Wednesday, July 23, 2014

The Sunshine Act: Is it just another attack on the physician's character?

I’m concerned about what is happening to the image of physicians in this country. Throughout history, physicians have enjoyed a stellar reputation as noble, trustworthy and selfless professionals who champion their patients. Although times have changed over the millennia since Hippocrates, I see the embodiment of this spirit in my colleagues every day. Of course, like all human endeavors, we have our share of those who work on the fringe, who use their position and the trust instilled in them to take advantage of the system or the individual. That, too, I have witnessed.

I contend that these make up only a fraction of the profession and truly are outliers; however, several recent instances have spotlighted this fringe element of medicine, painting physicians as a whole in a negative light and trampling our good reputation. These things, initiated by our government, have come in the form of statements, regulations, policies, and laws which, intended or not, all potentially damage the image of the physician by implying our across-the-board complicit dishonesty, greed and abuse of the healthcare system.

I don’t know if this is the absolute genesis or just when I began to take note. In the summer of 2009, President Obama was working overtime to drum up support for his signature healthcare reform bill. He traveled across the country speaking multiple times a day to groups large and small. His passion was palpable and he was clearly well-prepared. At a press conference in late July 2009, the president told the press corps: “Right now, doctors — a lot of times — are forced to make decisions based on the fee payment schedule that’s out there. Your child has a bad sore throat or repeated sore throats. The doctor may look at the reimbursement system and say to himself, ‘You know what? I make a lot more money if I take this kid’s tonsils out.’ ”

What? Did he really just say that? Surely this man, who is basing his legacy on reforming the healthcare system of the United States, knows better. Surely he has competent advisers. He must have misspoken in the heat of the moment. But less than one month later, at a town hall meeting in Portsmouth, NH, the president went in for another jab. After detailing the medical treatment of a diabetic patient, which he states “might reimburse a pittance,” he said, “But if that same diabetic ends up getting their foot amputated, that’s $30,000, $40,000, $50,000 — immediately the surgeon is reimbursed.”

There are so many things wrong with that statement, starting with whether internists are letting diabetics get worse for the financial benefit of their surgical colleagues and progressing through a series of increasingly absurd statements to the side-splitter that “immediately the surgeon is reimbursed.” This is from the mouth of the president of the United States, with all of his resources and all of his advisers and all of his presumed knowledge of this system he is determined to completely redesign. Why would he say something so damaging to the trust between doctor and patient?

This past April, we saw the fed’s public release of raw, unverified Medicare physician payment data that showed tens of billions of dollars paid out to physicians. No explanation was given of the work that was done for those payments. This incited a media dog-pile that focused on a tiny fraction of physicians who collect millions of dollars, creating an air of suspicion without justification. Never mind the meager reimbursements for the work we performed or the flawed (SGR) system for determining payments that Congress refuses to permanently fix. Despite the nobly declared intention of rooting out fraud and abuse, this data dump seemed to serve no real purpose other than to paint physicians as greedy and to foster ill will. 

Brace yourselves, as the next salvo soon will be cast across the bows of medicine in the form of the Physician Payments Sunshine Act under the National Physician Payment Transparency Program.

The Sunshine Act, a part of the Affordable Care Act, requires manufacturers of pharmaceuticals, medical devices, medical agents, and supplies to report “payments or other transfers of value” greater than $10 (or $100 aggregate annually) to the Center for Medicare and Medicaid Services. The payments will be posted on an Open Payments website to let the sun shine on possible conflicts of interest. Those in the medical industry have been required to track these payment and so-called “transfers of value” to physicians since Aug. 1, 2013. These include consulting fees, honoraria, food, education, research, royalties, grants, and current or prospective ownership to physicians or their relatives. Physicians need not do a thing. Just sit back and take it.

As of January, physicians could begin registering with CMS for the ability to review, in advance of publication, the payments they allegedly have received over the year. There will be a 60-day review period prior to the Sept. 30 publication date. That is 45 days to review the information and 15 days to correct any errors. The physicians must work directly with the manufacturers to correct any inaccuracies. CMS washes its hands of any verification or corrections. If the dispute isn’t settled by the publication date, the payment in dispute is published anyway but with an asterisk. Despite being electronic, the data will be revised only once a year — so, whatever goes up on the website, you, the physician, owns for that year.

I tried to register on the CMS website, and I believe that CMS hired the same company that created I spent more than an hour trying to find the physician registration after meandering through page after page. Once I found the registration page, it was not a problem. So, for those of you who have stuck with me through this diatribe, here is my gift to you: It took two attempts and cost me a few handfuls of hair, but I did it. When you register, be sure to have plenty of time and Propecia. 

These government actions raise several questions:

What effect will this Sunshine Act have on physicians? 
It’s hard to say. For a while, we’ll think twice before letting a drug rep into the office with a box of donuts. The Act may slow the dissemination of information on new drugs and devices. Front-page newspaper stories will feature physicians who are bringing in big bucks from the medical industry. But in the end, implementation of The Sunshine Act simply will be another waste of taxpayer dollars, another bureaucratic hurdle for manufacturers that will add to the cost of drugs and medical devices, and another sucker-punch to the eye of medicine. A more fruitful effort would be implementation of a Congressional Sunshine Act, but we all know that will never happen.

Why would there be an image campaign against doctors? 
The vast majority of physicians are honest, but a small number are not. These certainly are outliers, so must Congress think only of these outliers as it legislates? It is clear that the federal government wants deeper involvement in health care, and some people have suggested that in order for the government to justify involvement in an area not specifically within its duties, it must demonstrate a need, such as protection of the public (see Michael Crichton’s book, “State of Fear”). Perhaps the vilification of physicians is a tactic to gin up public concern and thus support government’s deeper involvement in health care. Certainly the complex and ever-changing rules and regulations of Medicare, OSHA, HIPAA, and the looming ICD-10 are making it more difficult for physicians to walk the straight and narrow, and making each of us just one step away from a breach.

How should physicians respond to these actions? 
We must continue to keep in contact with our state and federal legislators, and encourage them to press for elimination of those laws and regulations that have little real value and are costly and destructive. We must support the efforts of our physician advocacy groups, such as the TMA. We must do our best to keep up and comply with this ever-changing sea of regulations. We must maintain good relationships with our colleagues because together we stand and apart we will, no doubt, fall. We must continue to practice good and ethical medicine. But most importantly, we must continue to maintain close relationships with our patients so they will know us as we truly are and will see through the smoke-screen.

This post originally appeared in the President's Page of the July 2014 Dallas Medical Journal.

Tuesday, May 27, 2014

Is North Texas prepared for a disaster with mass casualties?

by Todd Pollock, MD, 2014 President

“Hope for the best; prepare for the worst.”
—Roger L’Estrange, 1702

Hurricane Katrina formed over the Bahamas on Aug. 23, 2005, and strengthened to a Category 5 hurricane in the warm gulf waters before striking New Orleans on Aug. 29. The city survived the initial assault, but death and destruction followed the catastrophic failures of key levees. The hurricane left 1,833 people dead and untold numbers of people injured, despite the city’s mandatory evacuation and prearranged evacuation centers, such as the Superdome, that housed more than 25,000 people who could not evacuate. The world watched helplessly on cable news as the tragedy played out.
In April 2009, an outbreak of influenza began in Veracruz, Mexico (later research points to ground zero possibly being in Asia), and Mexican authorities tried to contain the spread. Their efforts were unsuccessful and a worldwide pandemic ensued. This H1N1 influenza, similar to the virus responsible for the 1918 pandemic, mutated to kill not just the weak but also the previously healthy and strong by causing pneumonia and ARDS in a small but significant number of its victims. When the virus finally relented, more than 284,500 deaths were confirmed. However, likely more than 500,000 people had died, based on estimates that included deaths that were not confirmed by laboratory testing or were in people who did not have access to medical care. 
On April 15, 2013, at 2:49 p.m., two pressure-cooker bombs exploded near the finish line of the Boston Marathon. Three people were killed and 264 were injured in the blast set by two Russian-born brothers with extremist Islamic beliefs thought to be in retribution for US military involvement in Afghanistan and Iraq. A subsequent plot to attack Times Square was uncovered in the bombing investigation.
A little more than a month later, on May 20, 2013, tornados touched down west of Newcastle, Okla., at 2:56 p.m. and headed east, striking Moore, Okla. (pop. 57,000). Staying on the ground for 39 minutes, the tornado created a path of destruction 17 miles long and nearly 2 miles wide. With wind speeds of more than 210 mph, the EF5 tornado caused incredible damage. The National Weather Service had issued a tornado watch for the area at 1:10 p.m. and upgraded it to a warning at 2:40 p.m. It struck Moore proper around 3 p.m., giving this seasoned tornado-alley town more than 30 minutes to prepare. Despite this, 24 people were killed and 377 were injured.
Whether a warning is issued weeks, days or hours before an event, or not at all, many challenges exist in the organized and ethical distribution of first aid, triage and medical care; prevention of secondary infections; and utilization of limited resources.
Physicians have to make tough decisions in the heat of a crisis. Without planning or predetermined guidance, decision-making becomes even more daunting.
The North Texas Mass Critical Care Task Force was formed to address this. This regional collaboration is led by physicians and includes public health leaders, hospitals, ethicists, clergy, legal professionals, emergency management professionals, and elected leaders. The mission of the task force is the adoption and implementation of nationally recognized clinical guidelines for healthcare providers to use uniformly across North Texas in the event of an overwhelming disaster.

Efforts began in 2009 when the Dallas County Medical Society’s Community Emergency Response Committee asked the DCMS board for permission to address this issue. Under the chairmanship of John Carlo, MD, the committee began its work by focusing on the efforts of Robert Fine, MD, and the Baylor Health Care System, which had adopted a systemwide set of clinical guidelines based on the Institute of Medicine’s recommendations.
Soon after the committee started its work, DCMS became aware of the efforts of the Tarrant County Academy of Medicine Ethics Consortium, which had been working since 2006 to address ethical issues that might arise during a widespread infectious outbreak that strains healthcare resources. This led DCMS and the Tarrant County Medical Society to create the regional task force with Drs. Carlo and Fine, and two physician leaders from the Tarrant County Medical Society, Drs. Sandra Parker and Kendra Belfi, as the four cochairs.

Where the System is Vulnerable
The task force focused on two choke points in the critical care system — indications for emergency care/hospital admission and for ventilator allocation. Having consistent guidelines for these areas would better distribute the scarce resources and ensure the maximum number of survivors. Unfortunately, the state was nowhere near offering statewide guidelines, and task force organizers decided the group should not delay its work.
Fairness and consistency must be the ethical basis of any framework that allocates treatment in the face of limited resources. Therefore, the task force developed a decision-tree algorithm that protects patients by ensuring all are treated equally, regardless of considerations such as economic, social or political status.
The algorithm also protects the physicians who must make the difficult decisions.
In the aftermath of Katrina,
physicians were second-guessed and allegations of mistreatment, malpractice and even murder made headlines. Uniform guidelines give providers a well thought-out, predetermined and ethically based algorithm to follow to avoid Monday-morning quarterbacking.

The North Texas Mass Critical Care Task Force was guided by four goals:
to ensure maximum survival of individuals,
to ensure appropriate treatment is provided fairly and consistently,
to identify “best practices” in the use of the limited resources, and
to recruit the necessary leadership.

These guidelines are intended for use in Dallas, Tarrant, Denton, and Collin counties, and are to be activated only upon the governor’s declaration of a state of emergency. They do not trump individual physician judgment, but rather provide a well-reasoned and uniform framework for clinical decision-making and resource allocation in the fog of a disaster.
Draft Guidelines
After years of work, the task force has developed both adult and pediatric guidelines which provide a protocol for triage of patients, and make the best use of hospital and ICU resources that can be overwhelmed in a disaster. This draft has been approved by all involved county medical societies, hospital systems and county health departments, and the state has sent a letter of support. The protocols are based on three levels of incident severity or triage levels. Level 1 is early in a disaster or pandemic and is more preparatory in nature; Level 3  is worst-case scenario in which the strictest measures are implemented.
To ensure that the greatest number of patients survive, a modified Sequential Organ Failure Assessment (SOFA) scoring system — an objective and evidence-based formula — is used to determine an individual’s survivability. This score considers pulmonary, renal, hepatic, cardiac, and neurologic indicators to generate a score of 0–24. This score determines algorithmically the priority for hospital admission and for ventilator use, if indicated. Patients are considered low priority for hospital admission and/or mechanical ventilation if they have a low severity of illness (SOFA = 0) and thus a high chance of survival without treatment. Patients also are considered low priority for hospital admission and ventilator use if they are too severely ill (SOFA > 11) with a low chance of survival even with aggressive intervention. The most intense interventions are focused on those with the greatest clinical need and with the highest chance of survival with intervention. Every patient who needs care will receive care, although that care may strictly be palliative. The recommendations vary based on the triage level.

Your Guidelines, Your Voice
These guidelines, while fairly complete, continue to evolve and remain open for changes based on feedback and new ideas. It would be ideal if the Legislature passed safe-harbor protections for people who follow these guidelines. Unfortunately, challenges in regionalized legislation make this unlikely, and we must await a statewide plan before legislation will be considered. The Texas Department of State Health Services has notified the task force that it intends to create a statewide plan over the next two years and has invited us to participate in its development.
Feedback from physicians is most critical because we are the ones who must follow these guidelines. We must understand the basis of the guidelines and be comfortable that they are in the best interest of our community. Our patients will turn to us for answers when disaster strikes and medical care is sought, and we must be familiar enough with these guidelines to properly advise them and speak with a unified voice.
The draft guidelines, background material and minutes from task force meetings are available at
It is important that your voices are heard before disaster strikes. Please look over the guidelines and contact Connie Webster, senior vice president of operations, at 214.413.1426 or if you have questions or suggestions. Let’s hope that we never have to face a crisis of the magnitude that would stress our abundant healthcare resources. But if we do, we can rest a little easier knowing that we have prepared for the worst.

Thursday, April 17, 2014

DCMS President Responds to CMS Data Dump

In a stated effort to be “more transparent” and “help patients make informed decisions about the care they receive,” the Center for Medicare & Medicaid Services (CMS) has released information on its payments to physician. This made the headlines of every news show and newspaper last week. Headlines reveal staggering dollar amounts paid out to the physicians who serve the elderly and disabled, and highlighted a handful of physicians who collected millions. Conventional wisdom amongst physicians is to avoid the topic of compensation, but this information release and the headlines that followed necessitate a response to inject some balance and perspective.

Is this raw payment data helpful to the public in making informed health care decisions? It is highly unlikely and is more likely to deceive and inflame the public. To start, the number of physicians who collected millions of dollars from Medicare — the focus of the headlines — is represents less than 0.4% of physicians in the U.S., with a similar percentage in Texas. And, the dollar amount a physician collects tells nothing about that physician’s net income, quality of the care they provide, or whether there is any waste, fraud or abuse associated with those payments. The vast majority of physicians collects much smaller amounts and is in fact poorly compensated for the work they do by these government insurance programs.

The reality is that payments from Medicare are meager and barely cover expenses. On average, 61 percent of Medicare’s payment goes towards the treatments’ overall cost —expensive drugs, medical supplies and other expenses of running a business. The problem starts with how Medicare payments are determined. In medicine, unlike other businesses, charges don’t reflect what physicians are ultimately paid for the services they provide. The amount physicians are paid by CMS for a service they perform is derived by a formula adapted by congress in 1997 with the express purpose of controlling costs. These fees have not been increased, despite inflation and increasing medical costs, since its inception. In fact, using this formula, Medicare payments to physicians would have been cut 24.1 percent this year had Congress not stepped in to avert it. This unfair payment formula has been slated for overhaul for over a decade, but instead it was kicked down the road for the 17th time with a short-term patch. The unwillingness to permanently address this important payment issue has caused great concern among physicians, further limiting patient access as physicians often limit the number of new Medicare patients they accept into their practices.
CMS admits that this data has limitations as it acknowledges that the information has not been verified, does not account for the disease severity of patients being treated, does not account for overhead costs of the treatments, and cannot possibly asses the quality or, more importantly, the value of care. In fact, due to the potential for inaccuracies and lack of context, this raw data is more likely to mislead the public rather than aid them in making an informed decision about their health care.

Despite this poor reimbursement, most physicians continue to treat the Medicare community out of a deep feeling of commitment to serve their patients. There is almost certainly waste, fraud, and abuse in any system as large and with as much money in play as Medicare. As a taxpayer, when waste is found, I absolutely want CMS to root it out and develop ways to avoid it. When fraud and premeditated abuse are uncovered, I expect it to be prosecuted to highest degree allowed by the law. But, this raw data — unverified and lacking in perspective —has garnered headlines and unfairly portrays the physician as at best, excessively compensated, and at worst, criminal. Rather than focus on the few who collect large sums, this information release should shed light on how inadequately most physicians are compensated under Medicare. Only a more detailed analysis of the typical physician’s Medicare compensation will provide patients and policy makers with a more accurate picture. 

Todd Pollock, MD
Dallas County Medical Society President

Friday, April 11, 2014

Organ Donation — Plan to Give the Gift of Life

by Todd Pollock, MD, 2014 President

On a beautiful Saturday afternoon last September, a good friend of mine laughed and joked with his wife and two daughters as he got on his 1993 Harley Fat Boy to meet a friend for a leisurely ride in the countryside. He was an experienced and cautious rider. When he never arrived back home, his wife found him at Parkland, admitted as a “John Doe” after being struck by a car that entered an intersection against the light. His helmet did not prevent a severe head injury and he incurred several other injuries. 

His wife, confused and in shock, called me for help as I was a doctor, and she knew I had trained at Parkland and may have some insight. My wife, Kasi, and I spent a long night with her in the Parkland ICU waiting room, sitting in as the neurosurgeon explained things, comforting her and helping her understand the medical jargon. After he was stabilized and extensively assessed, physicians determined that his head injury was not survivable. 

A young, healthy, bright man with a beautiful, loving family and a wonderful future was struck down in a second, changing forever the lives of his family and of his many close friends. I can’t remember ever feeling such profound sadness. His wife kept telling me how thankful she was for my help that night, but all I could think about was that I never had felt so helpless and how badly I wanted to do something of substance. 

As physicians, we have experienced these life and death situations, but usually in a more clinical and emotionally tangential way. We give an update to the family, briefly share a moment, and then move on. Certainly, we care and we feel — but we compartmentalize. 

Much later, I realized that what my friend had appreciated was simply our presence — she didn’t have to go through the experience alone. I remember thinking how remarkably clear her thoughts seemed and how gracefully she handled herself through this terrible time. Most remarkably, through the fog of this horrible tragedy, this wonderful woman retained the goodness in her heart to give her husband’s organs for transplantation. She was able to turn what was a devastatingly negative event for her family into one with profoundly positive effects for many other families.

This was an eye-opening experience for me. I have been fortunate to have spent most of my life on the doctor side of the equation. As physicians, we are used to building emotional walls. We marvel at the incredible science of medicine and, in this case, organ transplantation. The storied history goes back centuries — from rudimentary attempts at grafting to Carrell’s pioneering experiments and anastomotic suturing techniques, (fellow plastic surgeon) Joseph Murray’s first renal transplant, and Jean Borel’s discovery of the immunosuppressive properties of cyclosporine isolated from fungus, to name a few. Every step along the way is more fascinating and amazing than the previous. 

But then there is the other side — the human side. These are the lives that must be taken away for this amazing process to take place. These are the people who are touched by the passing of a child, a spouse, a parent, or a friend. This is the situation that physicians experience by virtue of our profession and by the randomness of being on call or working a shift. If we blink and if we don’t stop and smell the coffee, we may miss the honor and privilege we have as physicians to share this important, life-changing moment with our fellow human beings. Also part of this human side are the people whose lives are saved or immensely improved by another’s tragedy. 

The Gift
The two sides of this story — the loss of a life and the giving of a life — are told beautifully by Tara and Todd Storch in their book, “Taylor’s Gift.” They share the story of the loss of their 14-year-old daughter, Taylor, in a skiing accident and the donation of her organs. Through their words you feel the indefinable grief that accompanies the loss of a child, and a view of the hospital and the medical process from a perspective that physicians typically don’t have. As the father of a 13-year-old daughter, it was a tough read and required a lot of Kleenex. 

The Storches also shared the stories of the individuals who received Taylor’s organs. Their emotional and spiritual journey getting to know the recipients depicted how their daughter lives on through them. There was the diabetic cowboy who received Taylor’s kidney and pancreas … the nurse with two young boys who received Taylor’s heart … the young man with renal failure who dreamed of bike riding and who received a kidney … and the young girl with intractable headaches, eye pain and vision loss who was given Taylor’s corneas. But the donations did more than alleviate their medical conditions; they provided the gift of freedom for the recipients to go where they want and accomplish their goals. They received the gift of watching their children grow and the gift of being independent. Organ donation isn’t just the gift of life but the gift of living a complete life. That was Taylor’s gift.

The Numbers
According the US Department of Health and Human Services, more than 113,000 people are on the organ transplant list awaiting a donor, and a person is added to that list every 10 minutes. Over 11,000 of those awaiting transplant are in Texas. And, while nationally 79 people receive an organ transplant each day, 18 people die per day waiting for one. 

In preparation for writing this, I spoke with Todd Storch, who has become an ardent supporter of organ donation. He and his wife started Taylor’s Gift Foundation to educate the public and promote donor registration, asking individuals to register to be an organ donor and “outlive yourself.” He explained the great disconnect between people’s support of organ donation and their registering as a donor. Although nine out of 10 people believe in organ donation, most of those able to register have not done so. Only 7 percent of eligible Texans are registered organ donors. I have been told that due to efforts of the Texas Department of Public Safety through the DMV and groups like Donate Life and Taylor’s Gift, the registration in Texas is now above 20 percent. However, I have not been able to document that statistic. This pales in comparison to a national average of about 40 percent of citizens over 18 years old, ranking Texas an embarrassingly 49th in the country in 2011, according to the Donate Life America Annual Report Card.

He explained some reasons for this disparity. First, it is human nature (at least in our culture) to avoid thoughts and talk of death and our own mortality. Therefore, people tend to put off conversations with family about their wishes and the process of registering as organ donors. Second, misinformation prevails about organ procurement, such as the fear that physicians will not do everything to save a patient’s life if they know the patient is a donor. Many religious misconceptions persist, although most major religions support organ donation. 

Another major factor for Texas’ low registration rate is people’s mistaken belief that they already are registered. In 2007 when Texas moved to an Internet database, the system purged many registrants, so it is critical that you confirm your registration. Each state runs its own registry. In Texas, Donate Life Texas is a nonprofit organization that is contracted by the state to maintain the registry and educate Texans about the benefits of organ donation. (Note: This organization officially is called the Glenda Dawson Donate Life Texas, named after the kidney transplant recipient and state representative who led the effort to create the registry.) You can register or confirm your registration at It takes only a minute. The state registration lists are shared with and accessible only by the national organ procurement organization, United Network for Organ Sharing (UNOS), which maintains a centralized database. 

When a deceased donor is identified, the hospital contacts Southwest Transplant Alliance, our local organ procurement organization. A transplant coordinator communicates with the UNOS computer network to generate a rank list of potential recipients based on compatibility tests such as blood type, antigen and tissue matching, length of time on the list, degree of urgency (for some organs), immune status, and distance between donor and recipient. A single donor can save as many as eight lives and, with tissue donation, can make life better for a whole lot more.

April is National Donate Life month. You can take just a few simple actions and make a critical difference in so many lives. Take the time to register or confirm your registration. Have that difficult conversation with your family, and educate your friends and patients. 

Todd Storch compares organ donation to life insurance. The contemplation and purchase of life insurance is difficult, but you buy it — not for yourself, but for the benefit of your survivors. Like life insurance, organ donation provides for your survivors, but there are no premiums.

I miss my friend Mike, but I am comforted by the thought of him “outliving himself” through his organs.

Dedicated to my friend Mike May, his family, and the people who are alive and living a better life from his gift. 

This post originally appeared in the President's Page of the April  2014 Dallas Medical Journal.

A Journey Through Time, Courtesy of the DMJ

by Todd Pollock, MD, 2014 President

It is hard to believe that the Dallas County Medical Society humbly began 138 years ago in April. It began as the Medical Society of the City and County of Dallas, with 17 physicians meeting weekly to discuss cases and the business of the day. An unexcused absence would cost you $1 (about $25 in today’s dollars, according to a quick Internet search). After a few fits and starts, the society took on its current name in 1884 with 30 members. Can you imagine the stories this organization could tell over those 138 years? 
In 1914, the society began the Dallas County Medical Society Bulletin to tell those stories. In 1919, it was renamed the Dallas Medical Journal. The complete archives from 1919 to present, in bound volumes, can be found at the DCMS office. A little quick math (no Internet search needed) reveals that 2014 is the 100th anniversary of our little journal. So I decided to take a field trip down to the DCMS office to peruse those old volumes and to journey through that history. 
Through the words of the journal, I planned to travel to a few interesting points in the history of Dallas, the United States, and in medicine. I started my journey with the first bound volume, which was late 1919 and 1920. I opened the volume of fragile, yellowed pages and thought about what was happening at that time. Of course, that was in the middle of the 1918 flu pandemic (1918-1920) that infected 500 million people and killed as much as 5 percent of the world’s population. I did not find direct reference to the worldwide pandemic, but its presence was evident. In those days, each journal contained a report from the Bureau of Vital Statistics, and I randomly selected one to review. In March 1920, there were 275 influenza cases reported. Of the 193 deaths in Dallas County (approximate population 200,000) that month, 17 deaths were from influenza (nearly 10 percent) second only to the 23 deaths from pneumonia (some of which likely were secondary infections of influenza). Interestingly, only nine cancer deaths and no cardiac-related deaths were noted. A June DMJ article titled “Important Roentgen Ray Findings in the Chest” stated that this fairly new technology was an “especially important subject with us because of the many chest complications following the influenza.” It reported about 500 “Roentgen Ray” exams of the chest, of which 90 percent were related to patients with influenza.
Although the tone of the journal in the 1920s was a little more formal and stiff, there was the occasional attempt at humor. For example, the January 1920 edition included a report from New York titled “Girls Ban Kisses as Epidemic Grows,” telling of a group of young women who formed a society sworn to refrain from kissing until the flu epidemic passed. The report ended with the statement that “we would rather not insinuate that it was necessary for our Dallas girls to refrain.” Each edition also included joke. I looked through several to find one to include, but suffice it to say that none has stood the test of time.
I jumped ahead to the January 1942 journal, the first volume published following the bombing of Pearl Harbor. There were no jokes in this edition. The journal begins with a message from the new society president, John L. Goforth, MD, who acknowledges the job ahead for DCMS members will be a tough one as “much will be expected and demanded of the medical profession in the immediate future.” He asked for “full, enthusiastic and constant cooperation of each member of the society.” This was followed by a passionate and moving note from editor W.W. Fowler, who set the journal’s tone with statements such as: 
Forces of evil are endeavoring to destroy every vestige of our freedom and liberty, but we sincerely believe that right will prevail. The great self-sacrificing and noble profession of medicine in America has ever stood for freedom and liberty in every avenue of life, and by the help of God we hope to see these principles for which our forefathers fought, triumph over our enemies.
His words fill the reader with pride of country and profession, and are worth a complete read. Each journal during the war years listed DCMS members who were serving in the military, plus their branch, rank and where they were stationed.
I decided to move on to better times. On Sept. 25, 1954, the doors of the current Parkland Memorial Hospital opened for business as “Operation Transfer” was initiated. That Saturday morning a fleet of 30 ambulances caravanned down Harry Hines Boulevard, transferring patients from the old facility at Oak Lawn and Maple to the new hospital. Two months later, Southwestern Medical School would open the basic science building, the first “unit” of many to come. DCMS President Frank A. Selecman, MD, describes this as “a part of the Great March of Medicine, and will bring added honors to Dallas as a growing Medical Center.” The facility was state of the art. “To attempt to describe the new building in the space allotted would be impossible, but in summary fashion can best be described as a ‘hospital of tomorrow.’” 
A short time from now, an even newer Parkland will open with facilities that will be equally as hard to describe. Parkland will be a shining symbol of the outstanding medical community Dallas has become and will continue that “Great March of Medicine.” 
The DCMS mission statement in part is to “promote a healthy community” and our Society has a long history of involvement in public health initiatives. This aspect of the Society clearly was demonstrated in the fight against poliomyelitis. In the mid-1950s, Dallas was selected as a site for mass inoculation of second-grade students with the new Salk vaccine. Because of the pressure to get the vaccine out to the public, the scientific evidence on the safety and efficacy of this new vaccine was not available publicly. The DCMS Public Health Committee stepped in, spending hours to thoroughly review the evidence and experimental data before approving this mass inoculation program. 
The medical community and the Society were heavily criticized for this perceived delay, but the Society did not waiver from its principles of protecting the public. This was clearly articulated by DCMS President, R.E. Lee, MD, in his May 1955 President’s Page. In the end, DCMS approved the inoculation program on the basis of a complete scientific analysis and went on to lead the inoculation program. In 1962 the Dallas Times Herald would laud the leadership of the Dallas County Medical Society for organizing the two “Sabin Sundays” where thousands of professional and lay volunteers vaccinated hundreds of thousands of people. 
Of course, no trip down Dallas’ Memory Lane would be complete without a look at the feelings that were generated by the tragic events occurring on Nov. 22, 1963. President Max Cole, MD, wrote of the “shock and grief” Dallas shared with the nation in the assassination of President Kennedy. He also pointed out the shock regarding circulating implications of Dallas being, in some way, guilty. Over the loss of a president and the irrational implications, he wrote, “Our city has been hurt. The hurt is there — and healing is necessary.”
I had a great time reading through those old journals. So many interesting articles, pictures, ads, and store names (remember Skillern’s Drugstore?) that were nearly lost memories. In this journey back through time, I realized that nothing is ever really new. Issues our predecessors struggled with in the past are reprised today and likely will be around in the future. Concerns the medical community wrote about 50 or even 100 years ago often could be reprinted today verbatim.  Ethical and moral concerns regarding the profession, concerns that the government will destroy medicine with this piece of legislation or that, the out-of-control costs of medical care, malpractice abuse, insurance company interference — all seem to repeat themselves time and time again. Yet the medical profession persists, just as noble and just as gratifying with continued advancement in curing disease, improving health and extending happy and productive life.
When I agreed to take on the role of DCMS president, one of my biggest concerns was the duty of writing the monthly president’s page. My adventure of looking back at history through the eyes of the journal didn’t alleviate those fears. I now appreciate more than ever how the journal provides a contemporaneous history of Dallas medicine and the presidents shoulder much of this responsibility through the views they express in their monthly essays. 
To honor and celebrate the Centennial Anniversary of the journal, an ad hoc DMJ Centennial Committee made up of three brave, past presidents — Drs. Gordon Green, Richard Joseph and Fred Ciarochi — have been tasked with reviewing all 100 years of the Dallas Medical Journal, a decade at a time. They will select the most meaningful, impactful and interesting essays, commentaries and President’s Pages in the journal’s history. The selected excerpts will be reprinted each month, starting in this issue. At the end of the year, the best of the 100 years will be selected and reprinted. I truly look forward to seeing what they come up with. Now that I understand the important role I have in documenting history, I’d better start thinking about what to write next month.

This post originally appeared in the President's Page of the March  2014 Dallas Medical Journal.

Dr. Pollock's Installation Speech 2014

President's Speech
by Todd Pollock, MD
Remarks presented at the DCMS Installation dinner on January 23, 2014.

I am deeply honored and humbled to be installed as the 131st president of the Dallas County Medical Society. Over the last several months, I have spent considerable time thinking about what I will be dealing with over the next year. There is little doubt that unanticipated challenges will pop up, such as the West Nile Virus epidemic that hit our area in 2012 that occupied countless hours of then-President Rick Snyder’s time or the difficult decision to discontinue the successful Project Access Dallas program because of funding issues. 

What anticipated events are coming down the road in 2014 that will affect the practice of medicine in Dallas? The new Parkland will be nearing completion and the efforts will continue to improve the care given in this integral piece of the Dallas healthcare system. We’ll face implementation of the 1115 waiver and its effect on the distribution of millions of healthcare dollars into the medical community. Probably the most overwhelming effects on the practice of medicine in Dallas, in Texas and in the nation as a whole will be the consequences of the implementation of the Affordable Care Act (ACA).

No matter on what side of the politics you fall, there is no debating that the ACA will have a profound effect on the practice of medicine in this country. This vast and far-reaching law will have effects that are predictable and many that are unforeseen. I anticipate that the law’s implementation will be looked back on as the focus of Dallas health care in 2014, and the repercussions will be felt most at the local level by the end users — the physicians and patients. The predictable positive effects, such as coverage for those with pre-existing conditions, extension of dependent coverage, elimination of lifetime limits, coverage for preventive care, and expansion of coverage to millions of uninsured, are difficult to argue with, at least on the surface. The Dallas medical community likely will face a great number of challenges and we must be prepared to navigate, adapt and, hopefully, conquer as the new healthcare landscape unfolds. My hope is that DCMS will make itself a valuable asset to its members in responding to these anticipated and unanticipated challenges.

The Challenges
So, what challenges of Obamacare might we anticipate? And yes, you heard me right, I called it Obamacare. Not out of disrespect —  I just find “affordable care act” ironic as I can’t see how this law isn’t going to make health care much more costly. This brings me to the first challenge — cost. The woes of the dysfunctional $600 million website are only the first symptom. Insurance premiums generally have gone up for 2014 and are expected to go through the roof in 2015. Copays and deductibles also are on the rise, leading to more out-of-pocket expenses for our patients. Millions of insureds have been dropped from their plans as a function of cost. Those who are shopping the exchanges are experiencing such sticker shock that the government blocked viewing of the premiums until the users register. Because of these high premiums, many people who always have had health insurance are considering paying the “penalty” (or “tax”) and going without coverage. Numerous new taxes and fees have been implemented. One of note is a tax on medical devices, which no doubt will be passed on to the consumer and stifle innovation. The costs are endless, and it is hard to believe that the economics are sustainable.  

Another major challenge will be in understanding this complex system with a myriad of new rules and regulations. Patients expect their physicians to have an intimate understanding of the system. And yet, studies have shown that physician understanding is only marginally better than the public’s. This isn’t surprising when the ACA bill is thousands of pages of legalese, and the regulations — most of which have yet to be written — will fill more than ten times that. It is this disconnect in information that is generating fear among physicians as well as our patients. This lack of understanding will result in frustration and worry, and even has spawned a cottage industry of fraud where everyone is a potential victim. The TMA has set up the “Hey, Doc” web-based video series to educate physicians on questions they may face from their patients. It is my hope that DCMS will join TMA in taking a leading role in educating our members.

I also am concerned about patients’ access to care. As physicians, we understand that just because you have an insurance card doesn’t mean you have access to care. Medicaid expansion may give health insurance to millions of people previously without, but those new enrollees may find few doctors who accept their plan because of the poor reimbursement and the inherent bureaucratic nightmare. For now, Texas is taking a pass on Medicaid expansion. But political pressure is rising. Recent surveys show that only 19 percent of Texas physicians take new Medicaid patients, and that number is falling. Patients who are participating in the exchanges may have trouble as well, as networks are limiting their numbers of physicians and hospitals in an attempt to keep costs in check. 

Additionally, for most exchange plans that have released their reimbursement figures, those numbers are, at best, disappointing, which further inhibits physician participation. The DCMS board of directors is anxious to find ways to reach out to those in need. Programs such as DCMS CARES are in place, and from the ashes of Project Access Dallas, a Blue Ribbon Task Force for the Underserved has been formed to develop strategies for providing healthcare access to those in need.

A significant shortage of doctors, especially primary care physicians, has been forecast. This doesn’t take into account the number of physicians who will retire early, many influenced by the new healthcare law. In a recent survey, 42 percent of physicians said that the new law would influence them toward early retirement, and nine out of 10 physicians would not recommend medicine as a career to their children. This is a sad commentary on our attitudes toward our noble profession. Texas may have some buffer to this trend, as we have seen large numbers of physicians migrating to our state for its favorable economy and malpractice reform efforts.

My Perspective
Now, I am a plastic surgeon, and although I perform reconstructive surgery and other insurance-covered procedures, my practice has a greater proportion of cosmetic, self-pay patients. My practice is not as directly affected by these systemic changes as the practices of most of my colleagues. So, what can I bring to the table as the president of this organization? What experience and perspective can I have that may be helpful in these changing times? This was the question I asked Stephen Ozanne, chairman of the DCMS Nominating Committee, when he called on me to take this position. That was the question I asked outgoing president Cynthia Sherry. It was the question I asked my father, and it is the question I continue to ponder myself.

The realm of cosmetic surgery is a microcosm of medicine and one of the few examples of how the healthcare marketplace behaves in a free-market environment. It is surprisingly little studied, as best I can tell, by economists and business academics. But it probably would have been wise for those crafting the ACA to have taken a closer look. From 1992 to 2012, the price of medical care in this country rose 118 percent, while the cost of all goods and services increased 64 percent. Compare this to the cost of cosmetic surgery, which rose only 30 percent — a relative decrease in price when adjusted for inflation. 

How is that possible? Although more than 90 percent of healthcare dollars are paid for by someone other than the patient, in cosmetic surgery patients pay for these services themselves. This skin in the game (pun intended) incentivizes patients to compare prices, seek second opinions and educate themselves on their options. This leads to competition in the marketplace. These competitive pressures have kept prices in check and spurred innovation. 

This isn’t isolated to cosmetic surgery. Other fields in which the consumer has a financial stake show the same pattern. For example, Lasik prices have fallen 20 percent since the procedure was introduced in 1999. Falling prices prompted innovation, resulting in new procedures such as Custom Wavefront technology with far improved quality. But the ACA has taken the medical marketplace in the opposite direction, and time will tell if this will be successful. Sadly, history — and economics — is not on the side of Obamacare.

If we can’t take an economics lesson from cosmetic surgery, perhaps other lessons inherent to the field are relevant. None of these characteristics is exclusive to plastic surgery, but each is integral in the specialty’s history and practice. One of the first things that comes to my mind is introspection. Whether it is the way an individual suture is placed, technical aspects of how an operation is performed, or even the performance of a front office process, one must continually and honestly assess how and what one is doing and consider ways to improve. Honest introspection leads to innovation, another distinguishing characteristic. Plastic surgeons always have been known for innovation. Examples include the likes of organ transplantation, microsurgery and wound healing. Search for new ways to make yourself, your practice and your field better and more efficient. As an example, to fill a need for more flexible OR time, plastic surgeons have led the way in office-based surgery and, in doing so, have mastered the art of practicing cost-effective medicine. Ask my scrub nurse, who watches with amusement as I struggle to get the most out of each strand of suture.

Probably the most important lesson I can share is to take the time and effort to develop a true relationship with your patients. This is the aspect of modern medicine that has deteriorated under the current system and will worsen under the new one. Insurance companies and government are wedges that have insinuated themselves between us and our patients. Physicians are affected through the stranglehold of bureaucracy, regulations and diminishing reimbursements. Patients are facing new rules, higher out-of-pocket expenses, and restrictions on the physicians they are allowed to see. Despite these obstacles, Gallup’s annual poll of trusted professionals consistently ranks “medical professional” at the top. Among all of the frustrations and challenges of our healthcare system, patients still highly value the patient-physician relationship. We cannot lose sight of this amid the sea of paperwork and regulations. So, when you enter the exam room, move your focus from the chart or computer screen, and give your attention completely to your patient. Foster that special relationship that we are uniquely privileged to share. This simple act will go a long way toward demonstrating that you are the patient’s advocate and not just another bureaucratic impediment for him to negotiate to get the care he seeks.  

As a final thought, I want to quote J.E. Miller, MD, a DCMS past president, who wrote in his October 1965 president’s page regarding the new Public Law 89-97 or the “Health Insurance for the Aged Act” that Congress had just passed. 

Only time will tell us the effect of this “Medicare” law on the American public, on physicians and the practice of medicine. We must not, and I repeat, must not exclude ourselves from exerting our influence as physicians and citizens on the provisions and effects of this law.… Government can never be capable of caring for the ill. Only the medical profession can do this. 

Nearly 50 years later, these words could not be more true.

Todd Pollock, MD, was installed as the 131st president of the Dallas County Medical Society on Jan. 23, 2014, at Park City Club.