THE BUSINESS OF MEDICINE

Is medicine a profession or is it a business?  To us old timers, medicine is first and foremost a profession; a calling.  As such, the business of medicine has always come second.  Unfortunately, neglecting the business side of medicine has led to my profession’s downfall.

Fast forward to current times.  Medicine has become big business.  Companies such as Walgreens have led the charge.  Obamacare has led to the creation of Accredited Care Organizations owned by corporate entities and poised to suck every available penny out of my once proud profession.  Physicians, Nurse Practitioners and Physician Assistants have become corporate America’s service technicians and patients have become cost centers to be controlled and serviced in mass.

What’s behind the changes in medicine?  Profits!  America’s leading healthcare companies have figured out the business end of medicine and are going at the business full gun.  Pharmacies are now doing acute and chronic care in their Quickie Clinics.  Does anyone see a problem here?  I certainly do!

In past articles, I have written about the ethics of selling cigarettes in a facility that administers care and medication to sick smokers.  Corporate America has taken greed to a whole new level.  Apparently, it is OK to help someone develop chronic obstructive lung disease and then treat him for his chronic illness for the remainder of his life.  

The treatment of chronic diseases entails more than just writing a prescription. It entails helping the patient develop healthy lifestyles.  Will the store front practitioner who is treating a patient for diabetes walk her through the store and show her everything she shouldn’t buy or will the sale on large bags of Reese’s Pieces catch the patient’s eye and will he/she end up with several bags of the sugary delight in their cart?   Will the three 12 packs of Coke for $9 sale be the diabetic shopper’s reward for purchasing his/her healthcare at such a convenient location?

Will the store front practitioner walk the hypertensive safely out of the store avoiding the racks of salt-laden chips and pretzels?  I think not!  Instead, the store designers will continue to set up food gauntlets designed to lead the customer to the most profitable products and fill the corporation’s coffers.

The business of medicine is the end of medicine as us old timers know it.  Ethics and morals will change and it will become completely ethical to sell an obese individual a diet pill, a six pack of Millers, chips, pretzels and candy.   If you can sell cancer sticks in a place of health, hell, you can do anything!

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Stewart Segal, MD

First, let me tell you that, if I could do it all over again, I would still be a doctor.  I would still move to Lake Zurich and would still have had an walk-in, open door policy.  Yes there are things I would change, but the basics would be the same.

Second, I have led a gifted life.  In telling you the truth about being a doctor, I am not looking for sympathy but instead, I am looking to bring you and your future doctors into a closer patient-doctor relationship, one that might be strong enough to actually change the future of medicine in the US.

THE FUTURE OF MEDICINE IS DISMAL!  Medicare for all is not the solution.  Medicare for all is the end of humane medical care!  Just look north to Canada to get an idea of what’s coming.

Now, back to my story.  It starts when I was seven years old and had a sore throat and fever.  Dr. P. came to my house to care for me.  I remember Dr. P’s visit as every time he made a house call, I got a shot in the buns.  Dr. P. was a general practitioner.  There were no family docs in 1958.

Dr. P. was a respected member of the community.  Many placed him on a pedestal.  Afterall, he delivered your babies, cared for your family, took out your gallbladder and did birth to death care for your extended family.  Most importantly to you, he helped create the doc that took care of you for the last 34 years.

Dr P’s office was like mine, first come first served.  Dr. P’s wife worked in the office, as did mine.  Dr. P made you wait your turn, as did mine.  I never heard anyone complain about the wait.  Unfortunately, that’s where the similarities ended.

By the time I hung out my shingle, the world had begun to change. The respected position that Dr P’s cronies occupied had already begun to crumble.  My colleagues and I mortgaged our futures to pay for medical school.  We gave up our 20s to gain the education and credentials needed to answer their calling, and it only got worse. We found that in order to pay our overhead and make a living wage, we had to work 80 hour weeks.

Today’s graduate has $400,000 or more in debt.  The dream of owning their own practice is gone!  Today’s physician is an employee whose rules are set by the corporation that employs him.  Medicine is now a big business and those of us with a calling, drown trying to fight the current that pushes us further and further into the computer monitor that sits between the patient and his/her doc.

I’ve gotten off track.  Every time I told Dr. P. that I was going to be a doc like him and join his practice, he told me that the practice of medicine was changing, and I should find something better to do with my life.  I ignored him.  I’m glad I did.

By the time I graduated, health issues had forcibly retired Dr. P. Again, I followed in his footsteps.  I opened my own office.  My wife ran it and, in the end, struggled to keep us financially afloat.  And, in the end, health issues retired me.  Strangely enough, Dr. P. has Parkinson’s as do I.

Is your doctor rich?  Everyone assumes he/she is.  Everyone (including his/her staff) assumes that docs rake in the cash.  Unfortunately, it’s not true.  Yes, physicians make a good income, but they work long hours (I often worked an 80-hour week), spend a great deal of time away from the family while on call, and have massive debt to service.  Oh yeah, they still have to deal with life and death situations on a daily basis as well.

Well, I got off track again.  I’ll resume tomorrow.  I hope you will stick with me as I think giving you an understanding of who your doc is will help you work with your doc to improve everyone’s lives.

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IT’S AN EMERGENCY

I’ve written about it before and I’ll probably write about it again — it’s an emergency until proven otherwise. Chest pain is an emergency until it is resolved and proven to not be of cardiac origin. Abdominal pain is an emergency until it is properly diagnosed and treated. The worst headache you have ever had is an emergency until your brain scan is reported as normal.

Yes, I admit it. I overreact to a lot of things. I am a pessimist by train, always guarding against the unseen enemy. I have to be! If I agree with your husband and treat his chest pain as indigestion, I may treat you for depression after the funeral. If I agree with your insistence that your abdominal pain is just the stomach flu, I may have to teach you to change your colostomy bag. If I underestimate your headache and give you the pain pill you are asking for, I may visit you in the nursing home the rest of your life.

Agreeing with you makes you happy the majority of the time. By the same token, disagreeing with you ticks you off when the tests all come back normal and you have to pay for the workup. You get a big, “I told you so!

It’s an emergency until proven otherwise, and, when the heart attack is real, I’m a brilliant diagnostician, an excellent doc. I saved your life. When it’s indigestion, I’m that quack who overreacts to everything. So, who am I?  Am I a brilliant diagnostician or a quack?

The answer to that is easy. I am your doc, working hard to keep you safe and well.  Like every other doc, I use my experience, knowledge, and evidence to create a differential diagnosis that is appropriate for your symptoms and then I act to protect and heal you as best I can. I don’t have to be brilliant. I just have to care for and about you. While I may be wrong about what ails you or, in retrospect, misspent your money, I am not a quack.

So, the next time I ask you go to the ER, please go! The next time I order an MRI, please get it! The next time I ask you to come to be examined, please don’t argue! I can’t examine you over the phone. There are things that can be done in the ER that I cannot do in the office. An MRI can find things that a physical exam cannot uncover.

One last thing. If it makes you feel good to say, “I told you so”, then say it. If not, then I would be grateful for, “Thanks, doc, for looking out for me.”

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YOUR HOME

Our greatest glory is not in never falling, but in getting up every time we do. 

Confucius
Chinese philosopher & reformer (551 BC – 479 BC)

A very wise man, named Gary, posted this quote on his facebook page; and I fell in love with it.  There are multiple ways to fall.  My patients fall literally, bruising, breaking, and lacerating their bodies. Then there is falling in a figurative sense.  My patients fall from grace by cheating, lying, or worse.  They fall out of love.  They fall off the wagon, off their diet.  They fall for the wrong person.  Falling is a human trait.  Falling leads to suffering and misery.  Getting up from a fall leads to recovery.

Confucius was right. What separates humans is not the act of falling, but the act of getting up, dusting yourself off and repairing the damage that leads to glory.  Over the last 30 years, I have seen many of my patients fall and injure themselves.  I have witnessed every type of a fall and some truly miraculous recoveries.  After reading Gary’s post, I realized the people I admire the most are people who keep getting up no matter how they fall or how often they fall.

Gary’s post was very timely.  As many of my readers know, I have started taking my own advice, eating properly, exercising and generally appreciating life. I want to warn you:  The older you are the harder it is to get up after falling.

I fell off my diet and exercise routine over the last few months.  Between the surgery, the Parkinson’s, and the depression accompanying the loss of my profession, I was attacked by the “too die for” foods of my past and I succumbed.  I was having trouble returning to my healthy lifestyle until I read Gary’s post.  “Our greatest glory is not in never falling, but in getting up every time we do.”  I’m up on my feet and back on the right path.

The next time you fall, get up as fast as you can.  If you can’t get up on your own, call for help from a friend or family member.  If you hurt yourself, get help.  When you can’t admit you fell due to personal pride or shame, recognize we all fall at one time or another and the true glory is in getting up!  

Confucius should have added an addendum.  Once you are back on your feet, learn from your fall.  Knowledge will protect you from the pitfalls of life.  If you can’t stop falling, you may need a cane, walker, psychologist, or priest.  Whatever the cause, get help!

Be happy, be healthy!

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SUDDEN DEATH

Here today, gone tomorrow.  The older I get, the more often I get the call: “This is the ER at Any Hospital, can you hold for Dr. X?”  Dr. X then comes on the line and tells me my patient had a catastrophic event, that the paramedics and ER crew did everything possible but that the patient expired.

My patient had no reason to die.  He was relatively young and healthy. Life had been good to him and he had been good to his body.  He didn’t die in an auto accident or on a ski slope.  He died at home and apparently, from nothing.  I can’t describe the feelings of loss, frustration, curiosity, and wonderment that accompany such an unexpected call.

Yes, people die from nothing.  In my world, it’s not uncommon to lose perfectly healthy patients.  Usually they die in an accident; but, occasionally, they just die.  Sudden death is a mean foe.  Sudden death gives you no time to react and is almost always permanent.  Sudden death also denies family and friends a chance to prepare for the loss.

As a doctor, the tsunami of emotions accompanying “the call” begin with loss.  He was one of those patients who always made me smile.  Even when he was miserably sick with a cold, he always had something nice to say.  When his life’s stresses mounted, he always found the positive side.  Yes, his death is a tremendous loss to my practice and the community.

When patients get it right, cares for themselves, follow the rules and still die from nothing, it’s frustrating.  I believe in preventative medicine.  There are healthy habits and there are those habits that are unhealthy.  Eliminating unhealthy habits, eating right, stressing less, enjoying life, and exercising should be rewarded with long life.  When a patient who does it right just dies, it makes me want to drown myself in hot dogs and chocolate cake!  I think I’ll go to Portillo’s and throw my own wake.

Curiosity strikes next.  Why?  Everyone wants to know why?  The pathologist is the doc who answers that question.  The pathologist is the doc who knows everything.  Unfortunately, the pathologist knows everything; it’s just too late.  Autopsies help answer the question why.  Hopefully, by answering the “why,” families can mourn in peace and docs can accumulate wisdom that can help them become better docs.  Unfortunately, there are times when even the best pathologist cannot answer the “why” and everyone has to accept that, in death as in life, there are questions that will never be answered.

Did “wonderment” seem like an inappropriate emotion when I listed it above?  It’s not.  I am always awed by how precarious life really is and how much people take it for granted!  If today is your last day, are you going to enjoy it or are you going to waste it worrying about tomorrow?  Do you have an “attitude of gratitude” or are you so involved with life’s stresses that you forget to give thanks for what you have?

If today is your last day, did you contribute to your demise by neglecting your health?  Did you waste your time on earth or did you accomplish what you set out to do?  Are you proud of what you’ve accomplished?  Did you make others smile and bring happiness to those you met?

SUDDEN DEATHI believe in preventative medicine; yet sudden death seems to make a mockery of it.  My patient died much too young.  Would he have died sooner if he had not played by the rules?  I have to believe he would have.  I have to believe that taking care of your body adds years to your life.  I know that “an attitude of gratitude” adds quality to your life.

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IT’S VALENTINE DAY, GIVE THE GIFT OF LIFE

It has been a very long day so this will be a very short article.  In the past, I have written about the miraculous ability the body to respond to its environment in order to survive.  In response to environmental stresses, your body can make new bone, muscle and blood vessels.  It can thicken your skin (calluses) to create a protective exoskeleton.  It can also learn to make new blood more efficiently.

The donation of blood and blood elements may well be the gift of life for another individual. Giving blood costs you some time and nothing more.  What you get in return is more than helping another soul survive.  You help yourself survive.  Giving blood is a stressor like running on a treadmill.  Your body has to replace what it has lost.  If you give blood on a regular basis, your body will learn to make blood more efficiently and faster.  If you are in an accident or bleed from an ulcer, your body will be better able to repair itself.

Donating blood proves that, by giving to others, you improve your own lot in life.  Sign up at your local blood bank.  Give and give often!

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SOUTHERN FOOD

You can take a southerner out of the south, but you can’t take the south out of the southerner!  I just spent four days in Charlotte visiting with my children and all of my bad southern habits blossomed.

I’m not sure if I would still be alive had I stayed in the south.  Day One started with a seafood Po Boy.  For those of you who haven’t had the pleasure of eating a Po Boy, it’s fried oysters, fried crawfish, fried shrimp and fried sausage, all on a bun slathered in Cajun mayo.  In other words, it’s a heart attack on a bun.  Did I mention that it’s served with fried hush puppies and collards?  

That was one of the healthiest of meals. Dinner on Night One was Southern Fried Chicken doused in peppered honey and more collards followed by chocolate cream pie.

I won’t bore you with the rest of the details.  Suffice it to say that I slid downhill from there into a vat of grease and collards (cooked in bacon fat).  In a previous article, I asked, “Why does bad food have to taste so good?”   I’m still looking for the answer.  After an unbelievably great trip, I have a new question.  Why didn’t I become a cardiologist and practice in Charlotte?  I bet business is good and I would be rich!

Renee, where’s my Crestor and when are we going back?

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PREDIABETES

Ever hear someone describe herself as pre-pregnant? Of course not! You are either pregnant or you are not! When I trained forty years ago, I was taught that the physiologic changes of diabetes started ten years prior to the clinical diagnosis of diabetes. Despite all the advances in our understanding of diabetes in the last forty years, very little has changed.

According to Medpage Today, the incidence of diabetes continues to rise. “An estimated 25.8 million Americans, or 8.3% of the population, have diabetes and almost a third don’t know it, the CDC said.” That is a staggering figure. “Another 79 million people have pre-diabetes, with high fasting glucose or hemoglobin A1c levels but not quite at the frank diabetes level.”

In the midst of an epidemic of diabetes, the medical world continues to be politically correct and it tells patients that they have a precondition entity and they have time to do something. It is my belief that understating the magnitude of the problems associated with diabetes is one of the driving forces behind the rise in the incidence of diabetes.

From my point of view, pre-diabetes is as absurd a diagnosis as is pre-pregnant. So why do physicians soft sell the diagnosis of diabetes? In my opinion, there are several answers:

  1. There are insurance implications involved in making any diagnosis. Pre-diabetes does not carry additional risk of being rated by the insurance industry.
  2. There is a stigma associated with the diagnosis of diabetes.
  3. Diagnosing diabetes means having to teach about diabetes, blood sugar monitoring, medications, diet and lifestyle modification. Education takes time and is rarely paid for by insurance companies.
  4. Patients do not want to hear that they have diabetes.

So, what’s the big deal? Knowledge is power! If you know you have diabetes and you know what you need to do to treat diabetes, then you have the power to reverse or control the disease. When you have a “sort of diagnosis” that requires you to change your lifestyle to prevent a disease you don’t really have and may never get, you “sort of” address it and will get around to it in time. Meanwhile, the physiologic changes of diabetes continue to erode your health.

On a daily basis, Docs see and diagnosis some of the 79 million patients who have pre-diabetes, hyperglycemia, elevated blood sugar, abnormal glucose metabolism and other names ascribed over time to this condition. Someone once said, “The devil comes in many disguises.” Undiagnosed diabetes is the devil; and the sooner you recognize the devil, the easier it is to get him out of your life.

The next time your doctor tells you your blood sugar or hemoglobin A1c is slightly elevated, think early diabetes. Regardless of what your doctor calls it, take it seriously. A diabetic diet and diabetic lifestyle are a healthy diet and lifestyle. If we all adopted the diabetic lifestyle, the numbers of patients diagnosed would fall precipitously. It is not as simple as “cutting out sugar”. Sugar is not bad. Nature does not produce “bad” foods; there are just foods that are abused and misused.

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HELP

In 2013, I wrote, “The problem is that I can’t quit!  Not caring for my patients would be like not breathing!  I’m a doc and I’m old school.  I believe my profession is a calling, not a business to be run by corporate America or the government.  I can’t imagine not taking care of Nolan, or JJ, or Hadley, or 1,000 other souls I am entrusted with.”

Six years later and I’m retired, not by choice, but out of necessity. Nine months into retirement and I still can’t breathe. I wake up every morning wanting to dress and go to the office.  Instead, I go to my computer and write.

This blog is my way of communicating with my patients old and new (readers). It’s also helping me breathe.  In reviewing my old articles, I have a rare opportunity.  I get the benefit of listening to a younger me lecturing the old me on how to live with Parkinsons and recover and maintain as much “Wellth” as possible.

Unfortunately, my blog is poorly organized, making it next to impossible for a new reader to see what’s available.  There are 121 articles published so far.  While they contain 40 years of accumulated knowledge, you have to scroll through a lot of material to find what you are looking for.  If any of you know WordPress and want to pitch in, let me know.  In the meantime, please make sure you are sending links to your friends and family.

I know there are people out there whose lives can be improved by reading my articles and sharing in my legacy. My hope is that, long after I’m gone, people will find answers and solace in my articles.

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A DOCTOR DIES TWICE

Baird Brightman, PhD’s article published December 23, 2019 really hits home.  I’ve been trying to deal with the loss of my practice and the systematic destruction of medicine as a whole.  Dr. Brightman’s insightful article has helped me understand what I am dealing with.  By clicking on the title of this article, you will be transported to Dr Brightman’s article.

In the past, I wrote about “AI” and its new place in the medical world.  For those of you that missed the article, “AI” is Artificial Intelligence. For years, doctors have warned the public, government and insurers about an impending shortage of primary care physicians.  That shortage has arrived!  On a daily basis, I hear from patients who can’t find a new doc.

I now believe that the shortage plaguing my patients was no accident.  Many of my colleagues and I spent the last 15 years fighting the insurers, PBMs and government on behalf of our patients.  We did not enjoy the fight.  We did not profit from fighting.  We had a sacred responsibility to care for our patients and put their needs above all else.  That relationship has killed the practice of medicine.

We, as a once powerful group, cost the insurers, PBMs and government a lot of money as we jumped through hoops getting approval for testing, medications and necessary procedures for our patients.  Slowly but surely, our power diminished.  We were demoted from physician to providers.  We were forced to accept treatment guidelines as law.  We were accused by the media and government of “fraud and abuse” which supposedly runs into the hundreds of millions of dollars.  The latest assault on physicians, as a whole, has to do with the “opioid crisis.”  Is it any wonder that people no longer want to go into primary care?

In a recent article on the net, a physician pointed out that, in the future, nurse practitioners (NP) will be referred to as “advanced practice providers.”  Physicians will still be referred to as “providers.”  Doesn’t it sound like an “advanced practice provider” has more training and experience than a lowly “provider”?  

I have trained nurse practitioners and physician assistants for years. I have been impressed with their capabilities and dedication, but they are not physicians.  Their training falls far short of your physician’s training. In the beginning, their licensure required that they be supervised by an M.D.  Those requirements are vanishing.

A recent article noted that 60 physicians employed by a local hospital conglomerate were fired and replaced by NPs.  Why?  The answer is simple.  NPs cost less than MDs!  Are you wondering what my point is? 

“AI” is cheaper than physicians, NPs, and PAs.  “AI” will not form a sacred relationship with patients.  “AI,” at least for a while, will obey the rules. It will not argue over a denial of services.  Google will become your provider and the younger generations will be happy to accept Googles advice[rS1] .

I’m actually scared!  Our upcoming move to North Carolina means that Renee and I need to find new docs.  That’s not going to be easy.  We are on Medicare which pays poorly.  I am sick, requiring multiple referrals which will mean extra hassles and expense for any doc who takes care of me.  I’m on multiple meds further complicating matters.  I also want a physician who will be caring, attentive (listen to me), and available when I need him/her.  My patients are telling me that such a person no longer exists.

If I’m scared despite all my knowledge and experience, I can’t imagine what you are going through!  Again, I’m sorry I had to leave you when I did.


 [rS1]

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