Monday, April 27, 2015

As A Physician Do You Have Adequate Financial Expertise?


Book Review – Physicians (and dentists, nurses, nurse practitioners, and other health care providers) need to understand money but most have limited financial expertise. No wonder and it’s not your fault. Four years of college, four more of medical school and three or more of residency left little time for personal financial education. But you still need that education and now is the best time to start.
The financial playing field is definitely not level and so you need to do what you can to level it. You are probably encouraged regularly to invest in various money making schemes that sound too good to be true. Making good financial decisions over time means the benefits can compound over long time periods – to your definite advantage.
Unfortunately, medical school and residency programs have essentially no time devoted for personal financial education and little if any time for learning the financial implications of starting a medical practice. You are on your own. Your natural mentors – professors, senior residents or senior colleagues in your practice – are probably no better equipped than you. Some medical students are obtaining combined MD/MBA degrees but this is overkill for just your own personal financial educational needs.
I was encouraged by consultants at Sage Growth Partners to meet Dr. Yuval Bar-Or. Dr. Bar-Or comes from a medical family (father and brother are physicians) but he entered the finance field, obtaining a PhD in finance from the University of Pennsylvania’s Wharton School. He is now a faculty member at the Johns Hopkins Carey Business School. His own family’s circumstances led him to realize that medical families need access to clear, objective, expert financial knowledge. He has written a set of two books, called Pillars of Wealth I and II, to address this need.
The books are straight forward, easy to read, thorough, yet not mired in financial jargon. In short, you can learn and do so easily. He begins with what he calls three axioms (reminds me of high school math!) 1) Your most valuable asset is earning capacity (not lucrative sounding investments); 2) Your most precious resource is time (saving now will pay off handsomely in retirement); 3) Your greatest enemy is procrastination. From there he reviews the basics of stocks, bonds, real estate, business ownership, insurance, annuities, 529 college savings plans, etc. He puts an emphasis on getting out of, and not entering into, debt (except a mortgage for a reasonably priced home.) This is followed by a discussion of risk and risk anticipation as a front line of financial defense. This leads to insurance – what you need and what you can avoid in terms of life, disability, liability and of course malpractice insurance.
It is an important principle that sound financial decisions early in your career have a big impact down the road – and so too do suboptimal decisions. You are probably bombarded by sales people that assume you have money to spend; some will have good ideas and products and many will not. Should you have a personal financial advisor? Or can you learn enough to make sound decisions yourself – for your own financial well-being, for your family and for your career?
A personal financial advisor would be worthwhile but you need to find the most appropriate person whom you can trust to offer sound meaningful advice and who charges appropriately. Pillars of Wealth gives suggestions on making this choice.
Bar-Or is articulate and passionate to meet. He thinks of himself as a financial risk management “physician”, i.e. to keep your finances healthy and functional while you help your patients stay healthy.
Your practice priorities are always uppermost but for some limited time and on a regular basis you deserve to consider your own financial health. Pillars of Wealth might be a good place to start. A chapter every few days will put you in a much better position over time to benefit financially from your education and training. These books are very well written and thoughtful. I will go so far as to say they should be must reading for all medical students and residents.
Note – Dr. Bar-Or and I met for lunch; we each paid our share. I bought his books before we met. I have no financial relation with him or his book sales.
 
 

Thursday, April 2, 2015

A Humble Opinion


Book Review - Readers of my posts know that I am a strong advocate for primary care and especially a primary care physician (PCP) that provides each patient with sufficient time. Time for the PCP to listen, to think, to treat and to prevent. This allows the patient and doctor to reclaim relationship medicine, a standard tenet of care in the past but now largely lost in our financially driven medical care system.
Dr Jordan Grumet is a primary care physician in Ohio who tries to assure his patients of a strong relationship, one in which they can build trust. Recently he has reduced his practice to about 600 patients and become “concierge.” Now he has more time for his patients and even some time for his family. For years he has written a blog entitled “In My Humble Opinion” in which he records his thoughts of events in his practice, in his home life and in his wide ranging mind. His posts are thoughtful, thought provoking, engaging, emotional and educational. Recently he published book curated from his posts and arranged into meaningful sections such as “The Grateful Death” or “In Sickness or in Sorrow.”
Dr Grumet’s book is a must read for anyone who cares – cares about their health, cares what they or their family receive from medical professionals, cares about what the doctor or nurse offers to  their patients. I have read Dr Grumet’s blog intermittently for the past few years. Always it leaves me with the sense that here is a real human being doing what he does best – caring for patients, one at a time and in the process trying to care for himself and his family. His book title - “I Am Your Doctor” - implies not a fact but a responsibility that he accepts when you come to him. The cover picture is equally powerful – a hand holding another’s, a clear and compelling symbol that this is a physician who wants to have a real relationship with you, his patient. Relationship medicine has largely been lost to today’s business and economic imperatives but doctors like Grumet are trying their best to retain it in their everyday practice. Dr Grumet brings us back to the true calling of what it is to be a physician and in his humble manner but compelling writing style reminds us that physicians are human with of the frailties and foibles as everyone else – the longings, the joys and the sorrows. But especially they want to be there with you as you experience those joys and sorrows, those exhilarations and frustrations that come with life, living and eventually dying. Here are two excerpts:
“Two weeks from now I will tell a man he is going to die. He will sit calmly in my exam room as he shifts his weight from side to side. Although his hair has grayed and his body has weakened, his face will sparkle with youth and vibrancy. He’ll stare deeply into my eyes and I'll detect a hint of mirth. "We're all dying, my friend." He will draw in a deep breath and put his hand on my shoulder. "The trick is learning how to live!" 

“It's not exactly Dr. Jekyll and Mr. Hyde, but everybody knows my level of patience varies from time to time. So I was surprised to find myself happily telling the emergency room that I would assess the patient shortly. The kids were horsing around on the playground, and I knew I would have to call my wife and ask her to come home. It would be my second 45-minute trip to the hospital on an otherwise busy Saturday afternoon. For some reason today, I was able to sublimate the automatic annoyance and return without emotional drama. I slowed down, calmly listened to the patient and reassuringly put a plan into place. Driving home, I felt both relieved and saddened by the joy that overcame me. Why didn't my life's work make me feel this way all the time? I guess it starts with one simple fact. I blame myself for every heart attack, stroke or new diagnosis of advanced cancer. As disturbing as that sounds, how could I not?”
 
Read this book and you will want him to be your doctor. Or at least you will want to find a primary care physician like him who practices real relationship medicine the way he does and who assures you that you will have his or her  undivided attention

Friday, March 27, 2015

Curing Medicare


Book Review.This might seem like a curious title for a blog post but it reflects a very serious national need. Medicare is the central method for financing medical care for those over 65. It brings major value but it has serious deficiencies. We are frequently reminded that the Medicare Trust Fund will shortly run low of money. Enter Dr Andy Lazris a gerontologist with over 25 years of experience caring for the elderly. In his book – Curing Medicare – he lays out the issues that truly need to be addressed if America’s seniors are to “Age Gracefully.”
Dr Lazris and I live in the same community but had never met nor knew of each other. A retirement community executive, knowing I was writing a book about primary care, urged me to meet him. Before our meeting the next week, I ran into an acupuncturist I have known for some time. He also spontaneously suggested I meet Dr Lazris and so did the CEO of a major nursing home chain. Each said Lazris was a terrific doctor, a humanist, a real “gem” and an all-around nice guy. With such a buildup it would have been easy to be disappointed. But I certainly was not.
Although he sees any adult patient, his practice is largely composed of elderly individuals living in retirement communities, assisted living or nursing facilities. He limits his practice to about 600 patients so each can get the time needed and deserved. He is at once humorous and wise, light hearted and dead serious. He clearly understands the needs of the elderly and likewise understands how Medicare works – including how it impedes care and encourages aggressive care when a more benign or palliative approach would be better medicine and certainly more humane. As he puts it, “sometimes less is more.”
Curing Medicare should be a must read by anyone who is over 65 and anyone who has loved ones that are growing older, in other words it is important for most of us to understand what he teaches us. Medicare has been a major medical and financial boon to most elderly individuals but it has some serious deficiencies and it behooves us to understand them. Dr Lazris writes from his personal experience and gives many patient vignettes to back up his observations. A major point is that it is often best to not diagnose and treat aggressively (or “thoroughly” as he puts it) but to use a more palliative approach. But Medicare in both its payment systems and its regulatory approach essentially dictates aggressive medicine, indicated or not. Whether in the home, an assisted living facility, a nursing home or the hospital, the pressures are for being “thorough”, often to the patients’ detriment if not outright harm. And such aggressive diagnosis and therapy are what make costs go sky-high. These and other problems are fully presented and discussed in a way that we can all understand and appreciate along with his commonsense recommendations for reforming Medicare.
Recently, Health and Human Services secretary Silvia Burwell announced that Medicare will shift from the current fee for service reimbursement methodology to one that rewards value, i.e., reduced costs yet improved quality. On the surface that appears like a responsible direction. But is it? In an Op-Ed in the Baltimore Sun, Dr Lazris lays out some critical issues that lead one to question the HHS rationale. He uses points and concepts discussed in detail in his book so a quick read at this link will be of interest to many potential book readers.
Overall, Dr Lazris presents us with an elegant approach to the care of the elderly, one that he personally uses as best he can despite the restrictions imposed by Medicare’s payment and regulatory dictums. He offers us commonsense suggestions on how Medicare could be vastly improved, offering patients much better quality of care yet at the same time offering Medicare (and our tax dollars) enormous savings. I recommend his book highly.
Next Time - Another book review - I Am Your Doctor by Jordan Grummet

Monday, March 23, 2015

Aging Gracefully Part 4 Comprehensive Primary Care For The Elderly


Comprehensive primary care is essential to good health, wellness and needed medical care during our elder years. It is critical to Aging Gracefully.

In the last few posts I wrote that Aging Gracefully physically requires attention to lifestyle/behaviors to assure good nutrition, plenty of exercise, reduced stress, no tobacco and – for preserving cognitive function – intellectual challenge and social engagement. That is what each of us needs to attend to but we also need a good primary care physician (PCP) to assist us on our journey. That PCP needs to have adequate time to listen and listen fully.
The Erickson Living retirement communities have developed an approach that appears to work well for its residents. Let me use it as an example. The fundamental concept is to assure that everyone has comprehensive primary care. The Erickson leadership learned that healthcare was of paramount importance to their residents. A strong program would be good unto itself but also a strong marketing attraction. After substantial study and trial and error they set the resident/patient number per doctor at a remarkably low 400 for their in-house salaried PCPs. They found that this 400:1 ratio was the ideal number of elderly geriatric residents per doctor in order to assure the quality, humanistic and integrative approach to care desired. (For comparison, the usual patient to PCP ratio is about 3000:1.) They have clearly demonstrated that this approach to primary care with a low number of patients per doctor (and a team that functions akin to a medical home) not only gives superior care but that it results in much reduced total costs of health care overall. 
According to the medical director, Matthew Narrett, MD, residents can have same or next day appointments for as long as needed, they are offered extensive preventive care (“It is never too late to prevent,”)    the PCPs are well versed in gerontology issues  and there is a strong commitment to listening. Some of the results of this approach: Chronic illnesses can be managed usually quite successfully without the need for referral to specialists but, when needed, specialists are readily available (many conduct office hours on site on a rotating basis eliminating the need to travel to a distant office). Hospital admissions are down absolutely and markedly so in comparison to equivalent groups of elderly individuals. The length of stay in the hospital for those who must be admitted is lower and the 30 day unanticipated readmission rate has consistently been below 11% (the national rate is about 20%plus) despite the average age of their residents being about 82, i.e., one would expect their average rate to be higher than the national rate for Medicare-covered individuals overall. Dr Narrett reported that resident satisfaction was very high. I confirmed that when I was at the Charlestown community to give a talk organized by residents. With no staff present, I asked the 90 or so attendees their impression of the healthcare program. I received only positive accolades.
At the Charlestown and Riderwood communities where I have toured (and other locations) the onsite clinic includes not only the PCPs, but one or more nurse practitioners, a podiatrist, and a suite for a visiting dentist, for an optometrist and for an audiologist. The podiatrist is full time (at the larger communities) but the others are there commensurate with the need. Various outside medical and surgical specialists (e.g., cardiology, gastroenterology, dermatology, orthopedics, etc.) offer office hours on site on a scheduled basis. The clinic has an on-site nurse to coordinate special needs such as preparing for surgery, returning to the community from the hospital, transferring to assisted living, arranging in-home special needs care, etc.
A Medicare Advantage Plan is also offered by Erickson Living to residents of their group of 18 continuing care retirement communities. In the Erickson plans (administered through United Healthcare) one can choose the on-site PCPs or continue with one’s own PCP, can access a wide range of specialists when necessary, can use most any hospital, can be driven to most off-site doctors’ offices at no cost, etc. Unlike Traditional Medicare where one must spend three days in the hospital in order to be eligible for Medicare to pay for the first 100 days of residential skilled nursing care,  this Advantage plan waives the required three day stay. In other words, if the resident would benefit, the doctor can make the decision and can arrange immediate referral to their on campus site. This of course eliminates a very costly and potentially hazardous hospitalization. There is also an on-site benefits specialist to assist residents with their questions. The most common plan costs substantially less than one might pay for both Medigap and Part D policies yet it includes greater benefits (e.g., basic dental) with few co-pays and no deductibles. 
Older individuals perhaps even more than others need comprehensive primary care. It is a critical aspect of Aging Gracefully. Unfortunately, most older people do not have the benefit of a PCP who can spend the time they need.
My takeaway from the Erickson model is that when the PCPs are allotted the needed time and can listen and think, the care is excellent, satisfaction is strong and the total costs come down substantially. It also means that the PCP can get back to relationship medicine where trust builds and healing is possible.
I am not advocating for Erickson Living or that you move to a retirement community but my recommendation is definitely that you seek out a PCP who can and will offer the time you need to assure good healthcare so that you can Age Gracefully.
Disclaimer – I have no financial relationship with Erickson Living. It is used solely as an example to demonstrate the utility and value of a PCP (along with a well-functioning team) who can offer each patient the time necessary for comprehensive primary care.

Wednesday, March 18, 2015

Aging Gracefully – Part 3 The Importance of Comprehensive Primary Care


Most people misunderstand what constitutes really good primary care.  We can slow the aging process with appropriate life style and behaviors as discussed in my last post. That is good but it is not enough. As we age it’s also important to have comprehensive primary care.  The usual expectation is that primary care is just for the “simple stuff” or for episodic care when we have a problem but that is a gross misunderstanding. 
Comprehensive primary care is actually much different. It means a close relationship between you and your PCP which is of course required to build trust and to heal. It means dealing with the episodic medical problems which occur from day to day and month to month throughout life. It also means actively managing serious chronic illnesses (a specialist in fact is rarely needed). It means coordinating that care however when specialists are needed. It means helping you to maintain your wellness and your health and working with you at chronic illness risk factor detection and reduction. And it means preventing acute illnesses through vaccines and other approaches.  This is comprehensive primary care and when it is comprehensive it can deal with perhaps 90+% of all of our health care needs.  Specialists are rarely needed, prescription use goes down and hospitalization rates fall substantially.  
 
The key requirements of comprehensive primary care include some basics – a well-educated, well-trained, up-to-date PCP who is committed to relationship-based care and uses a proactive team-based approach.  But the second key ingredient is time – time to listen, to think, to diagnose and to treat and to prevent.  Unfortunately most primary care physicians just do not have enough time today and the result is a tendency to refer to specialists. But with that time, they could have dealt with the problem themselves. 
Overcoming this time limitation is perhaps best done through some form of direct primary care -sometimes called membership, sometimes called retainer and sometimes called concierge medicine.  But whatever the name, the fundamental ingredient is to reduce the practice size from today’s standard of 2,500-3,000 down to about 500 individuals.  This allows the primary care physician to offer you same or next day appointments which last as long as necessary; the time necessary to listen and listen intensively; the time to give a truly extensive annual evaluation; the time to offer expanded preventive and wellness care.  Direct primary care physicians usually give out their cell phone number for the patient to use any time day or night and they respond to emails. 
 
Comprehensive primary care certainly costs more, but it offers better health and wellness. It offers better quality of care. Patient and doctor are more satisfied and in the end it substantially reduces the total cost of care because of the reduced necessity for specialists, testing, prescriptions and hospitalizations.  
To summarize this series of posts on aging, there is a steady slow loss of physiologic function in most of our organs over time. It is possible to slow this average of 1% annual decline and with it the ultimate functional impairments. It is also possible to avoid or certainly delay age-prevalent diseases.  But in both cases it’s up to us.  It’s up to us to adjust our lifestyles and we preferably need to do so beginning at a young age. It is never too late to begin a preventive program.  We can slow physical decline with exercise, diet and reducing stress.  We can avoid many diseases via nutrition, exercise, less stress and by not smoking. We can slow cognitive decline with physical activity, intellectual challenges and social engagement.  And we will definitely benefit when we make good use of comprehensive primary care.

Tuesday, January 6, 2015

Aging Gracefully – Part 2 Slowing The Aging Process


Can we slow the aging process?  The answer is a definite yes and it all has to do with our lifestyles and behaviors.  Here is a quiz.  What percent of Americans can answer yes to all five of the following statements?
 

Here’s a clue.  We know that about 20% of Americans smoke so the highest answer you can give to this question is that 80% could answer yes to all five.  The actual answer may surprise you.  It did me.  Only 3% of Americans can answer yes to all five! 

Let’s return to bone mineral density.  The way to slow BMD decline is to exercise and to eat a nutritious diet.  (Vitamin D supplements may also be necessary for those in temperate climates who get little sunshine on their skin.) So instead of a 1% decline per year it can be more of a ½% decline per year.  On the other hand for couch potatoe that decline won’t be 1% but it may be more like 1½ to 2% per year.  The same goes for cognition.  There are certain adverse factors such as vascular conditions and the metabolic syndrome (a precursor to diabetes) and also the chemicals released through chronic stress that speed up cognitive decline.  But there are also protective factors which we can control ourselves.  These include being physically active, intellectually challenged, and socially engaged.  It may be a surprise that physical activity is important for cognition but it has been clearly demonstrated to be critical.  Intellectual challenge is different than reading a book, even a complex book.  That’s not a challenge.  But if you belong to a book club and have to actively defend your perspective and point of view that then becomes a challenge.  Socially engaged means being involved as a human being with other human beings.  This is something that is frequently lost during older years if isolation develops due to limited mobility, inability to drive, etc. 

So the essential steps of slowing the aging process are: Avoid tobacco and remember it’s never too late to quit.  Reduce chronic stress because the chemicals released from stress have a very adverse effect on many physiologic systems such as immune function.  Eat a nutritious diet.  Do cognitive exercises which challenge your intellect.  Remain socially well connected. Physical exercise should include aerobic activity of about thirty minutes five days per week (just simple walking is adequate); resistance or weight training 2-3 times per week and balance exercises 2-3 times per week. 

 


To summarize, there is a steady slow loss of physiologic function in most of our organs over time. It is possible to slow this 1% decline and with it the ultimate functional impairments. It is also possible to avoid or certainly delay age-prevalent diseases.  But in both cases it’s up to us.  It’s up to us to adjust our lifestyles and we preferably need to do so beginning at a young age. That said, it is never too late to begin a preventive program.  We can slow physical decline with exercise, diet and reducing stress.  We can avoid many diseases by not smoking. We can slow cognitive decline with physical activity, intellectual challenges and social engagement.  It’s worth it.

Next post – The importance of comprehensive primary care in managing the aging process.

Monday, December 15, 2014

Aging Gracefully – Part 1 The Normal Aging Process


It is possible to slow the aging process.  No there is no Fountain of Youth and no, there is no pill that’s been discovered.  It’s all about lifestyle and this means starting at an early age and sticking with it through the years. 
I was recently invited to give a talk to a group of about 100 individuals contemplating moving to a continuing care retirement community.  The topic - is it possible to slow the aging process?  I titled it “Aging Gracefully.”  Here are my thoughts divided into three major categories:  the normal aging process, slowing the aging process, and (in a post to follow) obtaining the very best comprehensive health care.  The talk was picked up by the Howard Times of the Baltimore Sun; the reporter’s article is available at this link:  http://bsun.md/1AtQW7E
 “Old parts wear out.”  That’s normal aging.  It’s universal, it’s progressive and, at least as we know it today, it is irreversible.  Most organ functions decline by about 1% per year.  Fortunately our organs have a huge redundancy and so we can afford the declines without illness.  But eventually if we live long enough and the process continues at the usual rate a point is reached at which functional impairment or actual disease presents. 
Let’s use bone mineral density and cognitive function as examples.  During our childhood and teenage years our bone mineral density increases and with it our bone strength.  It reaches a peak at about age 20 and plateaus and then by age 35 starts a slow but inexorable decline of about 1% per year.  Should we live long enough we will reach a point which we can call the “fracture threshold” meaning that if we fall it’s possible to break a leg or a bone in our back.  Of course that 1% decline per year is an average.  Some people decline faster and some people decline more slowly.  We’ll come back to that point.  The same goes for cognitive function.  We’re at a peak at about age 20 and then there is a long plateau with a slow decline such that by the time we’re in our 80’s or 90’s most people have some noticeable decline in cognition. 
There are certain impairments that come with aging such as reduced vision, reduced hearing and reduced mobility.  We might not consider these as true diseases.  However there is also an increased prevalence of chronic illnesses such as heart failure, cancer, chronic lung and kidney disease and diabetes.  They often manifest in older ages but they actually originated many years ago.  For example coronary artery plaque buildup begins in childhood but may not manifest itself as a heart attack until the late 60’s.  Similarly lung cancer is on average diagnosed at age 72 but the cause began way back as a teenager when the person first went back behind the garage for a smoke. (BTW, not all lung cancers are due to smoking but for those that are, it was a long slow process over time.) 
These chronic illnesses are largely due to our adverse behaviors, our lifestyles.  The four big behaviors that need to be addressed are nutrition, exercise, chronic stress and tobacco.  We could add other factors but especially inadequate dental hygiene and excessive alcohol. All too many of us have poor nutrition (e.g. packaged and processed foods, lack of fresh fruits and vegetables, etc.) and at the same time we eat too much of it.  Most Americans don’t get an adequate amount of exercise.  It seems that everyone has some level of chronic stress and 20% of Americans smoke. 
To summarize, there is a normal aging process wherein organs reduce their function by about 1% per year. This rate of decline is related, in part, to our lifestyles beginning when we are quite young. There are also age-prevalent chronic diseases that are also life style driven. Our personal agendas need to include attention to healthy living so that we can preserve wellness.

Next time – Slowing the Aging Process
 
 

Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).