Tuesday, November 3, 2009

My rockin' the U.S.A tour

Twenty-one days on the road and 17,200 miles travelled since Labor Day.

Stops in Wichita, Kansas; Lead, South Dakota; Osage Beach, Missouri; Charleston, South Carolina, Phoenix, Arizona; Winston-Salem, North Carolina; Stowe, Vermont; and Rochester, Minnesota. Coming up next: 4000 miles and four days in Houston, Texas, followed shortly by a return to the Lone Star state, and then Sacramento, California. Upcoming early next year: Las Vegas, Nevada; Tyson's Corner, Virginia; and Hattiesburg, Mississippi.

No, this isn't the itinerary for Bruce Springsteen and the E Street Band. It is what I have been doing since Labor Day, meeting with physicians, mainly at ACP chapter meetings, to talk about health care reform.

Keeping in mind Will Roger's truism that "This country has come to feel the same when Congress is in session as when the baby gets hold of a hammer" shouldn't I instead remain in Washington, keeping an eye on Congress? Well, no. Although my job is to represent the interests of internists in Washington, D.C., I feel that I can't do that effectively if I don't spend time meeting with internists. We have a top-notch advocacy staff in D.C. that keeps me informed about everything, and modern technology allows me to be a mouse click from being (virtually) on the scene.

I mention all of this because some commentators on this blog have taken me and ACP to task for not listening to its members. I don't take it personally or defensively, but I doubt that there is anyone else who has listened to as many internists, in as many different places, as I have in the past three months.

What have I learned? First, I have not encountered a single instance of an ACP member reacting with "town hall" style hostility to my explanations of the ACP's views on health reform. This is not to say I found uniformity; internists, like the American people generally, have a wide and diverse range of views.

Like the young Med-Ped physician who I met with in South Dakota, who believes with all of his heart and soul that the current bills will lead to a loss of liberty, crushing taxes and debt, and government rationing of services. Like the ACP member in Vermont, who believes with all of his heart and soul that only a government-financed, not-for-profit, single payer system can provide Americans with equitable and affordable care. These ACP members, and many like them, are at polar opposites on the political spectrum, yet they expressed their views to me with civility and with a high degree respect for the ACP.

Internists' views also differ depending on where they live, but not as much as one might expect. Physicians in "red states" like Kansas and South Carolina are more likely to be concerned about the plans being developed in Washington, and those in "blue" states like Minnesota and Vermont are more likely to support them. But you find a range in all regions. In Charleston, SC, for instance, the first question to me came from a conservative doctor who was concerned that ACP was in favor of "government-run" health care, while the very next question was from a single payer proponent.

The most common sentiments I've encountered are confusion about what is in the bills; general agreement with ACP's views; hopefulness that the reforms will improve things; and anxiety that they could make things worse. To address the confusion, ACP continues to update its resources for ACP members, including a new snapshot tool that compares the new House health reform bill with ACP policies.

I have come away from my travels encouraged that most internists want health care reform, and that they place a high degree of confidence and trust in the ACP to do the right thing, an obligation I take very seriously. I am committed to continuing my efforts to listen to as many internists as possible, but even though I am listening, it doesn't mean I will always agree with you.

Today's question: Do you feel that there is "common ground" in internists' views on health care reform and of ACP?


Jay Larson MD said...

Even though there are wide political beliefs about health care reform and the ACP; there is at least one place of common ground amongst internists. That place is next to the patient trying to do the best we can for them to make their life better. Sometimes the reason why we do what we do is forgotten in all the noise.

Arvind said...

I find this statement very intriguing - "even though I am listening, it doesn't mean I will always agree with you". You sound like Barak Obama here. I always thought that a physicians' organization usually represents the will of its member physicians; and subsequently any one who is hired by the organization to espouse such views is obligated by his/her contract with the organization, to do his/her best to promote the views/message of such an organization.

Unless, of course, the organization does not truly represent the views of its member physicians, and/or you as an employee of the ACP somehow are of the belief that you are our "boss" in some way. If I understand correctly, our dues pay for employees' salaries and other costs associated with your travels, etc. So technically, dues-paying members, like myself, are your boss, and you job is to espouse the belief of members like me. If you agree with my characterization, then irrespective of what views and biases you might have, you are still obligated to represent our (member) views to Congress/government.

In other words, I find this statement of yours very disturbing (being polite here). If ACP is indeed such an organization, I will not hesitate to surrender my membership. At least I will assure myself that I am not contributing to a lost cause.

jfddoc said...

Somewhat off topic...did I see something about a CMS "Final Rule" issued late last week? This would have been the proposal to abolish "Consult codes", adjust fees for utilization of diagnostic equipment, etc.

Steve Lucas said...

From the other side of the desk I would like to echo Jay's comments. I have come to realize that much of the modern practice of medicine is driven by factors that force doctors into making choices they may not want regarding time with patients and medications/testing.

The one issue we can agree on is the current system is broken. From that we can find a great deal of common ground regarding fixing the problem. You will not find many patients fighting tort reform.

Doctors, and the ACP need to realize patients are on your side,

Steve Lucas

BDoherty said...

Response to Arkind:

Arvind says that, “I always thought that a physicians' organization usually represents the will of its member physicians; and subsequently anyone who is hired by the organization to espouse such views is obligated by his/her contract with the organization, to do his/her best to promote the views/message of such an organization.” Exactly . . . which is exactly what the ACP expects of me and the other professional staff hired to represent the organization’s views in Washington, one I accept as an absolute requirement. If I and the ACP were not interested in members’ views, why would the organization spend the money to send me out to chapter meetings, and why would I make the considerable personal sacrifice to do so?

The views I and my colleagues on the Washington staff have are those that have been given to us by the membership of the American College of Physicians—through its committees, councils, Board of Governors, and the Board of Regents.

The ACP Washington staff brings to ACP decades of expertise and experience in public policy analysis, politics, communications, and legislative strategy. We are encouraged by the ACP governance to be candid with them in providing advice on how to achieve the organization’s policy objectives. But it is the ACP governance that makes the policy, and we faithfully execute it, without exception, and without regard to our own personal views or individual political leanings.

Personally, I have almost 31 years of experience representing internists, and only internists, in the rough and tumble political environment in Washington, DC. In this blog, and in my travels to ACP chapter meetings, I try to give them my best analysis of the political scene in Washington and how ACP’s policies are being received.

Sometimes, this means that individual members, like Arvind, will disagree with my analysis of the political and policy environment, but I don’t think internists are well-served if I tell them only what they want to hear. It is also evident that Arvind disagrees with many of the policies adopted by his colleagues within ACP. Realistically, with 129,000 physician members, we have a range of views within the College membership, and that means that some will be upset that ACP’s positions aren’t in accord with their own personal views. But the internists in the states I have visited this fall have, by and large, told me that they believe ACP is representing them well in the current health reform debate. Even those who disagree with the ACP’s positions on the current health reform bills have expressed to me an understanding that we are doing our best to represent the diverse views of our membership. I will continue to listen respectfully to all of our members, and will continue to encourage those who disagree with ACP’s views or my analysis, like Arvind, to express their dissenting views.

PCP said...

I am sure the ACP is doing in their view what is in the best interest of the profession. That said, we are at a critical inflection point in the future of General Internist delivered Health care. For far too long, our issues, have been ignored and silenced by leadership. It would not be an understatement to say that PCPs and other cognitive specialists practices have been eviscerated by AMA endorsed bodies such as the RUC and the RBRVU system.
The irony is that patients and Internists alike miss the "art of medicine" side that has been trampled upon by insurance, Hospital, Big pharma, medical proceduralist organisations and their allies. It is not that I have anything against these organisations, they have successful lobbies and have skewed public policy in their direction, to the detriment of Generalism, and resulting in a massive escalation in costs. We on the contrary have failed miserably. Even in the midst of crisis, we settle for crums rather than push hard for what is needed.
The formula for redressing this is not entirely clear, and the sad truth is that General IM primary care sits on the brink of no return as a profession. 2% of Medical students choosing it is about as loud a statement as anyone could make. Another thing given short shrift in discussions is the trend toward employed Generalists, and Hospitalists. I believe this represents more Internists' escape from the unworkable environment created by health policy/payors rather than anything else. Physicians trading some of their autonomy requires a lot of screwed up policy and cornering. A continuation of this trend IMHO represents a failure of our advocacy efforts. A reversal of this trend is possible and is the metric I feel that best gauges the progress any policy change makes for reviving Physician led Primary care.
I fear that the framework being settled for by the ACP will not be one that convinces medical students that General IM deserves the attention of more than 2% of them. If we fail to dramatically change that over the next decade, tell me how Primary care can evolve into anything but armies of NPs and PAs and other mid-level professionals loosely supervised by a few doctors. I see that as a absolute disaster for our health care system. That is where I fear ACP policy takes us. The country needs to listen to General IM, to stop the alarming physician manpower trends, which as I said are nearing the inflection point of no return.

Arvind said...

Bob, your response is well taken. Being a member of the ACP since 1992 (the last 10 years as a sub-specialist), I must tell you that the ACP's policies have quite frequently hurt the sub-specialists' interests. In fact, I participated in a discussion conducted by Arlene during the last ACP annual meeting in Philly. This meeting was intended to focus on sub-specialists' feeling towards the ACP and to identify why so few participate in its meetings. There were ID, GI, CV, Endocrine specialists. There was unanimous conclusion that the ACP is at best marginally representative of sub-specialists and at worst hostile to their interests and well-being. If this is truly the case, then why should we consider the ACP as our representative body, and you, Bob, as our spokesperson? A truly representative organization would embed dissenting views within its message to Congress. Its time to decide whether ACP's step-motherly treatment towards sub-specialists should continue or whether it should clearly define itself as being representative of General Internists alone, so that sub-specialists can decide whether they still want to associate with an organization that does not represent their view/interests.

Jay Larson MD said...

PCP has hit some important high lights affected general internal medicine. Unfortunately we are already past the point of no return. The steps to address the general internal medicine crisis is akin to managing a diabetic with an A1C of 11%, coronary disease, end stage renal disease, blindness from retinopathy, and a BKA by increasing glipizide 5 mg per day. The art of Osler only exists in small pockets any more.

In regards to Bob’s and Arvind’s comments, the ACP is stuck in the middle. I know just as many general internists who feel that the ACP has not represented them as subspecialists who feel they are not represented by the ACP. The ACP is a very heterogeneous group. It represents both general internists and subspecialists.

Since there is no extra money going into the physician pie, any change towards one group will adversely affect the other. Increase reimbursement for cognitive services and reimbursement for procedures will have to decline. It is simple economics. Since the advent of the RBRVU system, the cognitive specialists have been stuck in the 1990’s while reimbursement for procedure based medicine has been accelerating. Hence, the wide discrepancy of value placed between cognitive services and procedures. A market correction of this value discrepancy will only result in wailing and nashing of teeth.

There is no right way or wrong way to fix this health crisis, just as there is no right way or wrong way to manage chronic diseases (so long as the outcomes are the same). We all see the path to disaster. All physicians are working their butts off, not just one group or another. We are all important and deserve respect from each other.

Now lets all sing a course of Kumbaya.

Steve Lucas said...

From a business perspective I feel medicine is facing some of the same business pressures faced in other fields as there is a shift from the independent operator to large group organizations.

Leading the fight for power, money and control is the AMA. They control both the pricing structure and the information system used to bill. Ask a person on the street to name a medical society and the only one they will know is the AMA, and that is the way they want it.

In the grab all you can environment of today we see:


"CHICAGO (Nov. 5) -- Advice about soft drinks and health from one of the nation's largest doctors groups will soon be brought to you by Coke.
The American Academy of Family Physicians has prompted outcry and lost members over its new six-figure alliance with the Coca-Cola Co. The deal will fund educational materials about soft drinks for the academy's consumer health and wellness Web site, www.FamilyDoctor.org.

(Notice "education" is once again used as the front for a strictly commercial arrangement.)

The Coke deal is not the only corporate alliance for the family physicians group. In 2005, it received funding from McDonald's for a fitness program. And its consumer Web site includes advertising for a variety of products, including deli meats and air freshener."

As I look a round I see many financial incentives designed to split the medical field into the haves and have not's. A look at some patient advocacy groups will find marketing people at the top with little of the collected funds going to patient information or research.

EMR/HIT projects have little if any medical input, but are designed to make large amounts of money for the IT companies involved

This headline appears in the WSJ Health Blog:
November 4, 2009, 8:46 AM ET
At Top Schools, More Than Half the Profs Have Industry Ties

What single and small practice doctors are facing today is an attack on the traditional way of practicing medicine. Divide and concur is a proven way to gain an advantage. Doctors do need to band together, or medicine as it has traditionally been practiced in this country, will be lost.

Steve Lucas

Steve Lucas said...

Typo: concur should be conquer. Never trust a spell check.

Steve Lucas

Rich Neubauer MD said...

I agree with Dr. Larson that the common ground is patient-centeredness. To expand on that a bit, I think this applies both to the individual patient-physician relationship, but also to advocacy and concern for the overall health of our citizenry. The Professionalism Charter ("Medical Professionalism in the New Millennium: A Physician Charter", Annals of Internal Medicine, 5 Feb 2002, 136:3, pp 243-246) articulates this under the heading of social justice: "Medical professionalism demands that the objective of all health care systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession."

On the issue raised in the discussion about how ACP represents generalists and sub-specialists I would add a few comments to Bob Doherty's. First and foremost, a collapse of primary care would not be best for sub-specialists. Second, professional advocacy should not just be directed at narrow economic interests. If that were the case, we would be a trade organization not a professional society. For many years, procedural sub-specialists have enjoyed a steep rise in income and a concomitant widened gap in income disparity compared to their generalist brethren. This needs to be recognized as a strong disincentive for those coming out of training from pursuing generalist careers. As such it is entirely appropriate for ACP as a professional organization to advocate for change on behalf of all our members, not just generalists.