It’s About the Doctor-Patient Relationship

Installation address by 2008 SLMMS President George J. Hruza, MD

I am truly honored and humbled to be your new President. I want to thank Drs. Slocum and Johar for having navigated the Society through a major transition in the change of executive vice president to Tom Watters. The Society is now stronger financially and in membership than it has been in years. With your support, I hope to build on their efforts.

The physician-patient relationship has always been central to caring for patients. Unfortunately, this bedrock tenet of health-care delivery is under siege. I see my primary role as your president and that of the Society to fight on your behalf to preserve and protect the physician-patient relationship from intrusive government regulation, managed care decrees and hospital system overreach. I have experienced first-hand what happens when patient needs are subrogated to the demands of the state or other third parties.

I grew up in the Czech Republic under a socialist government with government-run health care. When I was 8, I needed to have my adenoids removed. I arrived to the operating room, lay down and my adenoids were resected without any anesthesia. Apparently, the cost of providing anesthesia for adenoidectomies was not in the hospital budget. Government priorities do not always mesh with the needs of the patient.

One might argue that this would never happen here as we live in a democracy. My next experience with government-run health care was in Sweden, a democratic nation whose health-care system is touted as a model to emulate. When I was 12, I accidentally, partially sliced my little finger off on a piece of glass. I was not able to be treated at the nearest emergency room, as my bleeding, partially severed finger was not considered enough of an emergency to break the rule that I had to receive my health care in the district that I had been assigned. So, after having to drive over an hour to “my district” ER, I had my finger sown back together. Needless to say, these experiences soured me on government-run health care.

A little over one year ago, the Society held a strategic planning retreat under the leadership of Dr. Ravi Johar. We determined that the most important strategic function of the Society is advocacy, and in order to be effective we need a robust membership base and stable finances. My predecessors, Drs. Johar and Slocum and our executive vice president, Tom Watters, have been able move us from a large annual deficit to a balanced budget. With our financial house in order, we are now able to fully concentrate on standing up for physicians and our patients.

The doctor-patient relationship is constantly under attack on many fronts. I believe that there are three areas where the skirmishing is most current and where the Medical Society can have a meaningful impact: 1) pay for performance, 2) non-physician practice of medicine and 3) the increasing power of hospitals and other non-profit institutions at the expense of physicians and their patients.

At the Hippocrates Lecture in November, Dr. William Plested painted a grim picture of pay for performance. Pay for performance, while touted as a way to improve health-care outcomes, will instead lead to care delivery being determined by proprietary committee decrees irrespective of what is best for an individual patient. Health-care delivery innovation will be stifled as physicians will become mere robots following orders from above. In addition, in spite of claims to the contrary, almost all of these plans are really designed for “efficiency,” which is a code word for having care provided by the lowest cost provider irrespective of quality. The Society under the leadership of Dr. Slocum was able to beat back last year one of these ill-conceived “efficiency” type pay for performance plans introduced by United Healthcare. They have now gone back to the drawing board and with local physician input are attempting to develop a true pay-for-performance plan. We have been at it for about 18 months with nothing concrete to show for it as true performance indicators do not seem to save them money up front. The key is for the Society to be intimately involved at every step and to make sure that any of these plans are true pay-for-performance plans and not just a vehicle for cutting costs.

The non-physician practice of medicine poses a constant and growing threat to patient safety. There are many non-physician practitioners looking to take a piece of the action at the expense of our patients. In dermatology, I see the results with depressing frequency. A few weeks ago I saw a patient who went to a medispa without direct physician supervision to have her tattoos faded. She was treated with the wrong laser at the wrong settings resulting in third-degree burns complicated by infections that required hospitalization and now she is left with tattoos that have numerous hypertrophic scars superimposed on them. I am sure other specialties have similar horror stories. The Board of Healing Arts is finally working on developing a reasonable definition of what constitutes the practice of medicine. The Society has to help and encourage the Board to persevere in this effort and not let political considerations derail it as in the past.

The Society has teamed up with MSMA to successfully block the lay midwife bill that would have allowed just about anyone to deliver babies or even perform C-sections without physician supervision. Another potential threat to our patients are the retail clinics cropping up in your neighborhood pharmacy chains. We have to keep a close eye on this health care delivery model to make sure that misdiagnosis, delayed diagnosis or inappropriate steering to the affiliated pharmacy does not occur.

Hospital systems and non-profit institutions in St. Louis should be our allies as they were in our successful fight for meaningful tort reform. Unfortunately, at times they seem to be at odds with physicians and their patients. Whether it is changes in medical staff bylaws that reduce the physicians’ input into patient care at the hospital, economic credentialing or unreasonable non-compete clauses that force physicians to leave town with their families and leaving their patients to fend for themselves, the Society needs to take a firm position against such activities.

In order to effectively advocate on behalf of patients and physicians, a robust membership base is essential. The more St. Louis physicians who are members of the Society, the greater can be our impact with the media, insurance companies, hospitals, and legislators. There is strength in numbers. Fortunately, we have reversed a decade-long decline in membership with two back-to-back years of net increase in Society members. It does not take a lot of effort to recruit new members. I have been able to increase the number of dermatology members by a dozen during the last year by mentioning at one of our meetings the benefits of joining SLMMS and following up with a personal letter. As dermatologists represent only two percent of physicians, if one physician from each specialty did the same, we could increase our membership rolls by 600 members, or 50 percent.

During the coming year I will be asking for your help in continuing to increase our membership, which will strengthen our voice so that together we can fight for true pay for performance, to protect our patients from unsafe non-physician practice of medicine and to keep hospital administrators from interfering in the doctor-patient relationship. Together, we can have a meaningful and positive impact on the challenges facing the practice of medicine.
Thank you.