Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, October 30, 2009

Ask Your Lawyer If He Carries Malpractice Insurance; You May be Surprised

I've posted here and here about the responses of lawyers in two different states to the proposal that they be required to disclose to their clients whether or not they carry professional liability insurance. In general, the publicized responses have been against it.

I would like to share a modest proposal for dealing with this issue. Best of all, it doesn't even have to involve the lawyers at all.

Let me begin by pointing out that the essence of professionalism is responsibility; doing the right thing not because you will get in trouble if you don't, but simply because it is the right thing to do. Seen in this light, carrying professional liability insurance to protect your clients/patients against the financial ramifications of your inadvertent errors is the responsible course of action.

When presenting oneself to the public as a professional, it is to be hoped that one is representing that one is responsible. Therefore the vagaries of whether or not a given group of professionals (ie, doctors) is required by law to carry malpractice insurance is immaterial. It is not unreasonable for a medical patient, a legal client, or a patron of any other professional to assume that said professionals carry insurance appropriate for their business.

As came to my attention via the above linked posts, there are apparently large numbers of attorneys who do not take the responsible course of carring liability insurance. Here's what I propose we do about it:

I propose a large public service campaign to educate the public about the fact that many lawyers do not carry malpractice insurance. Just as consumers have been sufficiently educated to inquire of their doctors whether or not they are board certified, we should explain why it is important to ask their attorneys whether or not they carry malpractice insurance. The idea, of course, is to raise the question of why would one would want to engage the services of someone too irresponsible to protect his clients' interests.

Any philanthropist out there want to donate a couple of billboards?

Tuesday, October 27, 2009

More on H1N1 Flu; In Which I Call Dr. Anonymous onto the Carpet for Being a Wimp

The venerable Dr. Anonymous, although no longer technically incognito (like a certain dinosaur), has been busy of late. He's transformed himself from a full-fledged blogger into more of a media mogul, schlepping his trusty video camera hither and yon. He podcasts on Thursdays, and makes sure that Vegas is no longer confined to Vegas. He even has a regular gig on his local TV news. In the face of all this, he rarely writes true blog posts anymore. Leave it to me, then, to jump down his throat on one of the rare occasions when he actually does so.

His latest exposition is on the topic of H1N1 influenza. Bookended by a pair of very nice video clips, Dr. A sallies forth over well-explored territory, promulgating validated information about both the disease and the vaccine. After all that, though, here's where he falls down:
When it comes to immunization, it's definitely a personal decision.
Cut me a break! That's like going on and on about the risks of driving while drunk, and then saying, "It's definitely a personal decision." This is actually true. In fact, one drunk driver presents less of a numerical risk to the rest of the population than does one unimmunized individual during pandemic flu, especially if said individual works in health care. The DUI dude can only kill, at most, one or two carfuls of people, whereas the unvaccinated RN can wreak havoc throughout an entire institution.

Dr. A goes on to say this:
The only thing I ask is to just ask yourself this question - What is the risk to yourself (and your kids) if you DO get the H1N1 vaccine (mild side effects, in my opinion) verses the risk if you DO NOT get the H1N1 immunization?
Here's where I call WIMP*. Dr. A, you've just done an excellent job of explaining that the risks of vaccination are downright trivial, compared to the documented substantial risk of pandemic H1N1 influenza, especially to children. Why wuss out now and call on the patient to make the final determination of the balance of risk vs. benefit? You've just laid it all out for them. You need to take a stand and say that vaccination is the responsible course of action.

Patients are looking for our recommendations. When the issue is this clear cut -- and make no mistake, despite the pseudoscientific fear mongerers lurking around every corner, this is indeed one of the most straightforward decisions our patients are called upon to make -- we do them a disservice by wimping out and calling it a "personal decision".

Edited to add:

Every patient has the right to make "personal decisions" about whether or not to follow the doctors' recommendations. It is still our responsibility to come out and make those recommendations.

Man up, Dude.

(*Note to COG: that's not an acronym.)

Friday, October 23, 2009

Dino Road Trip, or: Tomorrow is the Day Yet Again

Tomorrow, Saturday, October 24th, Darling Spouse, the Rolling Peke and I will be heading back to where I was spawned for an author event at the Barnes & Noble in the Clarendon shopping center in Arlington, Virginia. If you're in the area and available, we'll be starting at 1:00 pm and we'd love to have you join us.

Wednesday, October 21, 2009

Texas Follows in California's Footsteps

The more things change...

Way back in June of 2007 I wrote this post, about the uproar in California when a rule was proposed compelling lawyers to disclose to their clients whether or not they carried professional liability insurance.

Now it's happening in Texas:
The Supreme Court of Texas has asked the State Bar of Texas Board of Directors to make recommendations in early 2010 regarding if Texas lawyers should disclose to the public whether they are covered by professional liability insurance (PLI)....Texas attorneys are not required to carry PLI. In fact, the American Bar Association reports Oregon as "the only jurisdiction that requires its lawyers to carry malpractice insurance." For some occupations, insurance is mandated, for others it's simply seen as a necessary (and responsible) business practice. While Texas attorneys seem to recognize the benefit of their industry's exemption from PLI, they seem resistant to the public being fully informed of this status.
(h/t, via WhiteCoat)

I'm not sure I can say it any better than I did before. I only hope that it's okay to plagiarize oneself:
From the [original] article [about the corresponding issue in California]:
Malpractice insurance protects clients who lose money because of a lawyer's negligence -- missing a filing deadline, for example, or providing incompetent representation that affects the outcome of a case.

A lawyer's insurance status is "a highly relevant piece of information that a new client deserves to know," said San Jose attorney James Towery, a former State Bar president and head of a task force that drafted the proposal.

The ultimate irony, of course, is their corresponding stand on medical malpractice insurance. Even as they go merrily picking our pockets with mandated levels of coverage, they bitch and moan about merely disclosing that they themselves can't be bothered to protect their own clients. Can you imagine the uproar that would ensue if doctors not only chose to go bare (if they had the option) but then refused to tell their patients? How dare they! How irresponsible!
Just to be clear: no one is proposing that lawyers be required to carry malpractice insurance, merely that they disclose to their clients whether or not they carry it. For those morons thoughtful individuals who claim they've never been informed whether or not their doctors carry medical malpractice insurance, it should be noted that in almost every state it is required as a condition of licensure that a physician carry certain minimum levels of professional liability insurance. Apparently in states that do not have this requirement (Oregon; Florida) doctors are indeed required to disclose the fact that they do not carry it.

This one continues to fall way beyond "irony", past "hypocrisy", and right off the chutzpah meter.Once again, lawyers are proving themselves to be the most outrageous assholes imaginable. (I guess it's true that everything is bigger in Texas.)

Epic WTF.

Tuesday, October 20, 2009

Published Again

I took my hospital up on the offer to write a column for a local paper. This was in yesterday's Daily Local News, serving Chester County, Pennsylvania:
Which Doctor Do You Call?
Edited for style, of course, but still all me.

Sunday, October 18, 2009

One of These Two Actions is Illegal

Which of the following two scenarios is illegal under Federal antitrust law:
  • Half a dozen family physicians (of about 50 on a given hospital staff) get together and decide to set all their fees for medical services to the Medicare allowed amount plus $10.
  • Two large insurance companies (together covering 80% of the market in a given municipal area) somehow between them manage to pay between 88% and 95% of the amounts allowed by Medicare.
That's right. The feds would go after the docs. That's because the insurance companies are specifically exempted from antitrust legislation known as the Sherman Act.

Perhaps a better question might be, "Which action is more anti-competitive and more detrimental to commerce and society as a whole?" Ah, but when has the law ever bothered itself with common sense?

Saturday, October 17, 2009

Health Care for the Unemployed

Appended to a note about how much she enjoyed my book, a friend asks:
I'd be very interested in any thoughts you have about getting healthcare to the unemployed and uninsured. Do you have some?
If she means, "Do you have any thoughts about large structural changes in the delivery of health care that decouple it from employment and insurance status?" then the answer is yes. However in addition to being the topic of my next book, these thoughts by definition have no chance of actually helping any of the unemployed and uninsured -- two groups that frequently overlap, of course -- right this minute. If, on the other hand, she means "Do you have any thoughts about getting health care to the unemployed and uninsured this very minute?" then the answer is also yes. Furthermore, they fit into a blog post.

I'd like to make it clear at the outset that I'm not discussing primarily charity care. There are several local clinics and resources available that provide care at reduced rates. The thoughts I have are about making medical care more affordable by thinking outside the box and off the grid.

Medical Care

First, find a good family physician you can work with. By this I mean someone whose opinions and abilities you respect, and whose advice you will follow. The well-trained family doctor can care for 90% or more of the problems you may have, and can do so far more economically than the collection of specialists most people in this country have come to equate with "the best medical care in the world". You do not need an annual visit to a dermatologist/gynecologist/urologist/cardiologist to check your moles/pap/prostate/blood pressure, even though they may tell you that you do. This will also spare you from undergoing expensive, unnecessary testing: annual stress tests and echocardiograms do nothing for stable coronary disease; once you've had three normal annual paps, the frequency can be decreased to every 3-5 years; and so on.

Tell your family physician about your uninsured status. Plan to pay for your medical care, preferably at the time of service. Rates are often substantially less than you think they will be. My regular fees work out to about $200 per hour (ie, $50 for a 15-minute chronic care visit; $100 for a half-hour physical, etc.) Most doctors near me would probably charge about the same, or accept that amount upon negotiation.


We are living in the golden age of generics. There are really surprisingly few patients who absolutely require expensive brand-name drugs. In addition to WalMart's $4 generics ($10 for 90 days), Target and Genuardis have almost identical lists. Many other pharmacy chains (Giant, Rite Aid, and others) will match prices, but you have to ask. Costco usually has the best prices. By law, you do not need to be a Costco member to use the pharmacy.


Laboratory studies are among the most overpriced components of medical care. The markups between what labs charge patients and their actual costs are truly sickening. I know this because their charge to me as a physician client is a fraction of the direct patient charge. By charging only a small markup for myself, patients end up paying less than half of what they would be charged by the lab. Additionally, there are assistance programs available. Then again, a qualified, thoughtful family physician (like me) will limit lab testing by doing only those tests absolutely necessary for appropriate diagnosis and treatment.


There is a free-standing radiology center near me that offers fantastic service, and completely transparent pricing. If you call them up and say, "I don't have insurance. How much is a chest x-ray?" they will say "That will be $62." (Actually, a rep stopped by the other day and told me the price for a chest x-ray had actually decreased.) If you need to schedule an MRI, they will say, "Can you come over this afternoon?" Again, competent family physicians (like me) will only order imaging studies if they are absolutely necessary to diagnose and treat you appropriately.


Every county has a public health department that includes immunization clinics for adults and children. Some are free; some charge (VERY reasonable rates; I purchase vaccines and I know what they cost). Pride should not be an issue: this is not charity. You pay for it with your taxes. (Montgomery; Chester; others easily googled.)

(Hospital Care)

This could be a project for venture capital: a cash-only, insurance-free hospital with transparent pricing. In the meantime (apologies for continually tooting my own horn), a qualified family physician ought to be able to keep you out of the hospital, and especially the Emergency Department. Aside from major motor vehicle accidents and complex trauma, a good family doc can take care of many things for which you may think you need an ER. Call first.

Other Ways to Save Money on Health Care

I would be remiss if I did not include a discussion of things NOT to spend money on when funds for health care are limited.

Supplements & Vitamins

Stop purchasing and consuming assorted vitamins and supplements. Things like CoQ10, antioxidants of all descriptions, and substances purported to "support" any aspect of your health should be avoided completely. They are completely unnecessary for your physical health, and downright hazardous to your financial health. All essential nutrients are readily available in high-quality food. Use the money you save to increase your consumption of vegetables, fruits, and fish.

Most Over-the-Counter Medications

Stick to generic acetaminophen (Tylenol), ibuprofen (Advil, Motrin) and naproxen (Aleve) for pain and fever. Just about everything else is useless. Cold meds like decongestants, antihistamines, cough suppressants, etc. have been shown not to work in children under 4. Originally, they were banned under age 2. That age is going to keep creeping up until it is finally recognized that they don't do squat. Saline nose drops/sprays/neti pots work best for stuffy noses. Use plain honey for cough. (Locally produced honey can help with allergies, too.)

When you get sick, you really do need to rest, increase your fluid intake, and be patient; not "a patient" (noun), but "patient" (adjective). Wait it out at least a week. Almost all minor illnesses will be improving by then.

Avoid Chiropractors

Intelligent chiropractors recognize that they are providing a form of physical therapy. The ones who still believe there is a vital force flowing from your brain to your spinal cord and out to the rest of your body, and that all illness comes from spinal subluxations disrupting these vital forces, are dangerous pre-scientific quacks who are nevertheless persuasive and effective at separating you from your benjamins. Save your money.

Avoid "Alternative," "Complementary" and "Integrative" Medicine

The more accurate term for all these modalities is "quackery". Acupuncture, homeopathy, reiki, therapeutic touch, and all kinds of other so-called "CAM" practices are collections of pseudoscientific nonsense that have been well studied (with your tax dollars, thank you very much) and shown scientifically not to work. Their practitioners are compassionate and persuasive, but their ultimate interest is their pocketbook and not your health. When you win the lottery and have more money than you know what to do with, feel free to waste it as you please. But if you're unemployed, uninsured, and/or worried about how to pay for healthcare, it is unconscionable to throw your money away on these services.

Drop the Gym Membership

Get out and walk, either outside in fair weather or inside in foul. Thirty minutes a day, a little too fast to comfortably have a conversation if you happen to be walking with someone else, is all you need for metabolic fitness.

Quit Smoking

Now is the perfect time. Cold turkey is the most effective, as well as the cheapest way to go. At $5.00 per pack, one pack per day is $35/week, $150/month, $1,825/year. That should easily cover a year's worth of routine medical care out-of-pocket.

Quit/Cut Down on Drinking

Alcohol isn't cheap, and it isn't particularly good for you either. Decreasing or eliminating it will do you no harm at all. While on the subject of liquid refreshment, the latest nutritional recommendations for drinks for children are "nothing but milk and water." Given that soda and most fruit juices are nothing but sugar water packed with empty calories, that's pretty sound advice for adults too. "Water" means from the tap, by the way. Your taxes go to make sure that it's absolutely perfect. Bottled water is a waste of money.

Stay Healthy with the Basics

They're called "basic" for a reason:
  • Get plenty of sleep
  • Eat well
  • Exercise regularly
Nothing sexy, exciting, or expensive about any of it.

Thursday, October 15, 2009

Marketing: It Works Both Ways

Seeing a new patient involves both of us getting to know each other. Not only do I have to take the medical history and get a sense of the new patient as a person, but the patient is also feeling me out and getting an idea about whether or not I'm someone they can work with as a doctor. Even if they've heard about me -- quite a lot about me, sometimes -- from family or friends, there's still the transition from stranger to friend that forms the emotional backdrop of the visit.

One thing I do to help patients get a better sense of *me* is invite them to read this blog. This is where I let it all hang out, pull no punches, say what I really mean, and generally reveal my true self to the world (scary as that may be to all concerned). People who know me have commented that I do it well; that is, what you read is what you get, both on the blog and in the book.

That's right: it turns out the book is just as good as the blog for getting to know me without actually meeting me. And that's precisely what happened last week.

A new patient came in for an appointment. I introduced myself, escorted him back to the exam room, and began with my usual opening line, "What can I do for you today?" And here's how he started:
I picked up your book in Barnes & Noble and really liked it. Then I looked at the back flap and saw that you were around here. I was looking for a new doctor anyway, so I looked you up. I really liked your philosophy, so here I am.
Actually, my head started spinning right after his first sentence. Here was someone I had never met, but who already knew me (after a fashion). That was unbelievably cool nice. The flip side, though, was that he already knew most of my stories. Whenever I started trying to tell him one, I stopped and realized that he'd already read about whatever it was I was about to tell him.

I must admit that I've been talking up the book like crazy to my patients -- along with just about everyone else I meet; I just see more patients than strangers in an average week. Still, this was the first time that the book has netted me a new patient. It turns out that marketing works both ways.

Wednesday, October 14, 2009

H1N1 Madness ( or: Crayzee is Relative)

I rarely link to Happy the Hospitalist any more because he's usually such a raving lunatic. However when Happy points out, albeit indirectly, that there are other people out there who actually make him look intelligent, that's saying something for the stark raving crayzee that's making the rounds.

Happy relates his recent experiences with H1N1 flu, and the near death of a previously stable asthmatic. He also links to a study from the Southern hemisphere about the results (not just the "risks", mind you) of H1N1 flu in pregnancy:
While pregnant women make up only 1 percent of the general population in Australia and New Zealand, 66 of the 722 ICU patients, or 9.1 percent, were pregnant women.
Countering this, we have Bill Maher, recent winner of the Atheist Alliance International's Richard Dawkins award (see here for full fisking), claiming that pregnant women should not take the H1N1 immunization, and that anyone who gets a flu shot is an idiot.

Furthermore, the Philadelphia Inquirer several days ago published a letter from not one but two women claiming to be registered nurses proudly proclaiming their plans to refuse the H1N1 flu shot, and encouraging others to do the same.

Listen up already, people:
  • H1N1 is just another flu virus.
  • It will kill many people, especially those with asthma and other underlying medical conditions.
  • The shot is not "untested" any more than introducing a new color of paint for a car and not repeating all the crash testing renders it "untested".
  • The virus doesn't care whether or not you "believe" in it.
  • People trying to spread doubt and fear about the vaccines are not your friends (even if they're your friends).
Flu shot naysayers are like people refusing to leave New Orleans as Katrina comes roaring ashore. Listen to them, and you or your children could die. Period.

Monday, October 12, 2009

Just Saying "No" to Colonoscopy

Just when you thought you'd heard it all; just when you thought you'd heard every unbelievable, incomprehensible, illogical policy* imaginable; just when you thought it was safe to champion preventive care, comes the Darwin Award for the lowest an insurance company can go.

There's this patient whose father, sister and aunt all had colon cancer in their 40's, so you recommend a screening colonoscopy. The patient is perfectly willing to go (only about 1 in 10 patients right there!) but is told by her insurance company that they don't cover screening colonoscopies.

That sucks, especially since the company prides itself on its comprehensive preventive care that covers annual mammograms over 40 (shown to cause more harm than good, when anxiety from false positives is factored in) and PSAs for men over 50 (never shown to lengthen life). Still, patients often have symptoms like fatigue and changes in bowel habits, which allow the procedure to be coded as a diagnostic colonscopy instead of a screening one.

Ready for the kicker?

This company won't cover diagnostic colonoscopies either.

Epic WTF?

Let me get this straight: whatever the symptom, whatever the history, whatever the possible diagnoses, under no circumstances will this particular company ever cover the specific non-invasive procedure known as colonoscopy?


How can they do this? By including this language in their "Plan Exclusions":
Colonscopy both screening and diagnostic is considered a non-covered service under this plan. This test may be appropriate for certain patients. This plan does not intend to recommend particular levels of care and if in consultation with their physician it is determined that this procedure is the most appropriate choice for their situation, they are encouraged to proceed with the procedure at their own expense.
Apparently, this is how the insurer transfers liability for non-coverage; it seems that this is permitted under the Supreme Court decision handed down in regards to insurer liability for non-coverage of an accepted level of care.

It turns out that this is considered purely a cost-containment measure.

What the hell next? There are plenty of other ways to save significant sums of money:
  • CT scanning is considered a non-covered service under this plan. This test may be appropriate for certain patients. This plan does not intend to recommend particular levels of care and if in consultation with their physician it is determined that this test is the most appropriate choice for their situation, they are encouraged to proceed with the test at their own expense.
  • Levaquin is considered a non-covered therapy under this plan. This drug may be appropriate for certain patients. This plan does not intend to recommend particular levels of care and if in consultation with their physician it is determined that this drug is the most appropriate choice for their situation, they are encouraged to receive this drug at their own expense. [Not all that bad an idea, actually. In addition to being hideously expensive, it's rarely the best choice.]
  • Chemotherapy is considered a non-covered treatment under this plan. This treatment may be appropriate for certain patients. This plan does not intend to recommend particular levels of care and if in consultation with their physician it is determined that this treatment is the most appropriate choice for their situation, they are encouraged to receive this treatment at their own expense.
It seems that in order to effectively contain costs, insurance companies are moving away from actually paying for medical care. And this is the private insurance that "most Americans are happy with"?


h/t to BS

* Aside from Medicare paying for kidney transplants, but discontinuing coverage for anti-rejection drugs after three years.

Saturday, October 10, 2009

Another Book Mention

Thanks to my agent, Janet Reid, for directing me to set up Google Alerts for all mentions of my name and book on the internet, which is how this little item came to my attention. In response to this well-commented-upon post about why the Doctor-Patient relationship cannot be 50-50 comes this, from The Patient Report:

On this website, TPR, we write a lot about the doctor-patient partnership. It is our goal to be clear that it is not possible for it to be a 50-50 partnership because one of the partners has been to medical school and the other has not—-and may feel rotten, besides.

That said, it still is a partnership, each doing the best he or she can. Let’s also remember that it often is the patient who gives the doctor the diagnosis, although not in Latin. Repeated takings of the history of the problem may enable the patient to refine a pattern or spot a symptom which, at the time, meant nothing. So, patients are no slouches in helping out in the diagnostic department—-they just may be not be expected to.

Many doctors have argued that “informed consent” is an ideal, not a reality.

This marvelous woman is making the same point but more bluntly.

Don’t give up on your partnership with your doctors no matter what she says.

But also know that she is right about who actually must make most of the decisions.

Thanks to Cheree Cleghorn for the kind words.

Friday, October 09, 2009

Colonoscopy Complications

Fighting a cold for the last week, I've still got this annoying little cough once in a while. Ran into a neighbor while walking the dog who heard me cough, and offered up this story:

She had a colonoscopy a few weeks back which was complicated by aspiration. As a result, she had been coughing up a lung ever since, although it was getting better. Her germophobic sister-in-law, upon hearing her cough, drew back in alarm, arm drawn over her face in fear.

Neighbor: You know I'm not contagious.

Germophobic sister-in-law: No.

Neighbor: Yeah, this is from my colonoscopy.

GSIL: Did they go up too far?

Saturday, October 03, 2009

Tomorrow is the Day (Again)

Anyone and everyone in the vicinity of the Valley Forge Barnes & Noble (150 West Swedesford Road in Devon, PA 19333) tomorrow, Sunday, October 4th at 2:00 pm, please feel free to join us for another reading and signing event for
(which you may or may not be aware is the name of my book.)

You Know You're Getting Old When...

Heading out to watch the Jock's Ultimate Frisbee team (which includes a sophomore with the same given name as the Jock) play a tournament, I arrived a little after they started. This meant he was busy, so I didn't go bother him. Instead I hung out on the sidelines, where there were a number of new players I hadn't yet met.

One of them asked me who I was, so I replied, "I'm the Jock's mom."

Her response: "Sophomore Jock? Or the other Jock?"

"The other Jock"? The other Jock. The *other* Jock.

There you have it. The poor kid only missed graduation by one year, and he's already "the other" Jock. Four years he's put his heart and soul into this team, and now he's just "the other Jock." Last year he was the team captain; this year he's "the other Jock."


(In case you hadn't figured it out, the title of this post refers to the kid, not to me.)

Thursday, October 01, 2009

Twenty Years

Happy Anniversary to me! Twenty years ago today, I hung out my solo shingle.

Last year, I forgot to post anything about it. Two years ago, I wrote about it here. Much has happened in the last two years, yet much has remained the same. Happily, my family is still all well and happy. Sadly, my income hasn't budged.

Twenty years ago, I saw three patients that first day. Today I begin the day with 16 patient visits scheduled, plus 27 others for flu shots.

I'm still blogging. I'm not checking the site meter nearly as compulsively as I once did; this is a good thing. I now have a laptop on my desk at work, though, so I check Facebook several times a day; this is probably not such a good thing.

I'm still writing; and now I'm published. I even have an agent, so I know that as I continue writing, there's at least one person who doesn't think my stuff sucks. This is an extraordinarily exciting time in my life, and I'm really looking forward to seeing how this writing thing develops as an ancillary career.

But now as then, what I look forward to most is the people. They're usually called patients, but what they really are is people who have done me the tremendous honor of allowing me into their lives at their most vulnerable; the best and worst moments of their lives; the beginnings, the endings, and everything in between. When I think of twenty years in practice, I don't think about the three locations, the comings and goings of assorted staffers, or even the hospital staff and committee meetings. I remember the patients; my patients; my friends. Now as then, they are the reason I do what I do, and why I love what I do. Now as then, I thank you all.

Me and the Rolling Peke,
both with fresh haircuts