Oversight (guidelines) carry potential for harm

Response to Dr. Pauline Chen’s “Does Oversight threaten the doctor-patient bond”? (Feb.26, New York Times Well Blog)

Economic oversight of doctors performed by heath insurers carries an inherent flaw that cannot help but undermine doctors’ integrity and their bonds with patients. That flaw is the inextricable relationship that insurers have with shareholders. Having to generate profits will always present a dangerous temptation for insurers to rationalize that good guidelines are good medicine. How can it be otherwise when CEOs and top executives have to present their strategies to boards of directors whose main responsibility is fiscal not medical?

The ascendancy of guidelines began when managed care began to exert their new-found power to control the way that doctors practice and the tests that they order. Since then, most doctors’ impressions of them is that they are a pretense for improving care. Although guidelines seem clear intellectually, they don’t easily translate into practice because they cannot reflect the real-time concerns and pressures that doctors deal. For example, most patients because they are living longer have not one but two, three, or more diseases. The interplay of multiple diseases, the multiple drugs they are on and, the social and psychological effects that result make each patient’s treatment unique.

With insurers and their responsibility to shareholder as the main drivers, it will be a challenge to free guidelines from the inextricable conflict that exists. Perhaps the boards that decide the guidelines should always be weighted in favor of doctors who of course should have no financial relationship with the insurers. Insurers should never have the predominant voice.

“Guidelines” have a sense of finality and authority that is dangerous. Their connotation is legal as well as medical. When situations arise that do not fit into a guideline’s plan, doctors may be held accountable unjustifiably.

Besides insurers’ financial interests that can create biases in guidelines, medical organizations that doctors look to for guidance also have their biases that can come from specialty societies and influenced by turf battles over what doctors can or cannot do. As recently pointed out in “Reassessment of Clinical Guidelines” JAMA, Feb. 25, 2009 by TM Shaneyfelt and RM Centor (www.JAMA.com), guidelines have overshot their initial purpose of being suggestions and have taken on the role of rules in addition to being market-influenced.

Who knows how or when this debate over guidelines will be solved or, if it ever will. There are many variables. Personal interests and conflicts of interest come from many sources, some obvious like insurers, medical device manufacturers, and pharmaceutical manufacturers. But others not so obvious like medical specialty organizations also bear part of the blame as reported in “Scientific evidence underlying the ACC/AHA clinical practice guidelines” JAMA, Feb. 25, 2009, by P Trioicci, JM Allen, JM Kramer, RM Califf, and SC Smith.

What is clear is that disease is never treated in the abstract. It is always alloyed with a person. Each patient is unique and because of that uniqueness the treatment however closely it follows a guideline, will have some component be it physical or emotional/spiritual that to a greater or lesser degree makes it different and peculiar to that patient. Leaving out this human dimension makes it easy to produce guidelines that seem rational but cannot deliver what they presume to.

Doctors have their judgment and experience and colleagues to assist them. Maybe that is enough.

Ed Volpintesta MD

The Humanities, Not Just for Spectators

Response to New York Times article “In Tough Times, Humanities Must Justify Their Worth” (The Arts, Feb. 25):

The humanities have retrogressed because excessive attention has been focused on their value to enhance appreciation of literature, music, and art. As valuable as these passive activities are, they are not the end point of an education in the humanities.

There is an active side that is rarely discussed and equally important.

The Latin humanitas, defines the person infused with the spirit of the humanities, not as one who, in isolation appreciates and gets enriched by the beauties of art but one who is engaged in the world fighting for what is right and just in the front lines to protect the values that are worth keeping in a civilized society.

It is in this active as opposed to passive sense, that the humanities find their fullest expression and worth.

Ed Volpintesta MD

Response to Dr. Pauline Chen's essay on "Getting Off the Patient Treadmill"

Dr. Pauline Chen’s concerns about health insurers paying physicians by comparing them to standards of cost-efficiency are timely and necessary. (Feb. 19, 2009, Link)

The biggest worry is that these pay for-performance [P4P] programs are driven mostly by a desire to cut costs, which in itself is not a bad thing. But since cost-cutting permits insurers to increase profits and dividends to their shareholders, doctors’ needs (and patients’) are obviously jeopardized. These programs are intended not only to cut costs but to control the way that physicians practice.

Although the standards that define the P4P plans have some value in treating patients, in real life, the many nuances of patients’ personalities and socioeconomic backgrounds make it impossible to grade accurately and fairly the comprehensive worth and competence, the total professionalism of any doctor. Attempting to do so robs doctors and patients of their unique qualities and all the nuances that enter into doctor-patient relationship, reducing both to faceless rows of data in statistical charts, which is the way that insurers deal with them.

But beside P4P strategies there are other that insurers use to control doctors. For instance, recently I received a brochure from UnitedHealth (1) informing me that I did not meet their “physician designation program quality and cost efficiency assessment” because I was no longer board certified in family medicine. Physicians are given two designations by UnitedHealth: one star for quality and two stars if both quality and cost effective standards are met. The information is then displayed in online directories for pubic viewing. They allow physicians a 45 day review period to clarify and request reconsideration of their designation status.

I considered writing a letter to them explaining why I thought they were unjustified and simply wrong in profiling me according to their standards. After all, they don’t know my patients or their personal needs, the socioeconomic climate of my community and the number and types of specialists in it. They don’t know how much time I spend with my patients or how well I connect with them or how successful I am in forming therapeutic relationships with them. Neither do they know how timely I am in making referrals or how hard I try to give patients same day appointments or how attentive I may be to their emotional needs. They know nothing of my character or integrity. They have never visited my office and don’t even know what I look like.

Also they don’t know that I had been board certified for over 30 years and that the boards no longer reflect how my general practice has tailored itself during that time so that it no longer represents the “generic” models the boards zealously want to impose regardless of physicians’ individual differences.

Although UnitedHealth states in their brochure that their physician designation program is not intended as a guarantee of a physician’s competence, clearly their profiling carries with it an implication of quality and competence that could prove harmful to any physician’s reputation and livelihood whose name is not included.

Insurance companies have no role in profiling physicians under any conditions. Profiling coerces doctors into following insurers’ policies and gives insurers a license to determine how medicine is practiced. By compartmentalizing doctors according to set standards that only reflect the cost-cutting and “scientific” side of medicine insurers make it impossible to concentrate on the non-scientific or humanistic side of medicine. And for the extraordinary doctor who does take the extra time to talk with patients and discuss their concerns and form a trusting and personal relationship, no set of pay –for-performance standards exist; and for many other other statistically independent functions which insurers do not acknowledge. In this context both patients and doctors become dehumanized, faceless cogs in the health care machine.

I decided not to appeal UnitedHealth’s after I read that UnitedHealth was sued for fraudulent billing practices (2) that exploited patients and physicians alike.

Seeking approval from an organization that used fraudulent business practices against doctors was senseless. It would only make me a hypocrite. Worse it would imply that I agreed with UnitedHealth’s flawed policy of quality and cost-effectiveness profiling.

Clearly, P4P programs and any other physician designation programs are an insult to doctors and just another example of how bad it can get for doctors when insurers impose standards for quality and cost-effectiveness. Hospitals have peer review committees that monitor physicians’ work and doctors themselves are committed to life-long study to improve their skills. Many mistakes in medicine are made because of poor judgment, fatigue, overwork, or communication and system failures—ironically some of these some of these factors are due to the working conditions imposed by health insurers--not lack of knowledge.

Pay for performance may make sense when it comes to making inanimate objects like automobiles, computers and radios.

But it’s bad for doctors and bad for patients.

1. UnitedHealth Premium Designation Program. Brochure. United HealthCare Services, Inc. Oct. 2008.

2. Nielsen NH. United agreement a victory for fair pay for physicians. Amednews, www.ama-assn.org/amednews/2009/02/09

Ed Volpintesta MD

Physician Profiling Rears Its Ugly Head

A large health insurer (1) is profiling physicians using so-called quality and cost effective parameters. Physicians are given two designations: one star for quality and two stars if both quality and cost effective standards are met. The information is then displayed in online directories for pubic viewing. They allow physicians a 45 day review period to clarify and request reconsideration of their designation status.

But should any health insurer be allowed to “profile” a doctor? Isn’t there a serious conflict of interest here since the insurer’s profits and the dividends it pays to its stockholders depend in part on how well it can make physicians conform to protocols aimed at increasing corporate profits?

Profiling of physicians has dangerous flaws that can harm doctors. Health insurers have nothing to base their profiling on except statistical data. These statistics don’t reflect the demographics of the communities where doctors practice, the number and types of specialists in their communities (important because it affects doctors’ practice habits), the demands of their patients or how much time they spend with them. Neither do statistics convey any information on how well doctors connect with their patients or how successful they may be in forming effective therapeutic relationships. They have no knowledge of how timely doctors are in making referrals, how hard they may try to get same day appointments when necessary, or how attentive they may be to their patients’ emotional needs.

Worse, profiling data indicates nothing about physicians’ character or their integrity. In short, profiling imposes a faceless personality that at best tells very little about an individual physician.

Insurance companies should not have any role in profiling physicians. Profiling is bad for patients as well because it gives insurers’ dangerous control to determine how medicine is practiced.

Ironically the same organization that is so intent on profiling doctors was recently sued for fraudulent business practices against doctors (2).

Clearly, profiling is an insult to doctors and just another example of how bad it can get for doctors when they let insurers decide on standards for quality and cost-effectiveness. Eventually, profiling will be used to make doctors conform to the conveyor- belt policy that is suited for dealing with inanimate objects like automobiles, computers and radios.

Profiling represents one of modern medicine’s great inconsistencies. Because it is driven by strategies dedicated in part to generating profits for shareholders, it is incompatible with the qualities of caring and service that patients expect from doctors.


1. UnitedHealth Premium Designation Program. Brochure. United HealthCare Services, Inc. Oct. 2008.

2. Nielsen NH. United agreement a victory for fair pay for physicians. Amednews, www.ama-assn.org/amednews/2009/02/09

Ed Volpintesta MD

The Medpedia Project

On February 17, 2009, the online Medpedia platform was released in beta. A description from the site follows:

"The Medpedia Project is a long-term, worldwide project to evolve a new model for sharing and advancing knowledge about health, medicine and the body among medical professionals and the general public. This model is founded on providing a free online technology platform that is collaborative, interdisciplinary and transparent.

"Users of the platform include physicians, consumers, medical and scientific journals, medical schools, research institutes, medical associations, hospitals, for-profit and non-profit organizations, expert patients, policy makers, students, non-professionals taking care of loved ones, individual medical professionals, scientists, etc.

"As Medpedia grows over the next few years, it will become a repository of up-to-date unbiased medical information, contributed and maintained by health experts around the world, and freely available to everyone. The information in this clearinghouse will be easy to discover and navigate, and the technology platform will expand as the community invents more uses for it.
In association with Harvard Medical School, Stanford School of Medicine, Berkeley School of Public Health, University of Michigan Medical School and other leading global health organizations, Medpedia will be a commons for the gathering of the information and people critical to health care."

Humanitas or Humanism?

Because humanism is so frequently invoked in discussing modern medicine’s decline I decided to study its roots. I consulted several respected sources for a broader and more conclusive understanding. The Unabridged Oxford English Dictionary, Webster’s 3rd New International Dictionary, Webster’s New World College Dictionary, the New Encyclopedia Britannica, and the Encyclopedia of Philosophy all were helpful. I even consulted the Jan/Feb 2009 copy of The Humanist magazine.

These sources defined humanism variously as a system of thought that viewed human beings not only as rational but also as susceptible to error and that they could act ethically and solve their problems without recourse to supernatural or theistic beliefs. Other characteristics included the development of human potential, a sense of benevolence, mercy, and compassion and, interest in the limits of human nature.

One definition in particular impressed me. The New Encyclopedia Britannica made reference to the Latin humanitas. It included qualities I had never seen before.

It mentioned that humanists cannot be solitary persons meditating on the problems of mankind in isolation. That a person of letters or a philosopher is incompatible with the person infused with humanitas. The person with humanitas must strive for balance between a life of contemplation and action and, that right action and thinking must be proved in the battlefield and debate.

This definition of humanitas as the quality which impels one to take one’s place in the line of battle struggling for what is right and just, of being engaged in the front lines of combat is a new to me. Ordinarily I would classify these traits as virtue or courage. I had never considered them as part of humanism as the term is commonly used.

Infusing humanitas into physicians’ understanding of humanism is something to think about. Particularly in these days of hostility and resentment against the medical profession. Most doctors are in a constant struggle to maintain their integrity and freedom, not to mention their ability to survive financially.

Being engaged on the front lines of combat is important if humanism in medicine is to be preserved.

Ed Volpintesta MD

Are Doctors Infected With The Stockholm Syndrome?

Medicare is a great social institution. It saves millions of people from financial destitution.

But many doctors feel unfairly treated by Medicare's payment schedules. For the past two years Medicare has threatened to cut physician reimbursement by 10% in 2008 and by 20% in 2009. After an outcry from physicians, the cuts were eliminated and physicians were given increases of .5% and 1% respectively. Many physicians were relieved to see that the cuts were reduced and some groups including the AMA actually thanked the Medicare Payment Advisory Committee (MedPAC) for being so understanding.

But rather than thank Medicare for the tiny increases which some consider an insult, it would have been better if medicine’s leadership had preserved physicians’ honor and dignity by rejecting them outright.

This pattern of being threatened then given a small reprieve followed by thanking the oppressors bears great similarity to the so-called Stockholm Syndrome which Webster’s New World College Dictionary defines as a psychological state in which hostages sympathize or even become friendly with their captors.

When threatened by severe price cuts that seriously jeopardize their livelihoods doctors may not be kidnapped or locked in closets but they are hostages none the less. And thanking those who oppress them for being so understanding makes them victims of the Stockholm Syndrome.

Clearly, to go from a 20% cut to a 1% increase represents quite a difference in any physician’s income. But still, groveling before Medicare and thanking it for a puny 1% increase is wrong. This weak showing is sure to encourage private insurers to use the same strategy. By threatening to drop doctors from their lists for failure to conform to their standards for quality and cost-efficiency, private insurers will have another tool to control doctors. This control will become acute once electronic medical records are in place and every treatment, test, and consultation ordered by physicians will become instantaneously available to health insurers to see who conforms to their protocols and who doesn’t.

Far better for the future of medicine if its leadership had rejected Medicare’s 1% increase and dedicated the savings to lowering patients’ premiums.

Ed Volpintesta MD

Medical Home, Gatekeeper: Skunk Cabbage By Any Other Name Smells Just As Bad

An article in the Feb. 7, 2009 issue of the New York Times, “For I.B.M., Insurer Reopens Test of Rewarding Doctors for Healthy Patients” (www.nytimes.com) described a new way that insurers plan to make primary care doctors more effective, pay them more for their coordinating skills. The idea is to centralize all of a patient’s care through a central clearing house that is managed by the patient’s personal physician. This approach is supposed to cut down on unnecessary testing and consultations. But, to a large degree many family doctors already act as if they were running medical homes for their patients. It’s part of their professional duties. They set up appointments with consultants and provide follow- up care and do their best to order the necessary tests, coordinate nursing home and home health care.

Although the medical home is touted as innovative it is a resurrection of the “gate keeper” concept that insurers tried to get primary care doctors to sign on to in the early nineties. It failed then because most physicians felt that it burdened them with more work than they could handle, more responsibility than they should accept, and more pressure than they could bear. Doctors who accept the idea are supposed to get paid more for their “new” coordinating functions. But the danger is that primary care doctors will be deluged with more paper work than they can handle. Already paperwork consumes 20% or more of their time and on some days much more.

Increasingly, over the past few years patients are told by many health care providers to “see your primary care doctor” whenever irritating and time-consuming paper work has to be done. Once personal physicians are formally designated as the “medical home” base they will be inundated with more administrative work than imaginable. Not only will this subtract from the time they should be spending with patients but, any added income will have to be spent on ancillary staff to help with the added paper work.

As medical home doctors, as part of cost and quality control it is inevitable that every treatment they prescribe will be tracked by insurer’s electronic medical record systems to assure that doctors are following their prescribed guidelines. Doctors who do not or who are considered outliers will be penalized. Eventually doctors will succumb to insurers’ demands or suffer economic sanctions.

Guidelines have strong financial goals and they have strong potential to dehumanize the practice of medicine more than it is. Doctors may rationalize that by following guidelines they are providing good care but, once financial considerations are put into the equation, the doctor-patient bond becomes tainted and any physicians will be forced to put insurers’ profits ahead of patients’ needs.

Common sense and economic saving could be injected into medicine if a new contract could be entered into with the public. One that is more “clinical” and less “scientific” could significantly cut down on health costs without jeopardizing patient safety. For starters, are complete annual physicals really needed every year? How about the exhaustive batteries of tests we do, the results of which often are normal and often done for legal reasons or because the patient just wants them? It seems that every other CAT scan I do uncovers an “incidentaloma” that leads to more scans, consultations, and sometime biopsies, not to mention the time lost in ordering them and getting clearance from insurers and explain to patients why. Many patients suffer needless anxiety waiting for follow-up scans.

It seems that manufacturers of new medical tests and machines have an incentive to invent more of them because there always will be a ready market for them. Desirous of a competitive edge, physicians and hospitals, like patients are desirous of new technology even if the benefits are marginal. And of course there is always the legal imperative to do everything to avoid malpractice suits based on allegations of not having ordered the latest new-fangled test.

Public dialogue is woefully anemic in solving our health care system’s problems. Universal health care which is on our lawmakers’ minds won’t work unless a new contract is struck with patients. The process must be led by physicians and, not, as has been the case by economists and lawmakers. It must include tort reform and assessment of new technologies' unintended consequences including costs, diagnostic confusion and, any legal consequences that may arise for its non-use.

Ed Volpintesta MD

Physicians need to unionize

Sooner or later the time and energy wasted on suing health insurers like Cigna and Aetna [“ Medical Groups Sue, Say Aetna, Cigna Shortchanged Doctors”, Health Care, Feb. 11] www.courant.com will enrage and galvanize doctors into persuading the federal government to give them a dispensation from the laws that prohibit them from forming unions.

Fortunes are spent by doctors’ organizations fighting these large insurers for improper business practices. And doctors waste countless time and energy in servile obedience to the guidelines and regulations that they force them to accept; as a result they are becoming demoralized.

Runaway greed and excessive executive compensation have become routine procedure for some health insurers. The October 6 issue of American Medical News reported that a former CEO of one health insurer was paying back investors $30 millions as a result of a class action suit in California brought because of improper financial activities.

The health care system cannot make any significant progress towards establishing a universal health care system unless greed is eliminated. About 47 million Americans are without insurance and 18% of the GNP is consumed by health care. Yet the nation’s health on average is no better than countries that spend about 11%.

A health system based on providing profits to shareholders by minimizing services to patients, raising their premiums, and under-paying doctors cannot provide a solid foundation for the country’s future health system.

Physicians’ unions can provide the counterweight necessary to put balance into the system.

Ed Volpintesta MD

Talking to Patients

In “In Matters of the Heart, Luck Can Make All the Difference” (Science Times, Feb. 10) (http://www.nytimes.com/) the author relates the story of having seen several doctors including a cardiologist who failed to diagnose his cardiac disease. Finally, he consulted an old cardiologist friend who, although he lived three thousand miles away, knew him well and over the phone urged him to go to the hospital. He did and was seen by another old cardiologist friend, whose efforts resulted in the author undergoing a quintuple bypass operation. That was ten years ago and the patient leads an active life.

Isn’t it the most telling of medical paradoxes that in an era dominated and defined by CAT scans, MRIs, numerous medical specialists, sophisticated medical procedures; and frequent media accounts of extraordinary breakthroughs in medical research-- still what often matters most is a trusting relationship developed over time in which doctors get to know their patients well?
Often it is this relationship, as the article made clear, that allows doctors to foresee problems in their early stages.

Medical students and residents are missing this experience because of pressure to discharge patients from the hospital quickly in order to comply with financial regulations imposed by insurance companies. Over-reliance on scans and laboratory tests undervalues the importance of getting to know patients well. There is a danger that our training programs will be turning out medical scientists not doctors. Not only does this dehumanize medicine, but it also makes doctors less effective as healers.

The author’s story is a good example of the importance of listening to patients that Howard Spiro MD pointed out in his letter, "When Imaging Falls Short" which appeared in the Dec. 15, 2008 sciences times section of the New York Times.

Ed Volpintesta MD

Threat of malpractice suits primary cause of moral distress

Dr. Pauline Chen’s concern over the difficulties, the “moral distress” that doctors and nurses feel because of pressures put upon them by administrators, insurers , lawyers, patients’ families and even one another is timely (www.nytimes.com, Well Blog, Feb 5).

This problem is not new though. It has existed for over two decades or more. Particular emphasis however needs to be placed on the way opportunistic malpractice lawyers launched frivolous malpractice suits on innocent doctors. As malpractice suits increased in number and in size of awards starting in the mid-nineties, doctors found their malpractice insurance premiums going out of sight.

But besides the skyrocketing costs of their malpractice insurance, doctors were threatened by other consequences. Their reputations and livelihoods were often at stake, not to mention the emotional stress they were forced to undergo while a suit worked its way through the litigation pipeline, a process that sometimes took from five to seven years.

Thus, in efforts to ward off any malpractice suits and to have good defense in case one were filed, many doctors started to practice defensive medicine. That is, they frequently ordered more tests and consultations than necessary. This raised the cost of health care immensely. It attacked doctors’ integrity because of the unnecessary tests they ordered and the sometime heroic efforts and resources they spent on saving patients for whom there was little hope of ever saving.

This pressure to “do everything” in order to avoid suspicion of neglect or under treatment and allegations of medical malpractice created a schism between doctors and patients. Increasingly, doctors started to view patients as potential lawsuits and the media’s reporting of dramatic malpractice suits lessened patients’ confidence in doctors and the health system.

This situation continues and is not getting better. Eliminating the loopholes that permit frivolous suits against doctors will minimize the financial incentives that some opportunistic attorneys exploit. It will lessen the moral distress that doctors and nurses labor under.

One way of doing this is to substitute “health courts” for the traditional adversarial-based system that is currently used. Health courts run on the principle that aggrieved parties are willing to settle differences in a reasonable manner without resorting to the underhanded and unnecessary adversarial methods used now. Using this method, patients would receive their compensation in months and not in years. The animosity between doctors and patients would be minimized. Such a system already exists in some Scandinavian countries.

Legal Messages Waste Doctors' Time

In his February 1 column “On Call, and Making Decisions in The Dark” in the Hartford Courant (www.courant.com) Dr. Herbert Keating mentions being awakened at 1:30 a.m. by a call from a nursing home to inform him of a minor problem. General practitioners hate getting these calls because as he implied they are really legal messages, not medical ones. Nursing homes make them because they are afraid of frivolous malpractice suits.

Malpractice lawyers should read his column because it illustrates how the fear of frivolous malpractice suits has infected every area of health care. Doctors, nurses, hospitals, home health care agencies, visiting nurses, nurses aides, school nurses, ambulance workers—health workers of every kind are fearful of being hit with malpractice suits of one kind or another.

Fear of malpractice suits takes its toll in many ways. In the doctor’s case he lost a good night’s sleep unnecessarily. But it also causes millions of dollars to be wasted on needless tests and consultations and destroys the trust that patients have in doctors.

The costs of health care continue to rise and many patients are losing their health insurance. If lawmakers can eliminate the loopholes that allow frivolous malpractice suits they will have taken a giant step forward in controlling costs for everyone.

Ed Volpintesta MD

Economic Hard Times May Bring Common Sense Back to Medical Practice

RE “Small Payroll, but Big Woes on Insurance” (www.nytimes.com) by Kevin Sack, Feb. 3: Paradoxically, there is a good side to this story describing how some businesses cannot afford to pay for employees’ health insurance.

Economic restraint may force some common sense back into the practice of medicine.
Medicine has become unnecessarily expensive because of over-dependence on expensive laboratory testing and imaging studies like CAT scans and MRIs. As beneficial as these tests can be, they are over-utilized and are a major factor that drives the costs of health care ever higher.

Simple changes like limiting the so-called annual physical only to the most basic of tests and not necessarily performing them yearly is a good place to start. Also many tests are ordered as batteries that include many expensive tests that are included for the sake of completeness but more often than not have little value.

Ed Volpintesta MD

Empathy Can Be Taught?

Response to Dr. Pauline Chen’s “The hidden curriculum of medical schools”

I am skeptical about empathy being taught. I mean real empathy, not the superficial kind that may be mimicked just to please a professor. It is more likely that empathy is learned in childhood from one’s parents or relatives. It may even be genetically related. But, who can say for sure?

The empathy I see is the perfunctory variety tossed off by saying hello when entering patients’ rooms or calling them by their first names. It has some value but patients can tell if it is genuine and if their physicians are truly connecting and concerned.

Taking courses in the humanities is helpful for expanding one’s critical faculties and studying great poetry or novels may give insights into patient’s inner turmoil, but whether they can teach students to actually embrace empathy as healers and make it a permanent addition to their medical skills for the rest of their careers is questionable. The seeds of empathy can be sown but unless the ground is fertile, its roots will be weak.

Unfortunately whether empathy can be taught or not, many difficulties obstruct its being applied effectively. Doctors today are constantly distracted by a stream of little interruptions throughout the day. Any single interruption is minor but collectively they form a tsunami of distraction. Most doctors find them overwhelming and exhausting. Day and night, their fax machines are spewing lab reports, CAT scans, pharmacy requests; visiting nurse forms and home health agency forms—all of which need to be reviewed and either signed and faxed back or acted on by calling a patient or ordering a confirmatory test. Not to mention the many phone calls from patients that must be answered.

Exercising empathy in a suffocating environment like this would be a challenge even for a saint.
When teaching empathy medical school and residency educators should tell the students the obstacles that they will face in private practice that discourage empathy. Eliminating the multitudinous distractions that make medicine almost impossible to practice humanely is one important way to assure the survival of empathy in medicine.

Ed Volpintesta MD

Recertification testing for physicians

Re “Federation of State Medical Boards Eyes Relicensing Policy” (Family Practice News, Dec. 15. 2008):

Tying physicians’ relicensure to testing after they have already been certified, or even if they have not been, carries great potential to harm good and competent physicians.

This proposal will be particularly burdensome for primary care physicians (general internists and family physicians) who have been in practice for 15-20 years or more. Many of them will have tailored their practices to their strengths and weaknesses, the demographics of their communities, the number of available specialists available, and other factors. Subjecting them to a comprehensive test is impractical.

Instead they should be tested in those broad areas of knowledge that they actually practice in. Topics like diabetes mellitus, hypertension, heart disease and hyperlipidemia for example. And if they are found to be deficient in any particular area they should be offered remedial study. The tests should not be based on a pass/fail evaluation.

Out of fear some doctors already attend board review courses to prepare for recertification spending significant money ($1,000 or more) plus several days away from the office force-feeding themselves on material that has little relevance to their practices.

Good physicians possess many qualities that which cannot be examined in a test. Character, empathy, ability to work in a team, effectiveness in establishing a good therapeutic relationship with a patient, are a few.

What happens to a good doctor who does not pass a test? Is he to lose his license?

Keeping current is important of course and the vast majority of physicians do. Retesting assumes wrongly, that they don’t. They presume that after at least 11 years of training and years of experience, doctors cannot be trusted to continue studying what they need to know in their particular practices. I, like many, consider this an insult and an effrontery.

If the Federation of State Medical Boards (FSMB) truly believes that doctors cannot be trusted to stay current in those areas they need to be, then the FSMB should reexamine the admission procedures of the medical schools and quality of the students they accept.

The FSMB is supposed to help doctors not intimidate or burden them with more worries than they are already burdened with.