means to have a health care system that actually values health? Or are we as a society going to believe that the direction we have been going is the best that we can do? Now, come up with your answer....

I've also read other weblogs where physicians are absolutely horrified by the prospect of a single payer system that the current examples of Medicare and Medicaid are going to spell doom to the health care system as a whole. Yes, if Medicare and Medicaid were the only payers in this nation and working exactly the way it is right now, I would be awfully afraid of what would happen to our healthcare system. However, in response to that concern, I propose the following.

Call me an optimist, but there have been numerous periods in American history that when there is a calling and we have an inspirational leader, we can acheive great things together. Franklin Delano Roosevelt and the New Deal and the defeat of Nazi Germany and Japan; John Fitzgerald Kennedy and taking the man to the moon; Lyndon B. Johnson and the Great Society. If we can do that then, how come we cannot acheive a perfected health care system for all, starting now? The great start, which I'm glad that President-elect Barack Obama stated in the debates, is that health care is a right for all Americans. And I think most people will agree on this now. Not too long ago, that was not the case.

Lately, over the past 30 years or so, we have not had the gumption or clarity to take us where we need to go...and just like someone who has not yet understood the importance of change because there is lack of awareness in the problem (alcoholics, for example), perhaps the most of us in the U.S. were led to believe that our system is the greatest and infallable in all the world. We've all heard in some way, shape, or form that our health care system is the "greatest in the world", and it's all because it's not "Socialized" medicine. Peel away the layers and over time, the symptoms of the illness we call the dysfunctional health care system shows through. The growing numbers of the uninsured. The hurting businesses trying to pay for health care for their workers and losing competiveness around the world. Our fallen economy. Mounting health care bills for families. Overflowing, overburnded, burnt-out emergency rooms, urgent care clinics, and primary care clinics. Rural clincs struggling to stay afloat. Medical students, wanting to do primary care, but with financial burdens, deciding that the wise thing to do is to be a specialist. The cycle feeds itself and leaving destruction, anger, frustration, and fear in its wake. And the results show. The "fundamentals" of our current system are misguided, bordering on unethical (in my opinion), overly complex, and highly counterproductive. These fundamentals are then fed and supported by fear and greed.

Right now we are peering down the chasm of this so-called illness and wondering, should we just continue to ignore it and pretend that it will just go away, or shall we face it and confront it?

Once we make the awareness, which believe we are at this junction (it's long over due, in my opinion), we have the capacity to start change and work together with a committed goal. Going back to my optimism statement, I believe that we have so much untapped potential - all of the current health care workers, those who work in our clinics, hospital, and yes, even the insurance companies, that can be channeled into this endeavor to look at our system with fresh eyes and renewing a commitment to care and quality for all Americans; look again and what it means to have "market-driven" medicine and focus again on what is good for all rather than just for a priveledged few. This is the stuff that's happening in the grassroots right now, in Oregon.

Imagine if this can spread to the rest of the nation. I can see, from our nation's history (I'm kinda a history buff), that we can have great ideas and great people - coming from true intentions that exemplifies the common good. Just look at our attempts to bring a man to the moon. We poured our efforts into education in math and science with true competition, not out of greed, but for the goal of space travel.

What I see is that we can have a system of health care that balances the independence of physicians and patients, taking the middlemen of payment out and consolidating it to the largest insurance risk pool (national insurance) and where the responsibility of the management of the risk pool is dictated by the mandate of the people (taxpayers and those who vote)...and where doctors no longer have to be torn between the triangulation and really focus on delivering quality health care (this is where my passion is!). What does that describe?

Single-payer health care.

Ahh, but do we have evidence that this works?

Yes, we do...think of all other industrialized nations in this world and everyone else has shown that health outcomes have generally improved when there is a unified, single-payer health care system (there's different variations, but all variations on the same theme, where everyone is covered). We may argue that the United States can choose to be different (like who else in this world use the English or Imperial system for measurements and temperature rather than metric?!?!...but that's another diatribe for me), but the cost of choosing to be different far outweights the benefit of making a smarter choice.

So, this is what I would say about the whole topic. Learn from others and learn from history. Use the links above to be the starting point and guiding light to get to the answer. Don't just take it from me, but maybe we'll all end up agreeing. Now that'd be nice, wouldn't it?

Hope, maybe?

I'm so glad the election went the way it did. Now, the hard work begins. Recognition of the problem is step one and that begins with more mainstream media attention being paid to the plight of the primary care physicians. The reason? Much that has been said here in this blog. Hopefully, the solution to the health care crisis will involve the recognition of the work of primary care physicians - prevention, education, and bringing back the meaning of health in "health care".

Well said...

In these tough times right now, we must take perspective of our view of this crazy world. This editorial below by Norman Solomon succinctly and clearly makes a claim for "waking us up" and taking perspective.


Published on Tuesday, September 23, 2008 by CommonDreams.org

Too Big to Fail and Too Small to Matter

by Norman Solomon

These times provide a crash course on the corporate state:

If a company like AIG is too big to fail, the government will rescue it. Mere people -- too small to matter -- are expendable.

The insurance industry is too big to fail. A person's health is too small to matter, so -- when it fails due to the absence or loopholes of insurance coverage -- that's tough luck.

The Defense Department is too big to fail. The people it's killing in Iraq and Afghanistan are too small to matter.

The U.S. nuclear arsenal is too big to fail. The Nuclear Non-Proliferation Treaty, undermined by Washington, is too small to matter.

Overall, the warfare state is too big to fail. The virtues of peace are too small to matter.

Agribusiness is too big to fail. Family farmers are too dirt-small to matter.

The leverage for the U.S. Treasury to subsidize Wall Street is too big to fail. The leverage to subsidize mothers and children kicked off welfare is too small to matter.

The political momentum for bailing out corporate America is too big to fail. The political momentum for funding adequate payment rates from Medicaid to reimburse healthcare providers is too small to matter.

The oil conglomerates are too big to fail. Global warming is too small to matter.

The prison industry is too big to fail. The need for preschool is too small to matter.

Corporate power is too big to fail. The ordeals of working people and want-to-be-working people are too small to matter.

Human worth as maximized by dollars: too big to fail. Human worth as affirmed by humanistic values: too small to matter.

The current odds of pumping at least several hundred billion taxpayer dollars into corporate America: too big to fail. The current odds of launching a massive federal jobs program: too small to matter.

Such priorities and mindsets are in overdrive at the intersection of Pennsylvania Avenue and Wall Street. But a basic shift in government priorities is possible. That's what happened three-quarters of a century ago, when a progressive upsurge prevented the re-election of President Herbert Hoover -- and then effectively mobilized to pressure the new occupant of the White House.

After campaigning in 1932 on a middle-of-the-road Democratic platform, Franklin Roosevelt went on to become a president who denounced the "economic royalists" and made common cause with working people and the unemployed. People across the country organized for social change. In the process, you might say, the power of progressive movements became too big to fail.

Something like that could happen again.

Little empathy

I came across a recent article on the Archives of Internal Medicine which struck a chord to me. Actually, I'm not really surprised since I have had concerns of this since I was in medical school and the emphasis on training for the "science" of medicine and the lesser emphasis of the "art" of medicine. I came in naively to believe that there is a balance to both. I still believe in that balance but the training for new medical professionals as well as the emphasis of over-specialization has definitely tilted to the point where we now see doctors no longer having that empathetic skill to connect to their patients. Even more striking is with the recent tide of "market-forces" and "letting the market decide" for medicine is how people are just treated like commodities and widgets - it's pretty sobering...whatever happened to real interaction with real people? It's definitely lost in translation with all the hype of the cure-all pharmaceuticals and state-of-art technology. *Sigh*.

A sorry state of affairs....

More bad news on the horizon - not much of a surprise as this trend was going on since I started medical school in 1996, however, I feel that the backbone has broken and the demoralization of primary care has, in essence, become the end result of the reliance and emphasis of overspecialization, supported by the the Medicare payment schedule equations and de-valuing of primary care visits in general.

This is nuts!

Just had to put this link on my blog as it completely astounds me that there are individuals to this day that believe that the healthcare crisis in the US can be solved by abolishing the "uninsured" term in the census and use the ER as the solution! The actual blog by John Goodman gives more details on this *ingenious* solution; which by the way was also the same solution George W. Bush suggested several years ago. As you can see, I'm all about single payer health care - it's really the only solution that makes sense from every perspective - for the patients, the physicians and health care providers, and the community.

Holidays (a late post by the way!)

I'm sitting in Illinois on a December day, writing this blog with the intention to reflect about this past year. It's been a steady year in my practice and I still remain committed to my vision about my practice. Overall, in the past 3 1/2 years since the inception of my practice, I believe that this style of practice is still viable...at least for me. Perhaps that's all one can really ask for, to find something that fits, even if it doesn't fit everyone. Here are my thoughts...

1. I am more and more concerned about the health care system of America. Every aspect of the deficiency of this system affects my practice but most of all, my patients. Things I have discussed before - such as the fragmentation of care, minimal value placed on primary care physicians, over-utilization of emergency rooms - all continue to be a trend that does not seem to be reversing. Every year, Congress is always threatening to decrease compensation to physicians but when reimbursement to primary care is already at the lowest tier, the very existence of primary care is threatened. There is so much talk about the need for preventative medicine, and a medical home but I'm concerned that it may be too little, too late. Will the upcoming election in 2008 focus on this important issue? I hope so, at least there's talk about it now...it's just a matter if there is enough people power to overcome the huge medical insurance and pharmaceutical industry juggernaut. There is only a few presidential candidates that are willing to fight it, however.

2. Insurance companies are become more cunning about saving money and increasing work for physicians for what purpose? As I see this happening, I can surmise one thing...the tide is turning about their clout and the insurance companies are feeling it and milking everything it's worth in the health care industry dollars. And why are physicians complying with this? I know I'm just as guilty as the next doc but I'm thinking more and more about ditching this system unless some meaningful change exists (see #1)...which means the attractiveness of a cash only practice is looking better to me every day.

I recall a moment in my medical school training when I was doing a rotation in rural medicine in Rolla, Missouri. I was following an emergency room doctor at 1 in the morning seeing patients. During a lull, he sat me down and drew me a diagram of 2 boxes, one box being the patient, one box being the doctor. He mentioned that the connection between the 2 boxes, just like any other relationship, is important for both involved. The relationship is jeopardized, however, when a triangulation occurs between the 2 parties. This is the middleman, the insurance company. And as this third relationship evolves, which began to develop after WWII in America, the less the 2 initial parties began to see eye to eye. Just like Machiavelli, the role of this middleman, in another level, is dividing and conquering. They have succeeded and thus the role that they play now, politically and culturally. Now more than ever, any fear about the decline of this middleman is parlayed as threat to the doctors - "You won't get paid!" and to the patient - "You won't get good health care!" and who wins? What other industry works like this? Perhaps my previous work as a cashier in a bakery/restaurant highlighted this; how absurd this system has become. Over the past year, I've been more in tuned to this absurdity...and it has colored the choices I have to make as a doctor about my future.

Finally, an update...

Finally, I'm ready to do another update (hasn't it been more than a year?!). It's been a crazy year so far in my practice...good for some reasons, not so good for other reasons, as it is with everything in life. Anyways, just a little blurb on something I recently read about "noncompliance", which I found to be an interesting perspective; something I will occasionally need to remind myself on how to deal with...