closing thoughts for the year 2007

P4P,quality,the plight of the general internist, the control of third party payers over physicians lead by CMS's price controls, the limits of evidence based medicine and its misuse, the egregious behavior of various entities that continues to sap the essence out of what being a physician was and should be are some of the topics I have thought and fumed about this year.

Several prolific and thoughtful medical bloggers have served to enlighten me on these and other topics .Those that come to mind are DrRich of The Covert Rationing Blog", Dr.Robert Centor of "DBs Medical Rants", Dr. R.W. Donnell of "Notes from Dr. RW" The hospitalist who writes the "Happy Hospitalist" blog, the tireless Dr. Roy Poses in the blog "Health Care Renewal" which explains and exposes so much of what is wrong with the vast medical business complex that you should not read it right at bedtime or after a heavy meal.

In regard to the internist's continuing hard times, Dr. Philip Alper in his "IM Insight" commentary found in Internal Medicine World Report ( www.imwr.com) informs us that two large California medical groups have stopped hiring internists apparently because they can't do as much as FPs can and are more costly than NPs. I have commented before about the loss of ethics and pride in the medical profession (hat tip to DrRich) and to my eyes that phenomenon seems more so in the internist world.The view of those two organizations should not do much good for the pride of internists.

It seems that they figure that internists are not good for much. The medical blog " In My Humble Opinion" give us some examples of cases where an internist did some good. In the cases he describes,we can see how much can go by and be missed by specialists and how the particulars and nuances of the cases are basically beyond the expertise and skill sets that mid level practitioners are likely to possess and fit exactly into what the internist is trained to.The internist whose cases are described to you clearly was taking total responsibility for his patients and worrying about his patients traits that the emphasis on the importance of which, old, over the hill docs fear may be lacking in the current resident training environment and that are being crushed by the current economic situation that squeezes the time available for physician-patient encounters and tries to replace their judgment with simplistic algorithms compliance with which may determine their economic survival.

The Happy Hospitalist puts pencil to paper and makes a convincing ( and depressing) case that the planned cuts in Medicare over the next few years may well make internal medicine practices financially insolvent.Go here and read how devastating these cuts will be to private IM medical care.

If it were a matter of rational argument and common sense ( as argued so well by Dr. Robert Centor) P4P would be dead in the water but as DrRich has made it so clear ,P4P is not about quality but merely another semantic maneuver to control costs and ration care. Centor's thoughtful commentaries regarding quality in medical care make me think that quality and P4P have as much to do with each other as do hot dogs and warm puppies. Dr. RW provides numerous examples replete with links illustrating how quality measures can go wrong and sometimes be harmful.

To get a sense of the issues covered by Dr. Poses I suggest you go to the November 2007 archives of "Health Care renewal" and I guarantee you won't think about some things the same anymore.

While it may not have been a good year for medical practice ( but at least maybe we are getting some clues as to some of the problems) it has been a good year for medical blogging and we are all fortunate to have so many intelligent,articulate, caring physicians out there trying to make things better and hopefully maybe they can. A ray of hope might be the increasing talk about and actual activity in the retainer practice arena. Maybe we can back to the premise that medical care is best determined by the individual patient with the help of his physician.

Happy New Year.