Random Thoughts from a Restless Mind

Fly an airplane. Take Dad’s car on a date. Finish your residency and perform your core surgery without a professor over your shoulder. The first solo is a milestone event, and many such events become life’s touchstones to which we return time and again. My first solo attempt to log on and clear out my “Basket” on EPIC, the EMR that I am mandated to use in order to continue to operate at a surgery center where I’ve been the primary ophthalmologist for >15 years? Meh, not so much.

At 0 Dark 30 I was doing glaucoma lasers, and I finished well before I was due in the office. Perfect time to log onto a dedicated terminal, take a look at the items demanding my attention, and get on with the real work of eyecare. Full disclosure: I called the IT guy with whom I’d bonded a  couple of weeks ago to see what I should do with the pharmacy boondoggle and received permission to blow off all of those entries. Whew! Home free. I sat down and went through the log-in process, just like my new best friend had shown me. No love. 0 for 15. Unable to log in.

BZZZZTTT. Sorry. Johnny, tell Dr. White about our lovely parting gifts for losing contestants.

Might turn out to be more like expected after all.

As I posted a few weeks ago, in order to continue to use an outpatient surgery center where I have performed surgeries for 15 years or so, I am now required to use the electronic medical record EPIC. My hope had been that I would be able to continue to run “under the radar” by utilizing my pre-–dictated notes and standard orders, signing the papers as I have done lo these many years. Tragically, this was not to be. Having come to this realization about a month ago I reached out to the IT department and asked for training on the system. Being the somewhat self–involved surgeon that I am, I naturally assumed that a single phone call or e-mail would see multiple individuals leaping into action in order to help me so that I might continue to use that surgery center and generate revenue for the hospital. Silly me.

Four weeks, a dozen conversations, several e-mails, and I am assured more than several telephone calls later, I finally received a call from IT and one of the physician–advocates/trainers. I explained that I had a back log of signatures (little did I know!), and that I would be taking ER call soon, and did he perhaps have some time available to show me how to use the EMR? In the first of several remarkably positive little things in this process, Andrew did, indeed, have some time available the very next morning when I, too, could sit with him for a little bit.

Andrew himself was one of those little surprises. And ex–cop who had put himself through nursing school with the intention of using his nursing degree as a springboard to management, he informed me that he was one semester away from an MBA. It was clear he was anticipating a hostile interaction; this had been his typical experience when teaching physicians the system, especially private practice physicians. I liked him instantly, we connected, which probably contributed to the speed with which we flew through phase 1 of my indoctrination.

This can’t be all good, of course, otherwise there would be no reason to do this series! After learning how to get into the system (no, you cannot change your username), we looked at my chart deficiencies, specifically op notes that needed to be signed tracing back to November. I cleaned up all the old stuff, and then we got stuck with all of the charts that were sitting there from last week. Apparently part of the efficiency of the system allows the medical records department to put you on the “bad boy” list as soon as the case is done! We agreed to ignore these deficiencies since these would still be paper charts needing to be signed and moved on to pharmacy orders.

This was rich. I looked at about 200 orders with a “signature required” tag. Things like IV orders, and medicine injected to into the IV. Some were anesthesia orders which have no business on my list, and essentially all of the rest had already been signed. Andrew told me he’d taken a look at my in basket before we met and deleted three or four months of the pharmacy orders. I think the number he used was 800,000 orders! Whoa, maybe this isn’t going to go as well as it looks like it might. There is no connection between the electronically entered pharmacy orders and the signatures on the order sheets! 30 some odd orders per patient, each one individually entered and requiring a signature. I did 22 cases yesterday! Are you kidding me? This is what my colleagues were talking about when they mentioned the four minute per chart rule.

Like I said, though, this was a surprisingly positive interaction. Andrew took a couple of screenshots and said that he was going to sit with the IT magicians and see if we might be able to figure this particular one out. Man, that’s gotta work. I mean, the whole exercise took me about 45 minutes, and I didn’t even learn how to ENTER an order.

I can sign one, though. I’ve got some ER call coming up, and I’ll have to do some–patient consultations as part of my responsibilities. I’d better polish up my “helpless look” and rehearse my supplications. Getting someone to take verbal orders is gonna be the key to salvation.

More to come…

I am about to be forced to use the EMR abomination know as “Epic” in order to continue to perform surgery at a particular institution, one where I spend ~10% of my clinical time. My work there is very profitable for the institution; I am not paid by the institution. At present my administrative load is 2X what it was 5 years ago, but the majority is borne by my staff. Once I am required to use their EHR my administrative load will increase at least 20X and I will bear all of it.

Why? My forms are standardized and fulfilling my part of the administrative load presently requires approximately 8 signatures for each case. 8 swipes with a pen on 8 pages layed out before me and marked “sign here”. Time = 0:10/case. Soon I will have to sign into the system for each case and move through a series of ~5 steps to reach the point where I will perform the digital version of my sweeping pen. Time, I am told by colleagues using the system to achieve this, = ~4:00/case. Let’s be generous and assume that they can’t possibly be correct, that it can’t possibly take 4:00 to do digitally what I now do with a pen (Heaven help if I have to enter pre- and post-op orders w/out standard forms!), and that it’s only 2:00. A typical OR day includes 20+ patients. 40 minutes added minimum. Did I mention that I have to do it TWICE because you can’t sign an op note right after surgery?

Lest you think this 52 yo doc is a Luddite and has avoided any and all such technology let me assure you that quite the opposite is the case. We have had an extremely efficient EMR in our office for 7 years; our management and scheduling has been done by computer for 16. My home is littered with Apple products. I’m a buyer of tech WHEN IT MAKES SENSE.

Unfortunately, it appears that I’m about to be forced to be a buyer of this “meaningless use” very soon. I thought I’d share the experience with you here. I’ll keep a log under “The Epic Adventure” and I’ll record not only my experiences but also the time I will be forced to “invest” in learning how to use the system and the time it takes me to comply with its requirements.

It promises to be quite a ride, albeit a rather slow one

Skyvision Centers has a subsidiary company called the Skyvision Business Lab. We do business process research for pharmaceutical companies, medical device companies, and other medical businesses in the eye care arena. One of the companies we have worked for is a very cool company that produces animated educational videos for ophthalmologists and optometrists. I had an interesting experience while talking to their chief technology officer. It was interesting because the conversation proved our basic reason for existence at the Business Lab, that it is impossible for any company to develop, sell, and install any kind of product in our world without understanding the ins and outs of every day activities in an eye care practice.

Of course, I always find it extremely interesting when I’m right!

It was a tiny little point, really, but how could you know something this small and seemingly insignificant unless you had spent time on the “frontline” of medical practice? The chief technology officer for the video company was frustrated because doctors and their staff were not using this really cool product that they had purchased. Furthermore, because they weren’t using it, they were failing to buy downstream products from the video company. As it turns out the salespeople for this company were telling the doctors that this particular product should be “turned on” by the staff at the front desk of the office. This is exactly the wrong place because the front staff personnel simply have neither the time, nor the understanding, nor any incentive whatsoever to do this! The product actually works beautifully if it is “turned on” by the back-office staff. Bingo! Problem solved.

So what does this have to do with Electronic Medical Records (EMR), and for heaven’s sake what does this have to do with underpants? It’s simple, really. When was the last time you bought a totally new type of underpants, underpants that you had never seen before, and underpants that you had certainly never worn before, without trying them on? Furthermore, what’s the likelihood that you would allow someone else to design, fit, and choose a style  of underpants for you if that someone has not only never met you but has never even seen a picture of you?!  That’s the image I get every time I read an article about EMR.

In theory the concept of an electronic medical record that would allow permanent storage of every bit of medical information, with the ability to share that information between and among doctors and hospitals involved in the patient’s care is so logical and obvious that debating the point seems silly. If you have ever seen my handwriting, for example, you’d realize that the entire field of EMR was worth developing just to make doctors stop using pens and pencils! Trust me on this… the doctor hasn’t yet been trained who is also a specialist in penmanship.

I actually trained at  two of the pioneering hospitals in the use of electronic medical records, and indeed in the use of computers in medicine in general. Dr. Larry Weed and Dr. Dennis Plante at the University of Vermont were pioneers in the concept of using computing power to make more accurate medical diagnoses. Both the University of Vermont Medical Center and the Maine Medical Center were among the very first institutions to develop and implement digital medical records for the storage and use of clinical data like lab reports and radiology reports. In theory both of these areas make sense, but in practice the storage and display of clinical data is all that’s actually helpful in day-to-day practice.

If this is the case, if the acquisition, storage, and retrieval of critical data is helpful, the next logical step must be to do the same thing with the information obtained in doctor’s offices, right? Well, in theory this makes a ton of sense. The problem is that nearly none of the EMR systems now in place have been designed from the doctor — patient experience outward; they’ve all been designed from the outside in, kind of like someone imagining what kind of underpants you might need or might like to wear, and making a guess about what size would fit you. With a few exceptions, tiny companies that are likely to be steamrolled in the process, every single EMR on the market is the wrong fit for a doctor and a patient.

Why is this? How could this possibly be with all the lip service that is being paid to the doctor — patient relationship and the importance of getting better care to patients? It goes back to that same tiny little problem that the medical video company tripped over: it’s really hard to know how something should work unless you spend some time where the work is going to be done. Electronic medical records in today’s market are responsive to INSTITUTIONS, insurance companies and governments and large hospital systems. System before doctor, doctor before staff, staff before patient. Today’s EMR’s have been designed with two goals in mind: saving money and reducing medical errors. Should be a slamdunk at that, right? But even here the systems bat only .500, producing reams of data that will eventually allow distant institutions to pare medical spending, but neither capturing nor analyzing the correct data to improve both medical outcomes and medical safety. Fail here, too, but that’s another story entirely.

So what’s the solution? Well for me the answer is really pretty easy and pretty obvious. Send the underwear designer into the dressing room! Program design, programs of any type, are one part “knowledge of need” and one part plumbing. How can you know what type of plumbing is necessary unless you go and look at the exact place where the plumbing is needed? How can you know what size and what shape and what style of underwear will fit unless you actually go and look at the person who will be wearing the underwear? It’s so simple and so obvious that it sometimes makes me want to scream. Put the program designers in the offices of doctors who are actually seeing patients. Set them side-by-each. Make them sit next to the patients and experience what it’s like to receive care.

THEN design the program.

I’m available.The  Skyvision Business Lab is available. I have a hunch that the solution will hinge on something as simple and fundamental as my example above — front desk versus back office.  It doesn’t necessarily have to be me, and doesn’t necessarily have to be us, but it absolutely is necessary for it to be doctors and practices like Skyvision Centers, places where doctors and nurses and staff members actually take care of patients. Places where patients go to stay healthy or return to health. Places where it’s patient before staff, staff before doctor, doctor before system, and all before the 3rd party payer.

For whatever it’s worth I’m 5’8″ tall, I weigh 150 pounds, and I’m relatively lean for an old guy. I guess it’s a little embarrassing to admit this… I still wear “TightyWhiteys”, but I’m open-minded. I’m willing to change.

Just take a look at me first before you choose my underpants for me.

*Sung to the tune of Janis Joplin’s “Mercedes Benz”

Uncle Sam, won’t you buy me, a Mercedes Benz.The Aetna guys drive Audi’s, I must make amends. Worked hard all through med school, make less than my friends. Uncle Sam, won’t you buy me, a Mercedes Benz.

Uncle Sam, won’t you buy me, a flat-screen TV. American Idol is trying to find me. I’m smarter than a banker; I’ve got my MD. Uncle Sam, won’t you buy me, a flat-screen TV.

Uncle Sam, won’t you buy me a night on the town. Big Pharma’s been busted, you’ve run them to the ground. Sold m’soul to my gov’ment, got pennies on the pound. Uncle Sam, won’t you buy me, a night on the town.

EVERYBODY!

Uncle Sam, won’t you buy me, a Mercedes Benz. The Aetna guys drive Audi’s, I must make amends. Worked hard all through med school, make less than my friends. Uncle Sam, won’t you buy me, a Mercedes Benz.

That’s it…

8:00 p.m. on a Friday night. An urgent page from Express Scripts. “Approval needed for sleeping medicine, Agnes Jones*. 800–333–4444.” Agnes Jones is a nursing home patient with a brain tumor.

4:59 PM, Friday afternoon. Telephone call from CVS pharmacy. “The nonsteroidal anti-inflammatory eyedrop that you prescribed is not covered by Mrs. Jones’ insurance company. We need your authorization to change to the generic version.” We told Mrs. Jones in writing that the generic version was inferior, caused pain, and had 10 times the complication rate. On Monday.

7:30 AM, Sunday morning. Telephone call from answering service. “Doctor, the prescription that you sent electronically on Tuesday for Mrs. Jones was written incorrectly. Please correct this and refile it immediately. Please remember that your status as a provider is contingent upon meeting our customer service standards.” Confirmation of receipt/prescription filled was received on Wednesday.

And, my very favorite, most recent telephone call, this one from the daughter of one of my patients. “Dr. White, NALC needs you to send them a letter proving that my father’s eye drops are not prescribed for cosmetic purposes.”

Welcome to the world of the American physician in the modern era. There are, of course, a host of entirely appropriate responses to all of these pages, beeps, and phone calls. However, this last one put me over the edge. I sat at my desk with the message in front of me, closed my eyes, and thought about how I’d REALLY like to respond. The totally, truly amazing part about this request to justify the eyedrop prescription was that, not only was all the information necessary to cover this already on file at NALC, and not only did a real, live human being actually look at this file, but she admitted that and gave me her name! Ya can’t make this stuff up.

“Dear Alex:

Thank you for this opportunity to express my thoughts about some of the pitfalls associated with the pending ‘meaningful use’ regulations for computerized health records. After you personally reviewing the record you requested information about eyedrops that I prescribed for one of my patients. There is apparently a concern about whether or not this patient is using said medication for cosmetic rather than medicinal purposes. As you know, among the more significant ‘meaningful uses’ of electronic medical records are to make sure that everyone has the same exact information about a particular patient, to utilize this information in such a way that proper care is ensured, and to be more time-efficient for the patient, doctor, and everyone else involved in the care process.

If you will open up your file again regarding the patient in question, JOSEPH Smith, you’ll see that, had meaningful use activity actually been applied, this entire communication could have been avoided. Had you actually read the file you would have seen that MISTER  Smith is an 87 YEAR OLD MALE with a long-standing diagnosis of GLAUCOMA. As your software no doubt shows, the eyedrop Lumigan  is a first line medical treatment for glaucoma. All of this information is contained in your database since Mr. Smith has been taking this medication for no fewer than five years, and the bill for his office visit was paid in full by NALC, diagnosis: glaucoma.

A copy of this letter will be forwarded to my US Rep. and two senators, the FDA, and CMS along with a note asking how they propose that all of their fancy new laws about EMR and ‘meaningful use’ will prevent lazy and incompetent file clerks from blinding my patients.

I trust that the information in this ‘old–school’ letter is meaningful enough to prove that Mr. Smith’s use of Lumigan is not for cosmetic purposes.

Sincerely,”

——————————————————–

“Dear Alex,

Attachment: Pic.JSmith.jpg

Seriously? Really? You would like me to prove that my toothless, 87-year-old patient named JOSEPH is not using his glaucoma drops for cosmetic purposes?! The guy with the electronic bill in your system with a diagnosis for glaucoma, taking three other glaucoma medicines, all for 20 years? The Joseph Smith who can’t be bothered to remove the 11 skin cancers growing out of his face like barnacles on a sun-scorched barge? COSMETIC?

This is a joke, right?

Sincerely,”

——————————————————————-

” Dear Alex,

You caught me! But please, don’t tell anyone else. We have the largest population of semi retired 87-year-old drag queens in America in our practice. They just can’t let it go! We have been prescribing medicines so that they could maintain their long, luxurious eyelashes forEVER. I mean, who WOULDN’T rather have long, thick, natural lashes, especially after a lifetime fussing with those falsies and all that icky, sticky glue. Joe has been SO happy!

It’s amazing how important it is for him and all the ‘girls’ to be able to bat their eyelashes at those cute boy orderlies in the nursing home.

Not that there’s anything wrong with that…

Sincerely,”

Sigh…

*All names are fictitious, of course. The examples are not.

It’s become one of those trendy phrases, “unnecessary care”. When you hear it on television or talkshow radio it’s usually said with a sneer. Indeed, the speakers almost spit the phrase out–“Unnecessary care”–like it tastes bad.  It’s almost always accompanied by “fraud and abuse”, or a not so subtle accusation that some doctor is profiting off this “unnecessary care” at the expense of some poor patient. But is this true? Is this always the case? Are there no longer any circumstances whatsoever where the doctor really DOES know best?

I’m an ophthalmologist, an eye surgeon.  Every single day in the office I see several patients who have enormous cataracts which have dramatically affected their vision, and yet they are not only totally unaware of this decrease, they are militant in their rejection of surgery to improve their vision. Some of them have vision which has decreased to a point where, not only would they fail their drivers license test, they are nothing short of a menace to society behind the wheel. Because cataract surgery is an elective procedure, the patient gets to choose whether or  not to proceed with surgery. In other words, operating on a patient with a cataract who does not feel he has a problem would be “unnecessary care”.

The opposite version of this happens every day, too. In about 25 states there are strict, numerical guidelines that insurance companies (including Medicare) used to determine whether or not cataract surgery is “medically necessary”. Not a day goes by when I don’t see a patient who is bitterly unhappy with her vision, and yet her measured visual acuity is better than the threshold for “medical necessity”. Despite the fact that this patient feels handicapped by decreased vision caused by a cataract, operating on her is considered “unnecessary care”.

It kinda tricky. Sort of a damned if you do, damned if you don’t thing. I know it seems like a rather fine distinction, but cataract surgery is actually a big deal when it comes to the economics of medicine in the United States. Did you know that there are almost 3,000,000 cataract surgeries performed every year in the United States? Could some of these surgeries have been “unnecessary”? I dunno. I’m really struggling with the definition of “necessary”, frankly. Is cataract surgery in my two patients unnecessary? Says who?

You can achieve the same relative mortality rates for atrial fibrillation with either a cardiac ablation, or a cocktail of medications. Maybe you are medicine–free with the ablation, and therefore free of not only the yoke of your daily medicine schedule and side effects, but also the considerable burden of navigating your health insurance-approved medication list. The ablation might be 10X the cost of the medicines, but does that make it “unnecessary”? Too much? Says who?

So how do these two cataract patient scenarios play out at Skyvision? Well, the very unhappy patient with a cataract of any size whose vision does not reach that threshold level of “medical necessity” always chooses to wait until her insurance will pay for the cataract surgery. Always, whether she is a retired schoolteacher or a wealthy heiress worth tens of millions of dollars. She leaves the office unhappy, frustrated, and frightened. She cannot enjoy her daily activities because she cannot see well enough, and she is frightened by the prospect of normal activities like driving.

The other patient? Well, this patient typically has a monstrous cataract, so brown and cloudy it’s like looking through beef broth, or even beef gravy. This patient gets angry, too, but he is angry at me. He’s angry and offended that I would have the audacity to suggest that his vision is poor, too poor to drive, for example. He doesn’t understand what 20/50, or 20/80, or 20/100 vision means, and frankly he doesn’t really care. He’s got a drivers license, dammit, and he’s legal to drive. These visits almost always end something like this:

Me: “What kind of car do you drive?”

Patient: “A crown Vic.”

Me: “What color is your Crown Vic?”

Patient:” White. Why?”

Me: “Because my wife and kids are driving on the same roads as you, and I’m going to tell them to stop and pull over every time they see a white Crown Victoria.”

I say THAT’S “necessary care”!

It’s the jobs, Stupid. That’s what should be on the office wall of every legislator at every level of government across America. Say what you will about Bill Clinton, but did anyone ever get it more than that first Clinton presidential campaign? A simple sign in their campaign war room reminded everyone of the central message: “It’s the economy, Stupid!”

It’s more than that, of course. Now, you could say, “It’s the jobs, Stupid!” What can you do to stimulate the creation of jobs now? Sure, you can take a page out of Rahm “Never Waste a Crisis” Emmanuel’s book and combat our crushing unemployment by pumping money into grand public works. Who doesn’t agree that our bridges, roads, sewers and subways are in dire need of repair? But everyone was enticed by President Obama’s promise of “shovel ready” public projects into which stimulus funds could be pumped, followed instantaneously by the hiring of willing hands to man those shovels. Stimulus I didn’t really turn out that way, so why would we embark on Stimulus II? Or III? Return on this investment was pretty much zero.

Nothing will get our economy moving faster and restore our national spirit than employing more people, and at a higher wage. Let’s take a quick look at the kind of job sector that would be most desirable.

Any industry into which we might pump money should have the ability to ramp up employment at the first dollar of public investment, or the first loosening of a needless regulation. OR BOTH.

Any sector targeted should be able to create and fill jobs across a broad range of salary, experience, and skill levels, and it should be relatively gender-neutral. It should reward achievement and educational advancement. Any jobs created should be domestic, although any hard products created must be attractive for export. It should be an American business sector that is expanding now, and poised for additional growth.

Pretty ambitious list of criteria, huh? Where will we ever find an industry or economic sector that could fulfill all of these criteria without some new genius discovery or mega-bureaucratic mischief?

Easy. Healthcare.

Think about it. Right now our country is fixated on cutting the money flowing into healthcare businesses such as hospitals, nursing homes, and doctors’ practices. Government regulations make it more and more difficult to make a profit while providing healthcare. Perhaps more frightening is the fact that similar regulatory agencies make it nearly impossible to bring new medical products to the market or build the sales of existing products.

Despite that, healthcare and related industries (pharmaceutical manufacturing, medical device manufacturing, health insurance administration and sales) continue to grow in all ways that we can measure, except the most important one: jobs.

I know your reaction. “We’re gonna go broke paying for healthcare as it is; how could we possibly pump MORE money into that?”

Hear me out before you dismiss my theory out of hand.

Every new regulation, every new requirement, every cut in payment for an office visit or a medicine or a hospital stay results in a net LOSS of jobs. And worse, pretty much no one in the entire healthcare and medical sector is hiring now, partly because of declining pay for services and products, and partly by the gloom caused by an assumption that the future holds nothing but more of the same.

We should try to identify regulations to remove. Start with removing the prohibition on drug companies marketing so-called “off-label” use of prescription drugs when it is clear they are beneficial. More sales of existing drugs means more jobs. More sales of existing drugs — along with fewer barriers to approving new drugs — means even more jobs.

People in healthcare and related businesses make a good wage, and there are jobs available across a broad wage scale. These folks buy houses, employ skilled trades, go out to eat and the like. As they advance, they earn higher salaries, and then they do the American thing: they spend it!

Pump more money into healthcare rather than less. Stop all of this talk of cutting payments to hospitals and doctors and instead index fee increases to inflation. Stop reducing Medicaid rolls and give doctors and hospitals an incentive to care for these people by increasing Medicaid payment to the levels of Medicare. That would create more jobs.

Education matters in all things medical, whether you are a doctor or someone working in a pharmaceutical factory. Generally, the more education you have, the better you fare economically. There is no systemic gender or race discrimination in healthcare. With doctors, nurses, hospital administrators, academicians, the only requirement is to be good at what you do. Same thing in related industries like medical device manufacturing; ambitious people of all types, men and women, young and old, can advance in their careers. Advancement means more job openings.

And guess what? More jobs means generating more income that can be taxed! More jobs create more spending and more sales that can be taxed! You could even encourage more of this by decreasing income taxes on those people most likely to spend that money, which would then create…wait for it…more jobs!

Oops. Sorry. Politicians are involved. Decrease taxes? That’s just crazy talk.

The next thing you know someone will propose some really crazy thing, like increasing the money we spend on healthcare.

*Credit for the idea to William J. Petraiuolo, M.D.

Alex, the question is: What is the one thing that ASCRS, the American Society of Cataract and Refractive Surgery, can do for its members that it isn’t already doing?

ASCRS, AAO (American Academy of Ophthalmology), AMA (American Medical Association), and the various and sundry other organizations of letters are all of the same ilk. Each one was founded with the idea that physicians as a general group, and more tightly defined specialist groups, needed some sort of representation. Some sort of trade group that would present our needs and desires to other groups like the government, insurance companies, and the public. You know, someone to take OUR side in a discussion, to support US in a debate.

So, how’s that working out for you, Doctor? How well are your trade organizations doing, you know, carrying the flag, supporting you and your issues, the things that matter to you? Like protecting your relationship with your patients? Protecting you from frivolous lawsuits and the incessant threats that make you add “cover my ass” to every treatment plan? How are they doing taking up the cause of preventing yet another government program from gumming up your day with more useless, purposeless paperwork? How’s all of that going?

Yeah…thought so.

Once upon a time organizations like the AMA stood for something. The AMA in particular was the ethics referee for all physicians, as powerful as a FIFA ref in the World Cup, and frankly just as impervious to outside influences and criticism. To be censured by the AMA was a serious thing, the only thing worse being the loss of your license to practice medicine. Now? Do you remember reading the histories of the eunuchs who waited on the Chinese emperors of antiquity, emasculated and with a veneer of power that they brandished with a flourish. They lived for the intrigue; they thrived on the daily ebb and flow of palace life, content to be AROUND the tables of power, though they were not really AT the table. It’s like that now.

When did it happen? When did this group of “all-powerful” become a collection of empty sacks? It probably started whenever the AMA lost its great battle over its prohibition of advertising, a case of free speech and restraint of trade in which the AMA was thrashed. It’s never been the same since then, just one small defeat after another. Indeed, the very nature of the game was changed at some point, whether it was the advertising defeat or some other tipping point.

I’ve looked very hard, called into play my most powerful google-fu, looking for the answer. Who led us to this point? Could it really have been a Dr. Chamberlin? No…to0 easy…can’t be. It would be just too perfect if the 3+ decades of universal appeasement as the modus operandi for all of the medical alphabet organizations could have been started by someone so named. Nevertheless, appeasement is precisely what organized medicine has all been about for decades.

Surely, if we agree to accept Medicare payment as our payment in full, they will trust us to do what is right for our patients. If we just agree to label our charts with these treatment and billing codes they will assume that we are doing what we say we are doing. Hey, they’re going to pay you a BONUS for faxing your prescriptions with a computer system. Well, you know, a computerized medical record is theoretically best for our tapped out payment system, and if we do everything just like they say there’s a possibility that they might pay a little bit so you’ll lose less money on it. Well, you know, there are some docs who have cheated the system, so we’ll have to accept the “guilty until we can’t find any way to not find you innocent” policy of regulatory enforcement.

Drip…drip…drip…the slow torture of seeing the next drop come…drip…each tiny capitulation labelled as “cooperation for the common good”…drip…the willful, purposeful blindness of the appeasers…drip…well, certainly THIS time they will reward us for being good team players…drip…no lesson ever learned…DRIP.

Well, Dr. Chamberlin, here’s what I’ve learned. It doesn’t work, this appeasement thing. It never does. It’s never enough, all that you’ve given up, all the times you’ve decided that we would “take one for the team.” Appeasement never works because those you wish to appease do not respect you, and because of that they do not respect US, the physicians. Indeed, they view us with barely concealed scorn. It doesn’t matter whether they are Republicans or Democrats, government or private, Aetna or the Blues, they know that you don’t have what it takes to ever take a stand. You don’t know what it is to use leverage, wouldn’t recognize it in your pocket, and would turn away from it if you did.

What to do…what to do? Believe it or not there are still some physicians out there who have neither emptied their (figurative) sacks, nor become so jaded and angry that they can no longer muster the empathy necessary to be a doctor. What should we do? Should we retreat to some nirvana, some mythical place like the mountain hideaway built by John Galt to house those who would traffic in excellence in a world where success is born of merit? Ah, would that we could. The closest that any might come to this is to retire, withdraw their services from the system and become conductors. Or provide their services to all comers for free; that would shake things up. Not many of us can afford to do that, and if we could not many of us are willing to walk away from that which has defined our very beings for so long.

So, what? Well, for me, I have gazed too long on a system built on the cynical abuse heaped on the followers of the appeasers to avoid becoming just a little bit cynical myself. It’s a game, you know? Games have rules and regulations, little battles that can be won even though the war might already be lost. Perhaps an extra patient at the end of the day. A perfect chart with every preferred practice pattern item covered. Who knows? The rules ebb and flow as the alphabet organizations push a little, pull a little. There’s always a game, a little battle, rules to play by, rules to follow, a way to win within the rules today. A cynical approach to a cynical battle, with hopes for no collateral damage. 10 years of that kind of today, and then…

Alex, the answer, apparently, is nothing, because that would be better than what they are doing now.

“I’m sorry, Doctor, but we can’t have you give that talk; you have a conflict of interest since you’ve been paid to do research on that medicine.”

“Well, Senator, it’s a conflict of interest for a doctor to sell those crutches in his office.”

“It is the opinion of this newspaper that physicians should declare to each patient any ownership interest they might have in a surgery center so that the patient is aware of any conflict of interest.”

And on and on the drums beat, droning incessantly and insistently about the dreaded “conflict of interest”.

In a world now run by the terminally attention deficited, with multi-tasking and synergy-seeking all the rage, we apparently have one domain in which nothing but the purest, most antiseptic, monastic and single-minded devotion to a single task and goal is acceptable: the provision of health care in America. Think about it…the simple existence of OTHER interests is de facto evidence of some nefarious CONFLICT of interest. The underlying assumption appears to be that it is impossible to have any additional interest–ownership of a business, a consulting agreement, stock or stock options–without the ability to devote your primary attention to the best interests of your patient. Any other interest is automatically bad, and every physician is guilty and can’t be proven innocent. How did we come to this?

There are issues and examples both substantial and trivial, and yet each of them is addressed as if they are one and the same. I bought pens last month for the first time in my professional career (I graduated from med school in 1986). It was weird. Who knew that there was a place called Office Max and that this huge store had not one but TWO aisles of pens to peruse?! I think it was Bics in a KMart the last time I bought a pen. Somehow this fact means that I have been making decisions for my patients based on all those pens I DIDN’T buy all these years. There’s only one problem with that: I don’t remember a single thing about even one of those pens.

And yet somehow accepting those pens is a “conflict of interest”. Seriously.

Why is it that if I somehow get something from someone, big or small, even if I perform some service or even buy something from them, that it’s a “conflict of interest” if some company or other might make money from what I do for my patient? Why is every peripheral interest that exists around the little silo in which I practice medicine–a space occupied by me, my staff, and my patient–why is that automatically a “conflict of interest” with some sort of negative connotation? That I must be doing something bad? Why not just “another interest”? Why can’t these things be a “convergence of interests” between what is best for my patient and any of the other stuff that might be going on around us?

Listen, I get it. There have been instances where docs have pushed inferior products on their patients because they had a significant financial incentive to do so. I’m reviewing a med-mal case right now where the plaintiff had an eye problem which resulted in cataract surgery. The cataract surgeons are not being sued, but I looked over the surgical record and saw that they put an inferior POS lens implant in this guy’s eye, and I KNOW they did that because they own the surgery center and that lens is dirt cheap. THAT’S a conflict of interest. But for every surgery center owner like this putz I know 50 who put in state-of-the-art implants because that’s what’s best for their patients. Those docs still make a profit, but it’s smaller because they are putting the patient first. Why is THAT a conflict of interest?

It’s not.

Three different companies make 3 versions of the same kind of medicine, all of which have identical efficacy and safety, and all of which sell within pennies of each other. How does one choose among them if one needs to be prescribed? Is it such a heinous insult to humanity to choose to prescribe the product from the company that pays the doc to consult on some other project? Or the company that brought in lunch? Or (GASP!) the one that left a couple pen lights in the office? Tell me, how and why is this a “conflict of interest”?

This trivialization of the concept of “conflict of interest” is actually weakening the protections that we should have against REAL conflicts that cause real harm. Pushing unproven technology (artificial spinal discs, anyone?) on unsuspecting patients prior to definitive proof in return for obscene “consulting” agreements, for example. Applying the same degree of moral outrage to a ham sandwich as we do to conflicts which truly pit the best interests of our patients against some profound interest on the part of the physician that prevents him/her from centralizing the patient is farcical moral equivalence. I think it is actually harming our patients.

Our most renowned medical editors, innovators, inventors, and teachers are withdrawing from public positions that require a monk-like aversion to these “conflicts of interest”. Who will replace them? Will the ascete cocooned in the conflict-free zone and unaware of what developments are on the way contribute? How about the teachers? Will we be taught by “specialists” who put together the purest power-points from the latest scrubbed articles, priests who are not stained by the sins of the those who are touched by the commerce of medicine by actually touching, you know, patients?

Here’s my bid: a true “conflict of interest” is one in which there is an essential tension between what is best for a patient, and some other ancillary benefit that might accrue to the physician. Something that makes the doc think about that other benefit first, before the patient. Everything else is an “additional” benefit. We should stop this silliness; stop trivializing the concept of “conflict of interest” through the dumping together of all other interests in the same gutter. We should all be allowed to ignore all but the truest of conflicts as we continue to put our patients’ interests first.

We should be allowed to seek a “convergence of interests.”