Fair hearing/peer review: truth or oxymoron? [letter]

              Letters JAOA • Vol 100 • No 12 • December 2000 • 761
Thoughts on a white coat
To the Editor:
When I became a freshman in 1977 at the
West Virginia School of Osteopathic
Medicine, Edward A. Schaekel, DO, the
family physician who taught medical ter-minology
and physical diagnosis, took it
upon himself to teach us about our white
coats. Dr Schaekel, who was never seen
without his white coat, introduced us to
our white coats by telling us that we should
wear them to class any time he lectured.
One very warm spring day, only the
class brownnoser wore his white coat: the
rest of us were comfortably dressed. When
Dr Schaekel stepped in front of the class
and saw that we had not worn our coats, he
snapped. In his tirade, he declared that the
white coat was a symbol of our profession
and that it would one day bring us respect
from our patients. It would bring us into a
community leadership role. It was a symbol
that our patients would learn to trust, and
it would bring us privileges not afforded to
other people.
Dr Schaekel concluded, “You will not
know what I mean until someone in des-peration
grabs the sleeve of your white coat
and crumples it in his or her hand. That
person will tell you the innermost secrets of
his or her heart and expect you to keep
them in confidence. When that happens,
remember this: don’t jerk away. Stand there
and listen.” Dr Schaekel was so upset with
us that when he finished these comments, he
dismissed the class and marched out.
Two years later, I was a student on a
rotation in Lancaster, Pennsylvania, with
Harold Finkel, DO, an outstanding osteo-pathic
pediatrician who has great insight
into all aspects of medicine and teaching. I
was with him the first time I saw a patient
die. After we had done all we could to save
the child’s life, I walked in the room very
sheepishly behind Dr Finkel so he could
tell the family that their loved one was gone.
I watched as he spoke to the parents. As
soon as he stepped to the bedside of the
mother, she grabbed his sleeve. He never
pulled away. It seemed like an eternity: he
talked, she talked, her husband talked, and
then she cried. After she stopped crying,
she let go of Dr Finkel’s sleeve.
When we left the room, Dr Finkel could
tell I was upset. He said, “It’s not always
important what you do. It’s important to be
there for your patient. The way I see it,
don’t just do something. Stand there.” I
never forgot what Dr Finkel did and said
that night.
It was another year before I had a white
coat experience of my own. In May 1981,
shortly before I graduated from medical
school, I was treating a man in his 70s with
congestive heart failure. We had treated
him all week and had considered discharg-ing
him that particular day because he was
doing so much better. Then it happened: the
patient grabbed the sleeve of my white coat,
and he started talking. He talked for 10
minutes before letting go of my sleeve. All
I remember that he said was, “Son, respect
your wife and your children; don’t work
your life away. That’s the reason why I’m
here today, dying alone.” Minutes later,
the patient died.
A dying man had given me 70 years of
life experience, 70 years of life philosophy,
70 years of knowledge in 10 minutes. I
should have written it all down, but of
course, I did not. At 26 years of age, none
of that meant anything.
Then came the end of medical school. As
I entered my internship and residency, white
coat experiences became too common. After
too many problems, too late at night, one
can become tired and cynical. However,
about that time in my career, another side
of my personality emerged—Sidney. Sid-ney
was one of those wild and crazy guys,
the kind of guy that could find humor in
every situation. He always took it upon
himself to make everyone laugh. Even dur-ing
a code, Sidney would tell a joke—never
anything rude or out of place, but something
to break the tension.
Sidney was often in trouble and needed
to be corrected. I remember the last time Sid-ney
was in trouble. After I received the
chairman’s tongue-lashing, and as I turned
to walk out of the room, he stopped me
and said, “Greg, I hope you never lose Sid-ney.
Oftentimes, wearing a white coat takes
it out of some of us.” The white coat—the
same white coat that Dr Schaekel had taught
us was the symbol of the profession, would
bring us respect, and would allow us priv-ileges
not given to other people—can weigh
too much if not lightened by a sense of
humor.
Twenty-three years have come and gone
since those days. I have come full circle. I
have learned that the white coat is a respon-sibility
and a privilege that should be worn
with pride and humility. The white coat
contains many lessons: Don’t jerk away.
Don’t just do something, stand there.
Respect your family, don’t work your life
away. And don’t let medicine snuff out the
Sidney in you.
Gregory Wallace, DO
Associate professor of pediatrics
West Virginia School of Osteopathic Medicine
Lewisburg, West Virginia
Director of medical education
Greenbrier Medical Center
Fairlea, West Virginia
Fair hearing/peer review:
truth or oxymoron?
To the Editor:
In 1986, the federal government enacted a
law establishing the Joint Commission on
Accreditation of Hospitals, whose stated
goal was to simplify hospital staffing by
allowing physicians to police themselves.
The Commission was established to assist
hospitals in issuing guidelines around which
Letters
departments and committees would form to
strengthen a hospital’s ability to govern
itself and to give physicians a chance to
work together to establish good quality
healthcare. In theory, the plan of establish-ing
specific committees (for example, qual-ity
assurance) to oversee physicians and
work with those outside the norm to
improve quality of patient care is a good
idea. Committees would be composed of
physicians and peers in the same specialty
and, as such, would be qualified to gener-ate
an opinion regarding the practice of a
specific specialty.
Many hospitals do practice this way;
however, I have found that quality assurance
(QA) in many hospitals in Dallas-Fort
Worth is set up to reprimand physicians
and use committee minutes against physi-cians
during recredentialing. In fact, many
committee members have served for years
and, as a result, have gained political power
that makes it easy for members to move
things along when ousting a physician—
particularly if the physician in question is
perceived as competition.
The following describes the fair hear-ing
process, peer review, and the proctoring
requirements that some hospitals have incor-porated
into their bylaws.
The fair hearing process, a pseudo trial,
is offered to physicians who have received
an unfavorable recommendation by the
Medical Executive Committee, which is
typically made up of the chiefs of depart-ments
who vote. The committee chairman
from the affected department initiates the
recommendation, while remaining panel
members, having no true understanding of
that particular specialty, side with that chair-person.
The physician in question may then
initiate the fair hearing with a panel made
up of specialists who are colleagues and
not peers, creating an impossible situation—
impossible because peers, who are frequently
competitors, may initiate the unfavorable
recommendation.
When one attempts to attain staff priv-ileges,
there is a 1- to 2-year waiting period
during which one becomes temporary, then
provisional, and, finally, active. During this
period, proctoring is done by one’s direct
competitor, who has a financial interest in
the outcome. All the proctor has to do dur-ing
this period is state his or her bias and the
proctored physician will not be given hos-pital
privileges. In essence, committee physi-cians
(competitors) have the ability to
destroy a new physician applying for priv-ileges
because the new physician is now
marked by that hospital, the National Data
Bank, the respective state board of medical
examiners, and by local hospitals. There is
too much at risk for the applying physi-cian,
especially if he or she is a surgeon.
Where is the physician supposed to work
after receiving an adverse recommendation?
It is time to objectively evaluate QA as
envisioned by the Joint Commission and
the manner in which the Medical Executive
Committee functions. Many things have
changed between 1986 and 2000. There is
increased competition for decreased reim-bursement,
resulting in a need for an eco-nomic
focus in one’s medical practice. With
younger physicians being critiqued more
exhaustively than the “good old boys,”
what can be done to create equity at the
hospital level?
We must make hospitals and their com-mittees
accountable for their actions. Hos-pital
bylaws clearly indicate that the burden
of proof of competency is placed on the
physician who has requested privileges there.
The standard is that one is guilty until able
to prove innocence. Only in America can a
professional who holds degrees and licens-es
have fewer rights than any criminal on the
street. This is a tragic and difficult way to
maintain cohesiveness within a hospital
staff. An alternate way of creating account-ability
would be to require changes in
bylaws whereby burden of proof becomes
the responsibility of the Medical Executive
Committee preceding their issuance of an
adverse recommendation about a physi-cian.
(Obviously, this should exclude situ-ations
that involve alcohol and illicit drug
use.) Another way to prevent abuse of
power would be to require that the Medi-cal
Executive Committee allow indepen-dent
reviews of a physician who has received
an adverse recommendation. A final sug-gestion
for maintaining fairness in the hear-ing
process is to establish annual commit-tee
appointments so that no one has a
chance of abusing these positions and form-ing
networks based on the buddy system.
It is unfair that one’s competitors are
given the power to decide whether one
receives an adverse recommendation. At
issue here is one’s right to practice, partic-ularly
with regard to surgeons whose prac-tices
are based on the ability to perform
surgeries in a hospital. Members of the
Medical Executive Committee need to enlist
the professional opinions of independent
experts as to whether a physician is prac-ticing
within the scope of medical guide-lines.
Committees should not assume that
proctors have no outside interest in what is
decided.
It is my fervent hope that organizations
understand the times in which we now live
and that what was appropriate and fair at
one time needs to be reevaluated and
focused to address current times. The US
Constitution is based on checks and bal-ances;
the same should be expected of hos-pital
bylaws that put one’s practice, one’s
way of life, and one’s future in others’
hands.
Roland F. Chalifoux, Jr, DO
Neurosurgeon
Arlington, Texas
Time for Medicare reform
is now
To the Editor:
The time is overdue for the Medicare pro-gram
to move toward a model more con-gruent
with its beneficiaries’ needs. Osteo-pathic
physicians, as primary care providers,
must voice their concerns politically to
ensure that Medicare coverage for their
patients and future generations is assured by
legislation.
Medicare must prepare for increasing
numbers of elderly as baby boomers and dis-abled
patients who require more expensive
technology, services, and medications grow
older.1 Benefits paid by Medicare from 1990
to 1995 surged 73% (to $113 billion), while
funds financed through payroll taxes grew
40% (to $96 billion).2 The Congressional
Budget Office estimates that Medicare
expenditures will increase from $176 billion
in 1994 to $286 billion in 2000.3
Although a government surplus is pre-dicted
for the next several years, progress
toward Medicare reform remains dormant.
President Clinton has proposed an expan-sion
of those eligible for the current Medi-care
program to include unemployed work-ers
aged 55 to 65 years for an estimated
cost of $4 per month, while early retirees
762 • JAOA • Vol 100 • No 12 • December 2000 Letters
could purchase the program for $3 per
month. This may sound appealing to many,
but adding 700,000 uninsured displaced
workers to the Medicare rolls could crush
the system.4
Inadequacies of benefits currently afford-ed
to members must also be resolved. Needs
not covered by Medicare insurance include
routine checkups, eyeglasses, hearing aids,
dental work, usual plastic surgery, and pre-scription
drugs.5 Medicare also does not
cover “government determined” services,
which can be deemed “medically unneces-sary”
at any time, affecting the patients’
personal finances and perhaps their physi-cian’s
liability. Medicare patients are often
forced to choose between buying costly pre-scriptions,
paying rent, paying utility bills,
and buying groceries.7
Although the current plan does approve
certain coverage, it is fraught with costly
deductibles and copayments.5 For exam-ple,
Medicare regulates hospital inpatient
day coverage under Part A with time limits.
A beneficiary is responsible for a deductible
payment of $768 for the first 60 days of
care, $192 per day for days 61 through 90,
$384 per day for days 91 through 150, and
all costs beyond 150 days. Part B services
require the beneficiary to pay an annual
$100 deductible fee, a basic monthly pre-mium,
and 20% of Medicare-approved
charges.
Kidney transplant patients are expected
to pay for all necessary antirejection im-munosuppressive
drugs after 36 months
following transplantation, though the trans-plant
could easily fail as the result of organ
rejection due to a patient’s inability to pay
for medications. Out-of-pocket costs can
easily devastate a limited fixed income com-mon
to many elderly and disabled persons
who are unable to work. The need for
reform remains critical as thousands of
elderly are faced with the crisis of being
dropped by their Medicare HMOs and risk
losing their prescription coverage. Conse-quently,
many Medicare beneficiaries are
forced to seek, when available, expensive
supplemental insurance.6
Gail Wilensky, Chair, Medicare Advi-sory
Committee, has stated that Congress is
not under enough pressure “to make the
difficult decision that a major change would
take.”7 It is now time to apply that pressure
to develop a solution for the Medicare pro-gram.
It is overdue and must be urgently
addressed by Congress. The solution must
keep the costs of Medicare affordable for
both the government and beneficiaries. The
government surplus that is now available
should be targeted to improving Medicare.
Osteopathic physicians have traditionally
been patient advocates, and that support
must now be heard in support of Medicare
reform. Patients should be encouraged to
support Medicare advocacy groups such
as The Century Foundation and Citizens
for Better Medicare to establish a united
appeal. Congress and the president must
not delay in enacting cost-effective, com-prehensive
change to address Medicare’s
inadequacies.
Anthony J. Linz, DO
Clinical Professor of Pulmonary and
Internal Medicine
Ohio University College of Osteopathic
Medicine
Firelands Community Hospital
Sandusky, Ohio
References
1. Medicare: Past, Present, and Future. Alpharetta,
Ga: The Medical Management Institute; 1987.
2. Spears J, Clark K. Medicare’s bad prognosis.
Fortune Magazine; May 27, 1996. Available at http://
cgi.pathfinder.com/fortune/magazine/1996/
960527/economy.html
3. Re-envisioning medicare: facts on medicare and
congressional proposals to change it. League of
Women Voters;1999. Available at http://www.
msnbc.com/news/215703.asp
4. Gleckman H. Clinton’s medicare plan: good pol-itics,
bad policy. Business Week Online. January 12,
1998. Available at http://www.businessweek.
com/bwdaily/dnflash/jan1998/nf80126.html
5. Medicare and You 2000. Original Medicare Plan
and Other Medicare Health Plan Choices. Health
Care Financing Administration, US Department of
Human Services; 2000:1-8,20-21.
6. Galewitz P. Medicare misery. Associated Press.
August 31, 2000.
7. Lagando L. Choosing between drugs, necessities.
Wall Street Journal. April 1999. Available at
http://www. msnbc.com/news/215703.asp
Questioning of OCF should
rouse osteopathic response
To the Editor:
Recently, while browsing electronically, I
entered the term craniosacral in the search
engine for Current Contents (all editions),
which turned up three articles1-3 that should
demand the attention of all those practicing
osteopathy in the cranial field (OCF). These
are rigorously designed studies generated
by three independent groups and published
in peer-reviewed journals that call into ques-tion
the ability to palpate the primary res-piratory
mechanism (PRM). More impor-tant,
statements appear in the abstracts of
these articles (the portion most likely to be
read by the casual browser) that question the
very existence of the PRM. Examples fol-low:
“The results did not support the the-ories
that underlie craniosacral therapy...”1;
“Further studies are needed to verify
whether craniosacral motion exists...”2; and
“It is possible that the perception of cran-iosacral
rhythm is illusory.”3 Those authors’
conclusions resemble those in a published
summary of my own research,4 based on a
“tissue pressure” or “interactive” model
for the cranial rhythmic impulse originally
published in this journal.5 My findings were
presented as a challenge, to which I have
received no response from the osteopathic
community.
I strongly encourage those who use this
form of manipulative treatment in their
practices to design, conduct, and publish
in peer-reviewed journals scientific studies,
done with the same experimental rigor
demonstrated in those cited above, and con-firming
the existence of the PRM, and clin-ical
studies demonstrating the efficacy of
OCF. Clearly, the burden of proof of effi-cacy
lies squarely with practitioners of OCF.
In addition, published evidence must be
consistent, scientifically reasonable, objec-tively
and rigorously evaluated, and repli-cable.
These recent studies represent a chal-lenge
to which the osteopathic profession
must speedily respond before scientifically
unsubstantiated claims regarding OCF
threaten acceptance of this modality and
weaken the public image and scientific cred-ibility
of the osteopathic profession.
James M. Norton, PhD
Professor and Chair, Physiology and
Pharmacology
University of New England College of
Osteopathic Medicine
Biddeford, Maine
Letters JAOA • Vol 100 • No 12 • December 2000 • 763
(continued)
References
1. Rogers JS, Witt PL, Gross MT, Hacke JD, Gen-ova
PA. Simultaneous palpation of the craniosacral
rate at the head and feet: intrarater and interrater reli-ability
and rate comparisons. Phys Ther
1998;78:1175-1185.
2. Wirth-Pattullo V, Hayes KW. Interrater reliability
of craniosacral rate measurements and their rela-tionships
with subjects’ and examiners’ heart and
respiratory rate measurements. Phys Ther
1994;74:908-920.
3. Hanten WP, Dawson DD, Iwata M, Seiden M,
Whitten FG, Zink T. Cranisacral rhythm: reliability
and relationships with cardiac and respiratory rates.
J Orthop Sports Phys Ther 1998;27:213-218.
4. Norton J. A challenge to the concept of cran-iosacral
interaction. AAO Journal 1996;6:15-21.
5. Norton JM. A tissue pressure model for palpato-ry
perception of the cranial rhythmic impulse. JAOA
1991;91:975-984.
Hardship deferment saves
residents’ money
To the Editor:
About this time of year every year a new
group of interns contemplates how to han-dle
repayment or deferment of loans accu-mulated
during 4 years of medical school.
Many students borrow the full $8500 sub-sidized
Stafford and $30,000 unsubsidized
Stafford loan each year of school. That can
lead to a debt at graduation of nearly
$180,000 including interest. Often, students
are not aware that they may apply for defer-ment
or forbearance for each individual
loan and do not have to choose one option
for all loans.
One way to minimize the growth of
debt after graduation is to try to qualify
for economic hardship deferment of the
subsidized Stafford loans in lieu of a for-bearance.
What is the difference? The gov-ernment
pays interest when subsidized loans
are in deferment status. Since the benefit
only applies to subsidized loans, the unsub-sidized
loans could be placed in forbear-ance.
However, it is simpler to put all loans
in hardship deferment status. Splitting defer-ment
and forbearance status among differ-ent
loans will not preserve deferment time
for the later loans. There are up to 36
months of economic hardship deferment
status available per account regardless of
the number of loans placed in that catego-ry
at one time.
For most students in private medical
schools, the subsidized portion of Stafford
loans represents a small fraction of their
debt, and using the deferment option saves
significant interest accumulation. If resi-dents
wait until they are attending physi-cians,
they may earn too much to qualify for
hardship deferment. The time to apply is as
soon as possible to ensure maximum ben-efit
of 36 months of government-sponsored
interest payments. There are strict guide-lines
as to whether one can qualify for hard-ship
deferment, but because medical school
is so expensive, more people can qualify.
The two criteria follow:
  Loans in repayment have to exceed 20%
of current annual gross income (AGI). Many
loan-servicing organizations will accept 1
month of pay stubs as proof of AGI.
  AGI minus annual loan payments must
not exceed $24,750 in all states and DC
except for Hawaii ($28,446) and Alaska
($30,932) for year 2000.
To estimate annual loan payments, take
the current interest rate of the loans and
find the corresponding factor given below.
Multiply that factor by the loan balance to
get the estimated monthly payment, then
multiply by 12 to get an annual payment.
Most Staffords are at 8.25% this year
(.0122653); use the factors .0121328 and
.0120011 for 8.0% and 7.75%, respec-tively.
For example, an intern finishes medical
school and approaches repayment with a
$100,000 balance. His salary is $35,000
per year, and the interest rate on his loans
is 8.25%. He took out $8500 per year in
subsidized Staffords for a total subsidized
portion of $34,000. His estimated pay-ments
are $100,000   .0122653 
$1226.53 per month, or $14,718 per year.
Check first criteria, AGI: 20% of
$35,000 $7,000, which is less than
$14,718.
Check second criteria: AGI annual
payment less than or equal to
$24,750 ($35,000 $14,718 
$20,282, which is less than $24,750).
Therefore, the intern can qualify.
How much will he save? For a balance
of $34,000 ($8500  4 years) at the current
interest rate of 8.25%, $280 per month.
That interest of $840 per quarter would
also then be capitalized each quarter. At
the current interest rate of 8.25%, and a
subsidized Stafford balance of $34,000, he
can save $9727 of interest if able to quali-fy
for hardship deferment for the full 36
months. The savings are even greater if
applied to future loan payments. The total
savings over a 10-year repayment is $14,317
in the above example. Without a hardship
deferment, if repayment is ignored for just
4 years of residency at 8.25%, the balance
will grow by 37%. Thus, for those who
can qualify, a hardship deferment lessens the
financial burden of today’s medical educa-tion.
At 8.25%, the $34,000 in hardship
deferment will mandate approximately $417
per month repayment for 10 years. If hard-ship
deferment is used now, future pay-ments
could be reduced on a monthly basis
through consolidation (more interest in the
long term) if found to be too great a burden,
but that is another issue altogether.
Andrew Weinberg, DO
Intern, Delaware County Memorial Hospital
Drexel Hill, Pennsylvania
764 • JAOA • Vol 100 • No 12 • December 2000 Letters
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