Faculty Bibliography

Afterward, she and I held to the slim chance of a cure. She hurried to show her latest art work at a local gallery, at the same time receiving chemotherapy. The medication made her vomit, and when she became dehydrated she carried intravenous fluids with her. She was a striking sight in my office waiting room, leaning against her IV pole as if it were a cane while talking on her cellphone to friends. I gave her morphine to make her comfortable. The drug lowers blood pressure even as it relieves advanced suffering. I tended to use high doses when a patient's life was all about pain, when he or she was lethargic from the effects of cancer and oblivious to all but the suffering. In Holland, active euthanasia is legal, which means that a dying patient can ask a physician to inject him or her with a deadly drug. This process gives the physician a new power, choosing the exact moment and the cause of a patient's death. It also requires that the physician decide when a patient's quality of life has been so compromised that death is in all ways preferable

At a recent AMA meeting in Chicago, some doctors said they were going to refuse to care for malpractice attorneys. But physicians' anger is not an effective tool for change. Besides, insurance companies, not lawyers, determine the prohibitive malpractice- insurance rates while ensuring their own profitability. No panacea exists for the malpractice dilemma, but a system of peer review in the courts and in hospitals would be a good start. Panels of experts in both venues could serve as a safeguard against frivolous lawsuits while ensuring that patients who have suffered true malpractice have their day in court. Current Michigan law shows how a panel can be a gatekeeper for malpractice actions. The law requires a review of all potential lawsuits before a mediation panel, which has two weeks to determine whether care has deviated from normal, accepted standards of practice. A patient may reject the panel's opinion, but then must pay the doctor's costs if the final verdict goes for the defendant. This disincentive helps to weed out frivolous suits

Mr. 'Enrand' came to me with depression, weight gain, high cholesterol and elevated blood pressure. Each of these abnormalities was mild, but they were likely to get worse if left untreated. Eight months after relinquishing my control, I took Enrand's blood pressure and discovered it was back to normal without medication. The scale indicated that he had lost 30 pounds during that time. His cholesterol was back below 200. Now he was sleeping through the night without Valium. Now that Enrand had passed through his midlife crisis and the crippling anxiety accompanying it, I realized that he'd been doing the doctoring. He'd learned to treat -- not illness -- but the fear that ran through the heart of it

If Plan B ever does go over the counter, doctors will lose the ability to keep track of side effects such as nausea, vomiting, headache and bleeding. Perhaps more importantly, patients might be steered into leaving their doctors out of important medical decisions. When a patient asks me to prescribe a routine birth- control pill (which may contain lower doses of the same progesterone, levonorgestrel, that Plan B contains), she often uses it as an opportunity to discuss not only her fear of pregnancy but also sexually transmitted diseases or other issues. The FDA's track record is mixed. Last December, it bravely banned ephedra because of an acknowledged inability to regulate the dosage or effects of the potent over-the-counter herb. But cold medications, Tylenol and aspirin have shown the potential to damage livers and kidneys after they were already over the counter and beyond the FDA's ability to regulate them. Where should the FDA draw the line? Consider that Plan B is a hormone at least three times as powerful as the progestin found in many prescription-only birth-control pills. Why prescription-only? Because birth-control pills have the potential to cause blood clots and strokes along with other serious complications that increase if the medicine isn't used properly

I had ordered a CT scan on 'Mr. Azziz' during a routine physical because he was a smoker. I had always reassured smokers that the test was routine, that a CT scan was more sophisticated than an X- ray in analyzing a smoker's lungs. But knowing that a CT scan or other state-of-the-art test could tell the future made many patients anxious, worrying about the results. I decided to show the CT scan to my office mate, a prominent pulmonologist. He crisply snapped the scan up onto his view box. This type of precision and ease at looking at potential cancers could frighten a patient if he saw it. The report already had the words 'suspicious for a bronchogenic neoplasm' written on it. Like the lung doctor, the radiologist who had interpreted the X-ray was pronouncing sentence on a man he'd never met. The technology told your future and could take away your hopes and plans with a single verdict

Siegel comments on the new prescription drug coverage. The new plan creates a system whereby patients will have to pay top price for drugs they must buy themselves before the coverage kicks again. The new Medicare bill will bring the drug companies easy access to a group that can't afford to underwrite their fancy corporate schemes

'Harry' is one of my elderly patients who could have been helped by a comprehensive, Medicare prescription drug plan. But when he hears about the bill signed by President Bush last week -- with deductibles, co-payments and a large cash contribution coming out of his pocket -- he simply shakes his head and moves to my drug sample closet. Once the full benefit of the new plan takes effect in 2006, Harry will have to pay a $420 annual premium. After he pays a $250 deductible, Medicare would cover 75% of his annual drug costs up to $2,250 and 95% of expenses above $5,100, but nothing for drug costs between $2,250 and $5,100. Harry will continue to be charged top prices at the pharmacy, and the government, forbidden to negotiate or leverage for lower prices by buying in bulk, will also pay top dollar for what little coverage they do provide. In the meantime, I remain Robin Hood with my drug samples, brought by sexy salespeople who interrupt me in the hallway on my way to caring for Harry and others

When [John Elias] hears about the Medicare measure, with its high deductibles, co-pays and the possibility of $3,600 coming out of his pocket, he simply shakes his head. 'Got any samples?' he asks me. Elias uses a wheelchair. He has diabetes and hypertension, and because he has no drug coverage, he relies on free samples. When I run out of his medicine for blood pressure, it soars out of control. His blood sweetens and unsweetens depending on whether I can offer him his diabetes pills. Many of my elderly patients overcome the cash-for-pills hurdle by turning to New York's Elderly Pharmaceutical Insurance Coverage (EPIC) plan. The feds should have looked more closely at this plan. With EPIC, if a Medicare patient is able to show need and an insufficient income, there is only a small out-of-pocket annual fee for medications and a small co-pay. The rest is covered by the state. New York, in turn, is responsible for negotiating lower prices with the drug companies for its EPIC members

Influenza affects up to 20% of the U.S. population in a given year, with 114,000 people hospitalized on average. While roughly 70 million Americans receive the flu vaccine every year, another 70 million should get it but don't. Health care workers, older people, those with respiratory or chronic illnesses, pregnant women and anyone who may come in close contact with the flu all should be vaccinated. In fact, it may not be long before the vaccine is recommended for everyone. WHO also has done a good job of not spreading panic by connecting the flu to the media megaphone the way SARS was. During the past century, three influenza pandemics -- diseases spreading over a large region -- caused millions of deaths worldwide, social disruption and profound economic losses. The scourge of 1918 wiped out 33,000 people just in New York City. Luckily, no one is hyping this history. This year has been a bad flu season in Australia and Chile, which might be a harbinger for a bad flu season here. In addition, since we have just experienced two mild flu seasons, some experts say that a severe one is due. But such speculation is about as sure as predicting the stock market. We are better off preparing, not predicting

While it is true that we still make a decent living, at the same time, we must hire more and more staff members to handle certifications, pre-certifications and referrals while also accepting lower payments. With the new fee reduction almost certain to filter down from Medicare to the HMOs the way such reductions have done in the past, it will become increasingly harder to stay level. Last year, an HMO penalized me and several other New York University physicians thousands of dollars each for what it deemed 'overcoding' -- that is, billing for longer or more comprehensive sessions than our documentation warranted. I called in a coding expert, who lectured me on the principle of better record-keeping being a sign of better doctoring and gave me an elaborate form on which to write patients' notes. Struggling with my professional identity, I try to find myself in the famed physicians' Hippocratic oath, which says, in part, 'In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction.'