Changing the Medical Conversation

Dealing with Covid-19 has been a stress on medical providers.  Retirees like me are dormant, and maybe even regret not being in the fray.  It has changed the conversation of medicine for the better, though.  We'll start with Provider.  The Flexner Report, not yet fully of Blessed Memory, purged practitioners of lesser training and instituted licensing and credentialing.  Physicians often resent parity with other practitioners for understandable reasons.  But with stresses on caring for high volumes of sick patients, a willingness to work and threshold of skill rises in importance.  Doctors get the most attention but good medical care also depends on nurses, technicians, housekeepers with their disinfectants and secretaries to direct patients to the right place and assure their appointments.  They are at personal risk and often have young families.  In a crisis we are all providers with a much flattened hierarchy.

As a reader of social media, medical and otherwise, the conversation in the charting rooms and doctors' lounges no longer focuses on the devaluation of physicians.  Those reviled dysfunctional EHR's have not gone away.  Eventually somebody will get back to our metrics and RBVU's.  But for now we are focused on good outcomes for patients.  Not just the doctors but the managers.  We are all rowing our canoes in the right direction.  Professional antagonism, even animosity sometimes, no longer appears in the physician restricted or public postings.  As we watch TV, we wish there was a Gong to get the President off the podium so we can hear from the learned doctor instead.  People have better priorities from this health stressor, both in public and in private.

Like most calamities other than the extinction of the dinosaurs, Covid-19 will one day pass from the forefront to fond anecdotes and ultimately to the history books.  It remains to be determined if the professional nobility of thought and expression will remain.  But for now we can admire those doing their best to mitigate our crisis and take comfort in knowing that our loftiest doctors can rise in stature above all others.

Not on Weekly Schedule

Every Sunday I outline my weekly schedule on a white board.  If it's a day ending in zero other than Shabbos, Sermo gets a notation in green marker, though not this week.  I'm just no longer interested. 

It's not the first social media that I've abandoned.  There was a great site called classmates.com, great only if free, that predated Facebook.  I reconnected with a lot of the old crowd that way, dumped en mass when a fee was added.  I used to chat with the 40-somethings every morning and some Jewish group chat in the evening.  Screeches from Abdul were worthy of mass use of the Ignore option but enough participants preferred to engage him and the site no longer was attractive.  Physicians Online introduced me to cyberspace.  They had a physicians chat or posting room.  It did not take long for it to appear as a talk radio echo chamber.  As Physicians Online became Medscape, they made a business decision to abolish the service rather than police it.

Sermo once served as a daily destination, a place to make virtual friends.  It took longer for the echo chamber to take over, but it eventually did.  My sign-in dwindled from daily to dates that end in zero but until now remained on schedule.  The new format did not help, hard to navigate, more international posters with concerns different from American physicians, and most importantly, lacking the sharp analytical minds.  Just not on this week's weekly planning.  Not interesting and really not interactive, which could take the mundane on more intriguing directions.  But they still do not charge a fee.  I'd have been gone long ago if they did.

Inundated by Covid-19

Last time I got in on the ground floor of a new disease, AIDS, I completely missed the boat.  I saw early AIDS as a VA hospitalist, not so much as an endocrinologist, so I never really learned its management except as related to adapting endocrine drugs.

Ebola, West Nile, SARS all passed me by professionally.

Now we have a new infection, a serious one, that dominates the news.  It is far rarer than things that I really see like diabetes, hypothyroidism, opioid OD's and respiratory infections of mostly non covid-19 pathogens.  Since nobody's really an expert, most of all the President and VP, it is another chance to enter on the ground floor of a new disease.  Too many distractions for me to become more than a novice at this one too.  But at least I should be able to master the classification of the respiratory viruses and get a better grasp of epidemiology this time.

Too Anemic

For only the second time in decades as a platelet donor, my willingness to provide for the chemotherapy recipients got turned down.  My first exclusion came about fifteen years ago following a stop in Belize on a cruise ship.  I stayed in the tourist area, climbed a Mayan pyramid and lifted the cap off a bottle of local beer.  If Belize had malaria, which the screeners at the blood center told me it did, I didn't come across anyone febrile.  I let the requisite time pass and resumed schedule.  While there have been a few aborted donations trying to use a single arm, I've always passed the screening until this morning.  Random tabletop Hb estimates 12.9g/dl and 12.5g/dl, below the screening cutoff of 13.  I felt fine, would probably have a higher Hb at the end since they take off plasma but return RBC but it was my first health related no go.  A second try in about 10 days.  This has been one of my prime activities for many years, recently increased in frequency after retirement, and one of the few opportunities to literally give a piece of me for the benefit of somebody unknown.  A piece of my identity that I don't want to lose.  Maybe a better result next time.

MHOP Closure

Word arrived that the hospital where I concluded my career, Mercy Philadelphia Hospital, would be abandoning their inpatient services in the forseeable future.  No precise word on when.  During my years there I was treated well, had challenging patients, admirable colleagues, and residents deriving great benefit from the experience they were receiving.  My own activity was about 2/3 office, 1/3 hospital.  I liked the challenge and flexibility of the hospital better. 

We served a poor community, Medicare and Medicaid for those with insurance at all plus a subsidy from the City of Philadelphia for those uninsured patients who received care from the City Clinics.  We had the nominal support of the Archdiocese.  What we did not have was economic viability that could take in more than we spent. 

It's hard to cite villains but I think medicine is heading in the direction that agriculture moved a hundred years ago.   Farms are bigger and hospitals are bigger.  During my active time, I saw the number of doctors remaining constant while the number of employees who could not bill for what they did mushroom.  Not that what the various managers did was unimportant.  Safety is much better than it once was, doctors are more accountable for decisions, investment in electronics required geeks to maintain everything.  But only the doctors brought in more money.  To support all these people, you need more doctors bringing more money into the system.  The number of outcome monitors, accountants, or DRG ladies could be kept under control.  A large network had the same departments as a smaller network with the same number of chiefs and not that much difference in Indians.  But if you had a fixed number of doctors, which we did, and more staff for them to subsidize, the system would collapse.  I think that's what's happening.

It expansion of scale a good thing or not?  Hard to say.  At MHOP I knew all the senior physicians and senior managers.  I doubt if the people at the mega-centers can say that.  I was treated well.  The physicians at the large institutions were more likely to be guppies in the big pond.  We probably take care of the same number of patients individually as our capacity really does not change when there are more of us. 

People that I hold in very high personal and professional regard can expect some displacement.  But they are still employable for the same reasons my esteem for my colleagues remains unshaken.  Unfortunately, I have no realistic input to make their professional resettlement less traumatic.

My receipt from a very fine local pharmacy listed no copay for me.  It included the retail prices that would have been charged for a cash transaction for each three month supply.  Citalopram $14, Lisinopril $14, Rosuvastatin $805.  My annual Medicare prescription coverage premium is only about $200 and they list Rosuvastatin as a Tier 1 which has no copay.  That means the insurer will not get my price of $805 for this.  It comes in a pre-packaged bottle of 90-pills made in India.  It has been past its patent expiration for a few years.  When Good Rx prices are surveyed, the prices range from about $15 to $173 which is what my previous mail-order pharmacy charged me as my co-pay, with a more expensive variant of the same insurance carrier classifying it as a Tier 2.  That is why they are my previous pharmacy and I have a new plastic insurance card with the lower premium plan.  Good Rx also lists each pharmacy's retail price with a variation from $140 to $765, all at pharmacies or pharmacy divisions that are household names and presumably commercial competitors.  And none are $14 like my other generic pills. Something is very amiss.

When I go to buy an artistic Jerry Garcia tie, which either goes with everything or with nothing, the difference from one retailer to the next will typically be a few per cent.  All prices are posted.  I can decide if it is worth spending extra time and gasoline to save $2.  I need not buy the shirt that I will wear with it from the same place.  And if Jerry Garcia's pattern is too garish for the infrequent occasions that warrant a tie, I can get one with no pattern for maybe a little less.  I am a consumer who need not give a reason for why I opt for one purchase over another.  For very large purchases like houses or cars, there is some bargaining room, though the consumer is probably at a disadvantage over the professional agent.  Even so, the purchaser can see the home's neighborhood or the car's odometer.  It is not a blind purchase.  If somebody tried to sell a home far above market value, it wouldn't sell.

While the pharmacy seems different from other retail purchases, it is not modelled after a Middle Eastern shouk or a casino either.  We don't bargain our price, though apparently our Part D carriers can leverage what they pay and pass along to us or sometimes not pass along to us.  Nor do we expect a bargain on Ladies Wednesday or a discount if the right horse wins at Delaware Park.  Instead we are kept in consumer purgatory, wondering why some of what we experience makes little intuitive sense.  And it's hard to conclude anything other than our elected officials letting us down in some way.

So why is a generic medicine prebottled in India so much different in any stated price, even under the best conditions, than the other generics?  Patent law times exclusivity for the patent holder, and for safety, when a pharmaceutical goes generic, a single competitor will be granted exclusivity for six months to see if the post-marketing generic pill is indistinguishable in any detrimental way from the original.  Then it becomes open market, unless a manufacturer wants to corner that market by buying competitors or other legal mechanisms to remain the only production source past patent expiration.  A recent New England Journal of Medicine Perspective Article, using Suboxone as the focus, details the multiple ways a manufacturer can game the regulatory system to maintain post-patent exclusivity and exorbitant pricing that a free market would effectively tame.  https://www.nejm.org/doi/full/10.1056/NEJMp1906680

After forty years of signing prescription pads, becoming proficient at the medication options, including price, for most pharmaceuticals used for endocrine disorders, addressing complaints from patients and sales pitches from company representatives trained to get me to prescribe more, I thought my understanding would be better than it really is.  If transparency fails among experienced professionals, the consumers of their doctors' prescriptions have no chance of escaping what registers as "rip-off" and probably really is.  We need to start with a better understanding of why one generic has a cash price tag of $14 and another has a cash price tag a minimum of ten times that but often much more.  Somebody is making more money than a free market would dictate, some of us are being extorted or even victimized at the peril of our health, and some such as the retailers and distributors are caught in the middle.  We consumers deserve better from the officials we choose to represent us.  So do our students of all ages who we try to teach the superiority of fair markets that ultimately prevail in America, usually as correction of prior abuse, throughout our history.  Correction seems long overdue.

Part of the Team

https://www.nejm.org/doi/full/10.1056/NEJMms1906654

This NEJM essay discusses transformation of medical culture.  It bridges a few realities as physicians go from independent professionals to employees who can be manipulated or leveraged.  Being one of them, supervised by decent people who were themselves supervised by people who I didn't know but I'd wonder a bit about, the top-down model has some real flaws.  While I was on the direct interface of the mission of patient care, I was never solicited for my experience.  I saw myself as part of the team, never a gadfly, but never enthusiastic.  I could be a loyal steward, but never an owner. Doctors follow the rules for the most part, both rules of mainstream patient care and rules of our employers.  We are very much a part of the culture of what is around us, but far less contributory than we should be.  Professional satisfaction is no longer a high priority in a medical culture.  The NEJM authors seem disturbingly content with that.