The Real Meaning of RD

Most of us understand that the acronym RD means registered dietitian. This blogger is trying to draw attention to her blog and states, “RD does NOT stand for “Really Dumb”.” Yes, Adele Hite is poking fun at herself and her occupation, but at the same time is very serious about the idea that her profession needs change. She uses an excellent example like the last link in her first paragraph referencing a very controversial article from the Huffington Post.

I am not sure why one of their own would take this provocative stance, but she has taken on her professional organization before and probably will again. I strongly agree with Adele that the Academy of Nutrition and Dietetics (AND) has gone too far in their attempt to become the only source of recognized nutritional advice. I even agree that this attempt is backfiring on them and some states are even considering (but to-date none have) stopping all licensing of RDs. My own State of Iowa is taking a hard look at the licensure of registered dietitians, presently now allowing them to expand their over reach.

Would I say that even current registered dietitians are rebelling against their own professional organization? Maybe, but a few people may be trying to reorganize it from within. This may be surprising, but if the current people remain at the helm, the organization will soon be a shell of what it was. Following the pronouncements of the American Diabetes Association (ADA) and the US Department of Agriculture (USDA) will not lead to good nutrition of any type. Many of her links do point out the fallacy being promoted by the AND.

The blogger speaks the truth about the AND putting restrictions on its members about avoiding even the appearance of a conflict of interest, but the Academy receives its funds from the food industry and the pharmaceutical industry and clearly has the appearance of solid conflict of interest. This is definitely speaking with forked tongue by a professional organization. Does “do what I say – not what I do” fit the situation.

Quoting from the blog an important point “On the other hand, the “party line” approaches for weight loss are so ineffective, the federal government (and many states) won’t cover many dietitian services to help people lose weight. According to Dr. Wendy Long, chief medical officer of TennCare:

“There’s really no evidence to support the fact that providing those services [from dietitians] would result in a decrease in medical cost, certainly not immediately, and even in the longer term.”

This lack of evidence may be due in part to the (sadly) limited scope of dietetic education and practice. The AND treats the USDA as if it is a scientific authority and not a government agency whose first mandate is to “strengthen the American agricultural economy.” It limits the training of RDs to USDA/HHS-approved diet recommendations despite the fact that even mainstream nutrition establishment scientists feel that the current US dietary recommendations are misguided and inappropriate.”

Follow the links in her blog to read what is behind her statements. I can only say that it would be smart to read carefully her full blog and if you have interests in this, to follow and read many of the links within her blog. I will only say that I am thoroughly enjoying reading her blog at this time. I sincerely hope to do an interview with her in the future. I fully support her position and hope that she continues to enlighten us. As a patient with diabetes, there is hope that changes will take place and either AND will change (doubtful), or a new organization will emerge to give us the correct nutritional advice we so desperately need.

We can all thank her for pulling together a few of the people knowledgeable about nutrition and dietetics that are working to correct the misinformation being foisted upon us by AND, ADA, and USDA. It is sad that the RDs that work for the USDA must spout the whole grains/low fat mantra to keep their jobs.

The Under-appreciated Professions

The four occupations included in this blog are among the most under appreciated professions. They still can have people within the profession that are bad apples for the profession. Most are a credit to the profession and do their jobs effectively and efficiently. Physician's assistants, nurse practitioners, nurses, and pharmacists are the occupations for this discussion. All have national organizations for support and advocacy. With the looming shortage of physicians, these professionals will serve a vital role in medicine and seeing patients on a more active basis. Links to professional organizations will be the profession below.

Nurses, whether they are registered nurses or any of the 68 different types of nurses, they have a role to fill and in general do excellent in their profession. The list of 68 may not be inclusive, but shows many of the areas that nurses may become specialized for their profession. Under the physician shortages, they will need to step forward and learn how to handle an ever-increasing load. Those that can obtain some additional education quickly will be in line for promotions and work in this expanded need.

Nurse practitioners (NP) and physician assistants (PA) will find more physicians that are more willing to work with them and expand their roles under the physician shortage. They will need to be cautious, as there will still be some physicians that will not accept their role or even work with them. These physicians will do more to damage the medical reputation of themselves and those round them. Physician shortage will not be easy for those still practicing.

If some of the hurdles can be removed, nurses, nurse practitioners, and physician assistants will in some of the more rural areas, be spending more time visiting elderly patients in their homes and using video conferencing (telemedicine) or telephone if necessary. Except in the states that have passed laws requiring physicians to physically see the patients before they can issue a prescription, physicians in the rest of the states should be able to issue prescriptions with the assistance of nurses, nurse practitioners, and physician assistants. In a small number of states already experiencing physician shortage, there is some talk about amending the law to allow these medical exceptions when driving distance is an impediment to physically seeing a physician.

The position of pharmacist is still being discussed, but physician resistance for allowing any pharmacist to issue prescriptions is still strong. One state is considering situations where a pharmacist would be able to renew prescriptions especially for certain chronic diseases like diabetes. Another largely rural state is considering allowing pharmacists with certain qualifications to be able to work with physicians in a capacity like nurses. Pharmacists in hospitals, assisted living facilities, and nursing homes may be given more responsibilities and with continuing education expand their roles even further.

Some pharmacists are already expanding their own roles in some of the larger chain pharmacies and this should also be considered and supported. Too many patients do not utilize their pharmacists to prevent polypharmacy conflicts. I think that there needs to be restrictions placed on patients using one pharmacy for one medication and another pharmacy for a different medication. If nothing more, pharmacists need a technology system to be able to access by name and social security number all pharmacies within a certain parameter to search for medications being taken by a patient to prevent medications conflicts. It is not unreasonable to find patients using three or more pharmacies for prescriptions and I have a few acquaintances that use this to keep (supposedly) others from knowing what other doctors are prescribing. I suspect prescription abuse to be honest.

Depending on how critical the physician shortage becomes will determine much of the expanded role for nurses, nurse practitioners, physician assistants, and pharmacists. Those that are willing to seek additional education now will be able to capitalize later. I know of two nurses presently studying to become nurse practitioners. I have written about the role of pharmacists here and need to say that some of the questions have been answered, but not all have been explained to anyone’s satisfaction. Walgreens has even gotten even more secretive while other pharmacies have become more open and transparent in what they want for their patients. Some of this is good while some actions do raise more questions.

It will be interesting to see what happens during the upcoming physician shortage. How long will we need to wait to get an appointment, how long will it be between appointments, will emergency departments continue to exist in some rural areas, and how many minutes will we have available with the doctor during appointments? These and many more questions are clogging my brain. I can only hope that I am fortunate enough to avoid many of these problems.

Terms for Doctor Types and Practices

Writing about medical practices is fun, but far from easy. Presently, medical practice seems in a state of flux. There has always been some jealousy among doctors, but not like we are seeing today. Many medical organizations are feeling that they are superior to others and applying pressures to state legislatures to limit or prevent new ideas from gaining a solid foothold in the medical community.

It is also surprising that some states have provided opportunities for different ideas to flourish, and other states use various means to try to restrict or limit new ideas. Several states in the early days of concierge medicine worked hard to prevent it from getting started. Two states invoked insurance fraud and claimed the practices would avoid state policies of medicine without insurance and they succeeded for a couple of years until challenged in court.

Concierge medicine is growing and becoming a larger force yearly. When two or more doctors join together in a practice, they can often afford a nurse acting in several capacities. When I wrote this blog, I was not sure I would ever be involved with one. However, I am a volunteer peer mentor for type 2 diabetes patients with a concierge practice and know of four other peer mentors working with another practice. I have also added another physician practice that I now serve as a peer mentor for type 2 diabetes patients.

Telemedicine is another growing area that some practices are working hard to expand and again many state legislatures are being lobbied heavily to limit the scope of practice allowed. I have said this before, but it is worth repeating, the word reciprocity is not in the vocabulary of the medical associations. Any patient that has a regular doctor and travels to another state should have the right to confer with their doctor back home over the telephone, Internet, or other electronic media without worry about some doctor in that state complaining that he/she was denied access to treating the patient. Yet this is where it seems headed.

Yet telemedicine is growing. Even some private practices are utilizing telemedicine and using physician assistants, nurse practitioners, and nurses in areas low in doctors to do the examinations and then either passing this information onto their primary care doctors, or when none are available, writing the prescriptions electronically. Most are in states admittedly allowing this and encouraging this. Some universities are also following this practice and have centers organized to do this – Kansas and Tennessee are two such states.

Although individual practices are becoming harder to find, there are still a few in existence, but for how much longer is the question. Hospitals are slowly putting the stranglehold on private practices and becoming increasingly monopolistic in their operations. They either hire the doctors out of practices or buy out the practice and establish a clinic. Many are concerned about the ethics involved as in some areas of the country hospitals are establishing clinics and moving hospitals to new areas, thus abandoning the inner city areas where they have been. Under the current Affordable Care Act, will the physicians be able to survive financially? Only time will expose the answer.

A simplistic, but accurate description of the various forms of medical practices that a physician can opt for are:

1. Academician: He/she can become an academician and start teaching medical students.

2. Single specialty doctor: The doctor may decide to specialize in a certain field and then carry on practice in that field.

3. Multi-specialty: This happens when within the same company, several medical specialties are employed who are in charge of different fields.

4. Solo: The medical practice may decide to set up his/her own clinic, which is a common practice in dentists.

5. Industry: The physician may decide to work for the research based activities taking place in the industry and work for pharmacological companies, research labs, and equipment manufacturers.

6. Hospitalist: Employed and works for a hospital.

Some doctors may fit within two or more of the practices listed above or may have two or more specialties that he/she is qualified to practice.

I find the following statistics very interesting and will quote, “According to the Bureau of Labor statistics, there were nearly 700,000 doctors in the United States in 2008. There are many ways to break down the types of doctors who practice medicine in the country. Increasingly, more and more medical doctors are becoming specialists, and the number of specialists has grown rapidly in the last four decades. According to the American Board of Medical Specialties, there are now 24 different categories of specialists that branch off into a total of 147 and different doctors who can be board certified in their specialty. But to handle the doctors in the country in a more manageable number, there are 6 different medical doctors who see patients somewhere in the country every day.

1. Doctor of Medicine. This is an allopathic doctor, the one who earns an MD degree from medical school and represents about 70 percent of all medical school graduates. Many study specialties that concentrate on different areas of the body, such as cardiology, gastroenterology and pulmonology.

2. Doctor of Osteopathy. This is the second type of medical doctor who attends a medical school and becomes an osteopathic doctor. These doctors attend an osteopathic medical school, which is outnumbered by allopathic medical schools by about 12 to 1. There is virtually no difference any more in the training between the two disciplines, other than a technique called Osteopathic Manipulative Medicine. This involves manipulation of the joints and body parts to help in the diagnosis of injury or disease. Many medical doctors with a D.O. degree go on to general practices, in areas like family medicine.

3. Doctor of Dental Medicine. Most people are familiar with dentists, who attend 4 years of dental medical school and handle the medical care of the teeth and gums and have a DMD or in their title. There also are doctors of dental surgery who specialize in dental surgery and have a DDS in their title. Many dentists specialize further into areas such as endodontics, orthodontics and pediatric dentistry. This requires additional schooling.

4. Doctor of Chiropractic. These medical doctors go to 4 years of chiropractic medical college and specialize in joint pain anywhere in the body. They have a DCM in their title. Many chiropractic treatments involve the manipulation of the spine and chiropractic doctors work on the principle that misalignments trickle down to affect the nervous system.

5. Doctor of Optometry. This medical doctor attends four years of optometric medical college and has an OD in his or her title. They are the primary doctors for the diagnosis and treatment of eye diseases and conditions.

6. Doctor of Podiatric Medicine. This medical doctor undergoes 4 years of podiatric medical college and then a residency program of 2 to 4 years to be able to diagnose and treat diseases and injuries to the lower leg, including the foot and ankle. In 2008, there were 8 accredited podiatric medical colleges in the country, awarding a DPM to graduates.”

More Assumptions Patients Should Not Make

Having written this blog about assumptions patients should not make, I need to revisit the topic to add a few more assumptions not to make and a few things that it is better to avoid. Some of these ideas have appeared in other publications.

Never assume you are receiving continuity of care.

This is more difficult especially when you have multiple chronic diseases or illnesses where you need to see a variety of specialists. This is a problem area that requires vigilance on the part of the patient and/or family members. This should be something that you consult heavily with your pharmacist to prevent conflicts of medications. Some doctors are great in looking at your records before issuing a prescription, but others can upset the best plans and it only takes one to mess it up and put you in grave danger.

Never insist on self-diagnosis or self-treatment.

While we know our bodies better than anyone, self-diagnosis by the patient can be deadly and is not recommended. It is better to write down all the symptoms that you notice and hand them to the doctor. A diary of symptoms can be a lifesaver when doctors put you off and make unwarranted assumptions. Sometimes these assumptions can be correct, but often they may not be completely correct and the partial treatments may mask the real problems. Let the doctor ask some questions and start eliminating possible problems. The doctor can then order any tests necessary to confirm or rule out illnesses.

Never assume your doctor is always right.

This is a problem for many patients. We do not want to believe that our doctor could be wrong. If you are one of these patients like me, just spend a few months watching the “Discovery - Fit and Health” channel and the “Mystery Diagnosis” program. Yes, most doctors haven't a clue of what is going on as we are talking about rare medical conditions, but the way these doctors handle these cases almost makes you want to reach into the TV and choke the doctor. Patients are often accused of wanting attention or are letting their imaginations get the better of them. While these are the extreme, I hear stories like this from people around me when they are angry with their doctor for ignoring them or not taking them seriously.

Do not assume that the doctor has preformed all the necessary tests.

As a patient, this may be impossible to know whether the necessary tests have been done. This is one time you, as the patient, may need to ask some very direct questions. Never mind what the doctor thinks, it is your health and these questions may save your life. How do you know what to ask? First, you need to ask what tests have been done and what they determined, if anything. Second, ask what other tests could be run. If the doctor starts dodging the questions, you know that there are more tests that may be of value, but this doctor does not know enough about them to be comfortable using them. This is when you know that you may need to seek another doctor.

Do not assume that the doctor is giving you the correct medication or dosage.

Many doctors will give you the best medication after evaluating you and your condition. They will ask questions and probably use some tests to make this determination. If the medication is new to you, make sure you get the correct spelling and then look it up in the Internet to determine if this is an established medication or whether you are being used as a guinea pig for a new medication. Some new medications may be excellent for you, but always be alert for unusual side effects and do not be afraid to talk to your doctor about taking you off the new medication and to an established medication. Read this by Trisha Torrey as she has some good discussion points for you to ask the doctor. It may be in your best health interest not to be a guinea pig for a new medication.

The next question is whether you are receiving the correct dosage. Most doctors will start with a lesser dosage and increase the dose if needed. Be cautious if you are started on the highest dosage and the doctor does not want to discuss his reasons with you or discuss alternative medications. I was considering changing doctors, but during the first appointment, the new doctor insisted that all my medications would need to be changed. When he ignored that I received many medications through the Veterans Administration and stated that I would be coming off insulin and go on oral medications for diabetes, I knew this was not a doctor I could work with. When he stated that my A1c of 6.1 was too low and that I should be between 6.5 to 7.5, I admit I went a little overboard when I asked if he had gotten his medical degree as a prize in a cracker jack box. I said that if he objected to one hypoglycemic reading of 63 mg/dl, then he had no understanding of diabetes and I would keep my endocrinologist and other doctors. That was the end of my appointment, and I suspect by mutual agreement.

Do not assume that your doctor will give you a referral if one is needed.

This can be a delicate issue. Some doctors are willing to refer you to a specialist. Other doctors are so puffed up with their own importance that they feel that they are the only source of medical care you need. Still others will just tell you to find another doctor if you ask for a referral. The last two types are doctors you need to avoid if at all possible. Be cautious if you live a long distance from your primary care doctor and it is even farther to the specialist or another primary care doctor. This article is a good review of possibly how to approach the topic, but be careful if you suspect you have a doctor mentioned above. Some doctors may seem hard to approach; however, done properly, you may get the referral needed. If you know that the referral is necessary, then you may need to request it and replace doctors if necessary. One alternative I have found that works is talking to my medical insurance company and explaining the situation. I was sent a list of acceptable primary care doctors and even a few specialists that I could see without a referral. I may have been fortunate with the person I talked to, but everything worked out for the best when I needed it.

I will continue to look for additional ideas for another blog on this topic.

Hospitals Will Destroy Your Diabetes Management

This blog got its start quite by accident and not one putting anyone or me in the hospital this time. In discussing patient centered care with David Mendosa, I rather exploded about hospital care. David, in his calm and collected way asked if I had read any of Dr. Bernstein and I had to admit I have not. David said he would provide me with a link to his blog about a letter to get signed when entering the hospital. After reading this, I may have to get up the courage to read Dr. Bernstein’s book. Unless there is something that I am researching, I seldom take time to read a book for the pleasure of reading. Since I do a lot of research about type 2 diabetes, I am not reading much published on the type 1 side of the spectrum. No one to blame but myself.

Back to hospitals and why they are on my list of “avoid if at all possible”. It is understandable that hospitals and doctors have an aversion to lawsuits and this drives many of the healthcare decisions they make. People with diabetes is one group that pays dearly for this aversion. Hypoglycemia is the fear that draws attention and dictates much of the policy for care when person with diabetes is hospitalized. The term that is used for most healthcare is defensive medicine. For patients with diabetes, this means allowing blood glucose levels to be maintained at levels that slow healing and can lead to increasing the risk for complications to develop. Thus the hospitals are caught in conundrum for care. The chance of hypoglycemia depends on the medication and if the patient is on insulin or sulfonylureas the hospitals use a level of blood glucose that will generally avoid hypoglycemia and is in the hyperglycemia range. Most, but not all, hospitals want the lower limit of blood glucose to be 180 mg/dl (10.0 mmol/l) or slightly higher. The longer your blood glucose levels remain at this level, the more you are at risk for complications. Because of the smaller likelihood of you developing complications while under hospital care, this is the goal of most hospitals.

Another area that patients with diabetes need to be concerned about is diet while in the hospital. Forget that you have diabetes and please do yourself a favor and do not request the diabetic menu. Because the dietitians for the hospital follow the American Diabetes Association in diet planning, the menu is high in carbohydrates and low in fat. This creates all sorts of problems for patients with diabetes. Those on oral medications will have extra problems because of lack of movement or any type of exercise. Those on insulin (which most that are hospitalized are converted to at least while hospitalized) will run blood glucose levels of 180 mg/dl or higher. The one procedure I will commend hospitals for is giving rapid or short acting insulin after meals so that if the patient does not or is not able to eat a meal, hypoglycemia is averted by not giving an insulin shot.

If you are scheduled for an operation or admitted to the hospital in an emergency situation, please be aware of the above problems and consider the letter in David Mendosa's blog. Even if it is an emergency admittance, if a family member or a close friend can advocate for you and have the letter presented, this may help. A reminder, you may have to stand your ground as most hospitals will refuse to allow you, the patient, to treat yourself for diabetes because they do not want the liability of something going wrong. I dislike saying this, but you are are higher risk of surgery complications and even death if the hospital keeps you on their diabetes regimen. Studies have shown this to be true and as a patient you need to be aware that this can happen.

I have a friend that lost about $300 because a nurse confiscated his insulin and testing supplies and destroyed them. Horror stories like this abound and this is because the hospital medical staff lack the training in diabetes care and some just don't care. Others do care and if you are mentally capable of managing your diabetes, they will allow this to happen even against hospital policy. So do consider the letter in David's blog and if needed adapt it to fit your needs. You will benefit your health by managing your diabetes versus letting the hospital manage it.

FDA Approves New Neuropathy Pain Drug

Get ready for a trip to the emergency room if you take this drug inappropriately. Also, keep this drug out of reach of children of any age less than 18. These warnings are necessary and very wise for a neuropathy pain drug just approved for use by the FDA. 

Other warnings can be found here and need to be taken seriously. For me, this will be one medication I will avoid if at all possible – FDA approval not withstanding. There are just too many potential risk hazards for me to be comfortable using this. The fact that this medication has to be doctor monitored so closely because of potential of addiction is another factor in my avoiding this medication.

The US Food and Drug Administration has approved US sales of NUCYNTA® ER (tapentadol), a twice-daily extended-release oral analgesic for the treatment of pain from diabetic peripheral neuropathy. The drug, produced by New Jersey-based Janssen Pharmaceuticals, Inc., provides around-the-clock management for moderate to severe chronic neuropathic pain. Janssen says that it is currently the only opioid on the US market that has been approved for treating the condition.

I will continue to suffer with what I considerate moderate chronic neuropathy pain rather that use this medication. I will continue to use gabapentin, which alleviates some of the pain and is not a narcotic.

While this medication may work for some people, after reading the warnings accompanying the press release and then the FDA link above, it is not a medication I wish to consider. This medication also has great potential for being abused like other controlled substances.

Contract Medicine – The Future of Medicine

As a patient that has had excellent medical insurance for most of my adult life, why would I support or advocate for another type of medicine. Quite simply – the current medical system is broken and with the government taking more power and intruding further into our lives every day, it is headed for the financial breaking point. Doctors in private practice relying on insurance and Medicare payments are finding it very uneconomical to stay in practice and live on the increasing cuts in payments, pay staff to submit insurance and Medicare claims, and meet the needs of the patients. Hospitals are seizing the opportunity to buy out these failing practices or hiring the doctors away from them, thereby increasing their monopoly.

The more exclusive the hospitals become, the higher the costs of patient care becomes. The hospitals are reimbursed for the recoding of simple procedures to complicated procedures. Does the doctor benefit, seldom, but the administration gets higher and higher salaries and bonuses. This is why we need the doctors and their preventive medicine, which is possible under contract medicine regardless of type - boutique, concierge, retainer, and direct care. These caring doctors practicing preventive medicine will decrease the probability of increases in chronic illnesses and diseases.

The current president of the American Academy of Private Physicians (AAPP), Gary M. Price, M.D., F.A.C.P., has some excellent points at the bottom of the front page of the AAPP website (sorry, this link is now broken - I suspect they rearranged site and removed some material). How long it will remain up is in doubt, but it is well worth the time to read it. I am quoting two paragraphs - “Direct practice restores the doctor-patient relationship to the lofty level it enjoyed before being constrained and degraded by government and insurance. We work only for our patients. We give them uncompromising care in an unhurried, respectful setting. Because we care, the physician becomes a trusted friend. And in direct practice we behave like any other free market: we listen to our customers and respond to their needs. Which is why we have evolved many variations of our model to serve every type of community and every income level.”

It is followed by a statement by Dr. Jordan L. Shlain, MD, San Francisco, CA - Internal Medicine. His point is well stated here - “We are building the wellness model of the future and actively critiquing the circular illness-model. The common denominator that sets us apart is our desire to listen longer, ask more questions, and take the time to work through a complex problem in the spirit of healthy living and longevity.”

Dr. Price lists contract medicine this way - “In the late 1990s a new movement was born in Seattle, Washington and Fort Myers, Florida. Creative physicians dissatisfied with the status quo opted out of the insurance-based medical system to invent a better way to care for their patients. This movement came to be known as Direct, Concierge, Boutique or Private medicine.” The last sentence is different than “boutique, concierge, retainer, and direct care” and does create some confusion as “direct” and “private” medicine are often seen as being the same. Direct primary care (DPC) may be a preferable term to direct or direct care. They are all private medicine and as a group should be considered contract medicine. All of the terms can be considered “retainer medicine”. Many doctors prefer the term “retainer” to boutique or concierge and that is the reason in my previous blog I listed the wide range of fees these doctors may charge.

Will there be a consensus about the terms? This is very doubtful, as many doctors do not like the terms “boutique” or “concierge”. They consider these terms elitist and while the fees may vary, they cannot accept the connotation that these terms may imply. This is a reason that the last sentence in the first quote from Dr. Price - Which is why we have evolved many variations of our model to serve every type of community and every income level” is so important as they are covering all aspects of contract medicine.

Back to why this is the future of medicine. Dr. Price states most of it very well and I quote, “Direct practice restores the doctor-patient relationship to the lofty level it enjoyed before being constrained and degraded by government and insurance. We work only for our patients. We give them uncompromising care in an unhurried, respectful setting. Because we care, the physician becomes a trusted friend.” This may not cover all situations; however, it does spell out the importance of restoring the doctor/patient relationship, putting the patient first and emphasizing preventive medicine instead of waiting for the illness or disease and treating these. This puts “human” back in the equation and makes the doctor and the patient be in tune with each other because the time restraints are removed and the doctor has time to be thorough.

From the AAPP website, clicking on “The Third Era of Medicine” button will bring you to one of the better discussions of the medical mess we are currently experiencing, or click on this link. I found the discussion about type 2 diabetes very informative and on target. Scroll down the page to “Trapped in the Oscillating Structure of the Second Era”, and then down some more to “To preserve the first era paradigm, the system refuses to embrace three key realities:”

1. Diabetes is in fact an escalating progression of systemic destruction set in motion by a well-understood clinical imbalance;

2. The imbalance and the resulting damage can be economically detected and measured very early in its progression; and

3. The destructive sequence can be inexpensively halted and reversed when addressed early in its progression.

This is a polite way of saying that our current doctors are so constrained that they will not attempt a diabetes diagnosis until the conditions have reached a level that requires medication. Yes, there are a few conscientious doctors that do diagnosis prediabetes, but do not usually do much further because they have no support system and if medication is required, insurance will not pay for anything. Our broken healthcare system comes to mind.

If the AAPP can state things like this, then they will be working for patients, which is more than I can say for the American Diabetes Association. Whether you consider contract medicine or not, the “The Third Era of Medicine” is very interesting and explains what the future of medicine may become. Dr. Price says. “Today, even medical schools are including direct practice in their curricula.” If potential medical students will acquaint themselves with the AAPP site and a few other sites like this one and this one, they might decide that medicine is for them. These potential doctors may be the ones to give real preventive medicine the goal of actually helping patients and preventing the development of some chronic diseases.

Of the many doctors that are wishing to retire – if they could, it is sad that they do not look to contract medicine for some enjoyment until they can retire. It is even sadder that many of these doctors will never fit in contract medicine for several reasons. Many are overly attached to the current system and are unable to rethink their situation to be able to work in contract medicine. Others have overvalued their worth and will not work in contract medicine because they cannot accept value in the Internet or using telemedicine. Still other doctors have become so ingrained in the quick appointments that having half an hour or longer appointments scares the dickens out of them, plus they cannot operate in the preventive medicine arena. To these doctors I will only say – retire, medicine may be better off without you.

Yes, I am an advocate for contract medicine and believe this may be a major part of the solution to our current broken medical system. Dr. Jordan Shlain is correct when he says, “The common denominator that sets us apart is our desire to listen longer, ask more questions, and take the time to work through a complex problem in the spirit of healthy living and longevity.” This idea is further restated in much of the AAPP website. Take time to explore the AAPP website. Just remember that some of it is for members only and not accessible to the general public, but it is better than many professional medical websites. Transparency is a term they do understand.

Affordable Contract Medicine

The more I read and research about concierge medicine, the more I become concerned that I have missed an important point. Some of this I know is me, but the rest is really muddied up in so many ways. I even made a mistake, when I wrote this blog. I used printed sources to pull together four areas of concierge medicine and there may be more definitions. I was using concierge medicine as a cover term for all types including concierge medicine. For now, I will stay with the four terms and add the term “contract medicine”. Contract medicine may be the correct cover term for the other terms that I am discussing.

Let me review the terms – boutique, concierge, retainer, and direct care (or direct primary care - DPC). All of these, by practice, are contract medicine or care. The contract is the result of a fee the patient pays at the first of each billing cycle to have access to that doctor for the coming period and if you wish to keep the doctor under contract and available to you. This does not mean that you, as the patient, will physically see the doctor that cycle, but the fee still must be paid. The fee is for only you and does not include other family members. Family members may be part of a family fee structure or handled on an individual patient basis.

There are several terms for the fee paid and include, contract fee, retainer fee, subscription fee, access fee, medical care fee, and the list goes on. Much of this naming depends on how the doctor wishes to describe it, and I will not attempt to list all possible terms. Most practices request the fee to be paid monthly, but some do collect on a yearly, semiannual, or quarterly basis.

An area that is still confusing (to me and others) is who is accepting medical insurance and who is not. Some of all types of contract medicine are accepting insurance. However, in general, doctors in direct primary care will not accept medical insurance, there are some exceptions. To protect yourself in all forms of contract medicine, be sure to ask if insurance is accepted as many doctors, of all types of contract medicine do not accept medical insurance, will not be submit insurance claims for you, and you are entirely responsible for all expenses not covered in the contract fee paid.

Boutique medicine generally has the highest fee range as could be expected. I cannot give the range, as I do not know what the highest fees are. Concierge medicine is generally considered the next highest monthly fee, but this is experiencing some lower fees. Retainer medicine is the confusing category. Some doctors do not want the label of boutique or concierge and use the term retainer medicine. The fees are broad ranging and can vary from $50 per month to several thousands of dollars per month.

Direct care medicine or direct primary care medicine is probably the lowest consistent fee. The majority range from $50 to $100 per month. No, this is not a firm range as some can be as high as $200 per month, but the $200 fee is generally considered out of the normal range. There are other terms for contract medicine, but few are mentioned or talked about and seem to be limited to certain specialties in medicine or what a few doctors are using to separate themselves from the normal forms of contract medicine. Having said that, the American Academy of Private Physicians (AAPP) does use the terms “private” and “personal” for many discussions of contract medicine.

In all types of contract medicine, patients have greater access to their doctor via phone, Internet, immediate appointment availability and some doctors are using telemedicine to meet the needs of the patients. Some doctors include house calls in the fee, but this is variable depending on the location and the time available to the doctor. Most contract medicine doctors have a patient count of 300 to approximately 1200 or slightly higher. Most, but not all, doctors will work on preventive medicine and treat illness or disease when it happens. The majority of doctors will be working hard to prevent illness and disease from happening in the first place.

Before signing any contract, check whether some or all lab tests will be covered by the contract fee. Some lab tests will probably be covered, but frequency and test costs will affect coverage. In addition, it is important to determine how hospital visits will be handled. Some may be covered by the monthly fee, but most will not. The lower the contract fee is, be alert for unusual expenses to creep into the cost factor.

The direct primary care model, especially, has drawn insurance industry opposition in part because the health insurer middleman is cut out of the equation. Insurers may benefit from direct primary medical care because patients who want insurance are still purchasing high deductible health plans for specialized care and hospitalizations. In addition, there is even talk that some insurance giants are actually talking to direct primary care pioneers MedLion of Monterey, Calif., and Seattle-based Qliance about providing patients in their practices with access to “wrap-around plans” that would cover their specialist and hospital needs. This “wrap-around plans” is gaining support in other areas of the country, particularly in areas where contract medicine is becoming more popular.

There is even some in Congress that are picking up on the contract medical care model and it is gaining momentum is a surprising bipartisan way. Even the New York Times has had stories of “concierge medicine for the masses.”

There will be more written about this in the coming months and I will blog about this when it happens. For those that want to follow a doctor in his change from group practice to a “direct primary care” practice, follow Dr. Rob Lamberts who posts about it here, here, and follow him on Facebook here or if you love twitter, he is here. On the two blogs, read the comments please as there is some excellent information in some of them.

The next blog will continue this discussion.