Published 5/1/2014

Readers Sound Off on SGR, Professionalism

Seventeen years! That’s enough. When are orthopaedists going to exercise the control we have over Medicare coverage?

Ten years ago I suggested that all orthopaedists deny care to all non-urgent and tolerable (according to the orthopaedist’s judgment) orthopaedic problems of Medicare patients for 3 months until the government fixed the problem. If that had been done then, access to care for Medicare patients would have been improving for the past 120 months.

What will access be like for the next 120 months? The government is going to continue to threaten the financial viability of orthopaedic practices until a crisis is reached. Let’s create the crisis now. The public is already aware of, and frightened by, the fact that if doctors participating in Medicare continue to be abused by the government, their access to care will be limited. The fact is that their access is already limited and it is only going to get worse.

We would be doing a service to Medicare patients to force the issue. The Medicare public is more aware of the legislature’s failure in looking out for their health care than most of us think. They would side with the doctors on measures to force the issue even if those measures seem rather drastic. Drastic measures are the only thing that our legislators will react to. All other strategies have failed.

If the AAOS doesn’t like this strategy, let’s just stop wasting our money on trying to change the sustainable growth rate (SGR) formula and just let the cuts go through. Then doctors won’t be able to afford to take care of as many Medicare patients and access will be even more limited as a result. When that happens it will be quite obvious to the public who is to blame and they will vote for legislators who are willing to fix the SGR.

That would be a very slow process, but at least AAOS won’t be wasting time and money on efforts like we’ve done for the last 17 years.

Douglas M. Duncan, MD
(a Medicare patient)
Springfield, Mo.

I enjoyed Dr. Azar’s column, “What Keeps me Awake at Night.” Unfortunately, I agree with almost all his points (including dressing like a professional when interacting with patients) and that really dates us! I say “unfortunately,” since the column clearly marks him as a “nostalgic professional,” defined as “one who places the patient’s or profession’s needs above one’s own personal needs.”

This wisdom comes from an article in the Journal of the American Medical Association (Arora VM, Farnan JM; Humphrey HJ: Professionalism in the era of duty hours: Time for a shift change? JAMA 2012;308(21):2195-2196), which states: “Nostalgic professionalism undermines the teaching of delivering care in teams, with orderly transitions of care.” The article goes on to say, “Residents continue to engage in behaviors that are consistent with nostalgic professionalism but are in direct conflict with the current system of residency training.”

Going forward, medical care is to be delivered by teams, and fostering a strong association between the patient and any one member of the team undermines the team itself. For example, the nostalgic physician might say, “I operated on Mrs. Smith today and have some concerns. I am not on call, but I know her condition better than anyone else, and if anything goes wrong during the night, please call me before you summon the on-call physician. Here is my number.” The team player would say: “I operated on Mrs. Smith today and have some concerns. If anything goes wrong, please summon the physician on call. I have adequately informed her of the case and of my concerns, so she will be capable of managing any problem.”

It might be worthwhile to point out to medical policymakers that, although doctors cannot be on call 24/7 and orderly transitions of patient care should occur among members of an established and defined team, we should still stress the time-honored concept of the therapeutic benefits of a close relationship between an individual patient and an individual doctor.
Andrew G. King, MD

New Orleans

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