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Some thirty years ago, Dr. Robert Westlake, Sr., who was then the Vice President - Medical Services (predecessor of today's Chief Medical Officer) at Community General Hospital, used to say that academic medical centers were better than community hospitals "if you happen to be an interesting case."
Dr. Westlake (shown in a photo from 1979) passed away in 2003. During his career, he was a proponent of primary care by internists (he was one) and family practitioners. He called primary care doctors "the captains of the ship," and he argued that the primary care physician knows the patient best (clinically, as well as within a family and social system context) and is best equipped to refer and supervise ("to captain") medical and surgical subspecialists who become involved episodically in a patient's care.
He also maintained that a routine case ("uninteresting" to academics) could languish in an academic hospital where it was more likely to receive cursory or disinterested attention from a resident staff (doctors-in-training).
We've seen many changes in health care since Dr. Westlake's day. The technology and medical expertise has improved in both academic and community settings. Services and technology that were esoteric ten or twenty years ago are now routine at community hospitals. And expertise that was once limited to the hospital setting has moved to outpatient settings.
There is, of course, a touch of ego and turf-protection in broad pronouncements about academic and community hospitals. Is an academic medical center always preferable to a community hospital? Is a "brand name" residency program always preferable to residency at a state university hospital?
My own informed self-interest tends to agree with Dr. Berwick -- and with Dr. Westlake. The community hospital serves an important role.
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I'm reminded of a patient I saw in my office many years ago, a young woman with a "positive review of systems" which is medicalese for having every complaint under the sun. After getting a detailed medical history and examining her thoroughly finding nothing wrong, I asked her if anything in her personal life was bothering her.
"Well gee doc, I hate my job. It's kind of...you know, stressful."
I asked her what she did (which I should have done in the first place). Her answer convinced me that she did in fact have one of the worst, most stressful jobs in the history of mankind.
She worked as a cashier at an impound garage. She had to take rather large payments from less than cheerful "clients" to retrieve their cars which had been towed. My advice: find another line of work.
Who says medicine has to be complex and arcane?
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During Hurricane Katrina, I called our local Red Cross chapter to offer my services in Louisiana. I attended their training course to do just that but was then told that I wouldn't be able to volunteer as a physician. Louisiana was unwilling to temporarily grant licensing reciprocity to out-of-state doctors even though it had experienced a massive disaster.
Any such physician assisting there would be practicing without a license and I surely don't need to review the medicolegal implications of that. Their state legislature is obviously filled with a group of rocket scientists!
I instead opted to be placed on a list of physicians willing to respond to in-state disasters (California in case you missed the title of this blog).
An interesting letter was published in the latest issue of JAMA. Lori A. Boyajian-O'Neill et. al. surveyed each state in the U.S. to find out what their policies were regarding the licensing of physicians in the event of a disaster. The chart they compiled lists three possibilities: an "expedited" licensing procedure, waiver of licensing altogether in the event the physician has a license in another state (reciprocity), or my favorite -- none.
Louisiana belongs to the expedited procedure group. During Katrina, their governor wrote an executive order suspending the usual licensing procedures. Apparently this wasn't in place at the time I considered going with the Red Cross (who would only send docs with a valid Louisiana license).
I was surprised to see that 18 states opted for no emergency licensing at all. Talk about protecting your turf!
Maybe every states' lawmakers should be reviewing their own laws. To me, emergency reciprocity seems like the way to go. For most state medical boards, a physician's licensing status can be checked reliably and instantly on the internet. Why wouldn't a state want a physician in good standing in his home state to volunteer in the event of an emergency?
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Dr. Myron Luthringer and patient Kelly Wheeler joined Carrie Lazarus on WSYR TV's "Bridge Street" Thursday to discuss Ms. Wheeler's robot-assisted surgery a week earlier.
Also appearing in the TV studio was the daVinci S Surgical robot itself. Carrie got to "test drive" the $1.65 million advanced technology under Dr. Luthringer's guidance.
Dr. Luthringer practices obstetrics and gynecology with Dr. Jennifer Marziale and certified nurse midwife Janice Beaman. Their offices are in Syracuse and Auburn, NY.
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Here's an idea I hate . Congress is considering regulating the amount of university endowments that schools may keep for themselves and how much they have to pass on to students (in the form of tuition cuts, financial aid, or scholarships). Do these guys really have this much time on their hands?
Laws such as those being proposed give our legislature the bad name that it has. Why a private, non-profit organization such as a university endowment "needs" to be controlled by the federal government eludes me. Don't get me wrong. When I read that elite schools such as Harvard could pay the tuition of their entire student body on just the interest that their endowments earn, I find that reprehensible and a poor reflection of their governance. But that's their problem, not the fed's.
Surely people will make the argument that as tax-exempt organizations, some limitations on their behavior is appropriate. Really? Is the federal government really so much the paragon of efficiency and insight that they should decide where the Red Cross or Harvard should allocate the contributions they collect? Is that what we want?
Likewise, some will point out that many (most?) students receive some federal aid in the form of grants or federally insured student loans and as such, the government has an overriding interest. To me, this just strengthens the position that the fed should get out of higher education completely.
My guess is that such legislation will probably go nowhere (although some provision for more transparent reporting of where endowment money actually goes may pass). I think though, that the real intent of such debate is to put a chill in the minds of fund managers' minds. The mere threat of such laws may well be enough to "influence" behavior. In my opinion such saber rattling is an immoral use of federal power.
Bad law. It's contagious.
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Earlier this month I wrote about the crisis in pension funding resulting from the intersection of the Pension Protection Act (PPA) of 2006 and the extraordinary market collapse of 2008.
I expressed a hope that, once the national elections were behind us, federal officials would consider legislation to “make it possible for companies to adequately fund their pension plans over longer periods of time” than are required by the PPA.
Last week the New York Times reported several senators have proposed such legislation. The report speculated that, if the bill was not addressed in the Congressional lame duck session, it would be considered in “a pension relief bill in January.”
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I REALLY want to be on the road at the same time as this guy: 85 years old and driving 100 MPH in snow and ice. Apparently they're pretty lax about such things in Canada. He only lost his license and the use of his car for one week.
My feeling is that while this may have been an appropriate punishment for a younger person, in this case, doesn't it suggest a blindness to the physical realities of getting old? Is it political correctness not to ask if the combination of this driver's age and actions alone betrayed a lack judgment and a decline in cognitive function?
Are such questions not to be asked even the face of an overriding public health interest? To me, this individual's "right" to drive should be terminated before someone else's life is.
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March 31st, 2009UncategorizedSome thirty years ago, Dr. Robert Westlake, Sr., who was then the Vice President - Medical Services (predecessor of today's Chief Medical Officer) at Community General Hospital, used to say that academic medical centers were better than community hospitals "if you happen to be an interesting case."