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Practicing Medicine Without a License
C HE ST
editorials VOLUME 106 I NUMBER 2 I AUGUST, 1994
Practicing Medicine Without a License D r Golubovic is correct-many categories of nonMDs have figured out a way to practice medicine without a license. His particular gripe is about managed-care clerks who decide before the patient is hospitalized how many days it will take to cure the patient. This determination is often made by a young nurse who reads from a computer screen or book about the average allowed stay for all patients with a certain condition. In particular, the allowance of 2 days to cure a hot gall bladder delivered to this 71year-old practitioner with 36 years of experience by a 19-year-old without a medical degree was the straw that broke the camel's back . There are other examples. Lawyers practice medicine in retrospect . With all the time in the world, the written record is analyzed and the doctor is held to standards that are often impossible to meet in the heat of the battle for the patient's life . I have actually been involved in depositions where the record of a cardiac arrest and resuscitation was dissected by opposing lawyers who were ready to skewer a physician for writing the time at which a drug was delivered between minute marks on an arrest flow sheet. Writing this down is the last thing one should be thinking of while resuscitating a patient from a cardiac arrest. Government bureaucrats have learned how to practice medicine without a license. Medicare regulations compel us to work up elderly patients outside the hospital; these patients could be handled more efficiently as inpatients with much less stress to the patient. Reimbursement for physicians' services can arbitrarily be reduced or changed without any reference to reality, as in the recent reimbursement change for critical care.' All of this is often done without any meaningful input from the physicians who actually practice the medicine that is regulated. Politicians also tell us how to practice medicine. Most of them have not gone to medical school either. The various health care plans circulating on Capitol Hill are not written by physicians, but do impact heavily on the practice of medicine. Most plans are based on time and motion studies and indicate that doctors seeing patients at a faster rate would result in the need for fewer doctors. The complexity of the cases and th e quality of the compassionate care are
not considered relevant. Yes, I do believe that Dr . Golubovic is right. In fact , I believe that physicians now spend fewer hours actually practicing medicine and more hours doing paperwork purely because of the regulations imposed by all of these people who have indeed figured out how to practice medicine without a license.
A . Jay Block, MD. , F.C .C.P. Cainesoille, Florida with Zivomar Golubovic, MD. Lake Worth, Florida Editor-in-Chief, Ch est ; Professor of Medicine and Anesthesiology, University of Florida (Dr. Block); Family physician, Lake Worth, Florida (Dr . Golubovic) Reprint requests : Dr. Block, 408 W est Uni versity, Suite 408 , Gain esville , FL 32601 R EFERENCE
1 Block A. J. Medicare , critical care, and the Clinton Health Plan. Chest 1994; 105:1305-06
Beta2-agonists and Their Antagonists For many years, sympathomimetic bronchodilator aerosols have provided the most popular form of therapy for chronic bronchospastic diseases and for acute exacerbations. During the last 25 years, occasional reports of adverse effects resulting from these drugs have led to suggestions that they should not be used in asthma. This repetitive concern has become more persistent in the last few years, and well-publicized reports suggest that patients receiving regular sympathomimetic aerosol therapy may suffer bronchospastic relapses and progressive deterioration in airflow when compared with patients who use their aerosol bronchodilators sparingly. Now, a thoughtful review by Taylor and Sears in this issue (see page 552) catalogues the evidence that allows them to make an indictment of l3-adrenergic agonists. These exp erienced investigators suggest that regular or frequent use of l3-agonists is both harmful and unnecessary in asthma; however , their studies appear to endorse prn , or pro re nata, therapy, even though this provides patients with the option to use the prescribed aerosol regularly several times a day for relief of perceived symptoms of bronchospasm . CHEST / 106/ 2 / AUGUST, 1994
329
editorials VOLUME 106 I NUMBER 2 I AUGUST, 1994
Practicing Medicine Without a License D r Golubovic is correct-many categories of nonMDs have figured out a way to practice medicine without a license. His particular gripe is about managed-care clerks who decide before the patient is hospitalized how many days it will take to cure the patient. This determination is often made by a young nurse who reads from a computer screen or book about the average allowed stay for all patients with a certain condition. In particular, the allowance of 2 days to cure a hot gall bladder delivered to this 71year-old practitioner with 36 years of experience by a 19-year-old without a medical degree was the straw that broke the camel's back . There are other examples. Lawyers practice medicine in retrospect . With all the time in the world, the written record is analyzed and the doctor is held to standards that are often impossible to meet in the heat of the battle for the patient's life . I have actually been involved in depositions where the record of a cardiac arrest and resuscitation was dissected by opposing lawyers who were ready to skewer a physician for writing the time at which a drug was delivered between minute marks on an arrest flow sheet. Writing this down is the last thing one should be thinking of while resuscitating a patient from a cardiac arrest. Government bureaucrats have learned how to practice medicine without a license. Medicare regulations compel us to work up elderly patients outside the hospital; these patients could be handled more efficiently as inpatients with much less stress to the patient. Reimbursement for physicians' services can arbitrarily be reduced or changed without any reference to reality, as in the recent reimbursement change for critical care.' All of this is often done without any meaningful input from the physicians who actually practice the medicine that is regulated. Politicians also tell us how to practice medicine. Most of them have not gone to medical school either. The various health care plans circulating on Capitol Hill are not written by physicians, but do impact heavily on the practice of medicine. Most plans are based on time and motion studies and indicate that doctors seeing patients at a faster rate would result in the need for fewer doctors. The complexity of the cases and th e quality of the compassionate care are
not considered relevant. Yes, I do believe that Dr . Golubovic is right. In fact , I believe that physicians now spend fewer hours actually practicing medicine and more hours doing paperwork purely because of the regulations imposed by all of these people who have indeed figured out how to practice medicine without a license.
A . Jay Block, MD. , F.C .C.P. Cainesoille, Florida with Zivomar Golubovic, MD. Lake Worth, Florida Editor-in-Chief, Ch est ; Professor of Medicine and Anesthesiology, University of Florida (Dr. Block); Family physician, Lake Worth, Florida (Dr . Golubovic) Reprint requests : Dr. Block, 408 W est Uni versity, Suite 408 , Gain esville , FL 32601 R EFERENCE
1 Block A. J. Medicare , critical care, and the Clinton Health Plan. Chest 1994; 105:1305-06
Beta2-agonists and Their Antagonists For many years, sympathomimetic bronchodilator aerosols have provided the most popular form of therapy for chronic bronchospastic diseases and for acute exacerbations. During the last 25 years, occasional reports of adverse effects resulting from these drugs have led to suggestions that they should not be used in asthma. This repetitive concern has become more persistent in the last few years, and well-publicized reports suggest that patients receiving regular sympathomimetic aerosol therapy may suffer bronchospastic relapses and progressive deterioration in airflow when compared with patients who use their aerosol bronchodilators sparingly. Now, a thoughtful review by Taylor and Sears in this issue (see page 552) catalogues the evidence that allows them to make an indictment of l3-adrenergic agonists. These exp erienced investigators suggest that regular or frequent use of l3-agonists is both harmful and unnecessary in asthma; however , their studies appear to endorse prn , or pro re nata, therapy, even though this provides patients with the option to use the prescribed aerosol regularly several times a day for relief of perceived symptoms of bronchospasm . CHEST / 106/ 2 / AUGUST, 1994
329