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WHY THERE MAY NO
LONGER BE… “A DOCTOR IN THE HOUSE”
When I was 7 years old, my grandmother was stricken with a horrible form
of colon cancer. It was a pivotal point in my life and, at this
time, I decided to become a physician. Our “Family physician”
at the time was knowledgeable, compassionate, and guess what?—even
made house calls!
As I look back, I realize it was the caring portion of his profession
that I admired. I was raised by my widowed mother and never knew
what it was like to have money, nor did I have a clue what physicians
earned. Neither mattered, I simply wanted to help people.
On Sunday January 20, 2008, a medical malpractice attorney here on
Staten Island decided to comment on the current malpractice crisis in
New York. His words were published in the Staten Island Advance and
clearly he is horribly misinformed. For the sake of the patients,
and the public of Staten Island, I would hope to set the record straight
by presenting some interesting facts to dispel the myths he recently
stated.
Contrary to any assertion that the insurers are getting rich by charging
exorbitant premiums, the reality is that medical liability insurance
companies are going broke. They are insolvent, or near insolvent,
and the only reason they have not been liquidated by the Insurance
Department is that the legislators have passed a law prohibiting the
department from placing them in liquidation. This law is unique to
medical liability carriers. Any other type of Insurance Company
writing other forms of insurance in New York, which was in this
financial condition, would have been shut down long ago.
Also, contrary to the accusation that the malpractice carriers are going
bankrupt due to bad investments, the investments made by these companies
are very conservative and suggestions that they have produced losses
because they were ill-advised, is without any basis. Premiums in
medical liability, furthermore, are set by the government of the State
of New York, not the companies. Furthermore, the largest medical
liability carrier in New York (MLMIC) is not even a profit-making
corporation. Hence, they are not in the business to “Make
Money”. In reality, the doctors of this state created this
company when every other insurer had left New York State because they
could not make any profit here! As a result, the doctors were
forced to create a mutual company which is owned by the very doctors who
are insured. Logically, the company does not, and cannot, exist
simply for doctors to extort money from themselves. Doctors have
every reason to keep premiums as low as possible but despite this
powerful incentive, rates continue to spiral upward and are at the very
highest levels throughout the United States.
As a result of the unprecedented and unreasonably burdensome premiums
doctors are currently forced to pay, and as we look forward to certain
future rate increases, many doctors have already left the state, do not
perform high risk procedures, and/or limit the amount of patients they
see (i.e., part-time practices, capped patient populations, etc.).
As a result, there is a growing access to care problem for patients in
New York. The ads being foisted upon the public flatly misstate
the conclusions of the Center for Health Workforce Studies relative to
access. In fact, the very Director of that effort has informed the trial
lawyers association that they are mischaracterizing their efforts.
Moreover, if nothing is done to remedy the situation before July 1st,
the speed with which access problems are now developing will accelerate
dramatically and a crisis will be inevitable. Moreover, these access
shortages will instantaneously become much more severe if Superintendent
Dinallo is forced to assess physicians the tens of thousands of dollars
which he says will be necessary if reform is not enacted.
Another correction for the public and patients to bear in mind is that
the outrageously high contingent fees the trial lawyers charge were
moderately reduced a few years ago not to help doctors but to help
injured plaintiffs who were required to pay trial lawyers huge
percentages of the monies that jurors awarded them – monies that the
jurors intended to be used for the patient’s future well being and
health care. While the trial lawyers reference other medical
systems throughout the world’s industrialized nations, they fail to
point out that the use of such contingency fees has been outlawed in
virtually every one of those same countries.
Moreover, the trial lawyers’ admission that liability premiums are
high because doctors are not infallible is astounding, as the law does
not require infallibility from anyone. To be held responsible in damages
– anyone so charged must be negligent. The fact that you are not
infallible does NOT mean you are negligent! Unfortunately,
that’s exactly where our tort system has taken us. To assert that
liability premiums are spiraling because doctors are not infallible is
absurd on its face. The law does not require infallibility but,
the trial lawyers, and unfortunately, many juries do.
Further, the trial lawyers’ plea for the uninsured patient rings
hollow. Perhaps if we could take a portion of the 15% of gross
income, which he suggests all doctors should pay for liability
insurance, we could finance care for the growing number of uninsured who
don’t have access to our magnificent healthcare. As an aside, I
wonder if the trial lawyers are aware there are currently 50,000
uninsured citizens on Staten Island, with no public hospital to care for
them. Staten Island is the only borough without a public hospital,
despite the continued efforts on the parts of physicians and our local
elected officials to obtain this service. This, in turn, has hurt our
local hospitals tremendously as physicians, unlike attorneys, cannot
refuse to see ill patients if the patients can’t afford it!
There is no such thing as getting a “retainer” before care is
rendered. We, as physicians, as well as hospital systems, do pro bono
work everyday! I invite the trial attorneys to spend one day in one of
our local emergency rooms and they will be amazed what is done without a
moment’s regard to an ability to pay!
The Harvard Study—so often misquoted by the trial lawyers—found not
that healthcare needed changes, but also that the civil justice system
was a complete failure. Today’s justice system identifies cases
without negligence as malpractice, fails to identify negligent cases and
remains prohibitively expensive.
In summary, we clearly are facing a medical liability crisis. If
our current system stands, many physicians will be forced to leave the
state, or alter the way they practice. Many Staten Islanders have
already experienced this with Obstetricians choosing to no longer
deliver babies! The physicians have no means of passing on the
additional costs to their patients, nor should they. Many families are
already paying $10,000-$15,000/year to insure their families.
Physicians do not even get cost-of living raises from insurers, despite
the fact that our costs are continually escalating. This crisis is not
physicians vs. lawyers as the trial lawyers would suggest. This
crisis is physicians simply trying to survive to continue to provide
excellent medical care. We only want to continue caring for our patients
in the best manner that is humanly possible. I am saddened by the
fact that if this crisis continues, many of us will no longer be able to
afford to keep our practices open. For my grandmother, and for all of
the patients and families of Staten Island whom I love so much, I pray
that such a day will never come. Yet, as we know, not all prayers are
answered.
People are often faced with having to make choices as medical care
gets more complex and technical. “Advance directives” is a general
term that refers to the oral and written instructions about our future
medical care in case we should be unable to voice our opinions.
As long as we can express our own choices these advance directives
will not be used. The health care proxy is a form of the
advanced directive which allows people to direct their medical care
even when they are in a coma or otherwise unable to communicate.
Both federal and state laws govern the use of advance directives.
The federal law, the Patient Self Determination Act, and state laws
protect the right of patients to refuse or accept medical treatment.
There are many types of advance directives. A living will is
a document that is written to state your wishes about medical
treatment should you be unable to communicate. A Living will is
not a legal document in N.Y. State. Once the doctor receives a
properly signed and witnessed directive, he or she is under a duty to
either honor its instructions or to make sure the patient is
transferred to a doctor who will. A medical “HealthCare
Proxy” is a document that appoints someone you trust to make
decisions about your medical care if you cannot make those decisions
yourself. It is not specific about the type of treatment
you want or don’t want. However, often patients will have both
a living will statement and a medical health care proxy. This
person need not agree with your decisions. It should however be
someone you trust to carry out your choices. It is important to
note that these requests are not limited to just withholding of
certain treatments, as it is also a place to specify what
treatments you would be willing to accept. If you do not have
such documents and can’t participate in your care than doctors will
make prudent decisions and discuss them with the next of kin.
However, as
many people know, family members may often disagree about what treatment
is proper.
It is important to be specific about those treatments that you do not
want and under what conditions you may not want them.
Some decisions are made on the basis that you may be permanently
unconscious with no hope of recovering or facing a terminal illness.
It is important to specify procedures as they relate to diagnostic
testing, blood products, the use of a respirator, surgery, dialysis,
drugs and cardiopulmonary respiration. You may also include
requests concerning pain medications, fluids, and nutritional support.
A discussion and expression of main philosophy of care with the health
care agent may be preferred.
Healthcare directive forms and booklets are given to all patients as
they enter the hospital. However, senior centers, insurance
companies and community centers may be able to help you fill out these
forms prior to admission to a hospital as it would be less stressful.
In order to be legal, the documents should be signed and witnessed
and the person making them should be able to understand what the
document means. In all cases, the document goes into effect when
you cannot communicate your own wishes, the medical personnel caring for
you are notified of your written instructions and/or you are diagnosed
to be close to death from a terminal condition or to be permanently
comatose.
Like all legal discussions at the time of serious illness or death
the best gift we can give to our family and friends is to be personally
prepared. This will alleviate a lot of stress for your decision
makers and also reduce conflict for them over differences of opinion in
relationship to your care.
Information about advance directives is also available by calling
1-800-989-9455. This is a non-profit organization that provides
information about advance directives and offers a wide range of other
publications and services.
| Preventing
Osteoarthritis |
By
Jack D'Angelo, M.D.
One of the most common complaints that we develop as we age is
stiffness in the joints with pain and progressive loss of motion.
This is commonly referred to as osteoarthritis. The most common
joints involved include the hip and the knee and account for more
difficulty in stair climbing and walking then any other disease.
Recently we have begun to focus on prevention techniques in order to
educate people about risk factors.
Prevention strategies focus on preventing osteoarthritis in those
who have not developed it; Secondary prevention by screening
asymptomatic people to prevent disease difficulties, and tertiary
prevention by focusing on those who already have it and keeping them
functional.
The recognizable risk
factors are:
Excess
weight. Unfortunately
this always creeps up in any discussion of health. Since lower
extremity osteoarthritis is the result of weight bearing then clearly
excess weight will aggravate the hips and knees. In one study, a
loss of only ten to fifteen pounds decreased the risk of developing
osteoarthritis by one half.
Major knee injury.
Most knee injuries that require the use of cane or crutches, prolonged
bed rest or surgery are usually the result of falls or sports training
errors. Knee injury of this nature appears to have an effect on
developing osteoarthritis.
Overuse injuries.
Some jobs are associated with frequent bending, lifting, and often such
overuse can result in osteoarthritis of the hips and knees.
Prevention techniques often must include:
Nutrition
is one understudied area in osteoarthritis disease prevention.
However, there is some nutritional evidence that Vitamin C and Vitamin D
play an integral role in modifying osteoarthritis. The intake of
natural anti-inflammatories such as those found in cold water fish such
as herring, mackerel, sardines can act as potent agents in promoting
better blood flow to the joints and hasten repair. Caloric
reduction with weight loss of as little as ten pounds can make a
significant difference in prevention as well as treatment.
Muscle
strengthening and
conditioning about the joints helps to distribute the forces of the
muscles contracting around the joint and may decrease the stress on the
joint. There is a fair amount of evidence supporting that exercise
can modify the symptoms associated with osteoarthritis. Exercises
can also be helpful in preparing for high risk activities in sports and
work issues. Careful attention to body mechanics and lifting
activities can modify high risk situations.
Non-steroidal
anti-inflammatories do not
have a role in prevention but can help modify the pain and symptoms of
osteoarthritis. These include the over the counter medications
such as ibuprofen and naproxen as well as prescription medications.
The use of any of these products should be discussed at great length
with your physician as these medications may interact with other
medications and do have their own risks.
There are endless reports about health store products that are
helpful in modifying the symptoms of osteoarthritis. Many of these
are poorly studied and the results are unreliable. The exception
to this is the use of glucosamine sulfate and chondroitin sulfate.
Glucosamine sulfate is a natural amino sugar that is highly water
soluble and well absorbed in the small intestine. Chondroitin
sulfate helps to draw fluid into the tissues to increase the elasticity.
The dose is usually 1500 mg of glucosamine sulfate and 1200 mg of
chondroitin sulfate daily. It will take about six to eight weeks
to feel the improvement. Recent data shows that this may be
helpful for athletes who place a great deal of joint stress on hips and
knees in order to modify the effects of excessive wear.
Osteoarthritis can affect the quality with which we live our lives
but exercise and nutrition are our best modes of prevention at the
present time.
| MSSNY Online Library is now open |
MSSNY and EBSCO publishing are pleased to announce that they have partnered to create a long-term member benefit that will allow physicians to access valuable online resources. The service will be available on July 1 via the MSSNY website. This value-added service for our member physicians would cost $350 per year for the DynaMed portion alone. (See below for details.) The other elements cannot be bought by individual practices.
“This benefit alone is worth the price of membership,” said MSSNY President Robert Goldberg, DO. MSSNY members will enjoy unlimited personal use of the research databases listed below:
- DynaMed
A clinical reference tool created by physicians for physicians for use at the point-of-care. The clinical information includes detailed coding information. With clinically-organized summaries on 2,000 topics, DynaMed is the only evidence-based reference shown to answer most clinical questions during practice. DynaMed is updated daily and monitors the content of over 500 medical journals. Each article is evaluated for clinical relevance and scientific validity.
- Health Business
This database provides full-text coverage of 130 well-known administrative journals such as Hospitals & Health Networks, Health Management Technology, Modern Healthcare and many others. This subset includes publications covering topics such as staffing, health care regulations, marketing and finance.
- Health Library
The perfect resource for a medical office's web pages. This database is the ideal resource for patient education needs because all of the content is written for the lay reader/patient and organized in a way that most consumers seek information. Many physicians print information from this resource for their patients to take home and read. The articles reflect national clinical practice guidelines and are free of racial and gender bias.
- Medline
Created by the National Library of Medicine, Medline uses MeSH (Medical Subject Headings) indexing that can search over 4,800 current biomedical journals.
| New Med Mal Product...with caution |
Physicians across New York State have recently received a solicitation from a med mal insurance vendor offering claims-paid insurance from a “risk retention group” (RRG). According to experts, a RRG is an insurance vehicle that is owned by its policyholders who have a common business or professional interest. An RRG is regulated by the state it forms in, yet can operate in all 50 states without having to get individual state licenses. This is radically different from traditional insurers who must get licenses from each state they operate in. RRG’s are allowed to operate by federal statute. By circumventing state licensure, states cannot control the rates or policy forms an RRG uses.
Financial and operational pressures on medical practices are forcing physicians to examine all options for med mal coverage. However, if RRG rates or policy forms differ materially from what is available from licensed insurers (e.g., lower rates for less coverage or with claims-paid insurance), there could be some market acceptance issues that insurance buyers should be aware of.
An RRG that forms in another state but offers professional liability insurance for physicians in New York is not covered by New York’s guaranty fund. Thus, should the RRG become insolvent, the State would not cover claims against policyholders up to $1 million per policy, thereby potentially exposing the insured’s assets. In addition, physicians insured by an RRG would not be eligible for the $1 million of excess coverage paid for by New York State. The RRG could offer its own excess coverage, but physicians would have to pay for it.
Without guaranty fund protection and State-provided excess insurance, hospitals that grant physician privileges may have concerns about insurance from an RRG, particularly if the coverage offered by the RRG is less comprehensive than they’re used to (e.g., claims-paid versus claims-made or occurrence). Hospitals could also be left exposed in a multi-party lawsuit (e.g., if claims-paid coverage is not maintained, who picks up the liability for reported but unpaid claims?). Physicians reviewing claims-paid insurance from an RRG are urged to check if their hospital will accept this form of coverage and understand how the coverage may be different from traditional med mal coverage .
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| Reflex
Sympathetic Dystrophy |
By
Perry Drucker, MD
Many of the patients we see develop a
complex of pain symptoms often referred to as Reflex Sympathetic
Dystrophy (RSD). In the past, this has been referred to as
“Causalgia” “shoulder hand syndrome”, “Sudek’s Syndrome”
and “Steinbrocker’s Syndrome”.
Most recently, the International
Association for the study of Pain changed the terminology again as
Complex Regional Pain syndromes, I and II.
Causalgia was actually first documented
in the 19th century by physicians treating Civil War veterans who
experienced pain after their wounds had healed.
This problem usually follows trauma.
It can be trauma that would be minimal, such as stubbing your toe or
more significant such as a fracture. The symptoms are:
- Abnormal changes in skin color:
white mottled to red.
- Abnormal sweating or chilling.
- Edema
- Extreme pain sensitivity
- Skin and nail changes
- Movement disorders, tremors,
stiffness.
The pain is usually the cardinal
feature. It is often described as burning and is made worse by
any kind of touch, including clothing, a bed sheet or even a mild
breeze. It can often progress from one site to others.
Traditionally, we have thought of this
as having three stages:
Stage 1
Usually last from 1-3 months. The severe burning pain is
followed by spasm,stiffness,
restricted mobility, vasospasm.
Stage 2
Lasts from 3-6 months. The pain can become worse, swelling may
spread and hair and nail changes occur.
Stage 3
is often marked by muscle atrophy, stiffness, limited movement.
While RSD is a physical illness, it is
quite clear that it often results in psychological dysfunction.
The new name “Complex Regional Pain Syndrome” does not mean we
have a new treatment or have identified a new cause. Rather, it
is meant to act as an umbrella to include a large number of similar
conditions that we don’t adequately understand.
For some reason in RSD, there is a
disruption in the normal healing process. Normally, when one has
an injury, a signal is sent to the brain to register “Pain” This
triggers part of the nervous system--the sympathetic system--to react,
which triggers an inflammatory response. This is due to the old
“fright flight response”. By allowing blood vessels in the
skin to contact, there is better blood flow in the muscle so that the
victim can move. However, in RSD, the system doesn’t turn off.
It is unclear as to why.
Treatment of RSD/CRPS must always
initially focus on education. It is often a frustrating process
for the patient because we are low on “why’s”.
The most important part of treatment
involves using the affected part as much a possible. This often
involves guiding a patient through various ways to manage the pain.
The goal is always to preserve the range of motion.
DRUG THERAPY
- Medications are often prescribed to alleviate the pain, help sleep,
reduce stiffness and cramps.
Many of the medications that are often
used, are under our “off-labeling” jurisdiction. For
instance, aspirin is a pain medication and approved as such — but
its off-label use was for the prevention of heart attacks. There
are many medications used like this for nerve pain.
We may use non-steroidal,
anti-inflammatory agents (ibuprofen, naproxen, etc.), antidepressants
to help with jabbing pain, anticonvulsants such as carbamazepine or
gabapentin to decrease burning pain.
The Clonidine Patch may also be helpful
in managing sympathetic nervous system pain, although it is an anti-hypertensive.
SUPERVISED
THERAPY - Physical therapy
is important to reinforce the importance of using your body.
Through the use of an assisted and supervised program, range of motion
of the joints is preserved, strength is maintained and we provide
stimulus for blood flow and nerve healing. Exercise helps a
patient maximize the function of the affected area. It is
crucial to any treatment, but is often limited by pain.
INJECTION
- Sympathetic blocks may help some patients. It has a three fold
purpose: to treat, to diagnose, and to give a prognosis.
Those are usually performed by a pain specialist, trained in
anesthesia. Although complications are rare, patient would be
monitored during the procedure. Often an indwelling epidural
catheter may be placed to administer pain medication and allow the
patients to participate more fully in an exercise program.
The use of a morphine pump to produce a
selective pain blocking effect on the spinal cord and a spinal cord
stimulator to use low intensity electrical impulses to trigger nerves
to stop pain transmissions has also been used when all else fails.
The latter is an invasive, costly procedure, and considering that RSD
is not predictable should be taken
with a realistic expectation.
ADJUSTMENT
ISSUES - Psychosocial
Intervention is mandatory for anyone in chronic pain, especially for
those with RSD. Treatment must address the physical and
psychological impact. Additional tools such as biofeedback,
self-hypnosis, visual imagery, self-healing and behavior modification
should be treated as serious parts of the treatment plan.
One of the areas often neglected is the
adjustment that follows the development of RSD. It is not just
the pain. It is the loss of being able to do both work and
recreational activities that are a significant part of our lives.
This has a profound adjustment on any individual and the grieving
process can be devastating. Many of these patients don’t
necessarily look ill and often friends, family members and co-workers
don’t fully understand the problem.
Research is being done by the National
Institute of Neurological Disorders and Stroke at the NIH. For
more information they can be contacted at 800-352-9424
SAVE THE DATE
Sunday, May 17, 2009
Get Involved & Make a Difference
RCMS Annual Legislative Brunch
at the
Richmond County Country Club
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Senator Clinton
visits Staten Island |
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Retired State Senator Marchi was the guest speaker as Dr. Jack D'Angelo passed the gavel to Dr. Joseph Motta as he became the 200th President of the Richmond County Medical Society. This year, the Annual Meeting of Richmond County Medical Society will take place on Wednesday, June 27th at the Staten Island Hilton Garden Inn. Dr. Motta will pass the gavel to Dr. Ralph Messo who becomes the 201st president of RCMS. |
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"Senator Savino with Drs. D'Angelo & Maese at the 2006 Walk for Autism". |
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"Dr. Zoltan Brody with Gov. David Patterson". |
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