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Healthcare Independence Day

Independence Day is upon us. One half of 2018 is in the history books. It seems like we just started in our 2018 adventures in healthcare delivery. The next few months should prove to be challenging in so many aspects.

In the past six months, drug prices at the wholesale and retail level have risen to an all-time high. Some medications that cost pennies in the past are now sold for hundreds of dollars. The medical insurance companies are requiring physician justification for uses of both medicines and imaging techniques. It takes at least one to two hours of time to negotiate each MRI. It takes months to get a prescription of human growth hormone approved for men and women who are deficient. Many times, I must refer patients to an endocrinologist who has almost no knowledge of Adult Onset Growth Hormone Deficiency. After their initial meeting with these specialists, patients reveal that these physicians have practically no knowledge of the research and advancements of human growth hormone delivery. It is absurd to require patients to see endocrinologists who have no experience or interest in our patient’s welfare. Some of these doctors profess the association between increased cancer risk and growth hormone use which is false and unproven. Some clinical data would suggest the opposite.

The Health Commissioner of Tennessee just released new opioid prescription guidelines. These are the strictest rules in the nation. The Commissioner has the opinion that overdose deaths are continuously on the rise. However, what is conspicuously apparent is the lack of connection between the prescription habits of Tennessee physicians and the opioid overdose deaths. Although the Commissioner states statistics about narcotic use for pain and the likelihood of overdose, there has been no reliable link between the two. Heroin overdose deaths have skyrocketed. Last I looked, Heroin is a schedule 1 which means the compound is strictly illegal and physicians cannot prescribe it for pain.

At the same time, the Substance Abuse and Mental Health Services Administration (SAMSA) of the Federal government claims that cannabinoid treatment (marijuana) is the most effective treatment for opioid addiction. However, State government officials who are openly concerned about the opioid disturbance refuse to approve cannabis for medical use. Cancer patients state that their oncologists tell them to smoke marijuana for their cancer pain and side effects from chemotherapy. These physicians are asking patients to use an illegal drug which is superior to any other medication they use to combat the effects of cancer, chemotherapy, and radiation. The Health Commissioner is noticeably absent in promulgating marijuana guidelines since the State Governor, and both State legislative bodies are opposed to its use in clinical medicine. We are in the throes of electing a new Governor, and several conservative candidates have stated that they will oppose any decriminalizing of marijuana use for Tennesseans.

Patients complain about the lack of time they have with their physicians. Doctors have told me that they can only use seven minutes to greet a patient, take a history, examine, create a treatment plan, write prescriptions, and complete the electronic medical record. If a patient has five prescriptions, it will take about two and one-half minutes to write them appropriately. More time will be needed if an opioid medication is necessary for pain control. How is any physician supposed to care for their patients in less time than it takes to hard boil an egg?

Physicians in the trenches are being yanked in every direction possible. It appears that medical insurance companies, pharmacy benefit management plans, health commissioners, State legislators, Governors, hospital administrators, pharmaceutical companies and ministers seem to have a desire to tell physicians how to practice based on their agendas. In today’s world, everyone is entitled to an opinion about how a physician should practice. The most disturbing part of the healthcare system itself is physician behavior in all its forms.

Physicians are not united. The American Medical Association (AMA) does not represent me. The AMA probably doesn’t represent most physicians I know. When I belonged to the AMA, the organization was high-jacked by public health physicians and academicians; it was uninterested in private practice doctors. I believe the AMA should be as powerful as the NRA when it comes to healthcare and physician-patient relationships. It is not. 

Physicians seldom speak to each other anymore. Specialists believe their knowledge is somehow sacred and definitive, even if they are ignorant about what they are allegedly expert in. Many studies have shown that physicians stop learning and are closed to novelty after they leave their residencies and fellowship training. Basic science and knowledge roll on despite their ignorance. I can read the most current information about an illness, treatment options and testing with one swift click of a mouse on my computer.

I do not perform specialty procedures; I believe specialty training is essential to patient safety in this regard. Discussing the merits of alcohol ablation for atrial fibrillation as opposed to the use of medication is not beyond an educated physician’s purview regardless of their specialty training or not. The clinical study data is available to all of us. We should be able to talk out our differences of opinion as they relate to patient welfare. The ultimate decision for any therapy relies on the patient’s hands, not the physician’s willful demands. A physician should treat and restore patients to the best of their ability, not comb patient data and cold call them for procedures of which the patient refuses to participate.

Physicians are typically loyal to one person: themselves. The interview process in medical school application makes sure that those who have the aptitude for medicine will perform like all physicians before them. No other professional school spends more money or time selecting out their students. Consequently, our egos do not allow us to form a common political bond that helps preserve the integrity of healthcare, especially when patient care is vital to our mission. My office staff spends hours conversing with insurance companies, pharmacy benefit management plans and hospitals trying to get medications approved, as well as testing. Some physician somewhere usually is on the other side of my requests, making a case not to perform necessary testing or allow the needed medication and at the same time, refusing to take responsibility for their decisions. I have had numerous heated arguments with physicians that serve in directorship roles or peer-to-peer liaisons, who refuse to disclose their training or whether they see patients daily. I have found that absolute power to control another human being corrupts people absolutely. There are no exceptions. Physicians have power over their patients, and many specialists believe they have power over the primary care physician to decide what’s best for a patient referred for consultation. No questions allowed.

Will the disturbances lessen over the next five or ten years? I doubt it. The younger physicians see themselves as working for someone somewhere. They want short hours, no responsibilities after they leave their offices, they do not want to take call, they want large six-figure salaries to maintain an epicurean lifestyle, they want to have numerous barriers between them and their opinions about other physicians who do not agree with their practice habits. They tend to do whatever is convenient, even if it means not treating a patient appropriately when an insurance company or pharmacy benefit management plan refuses to honor their evaluation or treatment plans. Their favorite words are: Sorry. Your insurance company refuses to pay for it. The patient is left standing without an advocate; they now fend for themselves in the boneyard of failed therapies.

I hope physicians wake up one day and see the world differently. If we have two cardiology or GI groups competing for the same limited patient pool, I don’t think they will come together to stop healthcare agencies from grossly underpaying their competitors. If the competitor drops out, the remaining group will snarf up the business instead of taking the high ground and provide secondary care to make a dollar. That’s the nature of greed; it has infected the healthcare industry nationally.

What am I going to do about it? Practice medicine the best I can given the constraints that hospitals and insurance companies have placed before us both. We are in this together, not alone. Appeals are now commonplace when in the past, they were rare.

Maybe more will join us. Then again, perhaps not.


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