How some spell Medicare relief: QUIT
Berkeley Rice highlighted the risks primary care physicians take on byaccepting capitated contracts ["The newest threat: Pressure to go beyondyour expertise," July 26].
At a recent malpractice seminar, a plaintiffs' attorney stated outright,"If a patient in a capitated plan has a bad outcome, all you have todo is get the doctor on the stand and say, 'Isn't it true, Doctor, thatyou make even more money the less care you give?' The doctor has to admitit, and--even though it's vague and irrelevant--the jury will eat it up."
After the seminar, without revealing that I'm a physician, I pointedout to the speaker that many doctors have no choice but to accept capitationto stay in practice. Why would anyone practice medicine, I asked, if welawyers make liability inevitable for every bad outcome? He thought aboutit for a while, then said he didn't know. -Janis E. Eiler, MD, JD Cincinnati
There is something I fear more than the malpractice pitfalls you exploredin the article: the pressure to use midlevel providers as primary care physicians.We have nurse practitioners performing cardiolyte stress tests, referringto psychiatrists, and even running freestanding clinics.-Sigrid Johnson, MD, Sweetwater, TN , email@example.com
The French have a saying, "The best is the enemy of the good."At one time, nursing homes in America were numerous and cheap because theywere mostly old homes converted into residences for people needing custodialcare. But because many such homes had various problems, states enacted lawsto upgrade safety and improve care. We doctors, along with the public, praisedthe new measures, but now we complain that hardly anyone can afford thesefacilities. Isn't there a happy medium where things could be just satisfactoryand affordable instead of close-to-perfect but unaffordable?
We've made expensive decisions that make life miserable for many nursinghome patients. It doesn't have to be that way. For example, I know a patientwith Alzheimer's disease who disturbed other nursing home residents by wanderinginto their rooms, thinking she was in her own. The good people of that homesolved the problem neatly by putting a half-door on her room, with the bottomlatched. This way, she could look down the hall and not feel locked up,yet still be no bother to others.
I'm now told that in most nursing homes this clever solution is againstthe fire code. A wandering patient must be strapped to a bed or wheelchair.Is this kind treatment? And in case of a fire, which patient would be inmore danger: the one with the bottom half of the door latched, or the onestrapped to a bed? -George B. Markle IV, MD,Carlsbad, NM
Since I've retired, not a week goes by when I don't receive at leastsix calls pleading, "What can I do? I can't get in to see my new doctor,and if I do, he just rushes me out and sometimes doesn't even examine me."
Why does it have to be this way? There are literally thousands of retireddoctors and nurses in this country who could help. As president of my localadvisory council for the elderly, I ensure that nursing home patients receiveproper care. Others could do the same for all these confused patients whohave neither the knowledge nor the ability to work their way through theMedicare maze.
If more retired doctors and nurses volunteered their time to help patientsget what they need from our health care system, Congress could forget aboutthe Patients' Bill of Rights and get on with saving Social Security. -Donald A. Fuesler, MD,Longview, WA
Susan Harrington Preston details the AARP's program to recruit seniorsto uncover Medicare abuse, and suggests ways physicians can cope with inquisitivepatients ["Will your patients turn into bounty hunters?" June21].
As an office manager for an internal medicine practice, I have a fewideas on how to handle senior vigilantes. When patients question their entirebill, you should explain only the services being paid to you--not others,such as lab work or physical therapy. If the patient wants to discuss thediagnostic or therapeutic value of those services, encourage him to makea follow-up appointment.
But there's an even better method for dealing with senior vigilantes:Stop participating in Medicare and bill patients directly. -Edgardo L. Perez-DeLeon, Detroit
Michael Pretzer demonstrates the absurdity of the American Associationof Health Plans' public relations campaign to get larger Medicare paymentsfor managed care plans ["Latest twists in the Medicare melodrama,"Washington Beat, June 21]. He mentions five AAHP press releases in whichan identical quote was attributed to different seniors across the country.Each senior allegedly said exactly this: "I can't imagine getting myhealth care anywhere else. I want choices at prices I can afford--that'swhy I chose a health plan."
Amazing, how consistent seniors seem to be in their thinking. -Linda Pearson, RN, Editor-in-Chief, The Nurse Practitioner Journal,Lakewood, CO,firstname.lastname@example.org
A physician asked whether his office staffers were right to turn awayan uninsured patient with a finger laceration and direct him to an emergencyroom [Practice Management, July 12]. Your experts advised that "itwas appropriate" for the receptionist "to direct him elsewhere."
Why is it "appropriate" for a medical office to refuse patientswho are uninsured? Why should I, as an emergency physician, be responsiblefor providing free care for the millions of uninsured patients in this country?I receive no tax funds, hospital stipends, charitable donations, or financialsupport from the local medical society, yet I'm required by federal antidumpinglaws to evaluate and stabilize every patient who arrives.
Your advice contradicts the spirit of your profiles of those exemplarydoctors who emphasize the humanity of our profession by going "theextra mile." If more physicians felt an obligation to practice theirart with a sense of charity and duty to the communities that support them,ERs would be better able to provide true emergency care at a reasonablecost to those who need it. -Francis E. Toscano, MD, Clearwater, FL, email@example.com
I enjoyed Doreen Mangan's article about e-mailing patients ["Save time and please patients with e-mail,"July 12]. I've found it to be an invaluable tool in my own practice.
For those still waiting to take the e-mail plunge, I offer these suggestions:Overcome your patients' apprehension about doctor-patient e-mail by usinga simple, intuitive address, that incorporates the practice's name or specialty.For a little extra time and money, you can create a Web site for your practiceto answer frequently asked questions, especially those concerning schedulingand billing. As Internet speed increases, your Web address might serve asyour phone number or as a place to do videoconferencing or patient interviews. -Vincent Vilasi, MD, >Herndon, VA, firstname.lastname@example.org
I find it hard to keep up with personal e-mail. I'd have to spend hours every day answering medical questions frompatients. Computers take up too much of my time, and life is too short.
I prefer phone conversation to e-mail messages, because it offers voice,tone, and inflection. E-mail offers only words, which can be misinterpreted. -John Hollingsworth, PA-C,San Diego,email@example.com
Your "Malpractice Wars" issue [July 26] presented a good perspectiveof physicians' No. 1 fear.
As a veteran of many lawsuits, I've been fortunate in having some excellentattorneys. I'd like to share with your readers some advice they've givenme:
The fact that you've been sued means only that someone had an unfortunateoutcome--most often caused by a natural consequence of disease. Don't takeit personally.
Discuss the pros and cons of the case and your game plan with your attorney,and listen to his advice.
Most lawsuits end at the deposition stage. Learn to use monosyllabicresponses to plaintiffs' lawyers' questions in deposition. Your goal isto anger the attorney so that he'll lose his train of thought.
If you present a calm, unshakable appearance at the deposition, the plaintiff'slawyer will try his best to settle. He doesn't want you in front of a jury.
Even if your name winds up in the National Practitioner Data Bank, yourpatients won't walk away from you. -Name withheld
In our country, litigation is always an adversarial situation, in whichthe truth is secondary to sympathy and playacting.
In the United Kingdom, malpractice trials aren't heard by a jury. They'retried before a judge who's knowledgeable in medical malpractice. Attorneyscan't sway him with histrionics. And they don't collect enormous contingencyfees.
Perhaps we should do away with the jury system for malpractice litigation.The lawyers would howl, of course. -Walter Schnur, MD, Cincinnati,firstname.lastname@example.org
In responding to surgeon Moshe Schein's opinion piece, "We couldtreat the world with what we waste at home" [May 24], one reader wrotethat Schein's lament about medical wastefulness was outdated [Letters tothe Editors, July 26]. I disagree.
In the 11 years and nine settings in which I've practiced family medicine,I'd guess that about half of the medical resources were wasted. I see anendless stream of the worried well who don't need medical care at all--peoplewith paper cuts, mosquito bites, and invisible rashes.
Occasionally, I'll chat with a colleague at noon and find that neitherof us accomplished anything all morning, despite having a fully booked schedule.Nobody we saw was sick.
We definitely could treat the world with what we waste at home. Of course,waste like this only occurs where third-party payers are footing the bill. -Bari J. Bett, MD,Lake Ridge, VA
Surgeon James Lally recounts the misdiagnosis and unnecessary surgerythat led him to advise a friend to sue his physicians ["Why I urgedmy friend to sue his doctors," July 26]. I find Lally's attitude aperfect example of what's wrong with our tort system: Somebody was at fault,so somebody should be liable.
While I agree that the physicians made a terrible error--the man hadan ulcer; they operated for cancer--the fault lies with the pathologist.Neither the surgeon, the gastroenterologist, nor even the hospital administrationdeviated from the standard of care. They relied on the pathologist's diagnosis.
Unless Lally is the one physician in this country who reviews every X-ray,biopsy slide, gram stain, and lab result, he's simply showing the knee-jerkresponse of the typical American malcontent consumer. Lumping the physicianswith the pathologist shows a lack of professionalism. It's the "shotgun"approach: Involve as many deep pockets as possible. -David P. Cohen, MD,Schenectady, NY,email@example.com