Corporate Healthcare

Yesterday, I was reading the Greenville Hospital System (GHS) medical staff newsletter.  One of the articles was excitedly explaining how GHS had struck an EXCLUSIVE contract with Blue Choice Medicaid.  This means that the 14,000 members of Blue Choice Medicaid in the Upstate area will only be able to receive their medical care from GHS physicians.  The article was presented as very exciting, positive news, but I saw it as an illustration of what is happening to health care in the United States as it moves away from individual centered health care to corporation based health care.

The deal between Blue Choice Medicaid and GHS, despite all of the claims about improving quality is really about money.  It has been done for the purpose of both GHS and Blue Choice making more money. Of course, contractual deals between businesses have been done as long as business has been around.  This makes sense, if you are talking about Walmart buying  a large volume of shirts from a manufacturer so that they can sell them cheaper to entice the consumer to come into Walmart and buy the shirts.  I think it is a different matter both morally and functionally to do this in healthcare.   In order for the deal between GHS and Blue Choice to work, a population of patients has to be bought and then their behavior as well as the behavior of their doctors controlled in order to produce “savings.”  This would maybe be okay if the patients were free to move in and out of the Blue Choice Medicaid plan, but whether you are talking about Blue Choice Medicaid plan or any other insurance plan, the patients do not have the freedom to move and out of their insurance plan.  As a consumer, I have the choice to buy a shirt at Walmart or Belks or wherever.  However, as a patient I am locked into the insurance plan that my employer chooses or in the case of Medicaid, the plan the state chooses for me.  I have no control over the deals that have been struck by these insurance plans.  If I am insured by Blue Choice Medicaid and my doctor is not part of the GHS network, I will be forced to either change doctors to one of the GHS doctors or go without insurance coverage, which few can afford.

This process has been going on for quite some time and it has been accelerated by the Affordable Care Act (Obamacare).  Once insurance began paying a majority of the health care costs, patients and doctors were no longer viewed as individuals, but now lives to be purchased and members/providers whose behavior was negotiated and controlled.  Obamacare brought Accountable Care Organizations into existance and this is driving much of what is happening now.  Under Obamacare, much of the money will be distributed to hospitals, who will then determine how the money will be spent for the healthcare of the populations under their control.  This is why hospitals have been very aggressive at buying physician practices and coalescing numerous hospitals into their networks.  The more healthcare a GHS can provide, the more of the money they can keep for themselves.

On the surface, GHS trying to provide a wide range of services themselves is not a problem.  However, it becomes a problem, when they establish themselves as a monopoly that drives out of business any doctors unwilling to be owned by a system and thus controlled by the system.  It becomes a problem when patient’s choices are limited because their doctor is not part of the system or their doctor is limited on who he/she can refer to based on whether they are part of the system.  It is a problem if the patient’s choices are challenged because the choice does not fit the patient behavior guidelines of the system.  It is problematic, when vastly different individuals with unique needs, preferences and biologies are all treated as one monolithic patient population.

As a doctor, I will never be owned by the system.  As a patient, I fear the kind of health care system being created is not in MY best interest.

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It’s The Attitude!

In 1992, in order to encapsulate the central issue in the Presidential election that year, James Carville popularized the statement:  “It’s the economy, stupid.”  I am reminded of this during some of my patient encounters.  I think of a couple  I delivered a few months ago.    This couple had transferred to me, from a local obstetrical group, part way through her pregnancy.  A major reason for transferring, was that they wanted a nonmedicated  vaginal delivery and believed they would be more likely to achieve that under my care than that of the obstetrical group.  Unfortunately, her delivery process turned out nothing like they had planned.  There was an induction, an epidural, vacuum and ultimately a cesarean section of a healthy baby boy.  At the conclusion of this birth, I felt terrible.  This couple had come to me for a specific style of delivery, but I believed I had failed to meet their expectations.  The day after the delivery I went to visit this mom and talked with her about her birth experience.  To my surprise, she was extremely happy with her birth experience.  Obviously, she was thrilled with her new baby,  she was also very happy with the whole experience and happy they had changed doctors, even though the details of the birth had not turned out the way they had planned. 

 

I have been reflecting on the reason for the positive satisfaction, despite the specific unpleasant details and I believe it can be encapsulated in the statement, “it’s the attitude.”  What was the attitude that this couple found appealing?

 

1.      This couple was treated like family.  Since I am the only delivering doctor in this practice,  I get to know them very well and they get to know me.  We not only talk about their pregnancy, but also about both their and my personal lives. They know that, except in a very rare situation, I will be the one shepherding them through their labor and delivering their baby.   I will not be turning them over to another doctor, who might have different ideas, because my shift is now over.  They have my personal cellphone number and can reach me when I am needed.  At the end of all this, the couple has no question as to whether or not my priority is their well being.

 

2.    Throughout the pregnancy all interventions are discussed and a seeking of approval is obtained.  This is even more important during the labor process.  Nurses did not suddenly start doing things because the doctor ordered it.  Rather, the reasons for any intervention are thoroughly reviewed prior to the intervention happening.  The attitude part of this is that they are treated as equals in this process.  While I may have more education and experience, their input is just as important as mine.  This is a collegial process with sincere give and take.   This means they remain in control of what happens, rather than being taken over by a big unresponsive medical system.

 

3.    All options were attempted.  During the labor, she was encouraged to move around and change positions.  Other methods of achieving a vaginal delivery were pursued.  There was no timer running, so she did not feel pressured by the doctor’s fatigue, schedule or arbitrary time line. By the time the decision to do a cesarean section was made, the couple knew there was no other option and were in full agreement with doing the section.

 

Every case is different and rarely there is a true emergency or situation, where the doctor has  to take a more paternalistic approach.  Nevertheless, that should be very uncommon.  

 

Too often, the doctor has the attitude that they are the educated professional and the patient’s views and concerns are irrelevant.  Too many times, doctors will make up rationalizations to justify what they want to do to the patient, rather than admitting it is a doctor preference or the way they do things.   

 

My view is that physicians need to be transparent with their patients.  Agree or disagree with the patient’s viewpoint, a physician needs to be collegial in their approach.  If the doctor disagrees with the patient’s viewpoint, than try to persuade them in a respectful manner.   A doctor should never approach the patient with a condescending attitude.  A doctor should not make things up, to get a patient to agree to a given treatment.  Physicians should treat patients the way they themselves would want to be treated.  It is the attitude!

I am Dropping My Health Insurance

After a great deal of thought I have decided to drop my health insurance.

As everyone without health insurance knows, this a very scary position in which to find oneself.  Being in the healthcare field myself, I am well aware that a single day of hospitalization can generate tens of thousands of dollars in bills.  I also know that as a 53 year old self-employed man with hypertension and a history of oral cancer,  once I drop my health insurance, I will never be able to get it again.  I also know that the older I get, the greater the probability of developing an expensive medical condition.

Given this reality, why would I drop my insurance?  The answer is that while I can still technically afford my health insurance,  I can no longer justify the extremely high cost of maintaining health insurance.  My premiums have steadily gone up, so that I am now paying $1,400 per month for a plan that comes with a $6,000 annual deductible.  This means that, I am now paying $18,000 this year, to prevent the health care system from bankrupting me.  No matter the item we purchase, there is a point at which we decide the price exceeds the value of the item and for me health insurance has now reached that point.  This is a single item in my budget and I cannot justify paying that amount of money for an insurance policy.  It is no wonder that so many families are unable to afford health insurance when the cost for it is this high.

I do not blame the insurance companies for this out of control cost of health insurance.  I know that insurance companies are not living in poverty and there is much about the way they do business that totally frustrates me, but neither do I think they are the major cause of unaffordable health insurance.  I believe  the major cause of high health insurance premiums is out of control health care costs and the premiums are rising to cover the ever increasing cost of health care.

Unfortunately, the politicians whole focus is on ways to pay for our health care, rather than answering the question of why is health care so expensive?

Some blame the costs on an aging population, advances in medical technology and too many in the population being uninsured.  While these things may be contributors to cost, I believe they are not the major reason for these runaway costs.  I believe the real culprits are other items.

The reality is we have created a health care system in this country that almost no one can afford.  It started back when employer and government provided health insurance was initiated.  This began the decoupling of health care from market forces and the price of health care started climbing.  This produced a vicious cycle of higher prices trying to be compensated by more subsidies and higher premiums and less control by patients and doctors.  Unfortunately, we have now gotten to the point that patients are no longer the doctor’s customers, but have become mere widgets to be manipulated by the system.  This view of patients will become fully manifest when Obamacare is fully implemented.  When market forces are removed, they are replaced by rules and enforcers of the rules.

A major contributor to sky rocketing health care costs is the escalating mounds of regulation.   The justification for these regulations range from preventing “improper payment”  to creating a perfect health care environment.  I could argue with these justifications, but right or wrong, the need to fulfill these regulations costs our health care system millions upon millions of dollars each year.  As an illustration of the impact of regulations on our health care system, go by a hospital parking lot Monday through Friday and see how many cars are in it.  Now go by the same parking lot on Saturday.  The amount of reduction in cars is an approximation of the cost of regulation to our health care system.   While one could make an argument for a small amount of regulation; we have long surpassed the ridiculous and we are now at a level where the whole system is in danger of collapsing under the weight of the regulatory burden.

Lawyers are a tremendous expense for our health care system.  There is, of course, the direct cost of malpractice judgments.  One can debate the merits of a tort system, but when a plaintiff is paid a judgment, the money for that payment ultimately comes from health insurance premiums.  The even bigger impact of doctors and hospitals being sued over bad outcomes is the cost of doctors ordering lots and lots of expensive tests and spending lots of time documenting, for the purpose of protecting themselves from law suits.  I am sure, some will argue that it is good that the fear of lawyers makes doctors so cautious, but I have to ask, at what cost?

Mandated coverage of all kinds of things is expensive.  The politicians, in their yearning to buy votes by looking compassionate, have passed more and more laws requiring insurance plans to cover various and sundry things.  There are many of these items, but some of the latest items have been mental health care, children to age 26, preventive health care, contraception and soon coming preexisting conditions.  This mandating of coverage may sound wonderful to those getting the benefits, but these mandates come with a huge price tag.  One of the major things is it eliminates an insurance company’s ability to offer an affordable policy because they have been mandated to cover so many things.  This creates a larger pool of people with no insurance at all because all that is available are plans that cover everything and are therefore too expensive for them to purchase.   All of these “wonderful” mandates will do one no good when one cannot afford to buy the insurance in the first place.

There are other factors impacting the cost of health care, but these are some of the major ones.  Whatever the reason for the costs, the reality is that health care in the United States is extremely expensive and health care is something everyone of us is going to have to purchase sooner or later.  What am I going to do?  I am going to be participating in a cost sharing cooperative (Samaritan Ministries).  There are a number of these out there, but their monthly premiums are $350/mo instead of $1,500/mo.  They provide no coverage for day to day medical needs (neither did my high deductible plan)  and take more time on my end, but in my mind not only are these plans markedly cheaper, but they are how health insurance should work.  We will see how it goes.

What is behind physician’s approach to immunizations?

Based on the number of comments from my last post on immunizations, this is a topic in which many people are interested.  I had no intention of arguing for or against immunizations, though not surprisingly some of the comments did take up that issue.  My goal was to bring attention to what I think is an improper and unfair approach by the majority of the medical community towards those who choose to not follow the standard schedule.  Based on the number of comments; I hit the nail on the head, that many parents have had unpleasant interactions with the medical community over the issue of immunizations.  In that post, I indicated that I have an opinion as to the reason for the hardline stance by most of the medical community on this issue and several asked that I expand on this, so here goes.

First of all, it is NOT because they make money from the vaccines.  I have seen this claim on forums, but it is just not true.  In fact, practices are happy if they do not lose money on immunizations.  The reimbursement by insurance companies barely cover the cost of the vaccine, much less all of the labor that goes into administering them. Vaccines are not a profit center for doctors.

The biggest reason doctors push immunizations is they really believe immunizations are critical to maintaining good health.  It is what they are taught throughout their training.  Numerous experts and professional organizations take the position that without the widespread use of vaccines, serious diseases would be rampant.  With all of this training and expertise supporting the use of vaccines, it just does not seem logical to them that a rational individual would object to their use.  Therefore, they conclude that anyone who objects to immunizations has to be either crazy or uneducated.

Secondly, they believe their role is to protect children.  Since, it is common knowledge that immunizations are so beneficial, it is critical that they do their best to overcome the objections of those parents who stand in the way of the children getting optimal health care.

Thirdly, the vaccines are not 100% protective.  Some individuals do not develop adequate protective antibodies when given the vaccines.  Therefore, if too large a portion of the population does not get immunized and thus the incidence of the disease increases, these immunized, but unprotected individuals are put at unnecessary risk.

Fourthly, the very palpable fear among physicians of being sued  has dramatically altered the way all physicians practice.    If a child ends up with brain damage following the administration of a vaccine according to guidelines, that physician is under no risk of being sued.  If a family tried to seek damages, it would be covered by the Vaccine Injury Act.  On the other hand, if a child is not immunized per parental choice and comes down with pertussis, for example, and has a bad outcome, the physician would be very exposed to the risk of being sued.

Next, we unfortunately live in a highly regulated society.  Every aspect of our lives is now controlled by some government entity or entities.  With regulatory agencies breathing down the necks of physicians it is problematic for physicians if a significant part of their patient population is not following the CDC guidelines.  This is even more true for those practices which are owned by hospitals and today most practices are owned by hospitals.

Last on my list is that it takes significantly more effort to care for families who do not follow the standard schedule.  If a child is brought in for his/her two month visit and just gets their shots according to the schedule, it is a very simple thing to roll out the typical two month shots and give them.  In contrast, dealing with a parent with concerns about vaccines or figuring out a schedule for those selectively vaccinating takes a significant amount of time.  Physicians are under significant time pressures, so anything that requires that they spend more time with a patient can put them on edge.

My last post was trying to promote a better understanding of those who do not immunize.  This one, is trying to improve understanding of the physician’s viewpoint.   I am not arguing for or against any of these opinions, just letting people know what is behind physician’s positions.

My next post will discuss why I give patients the freedom to choose.

Observations on the Immunization Controversy

Anyone involved in the healthcare of children knows there is a growing number of parents who are selectively immunizing or not immunizing their children at all.  The medical establishment is becoming quite alarmed about this trend and becoming rather unpleasant towards parents who are questioning the benefits of immunizations.

It has become an increasingly frequent experience for parents, who have concerns about the safety of vaccines, to have very negative encounters when interacting with the medical system.  These interactions range from being treated as ignorant weirdos who need to be properly educated, to the outright refusal of care.  We are, sadly, now at the point where a majority of pediatric practices refuse to care for children who are not immunized according to the official recommendations.  Here is a typical vaccine policy from a pediatric practice (http://milestonepediatrics.com/vaccine_policy.html)

My practice has the philosophy that parents, not the medical establishment, should be the ones choosing how or if they will immunize their children.  It is a matter of freedom, which to me, takes precedence over the science of immunizing.  I am personally in favor of vaccines and all of my children have been immunized according to the standard schedule.  However, I believe it is wrong for a physician to coerce a parent into vaccinating, when they are uncomfortable with it.  I believe each of us has the right to make our own decision and then we have to live with the consequences of that decision.  It grieves me, when I see the guarded or fearful look come into the eyes of a parent when I start asking questions about a child’s immunization history, because they are afraid of what will happen when I discover they are not immunizing according to the established rules.

This philosophy of freedom first, has certainly led to a boom in our pediatric practice as parents have sought a place where they can get medical care for their children, without having to endure an unpleasant doctor-parent interaction.   I now have had a significant amount of experience with selective and non-immunizers and I have some observations I would like to pass on to providers of health care to children:

  1. These parents are NOT ignorant.  In fact, many of them are far more educated about vaccines than most pediatricians.  Most physicians would argue they have misinformation and one can discuss the accuracy of the data on either side of this issue, but the issue is not a lack of education.  It is ridiculous and insulting when providers browbeat these parents over and over about the issue of immunizations.
  2. These parents are NOT weirdos.  These are very engaged, critically thinking parents, who are trying to protect their children from unnecessary risk.  The fact that a majority of the medical establishment does not agree with their conclusions does not make them weirdos or troublemakers.
  3. These parents are NOT unconcerned about their children’s well being.  They are every bit as committed to their children’s health as the parents who willingly go along with the standard immunization schedule.  They have simply come to the conclusion that the risk to their child from immunizations, especially at such a young age is greater than the risk from the rare diseases that we are immunizing against.  Again, one can disagree with their conclusion, but it does not make their motives wrong.
  4. I do not understand the reasoning, when a doctor says he/she will not take care of an unimmunized child because he/she is concerned about the child having proper medical care.  They claim that immunizations are absolutely critical to the well being of children, but then if a parent refuses to immunize, they tell the parent it is better for the child to have No care than to not have care the way they deem appropriate.  How is no care better for the child, than unimmunized care?  There are all kinds of areas where patients do not comply with our recommendations.  Why are immunizations treated differently than any other area of “non-compliance” where we take care of patients to the best of our ability within the context of that individual’s environment?  (I have my theories, but that is for another posting.)
  5. Informed consent should apply to vaccines, the same as any other medical procedure.  A major tenet of contemporary medical practice is “informed consent”  The theory is that a patient is given the risks and benefits of any intervention and the patient then chooses whether they want to undergo the procedure or not.  How is it “informed consent” when one does not have the right to say “No”?  No intervention, including immunizations, is risk free and yet parents are only ever given the positives of vaccines, never any potential risks.  That is not informed consent.
  6. There is a tremendous sense of disproportion on both sides of this controversy.   Every time a parent  puts their child in a car, they accept without hesitation, the risk that the child could be injured or killed during that trip.  At the same time,  those same parents agonize over the potential risk that a vaccine poses to the child, even though that risk is only a fraction of the risk we assume by putting our child in a car.  I am not arguing that a parent should not consider risk and benefit when it comes to vaccines, but I do not think vaccines are as dangerous as some would have us believe and parents need to keep things in perspective.  Pro vaccine advocates are just as guilty of overstatement.  To listen to the rhetoric, one would think that if a child is not immunized, they WILL get sick with one of these illnesses which we immunize against.  This is just not true.  Thankfully, these disease are all very uncommon and very few children, immunized or not, will develop them.  One can argue, that they are rare as a result of successful immunization programs and for some this is undoubtedly true.  At the same time, regardless of the reason, the low incidence of these illnesses does impact the risk-benefit calculations.
  7. Unimmunized children are NOT sicker than immunized children.  There are no studies comparing outcomes of immunized vs unimmunizing children and unfortunately this kind of study will never be done.  However, as I mentioned earlier, I have lots of partially or unimmunized children in my practice.  I can say, unequivocally, that these children are not sicker than the immunized ones.  In fact, they are in the doctor’s office far less than their immunized counterparts.  I do think they are at a slightly increased risk from vaccine preventable illnesses, such as pertussis, but that is a risk these families have chosen to take, over the risk from the vaccines.  For every other illness, they are not sicker and for a few reasons may be healthier.
  8. Unimmunized children are not a danger to immunized children.  Some argue that forcing children to be immunized or ostracizing those who are not, is for the purpose of protecting all of those children who are immunized.  Again, I question the logic.  In the first place, immunizations protect against very specific, but uncommon illnesses.  Since these diseases are so uncommon, it is highly unlikely that an unimmunized child will contract these illnesses and transmit them to immunized children.  Then if the vaccines are such successful sources of protection against disease, then even if an immunized child was exposed to a vaccine preventable disease through an unimmunized child they should be protected from getting the illness.  The reality is that these outbreaks that one hears about is mostly among immunized individuals and has little to do with a child.  This is not an argument against vaccines as vaccines do protect a majority of their recipients and even when an immunized person gets one of these illnesses it tends to be milder.  However, it is an argument against the emotional response of treating unimmunized children like lepers.
  9. You catch more flies with honey, than with vinegar.  The vast majority of parents who come in opposed to immunizing their children do eventually at least partially immunize their children.  They are mostly looking for a physician who will listen to their concerns and allow them the time and freedom to move forward with immunizations when they feel comfortable and not be forced into a one size fits all mold.  They are very put off with the condescending, even hostile treatment they get at many physicians offices.  If the real goal here is to keep children as healthy as possible, treating these parents respectfully will get much more accomplished.  By badgering unsure parents into immunizing, you will get some more children immunized, but you will also build walls and resentment with those parents.  For those parents who are sure they do not want immunizations at this time, they will just disappear from health care all together and that is not improving the health of the children.
  10. Physicians should be scientific about vaccines.  It astounds me how unscientific many physicians are about immunizations.  A scientist is always questioning and testing assumptions.  A true scientist looks at all possible explanations.  Very few physicians, who take adamant stands about the value of vaccines, have actually studied the subject.  They just quote what they were taught in medical school and accept the recommendations of the professional organizations as gospel.  If evidence arises that contradicts the assumptions, they just toss it away as irrelevant.  Obviously, we cannot independently study every topic with which we deal.  What I am asking is to keep an open mind, as we should with all subjects.

There is no question it takes significantly more time and energy to openly deal with this issue, but if our role as physicians is to be advisors and healers to our patients, it is right that we do so, regardless of the decision they ultimately make.

Stirrup Covers

A patient recently asked about the crocheted stirrup covers we use in our office.  I told her the story behind the original ones, which she enjoyed, so I thought I would share the story here.

About fifteen years ago, Geraldine came to me as a new patient.  She was 78 years old and was having some abdominal symptoms.  She had already seen a few doctors over a period of time, but no one had been able to diagnose the cause of her symptoms.  I did a work-up on her and unfortunately had to tell her that her symptoms were coming from ovarian cancer, which at this point was pretty advanced.  Because of her poor prognosis, even with treatment, she opted to not be treated for the cancer.  In a matter of months she was too weak to get out, so I began to make house calls on her.  Every couple weeks I stopped by her apartment to check on her, but mostly we just talked.

During one of these visits she told me she was so appreciative of my having diagnosed her problem, even if it was not fixable, and for my coming to see her in her home.  She wanted to show her appreciation by doing something for me.  What did I want her to do?  She was quite weak, so I was not sure what to tell her.  However, I had noticed that whenever I came to see her, she was crocheting something.  I had recently read about a doctor trying to make those horrid office stirrups more comfortable by putting crocheted covers on them.  I told her about the idea and asked her if she could make a pair for me.  Geraldine was ecstatic and within a week she had made me a whole bag of crocheted stirrup covers.  A month or so after this, Geraldine passed away.

Our stirrup covers have now been replaced several times over, but to this day, whenever I use them, I am reminded of Geraldine and the simple task that brought a sense of purpose to the twilight of her life.

Why Do Businesses Exist?

This past summer I had two very bright and eager student rotate through my office.  One was a health administration student in the School of Business at Winthrop University.  The other was a 3rd year medical student, who obtained an MBA prior to entering medical school.  I asked both of these students the question:  Why do businesses exist?  They both gave me the answers that they have been educated to believe are the correct answers, but neither of these students, educated in university schools of business could give me the correct and very simple answer.

As a physician, I am often told by patients that they do not want medicine to cover the symptoms, but an answer as to the cause of the symptoms.  Until one knows the cause of the symptoms, it is impossible to prescribe the proper treatment.  We are currently living in a day where widespread unemployment, economic stagnation, out of control debt and mutually exclusive political philosophies are the symptoms of a serious and life threatening disease.   If we want a solution to all of the symptoms, we need to know the underlying disease process.

Economic activity occurs as people exchange money for goods and services.  The money that people use to purchase goods and services come from one of two places.  They either earn it through their employment or it is given to them through charity or government programs.  In the first case businesses employ people and pay them for their work.  In the second case, money is given to charities and government by businesses and employed individuals in order to be distributed to those who are not employed adequately to meet their needs.  In both cases, the bottom line is that money originates with businesses.  Those business may be multibillion dollar conglomerates or a child’s lemonade stand.

If we have a sick economy, it is because there is an inadequate amount of business to generate the money required for all of the needs.  This brings us back to the original question, “why do businesses exist” for if we do not know why they exist we will be unable to create the environment in which they can prosper.

Businesses do not exist to employ people.  They do not exist to provide health insurance or other benefits to their employees.   They do not even exist to pay taxes, so the government can fund its programs.  Businesses do not even exist to produce goods and services.  Large or small, businesses exist so the owner of the business can MAKE MONEY.  Employment, benefits, taxes, charity, production of goods and services all happen on the way to a business making a profit.

When the regulatory environment becomes too onerous or fear of litigation too great or labor too expensive or tax burden too high or demand for the output too low for the owners of the businesses to make an acceptable profit, the business will disappear.  When this begins to occur on a large scale the entire economy suffer and that is what is happening in our economy today.

For a variety of reasons, it has become socially unacceptable to pursue profit in our country.  Even our business students do not want to admit it.  At one time, our country was the best place in the world for a business to prosper, but that is no longer the case.  Until we once again create an environment where making a profit is laudable and doable we will continue to have a failing economy and we will ALL be poorer for it.

That is my diagnosis and treatment for the problems plaguing our economy.

Keith Stafford, MD

What is a Doctor?

What is a doctor?  Sounds like a silly question.  It is the person one goes to see when you are sick or  want help to stay healthy.  The reality is what occurs when one sees that doctor is dependent on what that doctor thinks it means to be a doctor.  Here is what I think.

1)  A doctor is an individual who went to medical school and a residency to become a physician.  There are all kinds of ways of obtaining doctorate degrees in all sorts of fields.  I do not intend to diminish the accomplishments of those who earn doctorate degrees in various fields, but I believe when one says, I am going to see “the doctor” it should mean seeing one who has the training as noted above.  Numerous health care fields, like nurse practitioners, physical therapists and pharmacists are now awarding doctorate degrees as their standard degree.  I think this is confusing to patients and an attempt to obtain a status on par with physicians. There are many different health care providers, all with their individual and critical roles.  I disagree with the attempt to blur the lines between the different roles.

2)  A doctor has great amount of knowledge.  The education of a doctor  starts with many years of school (4 years of college, 4 years of medical school and 3+ years of residency) memorizing, learning and experiencing things that give him/her expertise in the field of medicine.  Throughout the career of a doctor, the learning never stops.  Today with the internet, it seems all one has to do is look up WebMD or Mayo Clinics and one can know as much as a doctor.  Certainly, the internet has expanded everyone’s ability to find information, but making a diagnosis or deciding on a treatment is much more involved than simply looking up a list of symptoms and there is the obvious diagnosis and treatment.   I wish it were that simple.  The fact is that human biology and behavior are far more nuanced than a simple matching of signs and symptoms.   While some things in medicine can be solved and resolved with cookbook formulas, much of it cannot and this is where the art of medicine and all those years of training and experience become so critical.  It is why a thinking doctor will never be replaced by a one size fits all computer.

3)  A doctor is a major influence.  Due to all of the education and experience a physician accumulates, society has granted physicians a significant amount of influence and authority.  That influence and authority is a great privilege and needs to be treated with even greater respect by the physicians to whom it is granted.  I sometimes wonder if many physicians are cognizant of the huge impact their words have on people.  A physician’s words and manners can be either soothing and healing or anxiety provoking and hurtful.  We doctors need to strive for the first.

4)  A doctor is an advisor.  I believe the primary role of a physician is to be an advisor.  It is my job to listen to the patient, examine as appropriate and analyze all of the available data and then render an opinion as to the appropriate course of action.  I do not get upset if a patient does not follow my advice.  It is their body and their choice.  Some doctors view themselves as THE AUTHORITY, but I believe this is the wrong approach.  There is a partnership that exists between a doctor and patient.  Each one brings things to the interaction that have to be considered.  Each patient approaches the situation from a different context.  It is not uncommon for a patient to have information of which I am not aware or had not considered.  I value this input from the patient.

5)  A doctor is a friend.  Over the years, many of my patients have become friends.  This is a wonderful aspect of being a family physician.  Whether or not I get to know a patient well enough to become a personal friend, my goal with all of my patients is to make them comfortable enough, that no matter the issue, they will be confident that my objective is to give them the same courtesy and rendering of my skills that I would give to my best friend.

Really Cool Delivery

I had a lot of positive feedback from my last post on “my birth plan.” A few months ago I had a delivery that really made an impression on me and I wrote it down, so that I could remember the details.  It illustrates the style, I wish was more prevalent in obstetrics today.  This is the birth story, as I wrote it down.

“I had a really neat delivery this AM for a super sweet couple.  It was the mom’s 3rd baby and she  was laboring on her side.  (I have delivered all of her babies.)  When it came time to push, I left her on her side as she was quite comfortable in this position.  Baby was occiput posterior, so it took some work for her to push it out.  Dad was sitting on a chair next to the bed on the side mom was facing doing very encouraging, support person stuff.  I was sitting on the bed, behind the mother.  There were no interfering drapes or sheets.  Because of mom’s position, as the baby was coming into view, the father was as close to her perineum as I was, so he got to see his child’s birth in detail, rather than peaking from up above.  The really cool thing was that since the baby was OP, as it was born, it had its eyes wide open and was looking right at his father, so his father was the first person he saw instead of me.  Then this baby took a big breath and began audibly crying while the head was still the only part delivered, which added another unusual twist to the delivery.

It felt so right to me,  because with me behind mom and dad being so close and involved, I felt like I was not even integral to this delivery, It was just something, very personal, that this family was doing together.  Then the icing on the cake was that instantaneous eye to eye contact between father and son as the head emerged.  I so wish I had it on video.”

When one feels all of the pressures with this kind of job, it is this kind of experience that reminds one as to why you keep doing it.

My Birth Plan

I have been delivering babies now for 25 years.  Birth plans have been around for that whole time, but they are certainly presented by couples to their doctors more frequently today than they used to be.  The increase in birth plan development is a consequence of couples trying to influence what happens in a hospital where one frequently becomes swept along by events out of their control.

I certainly do not mind being presented with a birth plan and using it to review a couple’s expectations and preferences.  However, in my opinion, it is far more important that one find an accoucheur (birth attendant) whose default style is in line with your birth plan, than trying to get someone to change their style to match your preferences.  In light of this I decided to write down my birth plan from the perspective of the professional who is being entrusted with caring for an expectant couple.  Here are my goals and preferences:

  1. Give the couple the type of birth that THEY want to experience.  While most overt birth plans are produced from those who are looking for a natural birth experience.  Not everyone is looking for this.  I have some moms who want no medications at all and I have some who want an epidural placed in the parking lot.  Whatever the preferences, I will do my best to accomodate them.
  2. Explain all interventions and get the mother’s permission, before doing them.  One of the biggest complaints I hear about unpleasant birth experiences is that things were done to them without them knowing what was happening.  While it is easy for a doctor to go into automatic mode, I do my best to not let that happen.
  3. Alleviate fear.  One of my frequent statements about pregnancy is that it is the permanent state of paranoia.  Couples are often plagued by the “what ifs”  and modern obstetrics often adds to this with the constant pursuit of worst case scenarios.  While it is certainly true that bad events can occur during pregnancy, thankfully this is the exception and not the rule.  My job is to be alert for  problems without turning every visit into a worry generating experience and to reassure moms when there is no reason to worry.
  4. Avoid Inductions.  I hate inductions.  Sometimes, inductions cannot be avoided, but even then I still hate them and really try not to do them.  No one knows what actually triggers labor, but one thing I do know is that forcing a uterus not yet ready to labor to labor is asking for trouble.
  5. Encourage mothers to stay out of bed and in motion.  The best way to reduce discomfort and to move labor along is to stay out of bed and move about and frequently change position.  One can also use birthing balls, whirlpool tubs, showers, hypnobabies.  Doulas are welcomed as part of the birthing team and a great help in keeping the labor moving along in a productive manner.
  6. Prefer no epidural.  If women want to have an epidural, they may, but my preference is no epidural as this allows for the most physiologic beneficial labor possible.
  7. Keep the stirrups stowed.  When someone is ready to have their baby, the nurse’s automatically reach for the stirrups.  I tell them to put them away.  In my opinion, the stirrups serve no useful purpose and they impede a mother’s ability to find the most comfortable position in which to give birth.  I deliver women in whatever position they are most comfortable and have delivered ladies on their side, hands and knees, leaning over bed, standing, squatting, whatever works.
  8. No episiotomy.  I avoid episiotimies.  (Hint:  when a doctor says they only cut an episiotomy when it is needed, they probably cut episiotomies on most of their deliveries)
  9. Put baby on mother’s chest as soon as baby is born.  The baby goes from me to the mom, not the nurse.
  10. Delay cord clamping.  I cannot say, that this is something that I fully understand, but it is frequently requested so I have incorporated it into my routine.
  11. View Cesarean section as a negative outcome.  Again sometimes cesarean sections are unavoidable, but I never view them as equivalent to vaginal birth for delivering a baby.  Whenever, I have a pregnancy ending with a cesarean section I review the various aspects of the pregnancy and labor to see if I could have done something different to have ended with a vaginal birth instead of a cesarean section.
  12. Maintain a relaxed environment.  Sometimes things can get pretty tense in the birthing suite, but it is my job as the team leader to keep things relaxed and low key.  I have no use for all of the drapes and masks.  I do  not even wear scrub suits (though my wife wishes I would).  This is how I got my nickname “Dr. Polo Shirt.”  I work at calling everyone involved in the birth by their name and try to treat them the way I would want to be treated.  
  13. Care for the baby I deliver.  I really like it when I get to take care of the baby that I have delivered.  This is one of the services that is unique to family physicians who do obstetrics. Keeping the pediatric care with the same doctor who one has gotten to know throughout the pregnancy provides a level of comfort not available with most other care providers.