Orthopedists and internists
Your front-page stories on sports injuries and on diagnosing and treating osteoarthritis generated some discussion in our department. ("Not all sports injuries need specialist care" and "Deciphering the telltale signs of osteoarthritis," July/August ACP Observer, page 1.) Truly, the non-surgical orthopedic consultation is a thing of the past. With the recent retirement of our last "over 60" orthopedist, we have no one to do these consults. Not all of these patients need surgery; many, especially the elderly, primarily need reassurance.
Particularly irksome are the orthopedists who will not schedule a consultation unless an MRI or CT is done. Rheumatologists are some help, but are usually interested in folks with positive serologic tests.
Good thing there are still some general internists who take care of patients.
Peter T. Smyth, FACP
Preman J. Singh, FACP
Your recent MKSAP Challenge addressed an important educational objective in the treatment of patients with metastatic breast cancer. (July/August ACP Observer, page 5.)
However, the MKSAP clinical scenario stated that "liver function values are approximately twice normal; serum bilirubin is normal."
Liver function is assessed by serum albumin and bilirubin determinations and a prothrombin time. Liver function and its value cannot be above normal. Serum aminotransferases and alkaline phosphatase are markers of hepatocellular and cholestatic or infiltrative forms of liver injury, respectively.
Presumably, this patient's serum alkaline phosphatase was elevated to about twice the upper limit of normal as a manifestation of her hepatic and/or bony metastases.
Richard H. Moseley, FACP
Ann Arbor, Mich.
Patrick C. Alguire, FACP, ACP's Director for Education and Career Development, responds: Dr. Moseley is correct. We have tried to be particularly careful in MKSAP 13 not to refer to "liver function tests" unless we mean synthetic function and specifically use the terms aminotransferase levels or alkaline phosphatase when appropriate. This one, however, got past us. Thanks for the correction.
A recent Washington Perspective column discussed a report from the Centers for Medicare and Medicaid Services (CMS) about the rising costs of physician services. ("Growth in physician spending packs a political punch," May ACP Observer, page 13.)
The article seemed to imply that those escalating costs are our own doing. Column author Robert B. Doherty, ACP's Senior Vice President, Governmental Affairs and Public Policy, wrote: "The CMS report does not say why that spending increased. It does say that 'understanding why part B expenditures are rising so rapidly is of great concern' to the agency."
Physicians are well aware of why costs are on the rise. Here are just a few reasons: increased patient loads; growing patient demands for more office calls, services, lab work and prescriptions; and end-of-life decisions that we have little control over and that dramatically increase the cost of medical care.
Another factor the CMS may not be aware of: In a state like Connecticut—unlike in California and Texas—we have received absolutely no malpractice relief whatsoever. Therefore, we sometimes do order an excess test just to cover ourselves.
It's been my experience that we do not go looking for patients—they come to us and they make demands. That's where the CMS should be looking if it wants to rein in costs for physician services.
Robert Aaronson, FACP
Mr. Doherty responds: Dr. Aaronson makes some excellent and highly plausible explanations of why physician service spending is increasing. ACP has made many of the same points in our communications to Congress, the CMS and other policy-makers.
Right after the CMS report was released, I wrote a letter to the Medicare Advisory Payment Commission, suggesting that much of the spending increase could be due to changes in demographics (particularly more patients with chronic diseases), evidence-based guidelines that may increase the number of visits to a physician, defensive medicine, technological innovation and better drug coverage.
The problem is that even though some of the spending increase may be due to such factors, we don't have evidence to support how much is due to them—and how much may be due to utilization that does not result in better quality.
Organizations like ACP must analyze why spending has increased to defend appropriate increases. But we must also be willing to address spending growth that does not result in better quality. With Congress reluctant to spend more without having some assurance that they are getting value, we ignore these political realities at our own peril.
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