Page images
PDF
EPUB

tomary element. Incidentally, our local Peer Review Committee judged the $600 fee to be proper. But the carrier then obtained a ruling from the state review committee that, under the latest Social Security directive, the amount of any prevailing fee arrived at by a carrier on the basis of its records could not be overruled. That was that.

The foregoing cases more or less speak for themselves. However, this present action should not be taken as criticism of those administering the Medicare program locally. Many of the Medicare disputes are being adjudicated by physicians employed by Blue Shield who have backgrounds of many years in private practice and a known understanding and sympathy for its problems. I wish to criticize a system, not the individuals who must operate within that system. Is the usual-and-customery fee system worth the price we pay in administrative delays and confusion? Could there possibly be a better way?

A frequent response to my melancholy cloakroom complaints about Melicare has been: "You're under no obligation to accept assignments. Deal with the patient directly. It's his responsibility to fight his own battles with Medicare." Of course that's true. Yet whether or not I accept assignment, whenever the carrier disallows a part of my fee he damages my reputation. It's very easy for a patient, having been advised by Medicare that your bill is not "reasonable" and therefore will not be paid in fu'l, to conclude that you have been overcharging too. just like all those crooked doctors he reads about in the newspapers.

Some doctors may shrug this off as just one of those things. But it isn't just one of those things, and it's folly to shrug it off. We're losing favor with the public and are being socialized, not because of any Fabian machinations, but because of a day-by-day, bit-by-bit erosion of our stature. There are doubtless many reasons for this but don't underrate the chipping-away process activated by Medicare fee misunderstandings.

The Medicare payment system can be indicted on three basic counts:

1. It's not what it pretends to be. We're clinging to a mirage, for we are not consistently being paid usual-and-customary fees, but often fees considerably less than that.

2. For all practical purposes, the system is almost unworkable. The examples cited bear witness to that.

3. The reduction by the carrier of charges submitted by doctors-the disallowance of fees as not "reasonable"-is a vicious and destructive process. Nor are such reductions uncommon: Last March 30, Medical Economics reported that reductions were being effected by Medicare carriers on 30 per cent of all doctor bills submitted. In other words, almost one-third of all Medicare patients are being “officially” told that their doctor's charge is not reasonable, or words to that effect.

We must consolidate as best we can what we still have-before our condition deteriorates further. If organized medicine has had one overriding shortcoming in socio-economic affairs, it's been an inability to interpret trends, gauge public attitudes, and thereby predict the future. We've never been able to lead because we've been too busy trying to catch up. That doesn't mean we've been wrong, but it does mean we've been ineffective. I think we make the same mistake when we shy away from fee schedules. We commonly think of them as being both inadequate and immutable. That needn't be the case. Doctors may still be in a position to achieve a favorable fee schedule, but time is short.

It's time to negotiate-now. I don't mean nationally but locally. (Even the Senate Finance Committee staff, now recommending that Medicare switch to fee schedules, speaks of nine regional schedules rather than one national schedule.) And any agreement should include a provision for a yearly revision of fees, either up or down, to adjust to changes in the cost of living, the revision to be computed by using the regional consumer price indexes published by the Bureau of Labor Statistics.

Yes, it's time to change course and secure a fairer, more workable, and less destructive system than Medicare offers to physicians today.

[From the Bulletin, August 1970]

AMERICAN COLLEGE PHYSICIANS PARTICIPATE IN THE VOLUNTEER PHYSICIANS PROGRAM FOR VIETNAM

(By Hal T. Wilson, F.A.C.P.*)

During the last four and one-half years, twenty-three members of the American College of Physicians have participated in volunteer physicians' activities in Vietnam.

The Amercan Medical Association's Volunteer Physicians Program was begun here in 1965 under the People-to-People program sponsored by the United States State Department. In 1966 the American Medical Association took over the program under the direction of Doctor Charles H. Moseley of that organization. Since the inception of the program, there have been fifty-seven internists amongst the 640 physicians who have participated in 730 tours of duty. Of these internists, twenty-three were Fellow or Members of the American College of Physicians.

It is difficult to say just what motivate these busy specialists to come to Vietnam to work under primitive medical conditions. It appears that curiosity about our nation's activity here is a prime reason to volunteer. Some doctors have worked in other foreign medical aid programs and many comment on the personal satisfaction of medical care amongst grateful patients with no interfering pecuniary bonds. Whatever the reasons for the initial venture, more than 14% of the doctors have returned one or more times. The internists have not only followed this pattern but four have accepted long-term positions here.

The quality of doctors participating in overseas medical assignments is impressive. Of those internists who have participated in the volunteer physicians program, thirty-five were board certified and twenty were board eligible. Surprisingly enough, not only did these doctors come from all fields of internal medicine practice, but thirty-seven of them were actively engaged in teaching or other academic activities.

The lot of the internist in practicing medicine in underdeveloped countries is a difficult one. Laboratory facilities are poor in Vietnam and the speed at which tests are returned is far slower than at home. Hospital conditions are primitive and histories and physical examinations are not the rule amongst Vietnamese doctors.

The doctors of the volunteer program work almost exclusively in province hospitals and in spite of the cross-cultural adjustment necessary, seem to enjoy very much their participation in the care of patients who are oftentimes desperately ill. The internists here have tremendous exposure to tropical medicine. Diseases which they have only read about before become everyday entities. Plague, tetanus, typhoid, hemorrhagic fever and typhus are present. Tuberculosis is the chief infectious problem but one can get a lifetime of experience with more exotic diseases like leprosy in a two month stint of service. The biggest problem is infectious diseases; also there are many degenerative and system failure medical problems related to the heart, liver and kidneys.

Educational activities that the internist can participate in whi'e spending two months in the volunteer program in Vietnam include bed-side teaching with senior medical students who are working in the hospitals at Hue, Danang and Nha Trang. Unfortunately, the students have to be led by the hand through the taking of the history and the examination of patients. Most of them have not had training in the approach to the patient before being sent to the province hospitals for practical work. The medical students speak fair Eng'ish and interpreters are generally on hand for morning rounds. Sometimes the attendance of these student clerks at Sunday morning and afternoon ward sessions is poor.

There have been some formal attempts in educational activities in the province hospitals. These have included weekly staff meetings where the Vietnamese and American staff discuss problems in common. There are also occasional regional medical meetings where the doctors from several nearby American and Vietnamese hospitals are encouraged to participate in discussions of cases, and in Can Tho and Danang Regional Hospitals series of lectures are held for the staff and students.

The American Medical Association has plans for sending teaching teams to the larger hospitals throughout Vietnam. This program will begin in the near future. *Field Director, AMA VP/VN, 1968–70.

These teams will include an internist as well as a pediatrician, surgeon and orthopedic surgeon. It is hoped that the present high quality of medical aid provided by the American specialist in internal medicine will continue and that many members of the college will see fit to return to Vietnam to participate in these educational steps.

Regarding motivation, some clue can be gleaned from Doctor Harold A. Braun of Missoula, Montana. "Finally, as no doubt has been said repeatedly by other returnees, the chief value is to the VPVN himself. This value should not be discounted as several hundred American physicians have had an opportunity to observe the Vietnamese problem' firsthand, thus contributing to the pool of American opinion shaping our actions in that country."

The problems of medical practice in an underdeveloped country are well outlined by the comments of Doctor Hendrik Rozendaal, of Schenectady, New York. He says: "The three hundred bed provincial hospital has a medical wing of fifty beds and a building for infectious diseases that contains thirty beds for tuberculosis, ten beds for cholera and twenty beds for plague. This number of beds is continually occupied with a very fast turnover of patients so that there is plenty of work. In addition, there is a very active medical out-patient clinic every morning except Saturday and Sunday. Most of the patients are very ill and the variety of pathology corresponds to that described by my predecessors. I found it fascinating to see and treat such a variety of diseases and was particularly intrigued by the gratifying response to modern chemotherapy. The patients are cared for mostly by their relatives, and I was disappointed in the efficiency and interest of the Vietnamese nursing personnel. How we had to fight to clean up the wards and corridors and to give the patients some personal attention! Progress is being made, but it is slow and the patience of American physicians is sorely tested."

Doctor Reverdy Jones, of Fairmont, West Virginia, echoed the conclusions of many of the internists when he said: "My two month tour of duty at Tay Ninh has been all too short; it has been highly pleasant and deeply rewarding. It has provided an opportunity to make the acquaintance of many fine American and Vietnamese and hopefully it has given me a chance to help my country and the Vietnamese."

Fellows and Members of the American College of Physicians who have participated in the Volunteer Physicians Program for Vietnam:

Donald P. Anderson, Los Angeles,

Calif.

Harold A. Braun, Missoula, Mont.
Edward L. Burwell, Falmouth, Mass.
Charles J. Cross, Columbus, Ohio
William S. Curran, Albuquerque, N.M.
Marvin B. Day, Hartford, Conn.
Lloyd W. Espen, Redwood City, Calif.
Elliston Farrell, Long Beach, Calif.
*Joseph F. Fazekas, Silver Spring, Md.
Richard France, Nashville, Tenn.
John Godfrey, Olean, N.Y.

Mark T. Hoekenga, Cincinnati, Ohio
*Deceased.

Reverdy H. Jones, Fairmont, W. Va.
Kurt Lekisch, Topeka, Kans.
Joseph P. Murphy, Casper, Wyo.
Robert B. Price, Richmond, Va.
Hendrik M. Rozendaal, Schenectady,
N.Y.

Alvin L. Sanborn, Fontana, Calif.
John W. Strizich, Helena, Mont.
Wayne E. Truax, Beverly Hills, Calif.
Carl M. Voyles, St. Petersburg Beach,
Fla.

Donald S. Weaver, Carmichael, Calif.
Hal T. Wilson, San Bernadino, Calif.

Senator EAGLETON. I understand that Dr. Fiordelisi has returned. Doctor, will you join us?

Dr. Fiordelisi is an intern in the St. Louis University School of Medicine hospital complex.

STATEMENT OF ROCCO FIORDELISI, M.D., INTERN, ST. LOUIS UNIVERSITY HOSPITALS

Dr. FIORDELISI. My comments will be very brief.

Mr. Chairman, members of the committee, I am pleased to be invited to appear before your committee to discuss some of the problems in medical education and to give you my opinion on several issues.

I would like to center my comments to the maldistribution of doctors. This is directly related to the decreasing number of graduating doctors going into general practice and an increasing number of general practitioners either retiring or going back to enter into a residency program.

First, many students go to medical school with the idea of becoming a general practitioner and to serve the needs of the many. The general attitude of medical school quickly alters this thinking. The general practitioner is regarded as a less than adequate doctor and is essentially classified as a second-class citizen among his peers. It is a wellknown cliche that the upper one-third of the class become researchers, the middle third the specialists, and the lower one-third the general practitioners. After investing the time, money, and effort necessary in getting a medical degree, why not invest a few more years and be able to practice the type of medicine you will be the happiest practicing 10, 15, or 20 years after you have finished training. In medical school you are taught by specialists, advised by specialists, and influenced by specialists.

The small community, in many instances, does not offer the type of living to which an urban oriented family is accustomed. In most cases the educational system is not up to the standards of the schools in the larger communities, and why should one subject his family to this.

The workload is tremendous, and the physical demands on the individual are also great. In many cases if the doctor goes to the small community he will realize that he is it, there will be no help, and in most cases the challenge is too great. Most young doctors are inadequately prepared to meet this challenge.

Part of the problem could be met with the establishment of family practice specialities in more medical schools. The AMA has established a specialty board of family practice. The Farm Bureau in some States has selected a number of places in a medical class and have subsidized their medical education, and in return the graduating doctor must practice a certain number of years in a community below a certain size population.

More doctors will feel adequate enough to meet the challenge if they are better prepared. Along with this, some prestige must be given to family practice.

The American public is spoiled with the best of everything. They are specialist minded and their health care is no exception.

I would like to make one quick comment concerning the attracting of doctors into the ghetto. First, I think it is necessary that the ghettos be made safe for the doctors. I personally have had my car stolen once, a brick thrown through the window another time. I was shot at a third time, and all the contents were stolen from my car on two different occasions. This has happened during my 4 years at medical school here in St. Louis. I honestly am afraid to go to the ghettos.

I would like to make a quick comment also concerning the use of paramedical personnel. This relates to Senator Abraham Ribicoff's article in the Saturday Review on August 22, I believe. He makes a statement, "Is it enough to leave paramedical training in the hands of universities and junior colleges in the academic isolation of the college campus or, on the other hand, should such training include a combination of both academic education and medical school training alongside medical students and doctors?"

If paramedical people are to be trained side by side with doctors, utilizing the same facilities, why don't we just train more doctors side by side with more doctors and turn out more doctors and leave the training of the paramedical to the areas limited to their training.

I would like to just throw out a couple of questions which I don't know the answers to. I would like to know to what extent and to what degree these personnel are to be trained. Who is to assume the legal responsibility of their performance? I would also like to know would any of you or your families be satisfied with the treatment given by an advanced trained paramedic.

Senator EAGLETON. I will answer those for you when you finish. Dr. FIORDELISI. In summary, I think the doctor is not adequately prepared to deliver the small community type of medicine, not mentally prepared for the dissuasive attitude of the medical school, and, three, the small communities do not offer enough incentive to the doctor and especially to his family.

Senator EAGLETON. Thank you, Doctor.

What is your specialty?

Dr. FIORDELISI. None as yet. I am a straight surgical intern intending to specialize in general surgery.

Senator EAGLETON. What is your home?

Dr. FIORDELISI. My home is here in St. Louis now.

Senator EAGLETON. If you get your board certification in surgery, where do you think you will practice?

Dr. FIORDELISI. I have no idea.

Senator EAGLETON. But not North St. Louis for sure.

Dr. FIORDELISI. I wouldn't rule it out. I don't know.

Senator EAGLETON. I took your previous testimony to be that you wouldn't rule it in because you were afraid to go to the ghetto. Dr. FIORDELISI. I don't know what the conditions will be 5 years from now.

Senator EAGLETON. Assuming they are no better.

Dr. FIORDELISI. Probably not.

Senator EAGLETON. Referring to your statement where you ask some questions and also where you say it would be better to turn out more doctors and leave the paramedical personnel to the areas for their training suits them, you don't envision then when you are in practice, the utilization of paramedical personnel to assist you in the rendering of your services?

Dr. FIORDELISI. No, I didn't say that. I am referring to the article where Senator Ribicoff says

Senator EAGLETON (interrupting). That is in the record, and he suggests that the paramedical personnel cannot be properly trained in the splendid isolation of an academic environment such as a junior college or a 4-year college, but a significant portion, albeit not all, part of their training has to be as in a medical teaching hospital. Do you dispute that?

Dr. FIORDELISI. No, I believe it is done now.

Senator EAGLETON. Here is your statement. "Paramedical people are to be trained side by side with doctors utilizing the same facilities, why don't we just train more doctors side by side with more doctors and turn out more doctors and leave the training of paramedical to the areas limited to their training." I took that to mean to get them out of the hospitals.

« PreviousContinue »