From the Mailbox

I continue to receive many interesting, candid, and informative e-mails from readers in response to some of my columns. As I did in the Sept. 20 column, I'd like to share some of them with you, along with brief replies.

The [Medicare] bill that passed Congress is neither a victory for us nor an acceptable compromise. And it is neither a cancellation (only in Congress is a six-month deferment a cancellation) nor a modest increase (0.25 percent for a year, really!). … I would really like to see the AMA "on the warpath" about this issue.

I'm not sure about your point that the increase is 0.25 percent for the year. It's a 0.5 percent increase for January through June, and if Congress continues that rate for the rest of the year, then it's 0.5 percent for July through December—and thus 0.5 percent for the whole year. It's only 0.25 percent for the year if Congress goes back to a freeze at the 2005 level for July through December.

Whether it's a freeze, or an increase of 0.25 percent or 0.5 percent, in no way does the AMA call any of those scenarios "acceptable." And if the previously scheduled 10.1 percent cut goes through in July, then we're back to the meltdown scenario about which I wrote in a recent column in American Medical News. As we've said repeatedly in AMA communications, we urge Congress to provide Medicare physician payment updates that reflect increases in physicians' practice costs, as captured in the government's Medicare Economic Index (MEI).

In regards to your request that we go "on the warpath," let me assure you that we've made this issue a top priority in our advocacy efforts for many years, as described in my Dec. 20 column. Unfortunately, we're dealing with a dysfunctional Congress, and the Congressional Budget Office "score" for a long-term Medicare physician payment fix ($262 billion to replace the current formula with the MEI) in the context of the "pay go" rule doesn't help. ("Pay go" requires that new mandatory spending increases or tax cuts be offset by an equal amount of mandatory spending cuts and/or tax increases.) So we're going to have to keep fighting this battle until we get that fix. In the meantime, we continue to remind physicians to review their Medicare participation options (PDF, 55KB); the new deadline to change participation status for this year is Feb. 15, but participation decisions will be retroactive to Jan. 1.

Is it true that the AMA is against a universal health care plan? Why?

We're in favor of universal coverage. Putting our plan (PDF, 1.04MB) into place, along with AMA policy on individual responsibility, will get us there. We're against a national health service approach (like that in the United Kingdom and Canada) that would allow the government to control all of health care. We believe the best approach is a mixture of private-sector and public-sector approaches to health care, and our "Voice for the Uninsured" campaign is very active in spreading the word about our plan.

I receive many comments about my blurbs "on the lighter side." In response to my musings on the use of humor to strengthen the bond between doctors and patients, one physician wrote:

I like to use humor among my patients in the practice of medical oncology, and most patients seem to appreciate it. But I remind myself quite often that it doesn't always work. I recall an incident with a Mexican patient almost 30 years ago, when she came for her second visit a week later with her daughter and she had lost a pound. Just to lighten things up I remarked, "Oh, where did that pound go?" At which point the daughter grabbed her mother and her chart and rushed out the door accusing me of insulting her mother.

Humor certainly can be dicey when there are cultural and language differences between physician and patient.

When I wrote in the lighter side that I had driven the mobile billboard for our "Voice for the Uninsured" campaign around the Iowa state capitol in Des Moines, with a link to photographic evidence, a colleague wrote, "I think you are a little overqualified to be driving that truck." In case anyone else was fooled, I confess that I didn't actually drive that vehicle; that was just a photo-op.

In another blurb on the lighter side, I mentioned having visited the hot springs in Hakone, Japan, where a vendor was selling eggs that had been hard-boiled in the hot springs. A sign on the shop promised, "If you eat one egg, longevity might be postponed for seven years. If you eat two eggs, longevity may be postponed during 14 years." In an e-mail to me, a colleague wrote, "I think I'd rather postpone aging than postpone longevity!"

One topic that seemed to strike a chord with many readers was Good Samaritan actions and laws, which I addressed in my Dec. 13 column. Here's a sampling of the many responses I've received on this subject.

I, too, was once on a transatlantic flight, when an old man felt dizzy. His blood pressure was very high: 200/110. He had all his meds in bottles with him. He hadn't taken them that day. I gave him everything he was supposed to take from his own supply. His blood pressure came down gradually to 140/80. At the end of the flight, the flight attendant offered me two bottles of red wine. I accepted them.

As you may recall, I mentioned in my column that I'd been given an expensive bottle of champagne in a Marlboro bag for my own Good Samaritan efforts on a flight to London. So I asked this reader if she had received the bottles of wine in a similar bag. She said she didn't remember but that she wouldn't hold it against the flight attendant. While I agree, I'd still like the airlines to stop being party to tobacco promotions.

I have rendered emergency care to an individual while on a flight from Baltimore to Providence, R.I. Since one is in the air, how do you determine which state's Good Samaritan law applies? In addition, the care rendered may involve crossing boundaries from one state to the next—or to several states.

State Good Samaritan laws do not protect individuals who render emergency medical care in a commercial aircraft. However, federal law does provide protection. Under the Aviation Medical Assistance Act of 1998, "an individual shall not be liable for damages in any action brought in a Federal or State court arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct."

In addition, the FAA established a rule requiring all U.S.-based commercial airlines to provide automated emergency defibrillators and train flight crews to use them. That rule, which took effect in 2004, also set guidelines for the contents of emergency medical care kits onboard airlines.

One of the interesting things that I have noticed is that it is extremely difficult to auscultate blood pressure manually because of the extensive background engine noise that is conducted via the stethoscope. Do others face that problem, too?

I shared that feedback with an aerospace medicine colleague, who pointed out the huge advances in aeromedical evacuation from the theaters of military operation: "Since World War II, when the practice of using aircraft to move casualties was refined, we have mastered many of the challenges related to keeping casualties alive while being moved thousands of miles. The problems related of determining the state of a patient's condition using direct physical assessment skills, a stethoscope, or other devices in an environment of high noise levels, vibration, and accelerative forces have been understood for all these years. The basic assessment problem is minor compared to the others that are faced by those who transport and treat severely ill and injured patients every day on aircraft."

This colleague suggested that we could do a better job in transferring knowledge of aeromedical practices and lessons learned about "care in the air" from the military services to the private sector.

Back in the 1970s, and maybe into the 1980s, the publisher of an [emergency medicine] magazine had a standing offer to pay $1,000 to anyone who could document a story where a physician had been successfully sued for stopping at the scene of an accident. Back then it seemed to be more of an urban legend. BTW—no one collected.

Perhaps the fear of litigation has a greater impact on Good Samaritan actions by physicians than litigation itself.

My one such incident occurred during a flight from Baltimore to Chicago. … The lead flight attendant asked me what to tell the captain, specifically if, in my medical judgment, the man was stable and we could proceed to O'Hare or if his medical condition was such that they should land at the nearest available airport. Told that we were about an hour from O'Hare, I said we could continue. However, I also remembered from a JAMA article that instead of requesting the plane land ASAP, a physician can recommend an "expedited landing" (no circling). I asked for the expedited landing at O'Hare with EMTs meeting the plane.

Thank you again to the many readers who have sent me their comments, commendations, and complaints. And I encourage you to write more. As we continue to share our ideas and opinions, we can change health care for the better.

Please send comments, questions, and replies to amaprez@ama-assn.org.