American Medicine: Unhealthy at any cost.
posted by Physician Executive at 5:29 PM
Tuesday, March 30, 2010
Tuesday, May 09, 2006
Three (3) doctors and no measurements:
Since my surgery of Feb. 6th 2006 I have seen three (3) doctors [ Dr. R. K .; Dr. E. R.; Dr. L. Y.] and tho' my condition is known to cause atrophy ( " Sudek's Dystrophy "), not one of them has performed a measurement on my symptomatic right lower extremity.
With as little science that Medicine has, you would imagine that, like a carpenter, for instance, they would attempt to measure up to a trade.
For the record on 5/9/2006:
Left Right
6" above the knee A/K 16.4" 15.75"
6" below the knee B/K 13.5" 13.25"
This of course is evidence of beginning atrophy of my RLE, not that the doctors will ever know or care.
They don't even rise to the level of tradesmen!.
MCS. 5/9/2006.
With as little science that Medicine has, you would imagine that, like a carpenter, for instance, they would attempt to measure up to a trade.
For the record on 5/9/2006:
Left Right
6" above the knee A/K 16.4" 15.75"
6" below the knee B/K 13.5" 13.25"
This of course is evidence of beginning atrophy of my RLE, not that the doctors will ever know or care.
They don't even rise to the level of tradesmen!.
MCS. 5/9/2006.
posted by Physician Executive at 8:53 AM
Thursday, October 06, 2005
American Medicine: UnHealthy at ANY Cost
In late 2005 the cost to Americans for their healthcare is $1.9 trillion dollars. What do they get for this?. Poor quality and little value. Some may remember the IOM/Institute of Medicine book ' To Err is Human ' in which it was reported that in American hospitals during one year in the late 1990s ' medical errors ' laid waste to 44,000-98,000 patients.
Perhaps ' medical manslaughter ' would be a better designation.
Then the IOM published ' Crossing the Quality Chasm '. Then things changed for the better with the implimentation of ' bridges to quality ', yes?. No!. The quality problems in American Medicine continue and do not seem to be abating.
The approximately 42 million Americans without any healthcare insurance whatsoever may be luckier than those of us who are sometimes engulfed by the American HealthCare ' system '.
Find out about your doctor ahead of time. Find out about the mortality/morbidity statistics of the hospital which may have your life in their hands sooner than you think. Find out about the ' new, improved, with enzymes ' technology that both doctor & hospital are trying to foist on you.
Be informed. Stay informed.
Most American doctors emerge from medical school, internship, residency & fellowship burdened with student debt. Unlike their European counterparts, who enter Medical School with a well-grounded classical education, have the wherewithall to be put through Medical School, and, so emerge from their training with little or no debt, thus enabling them to practice professional Medicine as gentlemen, the American doctor, upon completion of a long, onerous, totally-unecessary training apprenticeship, has to gear his practice to a business model, frequently degenerating into tradesman-like status .
And so the problem begins.
Much of EBM/evidence-based medicine will be ignored & demonized while attention is given to the acquision of money. Even when the student debt is paid off, by then the systen has so corrupted the no-longer young doctor by encouraging him to acquire the house-on-the-hill, the Mercedes, the condo in Hawai, the country club membership, a wife & kids ( who quickly adapt to that level of lifestyle) that he is obliged to continue to practice income-generating Medicine without regard to reasonably good patient outcomes. No!. His focus will now be, & forever remain during his active physician years, the maintenance of this lifestyle----a lifestyle encouraged by colleagues, hospitals, AMA, pharmaceutical companies, device manufacturers, etc. so that they can depend on him to use & prescribe their wares & offerings, further driving the cost of this health"care " ever higher, and, you can be assured, with little or no pay-back to the unsuspecting, medically unsophisticated patient.
This picture needs to change. There will be much resistance from the stakeholders in the above scenario. Unlikely that the needed changes will come from impedimentary forces within organized Medicine.
So, onwards & without them then!.
Latter-Day Sagas.
I am going to jump ahead so that you can read for yourselves a series of e-mails relating to myself ( a Physician, an executive, the Regional Medical Director of an Insurance Group, and, a much-aggrieved patient/' consumer ' ):
I had vascular surgery on my right groin at St. J.'s Hopsital in Phoenix, AZ on Monday February 6th., 2006. There were complications...were there ever. I had to deal with my surgeon at St. J's, the staffs at St. J.'s and my surgeon ( a Dr. R. K.) and my surgeon's staff. Because the AZ Medical Board has a certain ' interest ' in my doings as a ' doctor ', though I have not seen a consumer/' patient ', done any clinical work whatsoever in the past 7.5 years, and was not then in 1999 when I brought myself to the attention of that AZ MD Board upon advice from their addiction medicine designated monitorer, a Dr. M. S. seeing ' patients'/consumers, nor do I now, nor, further, do I intend to practice the ' science ' of Medicine ever again ( some say Medicine is mostly ' art ', but if so, it is lousy art and should never invade the chambers of decent people.)
Monday March 6th., 2006.
Dear Ms. K. M., MAP/monitored aftercare program coordinator,
It has been brought to my attention this afternoon that the AZ MD Board has requested my medical records of the past six months from my PMD. Though not having had any recent formal communication with MAP/AZ MD Board ( other than my keeping you informed of all surgical doings, their several complications, and the ' science ' of Medicine's ineffecient efforts to get me well again) the thought crossed my mind to ask if I should be treading on egg-shells with my still-remaining useful LLE in anticipation of such a letter?
One can only wonder why THAT request comes in the middle of my twarted recuperation from the recent surgery & its complications?.
One further wonders if it just might have something to do with my recent e-mails & public utterances regrading the Medical Guild, my comments regarding the poor quality of doctors, the JACHO-accredited sheds in which they operate, and the lousy pay-back to the Arizonan & American consumer/patient for their hard-earned dollar to Group Health Insurance Companies, often by way of mandatory contributions from their often-meagre paychecks?.
One can, at times, be almost grateful for one's First Amendment Rights and the protection afforded under ADA.
I will await your response to this question first: Who was it that directed MAP on this occasion to request my recent records from my PMD?.
As always,
I remain YOURS, Most sincerely, Ms. M.
( Dr.) Martin C. S., M.D., MBA.wrote:
Mike ( Dr. S.),
I had invited you to drop by to my home at a time that is convenient to us both as you had in an earlier e-mail note to me expressed a desire to do so.
I had not heard back from you.
FYI: I am now having Home Care for dressing changes B-TID to the nosocomially-acquired pseudomonas surgical wound infection resulting, partly, from my auto-immune response to the bioabsorbable sutures put in place 4 weeks today at my surgery at St. J.'s Hospital & Medical Center.
So, it would appear, the fates have intervened yet again to prevent me from going to a place of my liking.
I do not expect any of this fiasco & ' comedy + tragedy of errors ' to be resolved anytime soon.
Therefore, not to be further burdened by MAP/AZ MD Board issues, I am formally requesting you to advise me regarding my graduating from the MAP/AZ MD Board " Post-Treatment Supervision " program at the earliest possible time. You will know that I am eligible to graduate this July 2006 after a total of 7.5 years involvement with that entity and that I have fulfilled all of its requirements to date & continue to do so.
You will also remember that neither in January 1999 when I self-reported to BOMEX, or at any time since then, have I had any clinical responsibility for Arizona ( or any other State) patient care. Nor, may I emphatically add, do I intend to do any clinical work in the future.
However, having come to AZ in 1982 and been awarded an AZ license # 13xxx, I elect to leave AZ with that self-same license unrestricted. It may, in the future, have coinage in some other realm, at some other time, for some future purpose.
Any help and/or advice that you can afford me towards these ends would be greatly appreciated.
Marty ( Dr. M. S.)
3/6/2006.
Martin CS., M.D., MBA, Regional Medical Director ( RMD), Commercial Professional Services,
" All changed, changed utterly: A terrible beauty is born ".-from the poem " Easter 1916 " by WB Yeats [ In Remembrance of September 11th., 2001.]
From: M. S. of gsmon......@hotmail.com
Marty: When are you leaving? I would like to come visit with you next week if you are still here. I am concerned about your well being. Mike
From: "S. M. Subject: Updated Medication log s/p RLE surgery Monday Feb. 6th., 2006Date: Sat, 4 Mar 2006 03:05:26 -0500
<>
And here is where I am headed <> So as to get as far away as possible from American " healthcare '---the poorest quality, but most costly, in the developed World.
Dr. S., M.D., MBA.
3/4/2006.
Martin C. S., M.D., MBA
" All changed, changed utterly: A terrible beauty is born ".-from the poem " Easter 1916 " by WB Yeats [ In Remembrance of September 11th., 2001.]
' Do not go gentle into that good night,
' Rage, rage at the dying of the light '----Dylan Thomas to his dying father.
From:S. M. Updated 1/17/06Date: Fri, 9 May 2003 16:14:48 -0500
Current medications as of 3/3/06:
Inderal 80mg LA/day-anti-BP Hytrin 5mg BID-urinary burning, etc. s/p prostate ca procedures Avodart 0.5mg OD-BID for urethral burning. ( Discontinued one month ago) Prosed DS TID for urethral burning.( Discontinued x one month ago & replaced w/ Pyridium 200mg. BID.) Ibuprofen 200mg. ii B-TID-as above Lipitor 40mg/day-anti-cholesterol Doxycycline 100mg/day-antibiotic for gingivitis-intermittent. ( Discontinued.) Cymbalta 60 mg./day for depression, and peripheral neuropathy. Occasional Viagra 50mg. Q 2-3 times weekly, prn. Occasional Serevent & Atrovent Inhalers. -------------------------------------------------------------------------------------All above prescribed by Dr. E. R.-PCP------------------------------------------------------------------------------------------------
3/3/2006:
Am back on hydrocodone 5/500 B-Tid due to botched attempt at A-V fistula repair in right groing which has resulted in reaction to bioabsorbable sutures ( with some retained & causing ongoing problems.)
Further, as of today, March 3rd., 2006, nosocomial pseudomonas infection of surgical wound found and am on Levoquib 750mg/day.
======================================================================================================================================================================================
Hydrocodone i p.o. B-TID prn for s/p renal colic and urinary/urethral symptoms ( Rx by Dr. B. K., MD, urologist)
No hydrocodone required beyond late May '03. Had Percoset x two 5mg. Tabs s/p left internal iliac bypass surgery by Dr. R. K. on Sept. 5th 2003. At St. J.'s.
6/22/04: Prosed DS ( instead of Pyridium) as of May 19th. 2004 Rx by Dr. Gary Stillwagon of RCoG/Radiotherapy Clinic of Georgia. ( Dr. Riffer's office informed & printed list provided directly to him last week.)
Avodart 0.5 mg OD-BID ( for urinary hesitancy) since Feb., 2004. Lexapro 10mg. PO. & Zyban Discontinued by Dr. Al B. 12/13/04. Otherwise, above meds ( Hytrin, Ibuprofen, Lipitor,) remain as previously.
1/17/2006:
Am scheduled for lower extremities vascular surgery by Dr. R. K. at St. J.'s second week of February, 2006
Martin S., MD. 1/17/2006.
Update 5-04-2006:
I have since talked with Dr. M.S., the addiction medicine specialist designated by the MAP Committe of the AZ Medical Board to monitor those ' impaired ' physicians participating in the program at a cost, per physician, of about $567.00/month.
The good doctor does not see fit that I should exit the MAP program---despite the facts laid out elsewhere---until ' my time is up ' in July '06 and he wishes to help me stay sober ( at $567.00/month) until then.
As I am disabled and on STD/short-term disability from an insurance company now and for the forseeable future, it is not readily clear to me how the mandate of the AZ Medical Board ( to protect the AZ client-patient population from injury at the hands of AZ licensed MD physicians) is met, other than ascribing the decision to ' doctor think ', perhaps tainted with some minor economic considerations.
While monitoring us impaired physicians closely, it is not readily apparant that the AZ Medical Board devotes any time at all in discovering the abuses of delivery of Health'care' to Arizonans by the, presumably, unimpaired majority of MD physicians in this Grand Canyon State.
It would appear that the mandate of the AZ Medical Board to keep the citizenary safe from impaired MD physicians does not extend to their scrutinizing the poor Quality of AZ Medicine exhibiting itself as underuse, overuse & abuse.
This may very well be because they, the AZ Medical Board MD members, are themselves caught in this income-enhancement mind-set of most MD ( & DO & DC) physicians. Who can say?.
In any case, the AZ MD Medical Board does not appear to be interested in these matters. It must be the purview of the AZ Atttorney General then, I suppose.
It isn't that American doctors are any more incompetent that doctors as a whole, rather, the whole ' science ' of Medicine is predicated on some few anecdotal reports that ' this works better than that, & this doesn't work at all '. Most doctors swear by what they do as the best for THEIR patients since sliced bread. Most unfortunately for the poor slob of a patient the doctor's personal opinion is just that, a personal opinion, rarely bolstered by anything but a modicum of science to give it the patina of effectiveness. Much of this ' science ' will have come from the last drug rep. who left the doctor's office, leaving an ample suply of that pharmaceutical's company's wares. As day follows night, you can be assured that the next few patients will find that these ' supplies from the medicine cabinet ' are a sine qua non to his recovery from whatever. So, the patient will get a few doses of the crap from the ' medicine cabinet ' and, but of course, a prescription for those self-same noxious chemicals to be filled at his local pharmacy---for a fee.
Most of the Medical Guild see no conflict-of-interest with regard to this behavior, rather, they feel that they are ' practising Medicine ' ( well, they are certainly practicing somethine, income enhancement, perhaps---but certainly not the ethical delivery of ' care '.) And ' care ' is mostly all they can do, as ' cure ' is a very rare commodity in Medicine. ( Please note below under ' The Interventional Pain Specialist Experience ' that this very scenario occured on 5-1-2006 to me in a doctor's office, viz. I was given samples of Lyrica AND a prescription to be filled if the drug helped and when I ran out of the samples.)
The most mortifying of all to the Medical Guild is their impotence against Death. But, God they try----without regard for the patient or his family. And, given its inevitability, without regard for cost.
You will have noticed that when your doctor last saw you he would have listened to your heart & lungs with a stethoscope ( that's the gizmo they use for listening to internal organs; it is also their symbol, being carried even by orthopedic surgeons who wouldn't recognise a heart murmur if their income depended upon it, which, fortunately, it doesn't, as their luchre comes from cutting normal tissue and bone so as to make it abnormal, thus necissitating a need to do ' revisions ' and, thereby, increase their life-styles on the back of the of the mostly trusting patient. The hospital will be complicit in this arrangement) and will, almost certainly, not have asked you the ' being-duped ' patient to remove your shirt. ( Again, see below: This self-same scenario happened to me at a doctor's office on 5-1-2006, viz. The pain specialist listened to my lungs &, maybe, my heart---as I left clinical Medicine some time back I cannot remember if they can hear the liver with their stethoscopes---WITHOUT asking me to remove my Polo-like shirt. Why he was listening at all is a mystery to me as I was there for problems with my right lower extremity. The MA had taken my blood pressure & pulse rate....but he felt compelled to do it too! Risibly duplicative. You bet!)
And will he have washed his hands since his examination of the last patient?. Will he wear gloves in order to percuss, palpate, probe you?. Almost certainly not. So, sepsis is transmitted from one host to another, the agent of the bugs & viruses being the income-focused doctor.
The great principles of Lord Lister are laid aside for the doctor's convenience and the patient emerges from this ' episode of care ' with a fulminant infection.
Americans pay a pretty penny to get this kind of ' care '. [ mcs-3/17/2006.]
IF IT"S BROKE....DON'T FIX IT.
The health'care' providers, the AMA, the AHA, pharmaceutical companies, device manufacturers etc. are in no hurry to fix that which is clearly broken as the current profits are likely to be much reduced with a re-vamped system which has the potential to deliver quality healthcare at a much lesser cost to all Americans.
Medicalizng Everything.
My memory of my early years are vague. There is semi-oblivion for those several years immedately after my advent to this planet by means of birth.
I hope for the same before I exit. In fact I think that ' dotage ' is the human organism's way of preparng for this exit. It ( dotage ), of course has been medicalized as Alkzeimer's Disease, pre-senile dementia, etc. & a great healthcare industry has resulted, which has impeded Society looing at this period in our waning lives as a time deserving of as much attention, perhaps, as infancy & childhood. ( At least, in infancy one is guarenteed the presence of a mother--if not a father always present--to CARE for our needs.) Society has left this old-age period of life to the attention of doctors & institutions. Wrong move!.
The Health'care' industry underserves us from infancy to old-age, so why would they improve their results ( " outcomes ") for us in our age?. [ " If I had served my God with half the zeal with which I have served my King, He would not, in mine age, left me naked to mine enemies ", said Cardinal Woolsey in Shakespeare's Henry VIII.]
Death, taxes, & old-age should NOT be the purview of this Health'care' industry. They should be excluded from ' management ' of our old-ages & our deaths!. I would worry also, givng their lousy record, of having them responsible for my taxes. Better left to Turbo-Tax & accountants who operate under GAAP ( which doctors & institutions should take a look at as a model of respectability & responsible accountabilty----which they won't, thus, makng the urgency of removing aging CARE from them that much more acute!.)
AND, the insurance companies which benefit from our agings & deaths should be alerted to this fact ( as if they already don't know): The health'care' industry is wasteful of our healthCARE dollar ( at ALL times), but we baby-boomers now want, & demand, CARE, of a responsible & accountable nature ' in our age ', rather than being ' left naked to our enemies ', viz. doctors & institutions.
There is an answer: " Assisted CARE " cohousing communites, where the aging parent ( in the absence of a dutiful son) owns the LIVING space ( of ' assisted living ' ) in the way of a deed to property in an ' assisted CARE ' community, &, therefore, more of the long-term CARE insurance dollars can be assigned to that which really matters---CARE!.
MCS. 4/27/2006.
It's later than you think!. The Interventional Pain Specialist Experience.
Well, out of sheer desperation I visited one here in metro-Phoenix yesterday.I flled out the 6 page Pain Questionnaire and was admitted to an exam room. The MA/medical assistant admitted that she was not a " nurse " when I asked her---following upon her very first utterance to me: " Did have a MRI yet"!. ( My assigned pain doc at ths facilty had--he declared in a form which I had read--a financial interest in a MRI unit in their building. A connection?. Probably not, you think?).
The pain doc entered { Anes. with fellowship in Pain Mgt.} He asked: Why did I leave Medicine so early? I interpreted this to mean: Why did you leave clinical Medicine for Medical Mgt.
I retaliated by asking: How is it you entered pain management so prematurely out of anesthesia residency?
He listened to my lungs with the ever-present stethoscope that hangs about TV-type docs' necks who want the give the patina of " professionalism ". Look: Me Doctor!. ( Cheap shot? Sure, why not.)
I had taken off my sandals & stockings bilaterally so as to invite a clinical exam. He did do a manual muscle test, tested DTRs, did NOT test sensation in any form, pronounced that I was in the ' early stages ', tho' of what remains unclear. He did NOT ask me to remove my walking-shorts in order for him to examine that surgical wound in my right groin, from which all my troubles began!. If asked to describe my surgical site he could not do so even if his life depended upon it.
He proposed NCVs/EMG. I pointed out to him that, as my manual muscle test was normal for the most part, NCVs to exclude some other cause of neuropathic pain was indicated, but an EMG was meaningless ( & would add to the cost of the study.) When the issue of the MRI was earler discussed I clearly indicated to him that I was a careful steward of my medical plan(s) and their scarce resources. ( I, as a doctor, sure got the message that my lumbar spine was of some interest to them as their need for a lumbar MRI loomed large. ) He got the message.
He Rx'd Lyrica, the new " membrane stabilizer " heavily maketed at IASP's/Int'l Assoc. for the Study of Pain during The 11th. World Congress on Pain in Sydney, AU ( which I attended last August. [ Several ' drug detail ' persons came & went while I waited in the front office.] He was not there @ the Pain Congress as most pain docs don't often go to reputable pain congresses or conferences, preferring to attend upon self-congratulation-like Interventional Pain affairs where their methodologies ( nor ethics) are not challenged.
On the wall of the exam room hung, next to his partner's AAPM credential, another equally impressive piece of paper stating that the partner was proficient in Percutaneous Discectomy. It was only when you looked closely at the lower left corner of this piece of paper would you have noted that the partner's " proficiency " had been declared by Stryker---the manufacturer of the percutaneous discectomy equipment!.
Sad & worrisome, all of this, for aging Americans, no?
Marty.Martin Sheehy MD, MBA [5/2/2006]
care Vs. CARE; income Vs. OUTCOMES.
Last night I was on the phone to my former partner/associate---a past President of the American Congress of PM&R/physical medicine & rehab.--- asking him if it was legal, ethical & appropriate that a young women identifying herself as a " nurse " is scheduled to perform a NCVS/nerve conduction velocity study on my LE/lower extremity ( hopefully singular) tomorrow.
When I spoke to her yesterday to schedule this study I made enquiry re her proficiency in electrodiagnosis. ( As a physiatrist in NYC & here in Phoenix, I myself performed many of these studies, having been well-grounded in ElectroDiagnosis at Mount Sinai Medical School in NY during my residency.)
It appears that she does the NCVS ( & EMGs if needed) and the pain specialist who is this pain practice's medical director is the interpreter of the findings by this " nurse ". The MD in attendance is an anesthesiologist ( with a subspecialty in Pain Medicine courtesy of AAPM/Am. Academy of Pain Medicine ( latter not ABMS endorsed), is not in the room during the electrodiagnostic test, & for the life of me I can't see how either of them have the wherewithall to do & interpret NCVS so that it would have clinical relevance to this patient's CARE.
I suspect an income-generating motive.
In the interest of further information, I am scheduled for this test at high noon tomorrow.
" Do not forsake me, Oh my darlings..." :-)
Marty.Martin Sheehy MD, MBA [5/3/2006]
Actually the test was done by a nurse practioner/NP who arrived at the pan doctors' facility wth her Cadwell equipment in tow like a flight attendant.
She was proficient & pretty. [ The pain doctor, on the other hand---he does nothing for me.]
She performed NCVS/nerve conduction velocity studies on my common peroneal, posterior tibial, sural nerves, including H-reflex & F waves on BLE. That is appropriate. She, upon my questioning, got her electrodiagnostic training from her neurologist boss ( not by way of an accredited residency program as with MDs.) If a needle EMG is required, then the MD must, at least n Arizona, do that part of the electrodx. test.
I must assume all of this is legal & permitted within their scope of practice?.
It again goes to my point though: Doctors, increasingly, are superfluous to Healthcare, as most of what they do can better be done by " physician extenders ". I can't see why those NPs & PAs can't be taught also to interpret the results of test that they are skilled to perform.
Surgery, you say.
There is a hospital in Toronto which performs nothing but inguinal hernia repairs and has great outcomes and few failures. Granted, these repairs are done by graduates of Medical Schools who, right out of internship, get employed by this Toronto hospital, and get enormously proficient in the doing of these repairs.
Pray tell: Why Medcal School at all?. What matters is the skill they acquire to do the repairs well without complications. What need to know a cardiac/heart mumur, a ROM/range of motion of the spine, that a 300 mg/ml blood sugar suggests diabetes? What need to know? The " physician extender " nurse practitioner or the physicians' assistant can attend to such mundane matters.
Why can't this be adopted with lumbar spine surgeies, with cardiac bypass procedures, with liver transplants, with brain surgery?. Why not?
If trained for skill, the outcomes expected will follow.
No more Winters in Healthcare, all Springs---heading for glorious Summers, far from incompetent, greedy sons-in-law of Galen!.
And now we are here.....
C L A S S N O T E S
UCD CONNECTIONS PAGE SEVENTY ONE
C L A S S N O T E S
PAGE SEVENTY UCD CONNECTIONS
MARTIN SHEEHY MB BCh BAO ‘68
Martin has been the Regional Medical Director for
Liberty Mutual Insurance Group for the past eight
years, serving as adviser for its Workers’ Compensation
product line, west of the Mississippi, US. Prior to that
he served for more than 20 years as a medical director
of various pain centres in New York City and Phoenix,
Arizona. Additionally he is involved with the American
College of Medical Quality and the American College of
Physician Executives (as he once upon a time
supplemented his MD degree with an MBA) in a
sometimes vain attempt to bring order out of chaos to
what is loosely described as healthcare in the New
World. The photo above taken at Hallowe’en in 2003 is
his photo ‘for all seasons’, being suitable for St Patrick’s
Day, July 4th Independence Day, Bastille Day,
Hallowe’en and All Saints Day. He is the ‘Lord’ Sir
Richard Attenborough lookalike to the right on the
photo; the lady on the left represents a very green Lady
Liberty, thus its pertinence to his current corporate
milieu.
Perhaps ' medical manslaughter ' would be a better designation.
Then the IOM published ' Crossing the Quality Chasm '. Then things changed for the better with the implimentation of ' bridges to quality ', yes?. No!. The quality problems in American Medicine continue and do not seem to be abating.
The approximately 42 million Americans without any healthcare insurance whatsoever may be luckier than those of us who are sometimes engulfed by the American HealthCare ' system '.
Find out about your doctor ahead of time. Find out about the mortality/morbidity statistics of the hospital which may have your life in their hands sooner than you think. Find out about the ' new, improved, with enzymes ' technology that both doctor & hospital are trying to foist on you.
Be informed. Stay informed.
Most American doctors emerge from medical school, internship, residency & fellowship burdened with student debt. Unlike their European counterparts, who enter Medical School with a well-grounded classical education, have the wherewithall to be put through Medical School, and, so emerge from their training with little or no debt, thus enabling them to practice professional Medicine as gentlemen, the American doctor, upon completion of a long, onerous, totally-unecessary training apprenticeship, has to gear his practice to a business model, frequently degenerating into tradesman-like status .
And so the problem begins.
Much of EBM/evidence-based medicine will be ignored & demonized while attention is given to the acquision of money. Even when the student debt is paid off, by then the systen has so corrupted the no-longer young doctor by encouraging him to acquire the house-on-the-hill, the Mercedes, the condo in Hawai, the country club membership, a wife & kids ( who quickly adapt to that level of lifestyle) that he is obliged to continue to practice income-generating Medicine without regard to reasonably good patient outcomes. No!. His focus will now be, & forever remain during his active physician years, the maintenance of this lifestyle----a lifestyle encouraged by colleagues, hospitals, AMA, pharmaceutical companies, device manufacturers, etc. so that they can depend on him to use & prescribe their wares & offerings, further driving the cost of this health"care " ever higher, and, you can be assured, with little or no pay-back to the unsuspecting, medically unsophisticated patient.
This picture needs to change. There will be much resistance from the stakeholders in the above scenario. Unlikely that the needed changes will come from impedimentary forces within organized Medicine.
So, onwards & without them then!.
Latter-Day Sagas.
I am going to jump ahead so that you can read for yourselves a series of e-mails relating to myself ( a Physician, an executive, the Regional Medical Director of an Insurance Group, and, a much-aggrieved patient/' consumer ' ):
I had vascular surgery on my right groin at St. J.'s Hopsital in Phoenix, AZ on Monday February 6th., 2006. There were complications...were there ever. I had to deal with my surgeon at St. J's, the staffs at St. J.'s and my surgeon ( a Dr. R. K.) and my surgeon's staff. Because the AZ Medical Board has a certain ' interest ' in my doings as a ' doctor ', though I have not seen a consumer/' patient ', done any clinical work whatsoever in the past 7.5 years, and was not then in 1999 when I brought myself to the attention of that AZ MD Board upon advice from their addiction medicine designated monitorer, a Dr. M. S. seeing ' patients'/consumers, nor do I now, nor, further, do I intend to practice the ' science ' of Medicine ever again ( some say Medicine is mostly ' art ', but if so, it is lousy art and should never invade the chambers of decent people.)
Monday March 6th., 2006.
Dear Ms. K. M., MAP/monitored aftercare program coordinator,
It has been brought to my attention this afternoon that the AZ MD Board has requested my medical records of the past six months from my PMD. Though not having had any recent formal communication with MAP/AZ MD Board ( other than my keeping you informed of all surgical doings, their several complications, and the ' science ' of Medicine's ineffecient efforts to get me well again) the thought crossed my mind to ask if I should be treading on egg-shells with my still-remaining useful LLE in anticipation of such a letter?
One can only wonder why THAT request comes in the middle of my twarted recuperation from the recent surgery & its complications?.
One further wonders if it just might have something to do with my recent e-mails & public utterances regrading the Medical Guild, my comments regarding the poor quality of doctors, the JACHO-accredited sheds in which they operate, and the lousy pay-back to the Arizonan & American consumer/patient for their hard-earned dollar to Group Health Insurance Companies, often by way of mandatory contributions from their often-meagre paychecks?.
One can, at times, be almost grateful for one's First Amendment Rights and the protection afforded under ADA.
I will await your response to this question first: Who was it that directed MAP on this occasion to request my recent records from my PMD?.
As always,
I remain YOURS, Most sincerely, Ms. M.
( Dr.) Martin C. S., M.D., MBA.
Mike ( Dr. S.),
I had invited you to drop by to my home at a time that is convenient to us both as you had in an earlier e-mail note to me expressed a desire to do so.
I had not heard back from you.
FYI: I am now having Home Care for dressing changes B-TID to the nosocomially-acquired pseudomonas surgical wound infection resulting, partly, from my auto-immune response to the bioabsorbable sutures put in place 4 weeks today at my surgery at St. J.'s Hospital & Medical Center.
So, it would appear, the fates have intervened yet again to prevent me from going to a place of my liking.
I do not expect any of this fiasco & ' comedy + tragedy of errors ' to be resolved anytime soon.
Therefore, not to be further burdened by MAP/AZ MD Board issues, I am formally requesting you to advise me regarding my graduating from the MAP/AZ MD Board " Post-Treatment Supervision " program at the earliest possible time. You will know that I am eligible to graduate this July 2006 after a total of 7.5 years involvement with that entity and that I have fulfilled all of its requirements to date & continue to do so.
You will also remember that neither in January 1999 when I self-reported to BOMEX, or at any time since then, have I had any clinical responsibility for Arizona ( or any other State) patient care. Nor, may I emphatically add, do I intend to do any clinical work in the future.
However, having come to AZ in 1982 and been awarded an AZ license # 13xxx, I elect to leave AZ with that self-same license unrestricted. It may, in the future, have coinage in some other realm, at some other time, for some future purpose.
Any help and/or advice that you can afford me towards these ends would be greatly appreciated.
Marty ( Dr. M. S.)
3/6/2006.
Martin CS., M.D., MBA, Regional Medical Director ( RMD), Commercial Professional Services,
" All changed, changed utterly: A terrible beauty is born ".-from the poem " Easter 1916 " by WB Yeats [ In Remembrance of September 11th., 2001.]
From: M. S. of gsmon......@hotmail.com
Marty: When are you leaving? I would like to come visit with you next week if you are still here. I am concerned about your well being. Mike
From: "S. M. Subject: Updated Medication log s/p RLE surgery Monday Feb. 6th., 2006Date: Sat, 4 Mar 2006 03:05:26 -0500
<
And here is where I am headed <
Dr. S., M.D., MBA.
3/4/2006.
Martin C. S., M.D., MBA
" All changed, changed utterly: A terrible beauty is born ".-from the poem " Easter 1916 " by WB Yeats [ In Remembrance of September 11th., 2001.]
' Do not go gentle into that good night,
' Rage, rage at the dying of the light '----Dylan Thomas to his dying father.
From:S. M. Updated 1/17/06Date: Fri, 9 May 2003 16:14:48 -0500
Current medications as of 3/3/06:
Inderal 80mg LA/day-anti-BP Hytrin 5mg BID-urinary burning, etc. s/p prostate ca procedures Avodart 0.5mg OD-BID for urethral burning. ( Discontinued one month ago) Prosed DS TID for urethral burning.( Discontinued x one month ago & replaced w/ Pyridium 200mg. BID.) Ibuprofen 200mg. ii B-TID-as above Lipitor 40mg/day-anti-cholesterol Doxycycline 100mg/day-antibiotic for gingivitis-intermittent. ( Discontinued.) Cymbalta 60 mg./day for depression, and peripheral neuropathy. Occasional Viagra 50mg. Q 2-3 times weekly, prn. Occasional Serevent & Atrovent Inhalers. -------------------------------------------------------------------------------------All above prescribed by Dr. E. R.-PCP------------------------------------------------------------------------------------------------
3/3/2006:
Am back on hydrocodone 5/500 B-Tid due to botched attempt at A-V fistula repair in right groing which has resulted in reaction to bioabsorbable sutures ( with some retained & causing ongoing problems.)
Further, as of today, March 3rd., 2006, nosocomial pseudomonas infection of surgical wound found and am on Levoquib 750mg/day.
======================================================================================================================================================================================
Hydrocodone i p.o. B-TID prn for s/p renal colic and urinary/urethral symptoms ( Rx by Dr. B. K., MD, urologist)
No hydrocodone required beyond late May '03. Had Percoset x two 5mg. Tabs s/p left internal iliac bypass surgery by Dr. R. K. on Sept. 5th 2003. At St. J.'s.
6/22/04: Prosed DS ( instead of Pyridium) as of May 19th. 2004 Rx by Dr. Gary Stillwagon of RCoG/Radiotherapy Clinic of Georgia. ( Dr. Riffer's office informed & printed list provided directly to him last week.)
Avodart 0.5 mg OD-BID ( for urinary hesitancy) since Feb., 2004. Lexapro 10mg. PO. & Zyban Discontinued by Dr. Al B. 12/13/04. Otherwise, above meds ( Hytrin, Ibuprofen, Lipitor,) remain as previously.
1/17/2006:
Am scheduled for lower extremities vascular surgery by Dr. R. K. at St. J.'s second week of February, 2006
Martin S., MD. 1/17/2006.
Update 5-04-2006:
I have since talked with Dr. M.S., the addiction medicine specialist designated by the MAP Committe of the AZ Medical Board to monitor those ' impaired ' physicians participating in the program at a cost, per physician, of about $567.00/month.
The good doctor does not see fit that I should exit the MAP program---despite the facts laid out elsewhere---until ' my time is up ' in July '06 and he wishes to help me stay sober ( at $567.00/month) until then.
As I am disabled and on STD/short-term disability from an insurance company now and for the forseeable future, it is not readily clear to me how the mandate of the AZ Medical Board ( to protect the AZ client-patient population from injury at the hands of AZ licensed MD physicians) is met, other than ascribing the decision to ' doctor think ', perhaps tainted with some minor economic considerations.
While monitoring us impaired physicians closely, it is not readily apparant that the AZ Medical Board devotes any time at all in discovering the abuses of delivery of Health'care' to Arizonans by the, presumably, unimpaired majority of MD physicians in this Grand Canyon State.
It would appear that the mandate of the AZ Medical Board to keep the citizenary safe from impaired MD physicians does not extend to their scrutinizing the poor Quality of AZ Medicine exhibiting itself as underuse, overuse & abuse.
This may very well be because they, the AZ Medical Board MD members, are themselves caught in this income-enhancement mind-set of most MD ( & DO & DC) physicians. Who can say?.
In any case, the AZ MD Medical Board does not appear to be interested in these matters. It must be the purview of the AZ Atttorney General then, I suppose.
It isn't that American doctors are any more incompetent that doctors as a whole, rather, the whole ' science ' of Medicine is predicated on some few anecdotal reports that ' this works better than that, & this doesn't work at all '. Most doctors swear by what they do as the best for THEIR patients since sliced bread. Most unfortunately for the poor slob of a patient the doctor's personal opinion is just that, a personal opinion, rarely bolstered by anything but a modicum of science to give it the patina of effectiveness. Much of this ' science ' will have come from the last drug rep. who left the doctor's office, leaving an ample suply of that pharmaceutical's company's wares. As day follows night, you can be assured that the next few patients will find that these ' supplies from the medicine cabinet ' are a sine qua non to his recovery from whatever. So, the patient will get a few doses of the crap from the ' medicine cabinet ' and, but of course, a prescription for those self-same noxious chemicals to be filled at his local pharmacy---for a fee.
Most of the Medical Guild see no conflict-of-interest with regard to this behavior, rather, they feel that they are ' practising Medicine ' ( well, they are certainly practicing somethine, income enhancement, perhaps---but certainly not the ethical delivery of ' care '.) And ' care ' is mostly all they can do, as ' cure ' is a very rare commodity in Medicine. ( Please note below under ' The Interventional Pain Specialist Experience ' that this very scenario occured on 5-1-2006 to me in a doctor's office, viz. I was given samples of Lyrica AND a prescription to be filled if the drug helped and when I ran out of the samples.)
The most mortifying of all to the Medical Guild is their impotence against Death. But, God they try----without regard for the patient or his family. And, given its inevitability, without regard for cost.
You will have noticed that when your doctor last saw you he would have listened to your heart & lungs with a stethoscope ( that's the gizmo they use for listening to internal organs; it is also their symbol, being carried even by orthopedic surgeons who wouldn't recognise a heart murmur if their income depended upon it, which, fortunately, it doesn't, as their luchre comes from cutting normal tissue and bone so as to make it abnormal, thus necissitating a need to do ' revisions ' and, thereby, increase their life-styles on the back of the of the mostly trusting patient. The hospital will be complicit in this arrangement) and will, almost certainly, not have asked you the ' being-duped ' patient to remove your shirt. ( Again, see below: This self-same scenario happened to me at a doctor's office on 5-1-2006, viz. The pain specialist listened to my lungs &, maybe, my heart---as I left clinical Medicine some time back I cannot remember if they can hear the liver with their stethoscopes---WITHOUT asking me to remove my Polo-like shirt. Why he was listening at all is a mystery to me as I was there for problems with my right lower extremity. The MA had taken my blood pressure & pulse rate....but he felt compelled to do it too! Risibly duplicative. You bet!)
And will he have washed his hands since his examination of the last patient?. Will he wear gloves in order to percuss, palpate, probe you?. Almost certainly not. So, sepsis is transmitted from one host to another, the agent of the bugs & viruses being the income-focused doctor.
The great principles of Lord Lister are laid aside for the doctor's convenience and the patient emerges from this ' episode of care ' with a fulminant infection.
Americans pay a pretty penny to get this kind of ' care '. [ mcs-3/17/2006.]
IF IT"S BROKE....DON'T FIX IT.
The health'care' providers, the AMA, the AHA, pharmaceutical companies, device manufacturers etc. are in no hurry to fix that which is clearly broken as the current profits are likely to be much reduced with a re-vamped system which has the potential to deliver quality healthcare at a much lesser cost to all Americans.
Medicalizng Everything.
My memory of my early years are vague. There is semi-oblivion for those several years immedately after my advent to this planet by means of birth.
I hope for the same before I exit. In fact I think that ' dotage ' is the human organism's way of preparng for this exit. It ( dotage ), of course has been medicalized as Alkzeimer's Disease, pre-senile dementia, etc. & a great healthcare industry has resulted, which has impeded Society looing at this period in our waning lives as a time deserving of as much attention, perhaps, as infancy & childhood. ( At least, in infancy one is guarenteed the presence of a mother--if not a father always present--to CARE for our needs.) Society has left this old-age period of life to the attention of doctors & institutions. Wrong move!.
The Health'care' industry underserves us from infancy to old-age, so why would they improve their results ( " outcomes ") for us in our age?. [ " If I had served my God with half the zeal with which I have served my King, He would not, in mine age, left me naked to mine enemies ", said Cardinal Woolsey in Shakespeare's Henry VIII.]
Death, taxes, & old-age should NOT be the purview of this Health'care' industry. They should be excluded from ' management ' of our old-ages & our deaths!. I would worry also, givng their lousy record, of having them responsible for my taxes. Better left to Turbo-Tax & accountants who operate under GAAP ( which doctors & institutions should take a look at as a model of respectability & responsible accountabilty----which they won't, thus, makng the urgency of removing aging CARE from them that much more acute!.)
AND, the insurance companies which benefit from our agings & deaths should be alerted to this fact ( as if they already don't know): The health'care' industry is wasteful of our healthCARE dollar ( at ALL times), but we baby-boomers now want, & demand, CARE, of a responsible & accountable nature ' in our age ', rather than being ' left naked to our enemies ', viz. doctors & institutions.
There is an answer: " Assisted CARE " cohousing communites, where the aging parent ( in the absence of a dutiful son) owns the LIVING space ( of ' assisted living ' ) in the way of a deed to property in an ' assisted CARE ' community, &, therefore, more of the long-term CARE insurance dollars can be assigned to that which really matters---CARE!.
MCS. 4/27/2006.
It's later than you think!. The Interventional Pain Specialist Experience.
Well, out of sheer desperation I visited one here in metro-Phoenix yesterday.I flled out the 6 page Pain Questionnaire and was admitted to an exam room. The MA/medical assistant admitted that she was not a " nurse " when I asked her---following upon her very first utterance to me: " Did have a MRI yet"!. ( My assigned pain doc at ths facilty had--he declared in a form which I had read--a financial interest in a MRI unit in their building. A connection?. Probably not, you think?).
The pain doc entered { Anes. with fellowship in Pain Mgt.} He asked: Why did I leave Medicine so early? I interpreted this to mean: Why did you leave clinical Medicine for Medical Mgt.
I retaliated by asking: How is it you entered pain management so prematurely out of anesthesia residency?
He listened to my lungs with the ever-present stethoscope that hangs about TV-type docs' necks who want the give the patina of " professionalism ". Look: Me Doctor!. ( Cheap shot? Sure, why not.)
I had taken off my sandals & stockings bilaterally so as to invite a clinical exam. He did do a manual muscle test, tested DTRs, did NOT test sensation in any form, pronounced that I was in the ' early stages ', tho' of what remains unclear. He did NOT ask me to remove my walking-shorts in order for him to examine that surgical wound in my right groin, from which all my troubles began!. If asked to describe my surgical site he could not do so even if his life depended upon it.
He proposed NCVs/EMG. I pointed out to him that, as my manual muscle test was normal for the most part, NCVs to exclude some other cause of neuropathic pain was indicated, but an EMG was meaningless ( & would add to the cost of the study.) When the issue of the MRI was earler discussed I clearly indicated to him that I was a careful steward of my medical plan(s) and their scarce resources. ( I, as a doctor, sure got the message that my lumbar spine was of some interest to them as their need for a lumbar MRI loomed large. ) He got the message.
He Rx'd Lyrica, the new " membrane stabilizer " heavily maketed at IASP's/Int'l Assoc. for the Study of Pain during The 11th. World Congress on Pain in Sydney, AU ( which I attended last August. [ Several ' drug detail ' persons came & went while I waited in the front office.] He was not there @ the Pain Congress as most pain docs don't often go to reputable pain congresses or conferences, preferring to attend upon self-congratulation-like Interventional Pain affairs where their methodologies ( nor ethics) are not challenged.
On the wall of the exam room hung, next to his partner's AAPM credential, another equally impressive piece of paper stating that the partner was proficient in Percutaneous Discectomy. It was only when you looked closely at the lower left corner of this piece of paper would you have noted that the partner's " proficiency " had been declared by Stryker---the manufacturer of the percutaneous discectomy equipment!.
Sad & worrisome, all of this, for aging Americans, no?
Marty.Martin Sheehy MD, MBA [5/2/2006]
care Vs. CARE; income Vs. OUTCOMES.
Last night I was on the phone to my former partner/associate---a past President of the American Congress of PM&R/physical medicine & rehab.--- asking him if it was legal, ethical & appropriate that a young women identifying herself as a " nurse " is scheduled to perform a NCVS/nerve conduction velocity study on my LE/lower extremity ( hopefully singular) tomorrow.
When I spoke to her yesterday to schedule this study I made enquiry re her proficiency in electrodiagnosis. ( As a physiatrist in NYC & here in Phoenix, I myself performed many of these studies, having been well-grounded in ElectroDiagnosis at Mount Sinai Medical School in NY during my residency.)
It appears that she does the NCVS ( & EMGs if needed) and the pain specialist who is this pain practice's medical director is the interpreter of the findings by this " nurse ". The MD in attendance is an anesthesiologist ( with a subspecialty in Pain Medicine courtesy of AAPM/Am. Academy of Pain Medicine ( latter not ABMS endorsed), is not in the room during the electrodiagnostic test, & for the life of me I can't see how either of them have the wherewithall to do & interpret NCVS so that it would have clinical relevance to this patient's CARE.
I suspect an income-generating motive.
In the interest of further information, I am scheduled for this test at high noon tomorrow.
" Do not forsake me, Oh my darlings..." :-)
Marty.Martin Sheehy MD, MBA [5/3/2006]
Actually the test was done by a nurse practioner/NP who arrived at the pan doctors' facility wth her Cadwell equipment in tow like a flight attendant.
She was proficient & pretty. [ The pain doctor, on the other hand---he does nothing for me.]
She performed NCVS/nerve conduction velocity studies on my common peroneal, posterior tibial, sural nerves, including H-reflex & F waves on BLE. That is appropriate. She, upon my questioning, got her electrodiagnostic training from her neurologist boss ( not by way of an accredited residency program as with MDs.) If a needle EMG is required, then the MD must, at least n Arizona, do that part of the electrodx. test.
I must assume all of this is legal & permitted within their scope of practice?.
It again goes to my point though: Doctors, increasingly, are superfluous to Healthcare, as most of what they do can better be done by " physician extenders ". I can't see why those NPs & PAs can't be taught also to interpret the results of test that they are skilled to perform.
Surgery, you say.
There is a hospital in Toronto which performs nothing but inguinal hernia repairs and has great outcomes and few failures. Granted, these repairs are done by graduates of Medical Schools who, right out of internship, get employed by this Toronto hospital, and get enormously proficient in the doing of these repairs.
Pray tell: Why Medcal School at all?. What matters is the skill they acquire to do the repairs well without complications. What need to know a cardiac/heart mumur, a ROM/range of motion of the spine, that a 300 mg/ml blood sugar suggests diabetes? What need to know? The " physician extender " nurse practitioner or the physicians' assistant can attend to such mundane matters.
Why can't this be adopted with lumbar spine surgeies, with cardiac bypass procedures, with liver transplants, with brain surgery?. Why not?
If trained for skill, the outcomes expected will follow.
No more Winters in Healthcare, all Springs---heading for glorious Summers, far from incompetent, greedy sons-in-law of Galen!.
And now we are here.....
C L A S S N O T E S
UCD CONNECTIONS PAGE SEVENTY ONE
C L A S S N O T E S
PAGE SEVENTY UCD CONNECTIONS
MARTIN SHEEHY MB BCh BAO ‘68
Martin has been the Regional Medical Director for
Liberty Mutual Insurance Group for the past eight
years, serving as adviser for its Workers’ Compensation
product line, west of the Mississippi, US. Prior to that
he served for more than 20 years as a medical director
of various pain centres in New York City and Phoenix,
Arizona. Additionally he is involved with the American
College of Medical Quality and the American College of
Physician Executives (as he once upon a time
supplemented his MD degree with an MBA) in a
sometimes vain attempt to bring order out of chaos to
what is loosely described as healthcare in the New
World. The photo above taken at Hallowe’en in 2003 is
his photo ‘for all seasons’, being suitable for St Patrick’s
Day, July 4th Independence Day, Bastille Day,
Hallowe’en and All Saints Day. He is the ‘Lord’ Sir
Richard Attenborough lookalike to the right on the
photo; the lady on the left represents a very green Lady
Liberty, thus its pertinence to his current corporate
milieu.
posted by Physician Executive at 4:47 AM
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- Location: Phoenix, Arizona, United States
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