Faculty Bibliography

The daily squeeze hit me hardest the morning I saw a likable 68- year-old patient of mine waving at me through my waiting-room window. I'd been treating him for years, but he didn't have an appointment and I barely recognized him with his newly bald head, yellowed skin and shaking hands. My office staff wanted to turn him away because the day's schedule was already packed, but I sensed his desperation and made time for him. In the examination room, he told me that his oncologist had informed him bluntly that his cancer had spread and then dismissed him. I was the man's internist, his gatekeeper to the medical world, and he had returned to me -- not for expertise, but for warmth. The pressures are fierce for doctors to compromise their professionalism, their humane instincts, for business reasons. The Medicare Payment Advisory Commission suggested last year that the United States needs a payment system that more accurately reflects doctors' rising costs. Most doctors would agree. 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. And 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. 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. . . .' Well, doctors abandoned making house calls and gave up accepting a chicken in lieu of payment long ago in most parts of the industrialized world. But 'for the good of the patient' remains a noble ideal that has guided physicians for centuries. I feel it must continue to guide me

I wasn't so sure. The sinus expert to whom I sent Mr. N reported no evidence of a sinus infection and didn't believe the patient needed antibiotics. The infectious disease expert with whom I shared my office concurred. The neurologist who treated Mr. N for his headache thought he had a life-threatening inflammation known as temporal arteritis, and she started him on steroids to keep him from going blind or having a stroke. The arterial biopsy for temporal arteritis was equivocal, but the neurologist said this was often the case and continued treatment. I left a message for Mr. N's family doctor in Florida, but he didn't return my call. When I telephoned Mr. N, he sounded edgy and told me his family doctor didn't believe he needed to see all those so-called experts in New York. This doctor also apparently thought that there were many intangibles to this patient's case that only he could know because of the long history together. I acknowledged the value of this; I merely saw the imperative to communicate the new findings. Afterward, he decided that he no longer was happy with his local doctor. I was able to recommend another doctor with an office nearby. This doctor had similar training to that of my own and Mr. N's old doctor and was known to be a good communicator

The major drug companies have tried to resist controls but have been largely ineffective in dictating European prices. From time to time, they threaten not to supply the drugs, but that never happens. Last year, several of the world's biggest drug companies, hearing that Germany's Health Ministry was planning to impose a 4 percent price cut on prescription drugs, collectively donated almost $200 million to Germany's state-sponsored health plan with the express goal of staving off the reduction. Germany took the subsidy yet went ahead with the price cut anyway, and because 80 percent of prescription drugs in that country are purchased by the public health insurance system, the drug companies had no choice but to accept it. The idea that Medicare would name the price it is willing to pay for something is not entirely foreign. Medicare already dictates doctors' fees and laboratory and hospital reimbursement. Under the current system, doctors have an option. We can be Medicare providers and accept that the prices the government decides are fair and reasonable, or we can go outside the system entirely and not accept Medicare at all. If we choose the latter, our elderly patients will not be reimbursed for our services. We can charge top dollar, but then many patients would not be able to come to us. Extending this system to include the new prescription drug benefit would go a long way toward keeping drug prices down. Medicare could decide which drugs are duplicates and which have generic equivalents. If patients want a drug that is not covered by Medicare, they could pay for it. If a drug company brings to market a product it perceives to be exceptional and not simply a duplicate of what exists, then that company will have the option to go outside the system and charge full price

The idea that Medicare would name the price it is willing to pay for something is not entirely foreign. Medicare already dictates doctors' fees and laboratory and hospital reimbursement. Under the current system, doctors have an option. We can be Medicare providers and accept the prices the government decides are fair and reasonable, or we can go outside the system entirely and not accept Medicare at all. If we choose the latter, our elderly patients will not be reimbursed for our services. We can charge top dollar, but then many patients would not be able to come to us. Extending this system to include the new prescription drug benefit would go a long way toward keeping drug prices down. Medicare could decide which drugs are duplicates and which have generic equivalents. If patients want a drug that is not covered by Medicare, they could pay for it. If a drug company brings to market a product it perceives to be exceptional and not simply a duplicate of what exists, then that company will have the option to go outside the system and charge full price. The overall effect will be the savings of billions of health care dollars. Europe accounts for just over 20 percent of the pharmaceutical industry's more than $400 billion world market, according to IMS Health. The United States accounts for 46 percent. But with our unregulated practices, we're the source of more than 60 percent of the industry's profit. We're filling its coffers; we should use our influence to dictate prices. After all, the current $400 billion plan for Medicare prescription drug coverage can buy a lot more drugs at the prices Europeans pay for them

France, for one, has successfully negotiated prices that are as much as 15 percent lower than those suggested by manufacturers for the stomach medicine Prilosec (made by AstraZeneca), the cholesterol- lowering drug Lipitor (Pfizer) and the top-selling antidepressant Paxil (GlaxoSmithKline). In the United States, Lipitor, which brought Pfizer revenues of $8.6 billion last year worldwide, costs $2.38 per 10 mg tablet wholesale -- that is, the cost to pharmacies. The same pill is sold to French pharmacists for 75 cents. It costs 93 cents in Britain. The idea that Medicare would name the price it is willing to pay for something is not entirely foreign. Medicare already dictates doctors' fees and laboratory and hospital reimbursement. Under the current system, doctors have an option. We can be Medicare providers and accept that the prices the government decides are fair and reasonable, or we can go outside the system entirely and not accept Medicare at all. If we choose the latter, our elderly patients will not be reimbursed for our services. We can charge top dollar, but then many patients would not be able to come to us. We will survive outside the system if we provide an exclusive service that is in high demand. This 'loophole' is what makes the current system legal. Doctors and hospitals don't have to accept these scaled-down prices, and our patients don't have to go to places that participate. But if either side chooses to decline the system, the payment is made out- of-pocket. The same logic would apply to drug manufacturers. Extending this system to include the new prescription drug benefit would go a long way toward keeping drug prices down. Medicare could decide which drugs are duplicates and which have generic equivalents. If patients want a drug that is not covered by Medicare, they could pay for it. If a drug company brings to market a product it perceives to be exceptional and not simply a duplicate of what exists, then that company will have the option to go outside the system and charge full price. The overall effect will be the savings of billions of health care dollars

Siegel discusses reaction to the numerous terrorist alerts that the government issues. Tips are offered on whether it would be wise to get vaccinated for smallpox and how one would know when it was safe to come out of a 'safe room' following a terrorist attack

Added to this mix we now have the tangible-seeming risk of SARS. My waiting room is filled with patients brimming with the same question. ''Could I have SARS?'' a patient blurts out. Unsolicited, an office secretary replies, ''You must ask the doctor.'' Meanwhile, the 13-inch television set in the middle of the room is playing all SARS all the time and updating my patients on the virus every hour. New Yorkers are a nervous bunch to begin with, and their doctors are no exception. Most of us, doctors and patients alike, are medical Zeligs; like Woody Allen's character, we take on the symptoms and even the personality of the latest threat. In this case the global health alert and travel advisories that are meant to contain the droplets of the virus also spread virulent fear by word of mouth. The city felt this fear and vulnerability for many months pre-SARS; now the fear of bioterrorism has been converted into a fear of a deadly mystery virus. My office phone is ringing continually with respiratory complaints. I know better than to counter these concerns with the bald statistic of zero deaths from SARS in the United States so far. I don't want to appear to be playing down serious potential risk. If SARS spreads as easily as the common cold but is more deadly, it could cause medical mayhem here. Because we live in close quarters, the spread of any disease may be eased by proximity

In my son's kindergarten class, a boy, whom I'll call Ira, was labeled as a behavior problem. The other parents were worried: Was this child's silly and impulsive behavior something that would rub off on their children? Would all the children in the class misbehave and try to be like this unfortunate child? As a doctor I wondered if the child had been given a diagnosis such as attention-deficit hyperactivity disorder or if he was simply troubled and undisciplined. Even though I thought Ira to be a sweet child, I found myself automatically joining the bandwagon of parents who protested to the school that this child should not be allowed to be in the same class as our kids. We lost that battle, and I was dismayed when my son listed Ira in the group of his favorite friends. From that day on, I asked my son if there was word about Ira. We suffered through it together, until the day when Ira and his special teacher returned to the class. My son said everyone was happy, including the children of the forbidding parents. None of the kids thought they could catch what Ira had

A longtime patient of mine who suffers from severe asthma came to my office two weeks ago gasping for air. I knew as soon as I put a stethoscope to her hissing chest that I was going to have to admit her to the hospital for several days of intravenous steroids. The doctor in the New York University emergency room suggested -- strangely, I thought -- that I give her oral steroids first. I told him I disagreed. In such a severe case, intravenous delivery was by far the most effective way of calming an inflamed set of spastic lungs. But when I went to see the patient later that day, I found she had received the oral version, and, what was worse, she was still wheezing badly. The nurse explained to me that there was a shortage of methylprednisolone, the IV steroid I had ordered, because of the war in Iraq. Clearly, I needed to find out the extent of the problem. I contacted Dennis Karagannis, associate director in charge of supplies for NYU Medical Center's pharmacy. He explained that many intravenous and emergency medications were already in short supply because the FDA had stepped up regulation of their manufacture two years ago to ensure purity and consistency. At the same time, the market had changed, further contributing to the shortage. Many of the same products had become generic, making them cheaper in any form. A 125 mg vial of the IV steroid, which had sold for $6 a vial 10 years ago, was now only $2 a vial. The increased pressure on this shrinking supply suddenly worsened several months ago as the military began stockpiling medications for the upcoming war, Karagannis said. 'The companies ship right to the government,' he explained. 'We have to wait for the next production load. Right now several supplies are on back order or allocation, where you only receive your current monthly usage.' It turns out that steroids, lidocaine (a pain medication), morphine, atropine (a nerve blocker), dextrose (a sugar solution), sodium bicarbonate and some injectable antibiotics are among the drugs now in short supply

ONE OF MY CALMEST PATIENTS RETURNED FROM HONG KONG LAST WEEK, AND OF COURSE HE WAS WORRYING THAT HIS MILD COUGH WAS FROM SEVERE ACUTE RESPIRATORY SYNDROME, OR SARS. HE NERVOUSLY STUTTERED OUT THE WORD SARS, BUT AFTER I EXAMINED HIM HE ACCEPTED MY REASSURANCE AND RETURNED TO HIS QUIET WAYS. HE EITHER HAD A COMMON COLD OR WAS JUST WORN DOWN FROM TRAVEL, AND TWO DAYS LATER HE WAS FINE. For SARS, fear is the central pathogen, where the risks of acquiring the new mutated cold virus are far secondary to the fear of being infected. Uncertainty about what the risk really is promotes the panic - seeing SARS in the news causes us to personalize it, especially at a time when everyone is already feeling vulnerable from the war. Of course, we do need to track SARS before the bug starts to spread like the hysteria it is causing. SARS is a serious health matter but may galvanize fear because of the sudden attention. Publicizing preventative measures beyond the proper context may make SARS seem worse than it is