Posts

Prior Authorization

Recently a managed care plan notified me that one of my patients should be taking daily aspirin for secondary prevention of heart disease. A quick review of the chart showed that we had discussed this before, and the patient was likely already taking aspirin. Sadly, his medication list did not accurately reflect this fact. “I’ll fix that,” I thought, and entered an order for aspirin 81 mg daily. I’m sure you can imagine the next thing that rolled out of our fax machine: A prior authorization request for a 126-year-old generic drug that costs less than $1 for 100 tablets. How did we get to this point? In the halcyon days of yore, doctors wrote their orders, and somebody paid for it—no questions asked. Well, that is not exactly true. In the 1960s and earlier, most people paid for medical care out-of-pocket (or simply did without if they could not afford the treatment). It was the advent of Medicare, Medicaid, and the expansion of employer-sponsored health insurance that shifted the fina
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Medicine on a Grand Scale

Politics and healthcare are inseparable. This relationship is epitomized by Virchow’s oft-quoted declaration, “Medicine is a social science, and politics is nothing more than medicine on a grand scale.” Through most of the modern age—and certainly during our lifetimes—this has been a beneficial relationship, despite the vicissitudes of electoral politics. Apart from fringe movements, the progress of medical science has been endorsed, regardless of party affiliation. Unfortunately, there are alarming signs that the political consensus on the benefits of immunization is imperiled Medical students learn of German physician Rudolf Virchow (1821-1902) by way of his eponyms: Virchow’s node, the harbinger of gastric malignancy, and Virchow’s triad, the factors that provoke thromboembolism, a term he invented. Virchow’s other accomplishments include the development of cell theory and the coining of numerous medical terms—from agenesis to zoonosis. For these achievements, Virchow is conside
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Healthcare is a Team Sport

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There is a well-known painting that endures as an icon for compassionate medical care. Entitled The Doctor , it was the creation of Sir Luke Fildes, a renowned artist of the Victorian Age. The painting depicts a gravely ill child in a poor family’s cottage. Watching over the child is the eponymous doctor, illuminated by a solitary lamp. In the background, the desperate parents are revealed by the predawn glow on the windowsill, perhaps foretelling a new day and hope for recovery.  The Doctor , Luke Fildes, Public Domain via Wikimedia Commons Fildes was able to capture the drama of a life-threatening illness because he had firsthand experience. In 1877, his one-year-old son died of typhoid fever. This was before the age of antibiotics, immunizations, and public health. Doctors at that time had little scientific training and the nursing profession was still in its infancy. The prospect of
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Thirty-Six Months

In December 1944, thirty-six months after the United States declared war on Nazi Germany, the 101st Airborne Division was surrounded by German forces in the Belgian town of Bastogne. Six months earlier, Allied forces had landed at Normandy and begun their resolute march toward the heartland of Germany. In December 1944, the Nazis launched a surprise counter-offensive in the Ardennes Forest of Belgium and Luxembourg. The Siege of Bastogne was part of this wider campaign that came to be known as the Battle of the Bulge. Hitler planned to drive a wedge between the Allied armies, crush the encircled forces, and deprive them of material support for continuing the war. If successful, he believed the British and American governments would sue for peace. By mid-December, Hitler’s plan seemed to be working. The weary Americans holding the town of Bastogne were running low on food and ammunition. Even the weather seemed to be taking sides. Dense fog precluded air support, and freezing rain, hea
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Anti-Abortion Legislation

Letter in response to anti-abortion legislation: On behalf of the South Carolina Chapter of the American Academy of Family Physicians (SCAFP), we are writing to express our grave concerns with state legislative actions in response to the Supreme Court’s ruling in Dobbs v. Jackson Women’s Health Organization. Our concerns include the impact of enforcing the “South Carolina Fetal Heartbeat and Protection from Abortion Act” and other contemplated laws that we believe violate the sanctity of the patient-physician relationship and criminalize the practice of medicine. The SCAFP is the largest primary care organization in South Carolina, representing nearly 2000 practicing physicians and medical students. Family physicians provide care to patients of all ages and see the majority of reproductive-age women who seek office-based care. Family physicians provide reproductive health services including family planning, preconception counseling, pregnancy, postpartum, and menopausal care. In rural
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The Absurdity of Medical Freedom

Archie Cochrane (1909-1988) was one of the fathers of evidence-based medicine and the namesake of the Cochrane Collaboration. His professional life was profoundly influenced by his experience as a World War II prisoner of war. While serving as a physician in the British Army, he was captured during the Battle of Crete in May 1941. He spent the rest of the war as a medical officer in POW camps. Eventually, he was placed in charge of caring for Allied prisoners suffering from tuberculosis. The resurgence of tuberculosis during the war was a public health catastrophe. At that time there were no effective antibiotics for tuberculosis. The options available to Cochrane consisted of either bed rest or an intervention such as pneumothorax or thoracoplasty. Bed rest does have a physiologic basis (lying flat reduces the oxygen tension in the lung apices). As for the other treatments, no one knew if they really worked. These therapies were based on opinion—and
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The Destruction of Words

A colleague recently pointed me to a commentary in The American Journal of Medicine entitled “The Language Game: We Are Physicians, Not Providers.” I rushed to look up the article immediately, hoping to find corroboration for my distaste for the term “provider.” and anxious to read the words of kindred spirits who recognize the games people play with language. The authors start out fine, rightly proclaiming that words do more than express our thoughts—they also conscript our thinking and, ultimately, shape our actions. The term “provider,” the authors continued, is not a neutral term of inclusivity. Using this term to describe physicians has important consequences. It falsely equates the contributions of all members of the healthcare team and transforms the patient-physician relationship into a commercial transaction. So far, so good, but then the commentary takes a horrible turn. The authors proceed to link the term to the Nazis: "And here is the irony of “providers.” The term
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