Dr. Malia Reckons

I am sorry to say this, and I need to move beyond the emotion, but right now, I feel bitter.

This year, I have not been able to get a small order of 150 influenza shots. In past years I have had a couple flu clinics for my own patients on Saturdays and Sundays when I gave out about half my shots. The other half was given during appointments with high-risk patients, those I scheduled in October and early November with diabetes, heart disease, lung disease, chronic kidney disease, etc. Anticipating the flu shots, and trying to help them get better value from one appointment and not waste time and energy, I plan such appointments many months ahead of time.

Now, in an effort to get the influenza vaccine to high risk populations early, before the H1N1 flu vaccine is more available, and lessening the risk of confusing the two, the seasonal flu shots were sent from manufacturers directly to companies that run community outreach programs and large pharmacies.

That, by itself, would not be a problem if I also could get a supply to offer my patients in my own office. But, this year is incredibly frustrating, and I, like many, many other primary care docs around the country, am not getting an order of flu shots.

Adding insult to injury, at least one pharmacy is letting patients schedule times for flu shots but they do not yet have a formal protocol for giving them and therefore have to get a formal approval from me to give the shots. I'm spending time every day explaining to patients about the hassles I have had trying to get flu shots, encouraging them to get the shots, and then asking them to find the community outreach programs and pharmacies where the shots are available.

Like so often happens in primary care, this is a situation where I am trying to work for the benefit of my patients but then others in the system are getting paid while I'm left empty handed. It is a business model with fundamental flaws.

Consider this: for my own patients, with whom I have long, on-going relationships, and for whose care I maintain malpractice insurance, I spend time and energy getting them to go to a pharmacist (a pharmacist!) of a large corporation to get a flu shot. And, I must wonder, what happens to my patients if they have severe reactions? A post-vaccination reaction will be dealt with by whom? The pharmacist? Or me? Who gets the phone call if there are questions after the vaccination?

I am bitter, but not proud of it. I can not get flu shots, but large corporations can. I have to encourage my patients to get the flu shots, but then someone else in healthcare will profit from my efforts.

Watch for other blog posts later about this, but here I present a major problem in the American system and primary care. Society has two trump cards that get thrown at primary docs depending on the situation and on what the powers-that-be need at one time or another. Either docs are told: "this health care stuff costs a lot of money, so you better run a good business model and focus on value for the patients," OR, when it serves other needs, we are told: "but doctor, don't you have a moral obligation for the welfare of your patients and to not think of care as a business?"

In the end, the system is making doctors who can't maintain the business model and are so burnt out they can't maintain the proper moral tone. In discussion groups among doctors working hard to make primary care better, I see this feeling again, and again. And I fear the general public does not understand the situation or what the doctors are feeling.

I'm sorry, but, right now, I'm bitter.

--Timothy Malia, MD

Check out this video, The H1N1 Rap by family physician John D. Clarke, MD of New York City. It says it all.

As Dr. Clarke points out, for more information about the flu (seasonal and H1N1), there is plenty of good info at http://www.flu.gov/index.html

More influenza info at http://www.cdc.gov/flu/

Stay well -- Timothy Malia, MD

I just finished my Wednesday evening office hours. My last patient reported that almost 48 hours ago he had sudden onset of headache, body aches, fever and cough; but he had been well prior to symptom onset -- classic flu symptoms.

He already missed work yesterday and today.  He called me this afternoon, about 44 hours after symptoms started, and I fit him in this evening. His circumstances place him at high-risk for severe infection. A phone call to the pharmacy during the appointment will allow him to start the anti-virus medicine for influenza infection immediately. But I sure wish he had called yesterday so I could have evaluated him sooner.

Spread the word -- the antiviral medicines for influenza can only help if started within about 48 hours of the symptoms starting.  After that, the virus has multiplied in number enough that the meds won't limit them.  The meds only slow down the replicating (ie-multiplying) of the virus early on. If you take them in time, they can help lessen your symptoms, lessen how long you will be sick and lessen the chance you may pass the influenza virus to others.

IF YOU HAVE SYMPTOMS OF FLU (headache, body aches, fever, cough, fatigue... especially if sudden onset), CALL YOUR DOCTOR RIGHT AWAY so you can be evaluated the first day or so and possibly start the medicines that might help.

One point to consider, of course, is that the influenza medicines are meant for patients who are already quite sick or at the most risk of severe illness, especially those with other health problems (lung disease like asthma or emphysema, heart disease, kidney disease, diabetes, or if on medicines that weaken the immune system, etc). But I suggest you let your doctor consider your risk and total health, and whether the medicines are appropriate for you -- be in touch with your doc sooner than later.

Another thing to remember: many patients who die of influenza have pneumonia from a second infection on top of the initial flu infection. So, if you are being treated for flu, and you are feeling worse, or having problems with breathing, or having other difficulties, stay in touch with your doctor and get re-assessed.

For more information about influenza (no matter if seasonal flu or the 2009H1N1 flu), check these sites:

• http://familydoctor.org/online/famdocen/home/healthy/vaccines/477.html (good video explaining flu ... FamilyDoctor.org is one of my favorite health sites)

• http://www.cdc.gov/flu/ (has lots of information about both seasonal flu and the 2009H1N1 flu, or "swine flu")

Remember, the most common symptoms of influenza:

• fever
• cough
• body aches
• headache
• fatigue
• sudden onset of symptoms
• other symptoms may include sore throat, stuffy/runny nose, nausea or diarrhea, but those are less prominent.

If you have these symptoms, get in touch with your doctor right away so you can be evaluated, and, if needed, get treatment started as soon as possible.

Finally, below is a link to the CDC's latest flu activity map for the country which is updated weekly. Currently, most cases of flu are due to the 2009H1N1 virus.

http://www.cdc.gov/flu/weekly/WeeklyFluActivityMap.htm

Stay well -- Timothy Malia, MD

I got a good laugh today, in an unlikely way. It was while reading a physician's take on the current national health care discussion. Consider the low probability of such a thing!

In the mail I received the October Forum, the monthly newsletter for the Rochester General Hospital Medical & Dental Staff. As usual, the President's Message led on the first page, and this month, the president, Richard Constantino, MD, offered a perspective about the national conversation couched in terms of Yogi Berra quotes. Never before had I considered that Yogi's sayings, utterly glib illogic mixed with a profound inherent truth, fit so well in our health care debate. I may not agree with every point Dr. Constantino makes, but I thought the essay was nicely done. And I appreciate the call for us all to remain in the discussion.

So, as a baseball fan, and a physician who cares about the national conversation for health care reform, I happily offer Dr. Constantino's President Message for October, 2009. Enjoy!  (Note that emphasis, with bolding, is my own for Yogi's sayings)

October, 2009

Forum, President's Message

Richard Constantino, MD

As we approach the height of the baseball season with the playoffs and World Series coming up quickly, and as we are approaching the height of the political season with debate over healthcare reform, I thought we should enlist the opinion of a well known philosopher and pragmatic thinker as we move ahead. Many have an opinion regarding who will win the World Series and even more have opinions on healthcare reform. Who better to advise us on both than Yogi Berra? Over the years he has uttered a variety of statements that I think have application to healthcare reform. See what you think.

Yogi has uttered many memorable things, but none more memorable than "I knew I was going to take the wrong train so I left early." Many feel that healthcare reform is moving too quickly and that although necessary, we aren't really at the point where we could make  final decisions and any artificial time deadlines or goals represent leaving early, but perhaps on the wrong train.

The application of this one of Yogi's quotes is remarkable: "If you don't know where you are going you will end up somewhere else." In healthcare reform we certainly don't know where we are going and many don't even recognize where we want to be. A good number of individuals are happy right where they are.

Yogi once said, "you better cut the pizza in four pieces because I am not hungry enough to eat six." Many people feel that the changes we are making in healthcare will reapportion the pieces of the pie, but not make it any smaller and may not make it any better. We all recognize that we cannot afford the rise in healthcare that we have experienced, but all want to be sure the changes we make will be meaningful in reducing costs, and along those same lines, Yogi's statement, "a nickel isn't worth a dime today," does raise the specter of how we'll pay for our current standard of healthcare in the future or costs under a new program.

I think all of us fear creating a new healthcare system that misses the mark and even those things that have "slam dunk success" written all over them, may not be. Who could have envisioned that the very "successful" "Cash for Clunkers" program would lead to a significant impact on the used car and automotive repair business? Along these lines Yogi warns "90% of putts that are short don't go in."

Yogi's quote, "this is like deja-vu all over again" seems made for healthcare reform when one considers what happened to the Clinton healthcare reform of the early to mid 90s. It certainly does seem that many of the occurrences of that decade are being experienced again. And lastly, with remarkable logic, Yogi states, "nobody goes there anymore, it's too crowded." Certainly the healthcare reform field is crowded with many opinions, biases, thoughts, proposals and agendas. Rather than following along like lemmings or withdrawing from the entire arena because of its complexity and emotionality, I hope we'll all remain involved in our thoughts, opinions and desire to influence healthcare reform to create the best healthcare system we can. I know most of us wish that political agendas were less evident in proposals and debate. I know most of us believe that all Americans should have basic health coverage and when it comes to our politicians I hope they will work together in a nonpolitical way. I almost hear Yogi exhorting our leaders, "Let's play ball."

I have not touched on an actual health issue for a while. So here is a good one. 

With the cold and flu season approaching, you should consider how to keep yourself well -- and getting adequate sleep should be high on your priority list.

OK, this is not earth-shattering news, but it is now backed by some published research and is not just a casual recommendation.

I ran into this news in the NYTimes column called Really? which regularly looks at long-held beliefs or old wives tales about health and well-being to see if they hold water.  The piece about good sleep preventing colds can be found at http://www.nytimes.com/2009/09/22/health/22real.html?ref=health

The actual research was published in the Archives of Internal Medicine. The study found that adults getting more than 8 hours of sleep a night for two weeks were 3 times less likely to get a cold after being exposed to cold viruses than folks getting less than 7 hours. Also, better quality of sleep was protective. Here is a link to the article's abstract -- http://archinte.ama-assn.org/cgi/content/abstract/169/1/62

Basically, researchers monitored people's sleep for two weeks, then exposed them to rhinovirus, the pesky bug that causes the common cold. They then studied who was more likely to get a cold, and, lo-and-behold, less sleep and lower-quality sleep increased the risk of getting a cold.

So there is my advise to prevent colds: get your sleep, and don't forget to wash your hands.

Now, it's late (yawn), and we all should be hitting the sack (yawn), and preventing colds ... Good night ... Zzzzz...

--Timothy Malia, MD 

Disheartening moments are too frequently part of my day. A recent Sunday evening I got online to check emails and preview my schedule for the week. It was about 9pm and I was struck by three of the emails waiting for me. After considering them and replying to each, about 20 or 30 minutes later, I was disheartened about the options for health insurance reform discussions.

Each email related to financing of health care and was distinct in character from the other two.

And each was relevant to the current discussions of health insurance reform.

The first email was the most benign. I had seen the patient the day before, on a Saturday morning, for severe rib pain related to a fall a few days earlier. I highly suspected a fractured rib or two. But she needed pain relief more than anything else. A final part of the plan was to get an X-ray of the ribs on Monday to document the problem.

Her email was to report that the pain was doing a bit better and to ask if she can skip the X-ray. She explained how she has a high-deductible plan and would be paying out-of-pocket for the X-ray. Honestly, since she was doing better, the X-ray of the ribs would not be adding much to the plans. So I did not mind her skipping the study at that point.

The second email was different in character. The patient has a family history of early heart disease and uses two medications to treat his high cholesterol. He has traditional insurance with co-payments for appointments and his monthly prescriptions. In October he is scheduled for blood testing and a follow up appointment.

Though he continues with his overnight job, he is no longer working his part-time day job. Finances will be tight for the next few months and he is searching for ways to save money. His email was to report that he is planning to skip his two prescriptions the next few months and wanted to reschedule his October appointment for later so he can save his co-payments. His message closed with:

"I hope you understand for this time ... Please forgive me." 

My heart ached as I thought of him struggling financially so much that he would send me that message. And, professionally, I thought of how the plan to skip his medicines for a few months would potentially increase his risk for long-term heart and vascular disease, or, with high triglycerides, increase his risk of acute pancreatitis.

I replied with some ideas about saving money for his medicines and his care such as invoicing his copay that he can cover later, or checking other pharmacies for cheaper out-of-pocket costs for his medicines, but I have not heard back from him.

The third email that evening was from a young woman who has no insurance. She has some baseline mental health diagnoses which require two prescription medicines daily. She is working hard to improve herself and move forward in a positive way by attending a community college full-time on financial aid loans; plus she is looking for a part-time job.

Since last spring I have had concerns the medicines I am prescribing her are causing problematic side effects. I made adjustments and asked that we follow up more closely. Primum non nocere (First, do no harm) is a primary edict in medicine dating back to ancient Greece, so monitoring prescription medicine side effects is paramount to my job.

This young patient needed her prescriptions updated. Without them she likely could not continue in school. But she has no medical insurance and can not afford another appointment. Actually, she already owes me for the equivalent of three or four prior appointments and has from time-to-time gotten me some extra cash. So she was stuck between a rock and a hard place, and, professionally, I felt the same.

I have known her family for 16 years, have worked closely with her through many hard times and have been there as she worked to improve her health and life. She owes me money and needs medicines which I worry are causing problems. Another appointment would increase her debt, or lead to charity work by me.

No easy answers, but my soul ached. I did what I can for her and offered a plan to work together on these issues. After a few email messages back-and-forth I felt confident she was doing better after the medicine adjustments from the last appointment. She is continuing on her medicines which help her maintain a positive trajectory in life. We are planning an appointment in the next couple months so I can properly assess her. And she will continue doing her best to pay off the amount due for her appointments over time.

Our relationship as patient and doctor has been long and rich -- that richness gives value to what I do and, I hope, nourishes her life. I am not willing to drop out of her life professionally due to her life's current stresses. In the years ahead I look forward to her success and trust these difficulties will be only memories. Yet her struggles, and the need for that email, and her need to balance mental health problems with medications with school and with finances, are painful to see.

And so, late that Sunday evening, just a few hours before another week of patient appointments was to begin, I was disheartened. Patients faced financial challenges with traditional insurance, high-deductible insurance and when having no insurance. As a physician I feel a moral obligation to care for them, a feeling that goes beyond the business of health care. But, in the end, society has made health care a business, and there is only one way to keep the doors open in the American marketplace. I used time to try to help these three patients, but my soul's bruising made me less effective the rest of that evening, and each time I thought of the three of them since then.

What are the answers for financing health care so patients can at least get the treatments they really need and doctors can focus on providing reasonable services?

Those three emails related to only the most basic aspects of care, nothing exotic, and nothing that should not be part of primary care. Is it too much that I, as a family physician, can hope my patients did not struggle with the costs of only the most basic and reasonable services? And why do we as a nation not think that we all would be better off as a society, as a community, if health care financing allowed that?

Until there are real answers, however, I am certain I will continue to be disheartened; often.

--Timothy Malia, MD

I have had a busy couple weeks in the office (thankfully) so I have not had time to post on the blog. But my thoughts and perspectives are building, and one of these days the dam may break! I guess I'll just have to focus on a handful of brief posts and limit my diatribes. So, late this evening, just before bed, I wish to make a simple connection of the United States Constitution and the current health insurance reform debate.

Today, September 17, is Constitution Day in the United States. On this day, 222 years ago, the Constitution was signed by the representatives of the states thus forming a "more perfect union" than the Articles of Confederation before it. That Constitution was the boring part that explains how the federal government would be shaped and function. The Bill of Rights, the first ten amendments of the Constitution, which I would say is better known today, would not be passed until March 4, 1791, about two years after George Washington had taken office, and a year and one half after the first Congress had proposed the first set of amendments to the states (there were twelve offered, but two were not ratified, so the Bill of Rights had just ten amendments). A very good website with transcripts, images and plenty of interesting bits of history and information about the Constitution can be found at http://www.archives.gov/exhibits/charters/constitution.html

So today is a fine day to reference the Constitution in relation to the current health insurance reform debate.

There is a comment I hear mentioned from time-to-time in the media, most often by folks at demonstrations against the reform efforts, that I find asinine. The basic idea is: "Where in the Constitution does it say Congress can change our health care?!" or "what makes Congress think they can make these changes?!"

Honestly, to me this is a ridiculous question and suggests the person asking it has not tried to check the answer him/herself. Also, I believe it demonstrates how many people think of the Bill of Rights as the Constitution and do not understand that those were just the first ten amendments and have nothing to do with the original document.

Having spent the last hour or so reading the Constitution (OK, I admit it, some sections were perused while others were looked at more closely, but I did get through it), I am happy to point out the two sentences I feel make it absolutely obvious that Congress does have the right to address issues with our nation's health insurance and health care industries. Whether they should or not I feel is a reasonable debate, but I do not think there can be a question they have the right to.

First, see the first sentence of the Constitution: "We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America." (emphasis mine)

If one of the primary goals of the Constitution is to "promote the general Welfare," then I certainly would argue that taking measures in an effort to expand access to medical services or to make more affordable those services that improve health and well-being while often lessening suffering and allowing our citizens to maintain their optimal quality of life should be included.

Second, see Article 1 (which pertains to Congress), Section 8: "The Congress shall have Power ... To regulate Commerce with foreign Nations, and among the several States, and with the Indian Tribes;"

Considering that health care in the United States currently is about 16% of our entire economy (about US$2.5 trillion), a sum and a percentage that the Founding Fathers likely could never have fathomed, I certainly believe it is "commerce" of sufficient size, which also is "among" the states that Congress should have the right to make efforts at shaping it, and, hopefully improving it so as to "promote the general Welfare."

Now, as I mentioned, I do think a debate of how Congress should make changes to the health insurance industry, or if they should do it at all, is worth having. But, please, let us move beyond the asinine idea that the Constitution does not give Congress the right to make relevant laws.

And with that, please, stop the ludicrous idea that the 10th amendment has any relevance. Yes, it says, "The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people." But since the Constitution does delegate such power to Congress, it is ridiculous that any politician should speak of it as an actionable plan for a state to ignore a federal health insurance reform law that might be passed. And, sadly, too many ignorant Americans are getting riled up by this bunk.

Let us have a reasonable discussion of the issues, but let us stop wasting time on nonsense.

Happy Constitution Day!

Read it, discuss it, live it, love it!

--Timothy Malia, MD

Was Mother Teresa considered saintly because she did not do awful things? Did Tenzin Gyatso, the 14th Dalai Lama, win the Nobel Peace Prize in 1989 because he did not start wars?

No, both Mother Teresa and the Dalai Lama are revered for actively seeking peace and helping others. They went beyond what most people would do and, rightly, are acclaimed and loved as peacemakers.

In the same way, efforts to label the most healthful foods should identify those with obvious nutritional value. Such labeling should not award a seal for simply lacking unhealthful ingredients. Thus, the "Smart Choice" program, an effort by many of the largest food manufacturers in the country to voluntarily label their most healthful products, may be discrediting itself and, simultaneously, industry-based regulation of food labeling.

Before I discuss the Smart Choice program, please consider if the following is a healthful breakfast to give a child:

          1 Tablespoon of sugar

          2/3 slice of plain white bread (not whole wheat)

          1 multivitamin

          1/2 cup of skim milk 

Any half-thinking person would say, "no, that is not a reasonable breakfast." Yet, that "breakfast" is actually 5 calories less, and more nutritious, than a serving of Froot Loops cereal with skim milk.

How could any reasonable labeling system identify Fruit Loops as a smart choice? A front-of-package label calling it that would be an outright lie and essentially weaken the usefulness of such label on other, more healthful, more deserving, food products. Yet the Smart Choices program does just that.

I was dumbfounded when I first read the article in the NYTimes on Saturday reporting that Fruit Loops and Cocao Crisps sugary breakfast cereals would qualify as "Smart Choices." The article can be seen in full here -- http://www.nytimes.com/2009/09/05/business/05smart.html

The Smart Choices labeling program is being coordinated by large, national food producing corporations. The official website is http://www.smartchoicesprogram.com/ and, on first look, the program looks promising as it states it "was motivated by the need for a single, trusted and reliable front-of-pack nutrition labeling program that U.S. food manufacturers and retailers could voluntarily adopt to help guide consumers in making smarter food and beverage choices."

Now I wonder if by "guide consumers in making smarter food and beverage choices," the program actually means to guide them to smarter choices to improve corporate profits. I have no other way to understand the criteria that would label Fruit Loops as a smart choice if considering nutrition!

The Smart Choices program does set criteria to judge food products (http://www.smartchoicesprogram.com/nutrition.html) but looking at the nitty-gritty (http://www.smartchoicesprogram.com/pdf/Smart%20Choices%20Program%20Nutrition%20Criteria%20Matrix.pdf) I see that the NYTimes article is right that Fruit Loops would fit the criteria for a "smart choice" label. With that, I feel it obvious the criteria are either based on very bad information or are being overtly manipulated to encourage sales of higher-profit foods for the companies participating in the program.

A serving of Froot Loops is 1 cup and has 110 calories. In a serving there is just 1 gram of fat and about 25% of the daily recommended amounts for a good handful of vitamins. But, it is important to note that there is almost no fiber or protein in Froot Loops, and there are 12 grams of sugar. For comparison, 1 teaspoon of real sugar is just 4 grams.

The Smart Choices Program awards a seal if a breakfast cereal has less than or equal to 12 grams of sugar. Interestingly, Froot Loops has just that much sugar. Also, to qualify, a breakfast cereal must "encourage" the use of one or more healthful "food groups," two of which are "fruits" and low-fat milk products. Thus, I assume the nutritional label noting values if the cereal is eaten with skim milk "encourages" its consumption. But, I must also wonder if the criteria counts the "Froot" in the name, a homophone, as supporting the eating of fruits!

I am not happy that any food label would call Froot Loops a smart choice. It is not! Yet the NYTimes article reports: "Eileen T. Kennedy, president of the Smart Choices board and the dean of the Friedman School of Nutrition Science and Policy at Tufts University, said the program’s criteria were based on government dietary guidelines and widely accepted nutritional standards." And she was quoted as saying Froot Loops was a smart choice because it would be better than giving a child a doughnut. An absurd argument, I feel.

Other nutritional specialists disagreed as well. Walter Willett, the chair of the Department of Nutrition in the School of Public Health at Harvard University is quoted as saying, "These are horrible choices,” and “it’s a blatant failure of this system and it makes it, I’m afraid, not credible,”

Willett and many others have also spoken in the past about the poor criteria used by the US Department of Agriculture to make the Food Pyramid (http://www.mypyramid.gov/) and how it was influenced by the lobbying of big agricultural corporations and interest groups.

The NYTimes article also reported: "Michael Jacobson, executive director of the Center for Science in the Public Interest, an advocacy group, was part of a panel that helped devise the Smart Choices nutritional criteria, until he quit last September. He said the panel was dominated by members of the food industry, which skewed its decisions.

“It was paid for by industry and when industry put down its foot and said this is what we’re doing, that was it, end of story,” he said."

Jacobson also complains that credit is given for foods with nutrients added, like many of the sugary breakfast cereals.

Caveat emptor! Buyer beware! Any industry-based effort to label for nutrition risks lack of credibility. The Smart Choice program threatens to do just that. Rather, non-partisan groups should use stringent criteria that would label food products that are of unquestionable quality not because they lack unhealthful ingredients but because their ingredients are generally agreed to be predominantly healthful.

We can not ask the foxes to guard the henhouse. Be careful reading package labels suggesting healthfulness -- you may be helping coporate profits more than your nutrition. 

-- Timothy Malia, MD

Last winter, a local supermarket pharmacy started offering free antibiotics. Many common antibiotics were included, and a prescription for up to 2-weeks worth could be gotten at no cost, not even a copay.

Besides getting the supermarket chain some good (free) publicity, I suspect the program got it extra business. Since the antibiotics in the offer tended to be the least expensive, the store likely made back the money, and then some, from folks buying other supermarket items while they waited.

At the time, I was interviewed about the program by a local newspaper. That article can be found at -- http://www.wickedlocal.com/mpnnow/towns/fairport/x1708113095/Wegmans-offering-free-antibiotics.

My feelings on giving free antibiotics are mixed. My thoughts turn to the economics of the program as well as the clinical risks involved. I wonder how doctors and patients should approach this issue. And if this is a sign of things to come in health care.

I do think the program is a good business decision for the large supermarket pharmacy. But, I also suspect it could hurt small, private pharmacies which may offer fine, personalized care and service but can not afford to match the no-charge medicines. I was quoted in the article:

“Those small businesses often offer personalized service that is convenient and local, and I believe many patients would benefit from just that kind of care and attention,” he said. “With the marketing of the low-cost and free prescriptions at the large-store pharmacies, I fear the small community pharmacies may lose business and patients unwittingly may lose a service they dearly need.”

Yet there are many patients who are helped financially with this program even if they are only saving a few dollars. Those with no insurance for medicines likely benefit the most.

But I also worry about the pressure on doctors and patients to make decisions based on the out-of-pocket costs of the prescription. Initially, when the program was to be short-term, I had a few patients request prescriptions they would hold in case they needed them after the program ended. I declined each time -- besides possible insurance fraud, I do not like antibiotics sitting around our medicine cabinets and potentially being used inappropriately later. But there are other potential clinical risks, not the least of which is the unconscious shading of our decisions by finances. The article reported me saying:

“Patients will have to be especially careful that the treated condition is improving and, if it is not, they need to check with their physician for a possible change in antibiotic therapy,” he said. “The pressure to prescribe just the least expensive medicines means we all — doctors and patients — have to be sure the treatment is proper and effective, otherwise we are at risk of being penny wise and pound foolish.”

Considering the economics of health care and insurance companies, I also find it interesting that I, as a physician, am "contracted" with an insurance company and must charge a copayment for an appointment, but a pharmacy can drop a charge and "eat" the costs as they drum up other business in their store.

Is that the face of "free market" medicine if we move in that direction? I worry that small-office private primary care doctors will be crushed by large medical groups that off-set costs in one area to build up volume in another if these marketplace behaviors expand throughout health care.

A supermarket can make more money by linking their business to health care -- getting more customers in the door for free antibiotics will likely lead to more money spent on groceries the same day. It is a good business model. But, is it a good health care model?

Will I someday have to open a bookstore/coffee shop in the front room of my office and then not charge my patients any copay to compete with larger offices? And, if I do, will it be enough to "compete" against the false value of "health care supermarkets?" Will my patients benefit?

Free antibiotics. A good thing? A clinical risk? A sign of things to come? Let's talk in ten years.

--Timothy Malia, MD

This is not a typo:  doctors are not paid to "care" for you.

You may be thinking, "How can this be? What about the Hippocratic Oath? Don't doctors have a moral obligation to care for us? And isn't that what they do for a career?" Honestly, the system only pays physicians to see you for appointments and not to care for you. It is that simple.

The current payment system limits doctors' innovative options to offer care. When providing email communications or phone calls to assess an issue and offer recommendations, a doctor can either get no payment, arrange special payment from the patient for services not covered by insurance or stop working with insurance companies all together and use other direct-pay models.

I currently work with the traditional model and only take payments from insurances. Most doctors in the USA do the same thing. But I also do a lot of work with patients on email and the phone.

Consider two scenarios this past week where I offered care but can not get payments from the insurance companies.

The first is a patient who emailed me about neck pain. Her description suggested no significant problem and she asked about a certain chiropractor a friend had suggested. I emailed back saying that many of my patients work with that chiropractor and I had no concerns about him. At the same time, I suggested trying a couple days of ibuprofen and doing some gentle stretching exercises. I attached a form with those stretching exercises outlined and diagrammed. Finally, I warned about important things to seek care for if symptoms got worse.

Yesterday she emailed that she did well with the ibuprofen and stretching, and she did not go to the chiropractor. I was happy with that news and that my care helped her condition. But I still can not bill her insurance for that "care" because I did not see her for an appointment. I believe that with 10-15 minutes of email communication I helped her, prevented further costs to the insurance company, and empowered her for future self-care. I did my job, but there will be no remuneration from her insurance.

The second example relates to a patient on vacation with her family. Retired, the patient has a complex medical history that includes multiple myeloma with some severe illnesses and hospitalizations. Recently she had been treated for a bladder infection, and her oncologist had increased the dose for one of her myeloma medications. She, her husband and some of their children's families were on vacation at their summer cottage far from her regular doctors and with limited medical services nearby.

Just over a week ago I got a message that she believed she had a bladder infection again. It was late in the week and the local medical services near the cottage were not easily accessible. She preferred not to go to the hospital. With an email to the daughter and a phone call with the patient, we decided to watch her over the weekend and see if she could get in for an appointment on Monday at the local clinic. She did well but did get seen on Monday afternoon for the subtle urine symptoms. She was started on an antibiotic.

Later that afternoon, however, I got a string of phone calls and emails suggesting she was rapidly getting weaker, and, finally, at about 8pm I strongly suggested she proceed to an emergency room. At the emergency room, she was found to have low potassium. They treated her for that, sent another urine culture and also switched her antibiotic.

On Tuesday, the patient and family notified me about the emergency room events. Patient was feeling much better since the potassium was corrected. However, the antibiotic they gave her can interfere with her warfarin causing an excess risk of bleeding.  So on Wednesday, I called the hospital to get the urine culture report (it was negative), called the patient to be sure she was feeling well, and recommended she stop the new antibiotic. Other calls and emails were made later in the week, and at least two more calls are planned for tomorrow.

I am happy to describe how I actually "cared" for this patient. That is my work: assess a patient's condition, advise treatment or referral to emergency when needed, follow up on medication risks, and communicate with patient and family. In this case I likely used no less than 90 minutes for more than 12 phone calls, a handful of emails, review of reports, etc, but because I did not have an appointment with the patient, I can not bill her insurance.

Americans need to better understand the byzantine financing system for medical services. I think few people understand the truth -- doctors are not paid to care for you, only to see you for appointments.

True health care reform will need to include ways for primary care doctors to be innovative in their care and be remunerated for providing it. Above are two examples where I used my skills and my time to "care" for patients. Is there a good reason I should not be able to bill their insurances? 

--Timothy Malia, MD