The trend to cash medical practice

Some time ago, I did a post on my own blog about doctors dropping out of Medicare and many quitting all insurance. I really got thinking about this after the American Geriatric Society meeting in Chicago last year. I met a woman geriatrician, the only fellowship trained geriatric specialist in central Iowa. She had quit Medicare. That sounds a bit suicidal if all your patients are Medicare age. What had happened was she was being harassed by Medicare because she was seeing patients too often. Many of them were frail elderly living at home. She dropped out and began charging her patients cash for services. She was making a decent living after a year and was happy with her decision. I don’t know how many realize that geriatrics, as a specialty, is a university subsidized field. There is no private geriatric practice because the doctor can’t survive on what Medicare pays. She tried and had to quit. She is doing it on her own now.

The Weekly Standard has an interesting article this week on this trend. The doctor is not near retirement , as many of the folks I had previously talked to were. It took a lot of guts for him to start out this way and he explains why.

There are a couple of errors in the article and I will point them out.

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Lean practices and starting a trauma center.

The discussion of the pharmacy reorganization got me thinking of the trauma center that we started in 1979. That was well before I learned about lean practices or the Toyota method but I think we used a number of their principles anyway.

When we started our trauma center, we did something a bit like your pharmacy project. We were a small hospital (120 beds) in a new suburban area with the ocean on one side and national parks and mountains on the other. Orange County narrows down to a triangle which ends at San Clemente where the Marine base begins. We knew the county was going to regionalize trauma. A study had come out suggesting that too many people died because “the golden hour” was lost in trying to get doctors and operating rooms organized, especially at night.

Several large hospitals planned to enter a competition to qualify as centers; one of course, was the UCI medical center. None of them was within 25 miles of our hospital. We didn’t like the idea of seeing the injured patients, some of whom would be neighbors, being taken that far and we looked to see if we could set up a trauma center for our community that would pass muster with the EMS survey team. First we had to see if the hospital and medical staff would support it. My partner and I couldn’t do it alone.

I did a study of the finances of trauma. The stereotype is a drunken insolvent who is stabbed or shot. Our community is located along I-5 where it runs from Los Angeles to San Diego. We are between mountains and the sea. I took the records of all emergency admissions, who went to surgery or who were discharged with a “surgical” diagnosis and who went to ICU. Some of those were general surgery but by using a screen we got down to the trauma cases. I found that 85% of them had some sort of insurance. This was largely because most were auto accidents. Even if people don’t carry health insurance, somebody may have medical benefits with car insurance.

We presented this to the department of surgery and they turned us down flat. The vote was something like 33 to 2. We went to the Board of Trustees. At the time, the hospital was owned by a partnership, one of the dreaded for-profit hospitals. The Board was easily convinced that this was something we needed to do if this hospital was going to grow. Southern California is cursed with many small hospitals and few big ones outside of Los Angeles. I knew a vascular surgery group, of three men, in the San Fernando Valley that went to 12 hospitals. One of the reasons I moved to Mission Viejo was to get out of Los Angeles.

Anyway, we had the hospital on board but not the doctors. The hospital decided to make the trauma center a contract service like the ER. My partner and I would run it. The hospital hired a city planner to draw up a proposal for the county. They gave me a copy when he was finished and it was the size of a Chicago telephone book. I read through it and it sounded like a proposal for a shopping center. I rewrote it. A lot of it was useful, like traffic analysis, but the vast majority didn’t answer the right questions.

Then we had to figure how we could do this and not go broke. There were two of us. We would call other specialists, like orthopedists and neurosurgeons, as needed. That’s how we got around the surgery department. There were grumbles but they faded as the orthopods began to realize that trauma cases paid well, mostly. Then we figured out who is in the hospital at night. The other trauma center candidates all promised to have a surgeon and anesthesiologist in-house 24 hours per day. We could not afford that. We promised that the surgeon and anesthesiologist would arrive within 15 minutes of being called, usually before the victim. The ER doc would be there. That was just as Emergency Medicine was becoming a specialty and our ER docs were GPs.

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The Flight of the Intellectuals

Michael Totten, whose blog I read and support has a marvelous interview with Paul Berman, author of Flight of the Intellectuals. The interview is lengthy and wide ranging but worth the time to read it. Unfortunately, for some reason, Michael doesn’t have a permalink on the article so you have to scroll down to May 11. [Jonathan adds: Link to Totten’s post] One sample. They are talking about Bush Derangement Syndrome:

Paul Berman: I had an experience like that in relation to Ronald Reagan. I had a huge learning experience in Nicaragua in the 1980s when I was reporting for the Village Voice on the Sandinista revolution — a Marxist semi-communist revolution in those days.

Reagan was against the Sandinistas, and he did all kinds of things that, at the time, I thought were terrible. And I still think he did terrible things. Still, I was always astounded when I was among very poor people in Nicaragua to learn how many people liked Ronald Reagan. I would question them, and I could comprehend their answers, pretty much.

MJT: What did they say?

Paul Berman: Extremely poor market women, for instance, in an extremely poor town, would tell me, “the workers and peasants are suffering.”

I would ask, “Who is defending the workers and the peasants?”

And they would say, “Ronald Reagan.”

I said, “Ronald Reagan is defending the workers and peasants?”


MJT: [Laughs.]

Paul Berman: And they would say, “Yes!”

All they knew—and they got this from the Sandinista news radio—was that if the Sandinista regime had a bitter enemy anywhere in the world, it was Ronald Reagan. And therefore they felt he was defending the workers and peasants. Their way of speaking about the workers and peasants reflected the Marxist rhetoric, but they hated the Marxists.

MJT: [Laughs.]

It is terrific, as are most of his posts.

Education and traditions.

In my years in medicine, which began in 1961 or even earlier with premed, I met a few very colorful teachers. From time to time, I would like to profile some of them lest they be forgotten as people and remain only an entry in a dusty bound volume in a library. One such was a neurosurgeon named Aidan Raney. When I began to do a little research on him, I found that Google searches turn up only his son, a very good cardiac surgeon in Newport Beach. I remember the son as a high school student I met once.

When I was a third year medical student, my medical school had a program in which students could spend a summer with private practice physicians to see what the life was like. I spent a summer with Aidan Raney. I wasn’t so much interested in neurosurgery but wanted to see more of it before I committed myself to a career. Doctor Raney had been the first neurosurgery resident at the new Los Angeles County Hospital after it opened in 1933. The old hospital, now torn down, had been in service since about 1913. The University of Southern California medical school, which had closed in 1920 as a consequence of the Flexner Report, reopened when the new hospital opened and graduated its first class in 1932.

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The Erector Set

This is my maiden post as a new Chicago Boy so I thought I would recycle a post from my own blog that might be of interest.

My grandson’s birthday was two weeks ago, and his father’s is next weekend. I thought I would give him (the grandson) a toy that I was sure he had never heard of, an Erector Set. I have a medical connection, as well as a childhood connection, with this toy, now largely forgotten. I had Lionel trains when I was a child in Chicago and eventually had HO gauge trains, as well. When I had sons old enough to play with trains, I built an elaborate train set in my garage. Then I learned that southern California is not the place for toy trains. The boys were outdoors all the time and the train set gathered dust.

Few kids today will have the chance to enjoy the Erector Set. Like so many cold climate toys, it is never seen in southern California. I wonder how many sets are sold in Chicago ? There  is still a small source for this toy; but the glory days of the Erector Set were long ago. The toy was invented by A.C. Gilbert; in 1913. The story is interesting. Gilbert was a Yale Medical School graduate and had also won a gold medal, for the pole vault, in the 1908 Olympic Games. He built a new design bamboo pole that he used in his winning vault and he sold these, as well as other toys.

Like many residents of New Haven, Connecticut, he often took the train to New York City; and on one trip in 1911 he was inspired with what would be the most popular of his dozens of inventions.

Watching out the train window as some workmen positioned and riveted the steel beams of an electrical power-line tower, Gilbert decided to create a children’s construction kit: not just a toy, but an assemblage of metal beams with evenly spaced holes for bolts to pass through, screws, bolts, pulleys, gears and eventually even engines. A British toy company called Meccano Company was then selling a similar kit, but Gilbert’s Erector set was more realistic and had a number of technical advantages — most notably, steel beams that were not flat but bent lengthwise at a 90-degree angle, so that four of them nested side-to-side formed a very sturdy, square, hollow support beam.

Gilbert began selling the “Mysto Erector Structural Steel Builder” in 1913, backed by the first major American ad campaign for a toy. The Erector set quickly became one of the most popular toys of all time: living rooms across the country were transformed into miniature metropoles, filled with skyscrapers, bridges and railways. Those kids who already owned a set would beg Santa annually for an upgrade, aiming for the elusive “No. 12 1/2” deluxe kit that came with blueprints for the “Mysterious Walking Giant” robot. It is difficult for anyone under the age of 35 today to appreciate just how popular the Erector set was for over half a century.

Now, it happens that I have a personal connection to the Erector Set. In the early 1970s, a patient was referred to me with an esophageal stricture. He was in his 90s and had been told he was too old for a major operation like that. He and his wife had emigrated from England in 1913 and he was looking for a job as an engineer, when he met A.C. Gilbert, who was having trouble selling his new toy. Gilbert had invented the Erector Set and had built a few samples of what could be constructed using the new kit of materials but the set consisted of lots of perforated metal pieces and machine screws and nuts. The challenge was to design structures that children, with some parental help perhaps, could build. I had a set at the age of six and spent hours with it.

Gilbert needed someone to build sample structures using the set and write instructions on how to build them. He took the job and spent years working on new designs and instruction books. The first Christmas after he began work for Gilbert, the giant New York City department stores, Macy’s and Gimbel’s, wanted sample structures to help sell the toys. My patient built a huge suspension bridge for one store, that crossed over the cash registers, which in those days were arranged like the check-out lines in today’s supermarkets. The bridge was over 20 feet long. As soon as the other store saw his bridge, they wanted one just like it. He built another and the toy’s popularity took off. For years, he worked for Gilbert although, when I knew him, he had been retired to San Clemente for years.

He and his wife were in good health with the exception of this stricture that was so tight that he could only swallow liquids. It was a consequence of esophageal reflux and the scarring that chronic reflux produces.  He was very lucky that it had not developed a cancer.  He subsisted on apple sauce and other pureed food that would not pass through the stricture until he jumped up and down while standing against the wall. Every few mouthfuls, he had to stand up and jump until the food went down. He had been told he was too old to have it fixed, or even dilated, and his only option was some sort of feeding tube. Needless to say, he was skinny and the operation seemed to be feasible to me. Larry Mathis, a long time GP surgeon in San Clemente was his GP and Larry and I decided to try to fix his stricture. At surgery, his esophagus, just above the stomach where most benign strictures occur, was so tight that it split when I tried to dilate it from below with my finger. There is a procedure called a Thal Patch(pdf). It is used to close esophageal perforations such as traumatic tears and ruptures, like the Boerhaave’s Syndrome. In this case, I had created the hole in the esophagus by tearing open the stricture. I made a Thal patch from his stomach and closed the hole without recreating the narrow section. The surgery worked and he recovered very well. He hadn’t been able to eat solids in over five years. As a reward, he told me his story.

A few years later, he presented with symptoms of acute cholecystitis but at surgery I found a cancer of the colon next to the gallbladder. About  a year later he died of the cancer, having nearly reached the age of 100.

A.C. Gilbert also invented a number of other toys that were Christmas traditions for half a century. They included chemistry sets, physics sets and even a nuclear radioactivity set that included a Geiger counter. I had several of these, including the radioactive set. Those were the days before TV when children played with educational toys and were not so self-conscious about it. Today, the ATF would probably raid the basement of a child who had one of those sets.