Authentic Medicine Gazette

Enjoy our most current issue of the most popular medical e-newsletter on the internet.

Blogs and Thoughts for July 12th to July 18th, 2018

Here is what we had this past week:

  1. Ridiculous Study of the Week: Try My Better Hamster Wheel
  2. Is This What All Hospitals Think of Primary Care Docs?
  3. When Ivory Tower Idiots Attack DPC
  4. Why Aren’t These People At Work? by Pat Conrad MD
  5. Ridiculous Study of the Week: EHRs Save Lives
  6. Friday Funny: The People Trying to “Fix” Our Healthcare System
  7. Quote of the Week: Selina Meyer


1. Ridiculous Study of the Week: Try My Better Hamster Wheel

July 18, 2018

A study just came out showing that paying more for Medicaid patients doesn’t entice doctors to take any more Medicaid patients. You don’t say?

Boosting Medicaid payment levels did not incentivize primary care physicians (PCPs) to accept more patients with the government-sponsored health insurance, a longitudinal analysis of claims data for over 20,000 physicians revealed.

A few observations to start this off.  I looked at the study briefly and it really doesn’t make sense.  If a doctor is employed and is paid by an RVU system then it doesn’t matter if Medicaid is paying her employer more as she gets remunerated the same.  In other words, the doctor doesn’t care as she just sees the patients in front of her.  So the doctor isn’t the rate limiting step here.  It seems to me that the employers or hospital systems should be the ones scrutinized over this.

Also, there is no mention that Medicaid patients are really hard to care for.  Let’s be honest.  We all know it. I am not saying that every Medicaid patient is difficult in complexity or baggage but on the whole they are a much more difficult population.  I worked in a FQHC for 10 years so I have a lot of experience in this.  So would a private doc open to Medicaid patients if she is “almost” being paid the same as Medicare?  Probably not.

My favorite part of the piece, however, is what I really want to highlight.  Another ivory tower idiot had to tell the world how to fix this problem.  This one from Harvard Medical School:

Allan H. Goroll, MD questioned whether an increase in fee-for-service (FFS) reimbursement is the appropriate way to incentivize Medicaid participation. “This is not to deny that an astronomical increase in evaluation and management valuations might have some result, but certainly not the aforementioned raising of FFS pay from an impossibly low Medicaid level to an undervalued Medicare level,” he wrote. Goroll noted that methods meant to increase volume will have little effect on practices that are already overloaded or caught in the “hamster wheel.”

Yes, the dreaded hamster wheel.  Docs are dying out there trying to finish their day.  The last thing they care about is adding more difficult patients.  Maybe he is onto something.  Maybe he will recommend DPC?  Then it goes on:

The current FFS payment model, he wrote, is derived from recommendations by the “specialty-dominated” American Medical Association’s Resource-Based Relative Value Update Committee, which “has routinely undervalued primary care evaluation and management services for decades, forcing primary care practices to maximize volume to stay in business.”

Exactly, he does get it!

He pointed to other payment models, such as one he helped develop that substitute FFS with a prospective, risk-adjusted comprehensive payment for delivery of comprehensive care. While a base payment covers practice expenses, a bonus payment is tied to specific patient- and cost-related measures.

And my bubble is officially burst.  I always underestimate the egos of these pompous jerks.  He actually is pushing a payment model he developed! And what is his system? It’s “a prospective, risk-adjusted comprehensive payment for delivery of comprehensive care. While a base payment covers practice expenses, a bonus payment is tied to specific patient- and cost-related measures.”  I don’t know what any of that means other than it will 100% fail.  He just let the hamster off one wheel and put it on another.

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2. Is This What All Hospitals Think of Primary Care Docs?

July 17th, 2018

Becker’s Healthcare spoke with Cathy Jacobson, president and CEO of Milwaukee-based Froedtert Health, prior to speaking on a panel at Becker’s Hospital Review 7th Annual CEO + CFO Roundtable titled, “The Digital Imperative: The Open & Shut Case for Innovation”.  All this gobbledygook means she is a pretty big deal to other administrators.  I was tipped off by Shane Purcell MD about her thoughts on primary care physicians highlighted in the piece:

Q: What’s one conviction in healthcare that needs to be challenged?

CJ: That every patient needs a primary care physician.  As we start stratifying our patients into distinct populations based on their health needs and develop that insight further into consumer driven wants, we are finding that a substantial sector of the population does not want or need a primary care physician relationship.  People need primary care but not necessarily a physician relationship. We need to stop trying to fit patients into our health system-driven model and develop the means to serve their health needs on their terms.  If we don’t, someone else will.

How does that make you feel?  Pretty crappy, right?  I have known this for a long time.  Hospitals want patients to be linked to THEM and not you as a doctor.  You should have noticed their commercials over the years with hospitals saying “as your healthcare provider”, etc.  It is about wordplay and confusion to make patients feel that the hospital is the doctor and the doctor is the hospital.   We know that this isn’t true. If doctors and nurses left the system then they pretty much just have an empty building.  In fact, if a doctor is missing for a day there is panic and mass hysteria.  If a CEO or other administrator goes missing for a month no one notices.   But the patients don’t know this as no representative organization (AMA, AAFP, ACP) has made a campaign to push back (Thanks, guys!).  Linking patients to a hospital and not a doctor has been the goal for years because hospitals want the patients’ loyalty (and money) so that their doctor has to refer to them and if the doctor leaves they can just replace her with another doctor or MLP.  We are being treated as pawns in a chess set.

The sentence “People need primary care but not necessarily a physician relationship” is very disturbing to me and goes against EVERYTHING I believe in. With one sentence she wipes us out totally. With one sentence she disrespects 2/3 of all doctors.  And there will be no repercussions for this.  None.   But you want to know the truth?  The truth is that she and other administrators are afraid.  They know they’re the ones who are not really needed.  If the future leads to doctors unhinging themselves from the hospitals then we take back control of our future and the reigns of healthcare.  The ones who serve the patients’ “health on their own terms”  will be us.  We are the “someone else” she is worried about.

It’s time we shake the box.  It’s time we free ourselves from being shackled to hospitals.  It’s time for a physician ONLY revolution.  What are we waiting for?

Here is the link to the #1 DPC Book on Amazon


3. When Ivory Tower Idiots Attack DPC

July 16, 2018

A recent JAMA article called Direct Primary Care One Step Forward, Two Steps Back recently came out and they did their typical routine of attacking DPC.  In the article they say:

Proponents of DPC argue that the model generates system-level cost savings, improved patient outcomes, broader access to care, and clinician and patient satisfaction. Because DPC models do not rely on fee-for-service reimbursement, physicians are able to devote resources to previously nonbillable care coordination efforts. With a smaller patient panel and because DPC physicians do not bill third-party payers, physicians can focus on building therapeutic, longitudinal relationships with patients. DPC advocates suggest that these changes yield significant improvements in both patient and population-level health outcomes, reducing the rates of hospital readmissions, specialist visits, radiologic and laboratory testing, and emergency care.

Okay, so far, so good but then they go on to say:

“Individual DPC practices have indicated that practice-level data on outcomes support these claims; however, no study, to our knowledge, has produced data to support anecdotal claims by individual practices.”

Okay, to their knowledge, there is no evidence but then they go ahead and basically say we are going to cause tons of problems including:

  • Targeting healthier patients and declining coverage to the ill.
  • It is unlikely that patients most in need of care would be willing or able to afford an appropriately risk-adjusted retainer in a DPC setting.
  • DPC fails to address fundamental market inefficiencies and facilitates a substantial gap in catastrophic coverage
  • DPC circumvents the quality metrics and incentive structures designed to improve population health and reduce national health care expenditures. DPC practices once held accountable through value-based payment systems have no obligation to report or measure quality metrics.
  • Lessons learned from DPC—mainly the potential utility of global capitated payments—should be applied when developing new payment reform models and envisioning a new future for primary care delivery. However, DPC is not the answer to the problem

Remember when they said there was no evidence? So, all their “conclusions” are based on what?  Fear and hatred.  This article was written by ivory tower “doctors” from Warren Alpert Medical School.  They do not want DPC to succeed but it is succeeding and that pisses them off. In fact, this article in Medical Economics by Kimberly Corba DO shows that DPC may be the link to the “fourth aim”, which is “improved clinician and staff work life.”  Now you can really see why his makes them mad. These non practicing doctors do not want practicing doctors to enjoy their patients and their career. They want us stuck under their control and to be their guinea pigs as they experiment on us with any new bogus fad like quality metrics and healthcare teams.  But again, these are NOT proven either.  Their logic is ridiculous.

Our jobs are simple.  Doctors see patients directly without the interference of the insurance companies, the government or these ivory tower idiots.  Their big complaint is that we cherry pick but the truth is that everyone one of us see very complicated patients of all races and socioeconomic status and most of us give away 5-10% of free care. And we do a better job with these patients because we spend time with them. For the rest we charge a very reasonable price, less than a cell phone bill or a cable bill.

I for one would like to respond to these authors, and every other critic of DPC, by saying “Be Well”.  You can try all you want to stop us but it’s not going to happen.  We get the last laugh while you are stuck in your miserable windowless office trying to make yourself feel important.  The truth is…you aren’t.

Listen to one of our podcasts here

4. Why Aren’t These People At Work? by Pat Conrad MD

July 15, 2018

This week I shelled out $731 to Uncle Sam for the privilege of being able to legally prescribe controlled medications.  As a full-time ER doc, I have to have a current DEA number or I can’t work.  Last week the rat-licking scumbags at Blue Cross raised their premiums another 10% for no apparent reason, and dutifully vacuumed that money out of my bank account.  I have to shell it out for lack of a better option, in order to continue having health coverage.

So perhaps you’ll understand my complete and total lack of sympathy for those on whom the compassionate classes would further bestow victim status in this latest news on the Medicaid front.  The reliable old Kaiser Family Foundation is wringing its hands that between 1.4 and 4 million Medicaid recipients might lose their benefits if states begin instituting work requirements for those able-bodied that are on the program.  The states will have this flexibility as a result of the Trump Administration seeking trying to help states in dealing with crushing Medicaid budgets.  CMS reported in April that there were 67,305,506 Medicaid recipients (excluding the little CHIP’rs), so 4 million losing said coverage comes to less than 6% of the total.  That total, interestingly enough, grew over 16 million in the preceding 5 years.  So thanks, ObamaCare.

Kaiser estimates that about 23 million would be affected by the new rules, because they are not elderly or disabled, adding that most of these have jobs.  So about a third of all adult Medicaid recipients might be affected, and most of them work.  So what is the problem?  All one has to do to keep their “gold card” current is to work 20 hours per week or attend job training classes.  What’s the problem?

Kaiser:  “In all scenarios, most people losing coverage are disenrolled due to lack of reporting rather than not complying with the work requirement.”  You mean all they have to do is fill out the paperwork?

Kaiser:  “Adults who are already working likely will have to report and document their hours… There is a risk of eligible people losing coverage due to their inability to navigate these processes, miscommunication, or other breakdowns in the administrative process.”

You mean beneficiaries are too stu-, uh, mentally infirm to fill out the forms?  So by implication, Kaiser (soon to be joined by other ostentatiously compassionate hand wringers) is suggesting that a great many working poor could lose access to health care because they can’t be bothered to fill out the forms, which might be too hard anyway.

Which reminds me of a funny story.  Last week in our little rural ER, one of the frequent fliers came in – on the ambulance, of course – for a trivial complaint.  He was transported, triaged, examined, all free of charge, in accordance with federal EMTALA requirements.  While awaiting discharge, the very pleasant lady from the business office brought a packet of forms for him to complete for financial assistance.  She had brought this packet to him on previous occasions, as this was his 24th visit in recent months.  In fact, this time she had even filled out most of the forms and only needed a few items like his signature, driver’s license, and work place (he does work).  She pointed out that he could quickly get this information and she would handle the rest.  He demurred.  She pointed out that they had done this dance many times.  He yelled at her, demanding that she not treat him like he was stupid.  She responded, “Then stop acting like you’re stupid!”  He cursed her and stomped out AMA.

The patient is (too) well known to us, and is assuredly not illiterate.  He has his own car, and a job.  He is also entitled and able to play the system without fear of consequence.  For those of you who don’t spend any time in emergency departments, you had better believe this sort of scenario is playing out in every ER nationwide.

There are truly disabled people for whom the state – NOT the federal government – should provide some safety net.  I am happy to contribute my share for those, and glad to treat them.  There are also the working poor, for whom the state should offer assistance as needed, as well as accountability.  Those able-bodied, otherwise mentally competent who cannot be bothered to get off the couch should not get health coverage on the taxpayer dime.  If I have to fill out paperwork to care for them, and for myself, then I will have no sympathy when they cannot put forward even this minimal effort on their own behalf.  The implication of the Kaiser piece is that productive citizens who pay the damn freight should have no say in the matter.

At least be well with one of our t-shirts. 



5. Ridiculous Study of the Week: EHRs Save Lives

July 14, 2018

The idea that an electronic health record (EHR) or electronic medical record (EMR) saves lives never occurred to me.  I would think that good doctors with good nurses on a good team in a good hospital really did the trick.  But what the hell do I know?  To a few researchers, however, they found it their mission to place all the importance on the EHRs.  This is what they found:

Evidence linking electronic health record (EHR) adoption to better care is mixed. More nuanced measures of adoption, particularly those that capture the common incremental approach of adding functions over time in US hospitals, could help elucidate the relationship between adoption and outcomes. We used data for the period 2008–13 to assess the relationship between EHR adoption and thirty-day mortality rates. We found that baseline adoption was associated with a 0.11-percentage-point higher rate per function. Over time, maturation of the baseline functions was associated with a 0.09-percentage-point reduction in mortality rate per year per function. Each new function adopted in the study period was associated with a 0.21-percentage-point reduction in mortality rate per year per function. We observed effect modification based on size and teaching status, with small and nonteaching hospitals realizing greater gains. These findings suggest that national investment in hospital EHRs should yield improvements in mortality rates, but achieving them will take time.

I cannot find the full study and refuse to pay money for it.  I just don’t care enough.  I am no statistician, but it is hard to fathom that a .11% or a .09% change in mortality rate means anything.  I am also perplexed with the “new function adoption” discovery they found. What does that mean?  “Hey, Barbara, I found the a way to copy and paste!  Let’s just use that instead of adding any new information?”

Overall, this study just seems ridiculous.  It is has no depth.  No “aha” discovery.  Intuitively, EHRs can be good if they are workable and not overly complicated.  Once you mix in quality indicators, absurd layers of security, and fluffed notes for billing then they become a piece of crap.  Just my thoughts.

Be well and get one of our t-shirts here

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6. Friday Funny: The People Trying to “Fix” Our Healthcare System

July 13, 2018

This is what happens behind the scenes. Ivory tower doctors, MBAs, administrators and politicians are deciding our future while we walk off the cliff like lemmings.  Let’s stop this madness.

Thanks for another great cartoon.

Get one of our books here. 

Comment Here


7. Quote of the Week: Selina Meyer

July 12, 2018

“I’ve met some people, some real people, and I gotta tell ya, a lot of them are f**ing idiots.”

Julia Louis-Dreyfus as Selina Meyer in Veep

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Comment Here



Douglas Farrago MD

  80 comments for “Authentic Medicine Gazette

  1. Wandal
    January 31, 2018 at 10:57 am

    Love the Gazette, Doug. One thing: We see lots of fads in society, including in medicine, and the latest one is “physician burnout”. Seems every medical publication now has to have a feature on that . . . or at least a comment or letter to the editor. I’m sure there is an element of truth in all of that BUT part of me wants to say ‘what a bunch of cry babies’. There are a LOT of people out there that just don’t get it: They see the salaries of physicians consistently near the top (especially specialists!!), look at the income they and their friends/family/neighbors have and get pissed off. Life and work are hard on a lot of people; more so than on physicians. Income disparity is very wide and growing in this country and it is causing a lot of ??? anger, envy, voting for Trump ??? Just saying . . .

    • bobby garrison
      February 7, 2018 at 3:30 pm

      up yours. way to blame the victim. I can’t have a problem ’cause other people have problems too?? I can’t have a problem ’cause other people don’t make as much money as I do?? Are you out of your mind? Please tell me you are not a physician as you seem to have lost all empathy (and possibly sympathy.)

    • Frank J. Rubino MD
      March 8, 2018 at 10:48 pm

      I don’t think “burn out” is the issue. It is anger. Deep seated anger to the nonsense in health care.
      Meaning less metrics , meaningless MOC crap, Quality measures, etc. ANGER.

      • Mary Lang Carney, MD
        March 28, 2018 at 9:38 pm

        Frank: I totally agree with you!! When will the stupidity end?

        • Frank J. Rubino MD
          April 16, 2018 at 7:38 pm

          Hi, good to hear from you.

  2. Dennis Kabasan
    April 27, 2017 at 10:23 am

    I ordered the Cryohelmet for my sixteen year old daughter, who sustained a concussion, with brief loc, after being struck in the forehead by a soccer ball, in a school match, two weeks ago. She’s been wearing the helmet, as recommended, one hour at a time, since it arrived three days ago. Her pediatrician is following her. She only tolerates a few classes each day, d/t frontal and temporal headaches and extreme tiredness. Sleep helps her. Is there any benefit to longer wear-time? Thanks.

    • Doug Farrago
      April 27, 2017 at 10:31 am

      See my email to you

  3. April 12, 2017 at 2:52 pm

    For some reason, my version of Authentic Medicine is delivered with comments from 2011 and 2012.

    Any notion of what may be going on?


    • Doug Farrago
      April 12, 2017 at 3:55 pm


  4. John Comis, DO
    May 30, 2012 at 11:34 am

    Please encourage the KOM to join his friends at QC13.

    (…of the lemons)
    PS the healthcare system is so terrible it is beyond any further comment.

    • Doug Farrago
      May 30, 2012 at 12:27 pm

      I will try.

    • au-digit
      January 26, 2017 at 3:33 pm

      The Bush you quote was #41.

  5. Gary Gaddis
    May 20, 2012 at 7:43 pm

    Regarding our Federal government, Centers for Medicare and Medicaid Services (CMS), Secretary of Health and Human Services Kathleen Sebelius, and the growing gap between CMS perceptions and reality, here is my sarcastic “Sound Bite” suitable for the brief attention span of our electronic news media:

    “Since the Department of Justice is headed by an attorney, and the leader of the Federal Reserve is an economist, then how is it logical that the Secretary of Health and Human Services is also headed by an attorney?”

    Does anyone else agree with me?

    • Kristina Berger MD
      May 21, 2012 at 7:31 am

      There are too few physicians in politics. Is it because we dont have the stomach for it, or another reason? I know if there were more of us as policy makers, the healthcare system in this country would improve greatly.

      • Simon Cummings
        May 23, 2012 at 8:59 am

        My vote is for Doug and not the type of physician represented by the Cardiologist who told me that he wasn’t interested in cardiac rehabilitation cos there’s no money in it!

    • Judy
      May 24, 2012 at 8:58 pm

      No, I think that it is correct for a lawyer to head the Department of Health & Human Services. Only a lawyer can read the volumes of crap they put out as regulations and find a loophole way to still make a living; only a lawyer can repeatedly find a way to let someone die and it be due to no fault attachable to him; only a lawyer can write voluminous policies that effectively help only a select few of his supporters and require the rest of the populace to pay for it except himself; and only a lawyer can sit passively by and provide no useful assistance to a group of sick, needy people but still require them to pay for his service. If you will think on these comments for a few minutes, you may change your opinion.

      • Bill
        June 4, 2012 at 9:22 pm

        Hey Doug ! I am a lawyer. never made more than $85K /year and spent my entire career in trenches helping people, most who did not have much money, with problems, many of them caused by their own bad decisions and choices. and I love your journal.
        Given the wide range of attitudes, opinions and incomes among doctors do you really want a politically-connected MD in charge ? maybe an orthopedist ? xoxo

        • Doug Farrago
          June 4, 2012 at 10:43 pm

          The description “politically-connected” should remove that person from contention immediately.

        • Dr Bonz
          June 21, 2017 at 8:29 am

          Dear Bill.

          F*** You.


          An orthopedist.

    • Jeff
      February 22, 2017 at 3:14 pm

      I agree, absolutely, that HHS should be headed by a physician.

      What about having an advanced practice nurse in that role?

      But (God help us) not an attorney, a chiropractor, a homeopath, a naturopath, a shaman, or a faith healer!

      On second thought, a shaman would be better than a lawyer any day.

    • Jeff Palmer
      February 22, 2017 at 3:16 pm

      I agree, absolutely, that HHS should be headed by a physician.

      What about having an advanced practice nurse in that role?

      But (God help us) not an attorney, a chiropractor, a homeopath, a naturopath, a shaman, or a faith healer!

      On second thought, a shaman would be better than a lawyer any day.

    • John A Goldman, mD
      March 4, 2017 at 3:10 pm

      thank goodness in 2017 it is a physician

  6. Alan Levine
    May 9, 2012 at 9:03 am

    You have bemoaned our lowly position in hospitals, commenting how few recognized our contributions on Physician Recognition DAY. In what I feel is a further diminution of what we do, my hospital is now celebrating Nurse Recognition WEEK!!!! How far we have fallen………….

    • Doug Farrago
      May 9, 2012 at 2:53 pm

      I agree

      • Jack Forbush
        May 23, 2012 at 12:10 pm


    • Common Sense
      May 30, 2012 at 4:54 pm

      So you’re denigrating nurses in an attempt to rally support for your plight? It is just as easy to argue that since nurses spent 7 times more time with patients, theyre deserving of their week.

      Or, you know, we could all just stop getting butthurt over who has the longest display of solely symbolic “appreciation” and get back to working as the team we were intended to be.

      We’re your knights and you’re our Earls. There is nothing to be gained by making besouring diatribe. Be good to your staff and your patients and you’ll have more appreciation and recognition than your little heart can handle.

      • Doug Farrago
        May 30, 2012 at 5:11 pm

        You really need to have read the thread completely before making that comment. Please check out the blogs on how Doctor’s Day has been totally dismissed. Maybe then you will understand how we feel. This is NOT about doctors against nurses. It really is about administrators.

      • Doug Farrago
        May 30, 2012 at 5:12 pm

        You missed the point on this. It is about Doctor’s Day being totally dismissed by administrators. Please read those blogs.

        • Alan Levine
          May 31, 2012 at 8:56 am

          That was exactly my point. In recognition of out efforts several years ago my hospital–a level 3 teaching hospital–gave chocolate bars (small ones) to the docs. Nurses this year received flowers and other shows of appreciation.

          • JoAnne Fox
            June 8, 2012 at 7:23 pm

            Acknowledgement of a job well done would have been nice. I got a scoop of hot cocoa mix, repackaged in a baggie, with a little note attached telling me how wonderful nurses are.

  7. Doug Given
    April 25, 2012 at 5:29 pm

    What a screw job from the lovely IRS on the Mandate.

  8. Judy
    April 18, 2012 at 10:05 am

    think you should run for President, as long as you will continue to keep up this site after you win!

  9. Dave Hoffman
    February 29, 2012 at 11:20 am

    Great thoughts as always, Doug!

    Is there a way to start new comment threads each time you post a new entry?

    • Doug Farrago
      February 29, 2012 at 12:31 pm

      Each entry is a blog and has their own comment section

      • t mcglone
        April 4, 2012 at 8:25 pm

        Having “served” for 15 years, those are finely edited comments fit for civilian consumption .

  10. February 29, 2012 at 8:53 am

    today’s (feb 28, 2012) gazette was one of your best. some might say that your gazette is merely entertainment. i however, enjoy the articles with their kernel of truth/fact at the center and your encouragement for us to critically examine the field of medicine that we are a part of. the top ten signs that a hospital stay isn’t going well is what we see all our careers. uphoric for gout patients who like beer and ujerky for cardiac patients and the statin report were particularly good reading. i don’t know how you find the time or energy to do this. i was usually totally exhausted by the middle to end of my workday. thanks again.

    • Doug Farrago
      February 29, 2012 at 9:06 am

      thanks, dennis! I appreciate the feedback and I am truly flattered.

  11. Angi Wall DO
    February 9, 2012 at 9:18 pm

    I’m with Doug on the dietary/diabetes. It’s not often you catch those guys looking good in a bikini and munching on carrots.

  12. Dr. Veronica Friel
    January 25, 2012 at 4:20 pm

    More! More!! Doug, keep it coming!!!

  13. Robert Bosl, MD
    January 25, 2012 at 1:27 pm

    Regarding relationship of AD & DM, and comment that DM is dietary–too simplistic and likely wrong. We know about dysmetabolic syndrome & PCOS etc. which is genetic, DMS causes weight gain and subsequent DM. Consider whether strong relationship of DM to increased risk of AD is also genetic predisposition to both rather than one causing the other.

    • Doug Farrago
      January 25, 2012 at 2:06 pm

      100% disagree. Predisposition is not a certainty. How can you NOT think DM is dietary related?

      • Robert Bosl, MD
        February 1, 2012 at 4:12 pm

        My earlier comment may have been oversimplified–just tried to point out that some legit. MD’s believe in insulin resistance as a cause of some obesity issues than the result thereof, and it is conceivable that the “insulin resistance gene” may also play a role in development of Alzheimer’s.

    • Bridget Reidy
      March 8, 2012 at 6:49 am

      Ever consider the relationship between Alzheimer’s and diabetes might be iatrogenic brain damage from hypoglycemia? I’m always shocked at how lightly my patients consider the risk of it.

      • March 16, 2012 at 12:13 am

        May I suggest that the dementia with chronic diabetes isn’t Alzheimer’s, it is more likely to be due to the vasculopathy that accompanies non-well controlled diabetes or elderly age + diabetes. So the relationship is between DEMENTIA and diabetes, not Alzheimer’s Disease and diabetes. The fact that most elderly diabetics are vasculopaths, and the recurring theme in medicine that the brain depends on a constant supply of glucose and oxygen to function well, and that vasculopathy impairs oxygen and glucose delivery, is much more plausible than recurrent hypoglycemia.

  14. Scott Miller, MD
    January 25, 2012 at 12:34 pm

    I work in urgent care and when I get home at night I am too tired to exercise. I find that the exercise I get from going back and forth in order to finish the articles in your journal gives me the physical exercise I need to stay healthy and sane. Thanks, Doug! Could you get me a beer when you go to the kitchen?

    • Doug Farrago
      January 25, 2012 at 2:08 pm

      You got it!

  15. Allyagottadois
    January 18, 2012 at 8:55 am

    If I can print it out in its’ entirety, I can leave it casually around the hospital. Mailroom, Medical floors, ICU, ER, surgical suites, administrative offices, JACHO. Because All I’ve got to do is: everything everybody tells me to do.

  16. Dr. Bill Ameen
    January 1, 2012 at 11:31 am

    Hey Dr. Doug,
    To start the new year right, this ticks me off! I was belatedly reading the 11/4/11 issue of THE WEEK, an article about the Top 1% wage-earners. It takes annual earnings of $516,000 to qualify. Guess what? One out of six of the Top 1% is “in medicine”…I suppose some could be CEO’s of Big Pharma, but I suspect a large number are like the pediatric surgeon who heads the AMA and lives overlooking Central Park, and probably every orthopedist. Sorry, but I believe that anybody who makes that kind of dough either 1) inherited it, 2) stole it, or, as with most surgeons, sports figures and actors, 3) was grossly overpaid (as by insurance companies).

    • Doug Farrago
      January 1, 2012 at 12:32 pm


  17. bill lorentz
    December 28, 2011 at 11:25 am

    I am a recent professor emeritus from a well known university medical school. For a number of years I worked with administration as an associate chief of staff. We spent considerable time and effort reviewing patient satisfaction scores using a well known national company and were quite excited that ours were consistently higher than most othere and certainly higher than I thought was reasonable.
    Bottom line-we discovered that the administrator in charge of managing the satisfaction suvery was “doctoring” our results. When we changed over to a more honest effort our scores dropped significantly. However, no one in administration was happy with our new lower scores and the subsequent need to address the outcomes.

  18. David Devonis
    December 16, 2011 at 11:17 am

    Impressed that a lot of teachers are reading this material. Your site is the Writing on the Wall. Keep it coming!

    • Doug Farrago
      December 16, 2011 at 1:35 pm


  19. Dr. Bill Ameen
    December 15, 2011 at 10:46 pm

    Hey Dr. Doug, Heard that due to droughts affecting the peanut crop the price of peanut butter will go up. There’s a worsening shortage of PCP’s, so guess what? They’re paying us less..and less…and less. Also, latest Medical Economics has lead article about MOC. I was gritting my teeth reading remembering when you published the ABIM chief’s salary at $600,000. I’m sure ABFP CEO’s isn’t far behind. Where are the studies showing MOC (or even boards) make any difference in our performance? Finally, get “The Parking Lot Movie” on DVD. It’s a hysterically funny documentary about the parking lot behind The Corner at U.Va that will remind you of your days there!

    • Doug Farrago
      December 16, 2011 at 5:04 am

      Thanks for the great points, Bill! Will need to get that DVD, as well. On one of my first dates with my future wife she remembers me checking all over the ground for parking lot tickets that were cheaper than the one I had in my hand. I was a class act.

    • Dr. Veronica Friel
      January 25, 2012 at 4:16 pm

      Peanut butter prices going up? At COSTCO, the price of the large-size Jiffy Peanut Butter remains the SAME – the large-size is simply 8 oz. smaller.

    • Connie Severin
      February 8, 2012 at 1:06 pm

      Thanks so much for adding that bit about the movie. I just ordered it off Amazon. I worked at UVa Med Cen from 1980-1985 and remember the strip and the parking behind it (apparently pre-Farina days). I remember some sort of parking honor system and some lot Nazis from back then too, but obviously predating when this documentary is set. It was about the only parking within a mile of campus too, so finding any spot at all was a miracle. I’m looking forward to the video. Thanks for the heads up.

  20. Mary K Freel
    December 9, 2011 at 7:08 am

    RE: Grading Dr. on patient performance. Can you grade me if I work in a factory stamping out parts? Absolutely!! If the part doesn’t meet specifications then I’ve failed. Can you grade me on my patient’s health performance? Absolutely not!! I can only control a small part of what goes into a patient’s health and as studies have shown patients often pay for the dr. advice and then do nothing or the opposite. What a wonderful world it would be if when the dr. told his patient to lose weight and quit smoking they went right out and did those things. I was a nurse for 22 years and a teacher for 10 and in both professions I was the one who got blamed for whatever didn’t go right–whether it was poor scores on tests and the patient not getting better faster. Until people take ownership in their own health and realize that they are the number one reason that their health doesn’t improve the overall health of this nation will not improve and so our health care costs will continue to rise.

  21. Bridget Reidy MD
    December 8, 2011 at 10:44 pm

    I agree with the teacher and have always been suspicious of both of our “quality” grading.

    The recent issue of AMA News gave opinions of practicing docs on lots of little issues but NONE on their main article on why small practices (aren’t they usually run by docs?) aren’t getting EMR’s. Gee 15% more pay for 50% more work – why wouldn’t we bite? I wonder if it’s a censored rag. Thank you Doug for validating our voices.

    • JoAnne Fox
      June 8, 2012 at 7:32 pm

      Where do you find doctor owned small practices?? Most everyone around here is owned by one of the two hospital systems, and one has the gall to proclaim itself “not for profit” – I guess if you don’t mention the wholly owned subsidiaries they don’t count.

      • Doug Farrago
        June 8, 2012 at 8:27 pm

        Hopefully you will find them in the future

  22. Pat Nagle
    December 7, 2011 at 11:45 am

    I enjoy your site. I appreciate your heartfelt concern for patients and your irritation at the “solutions” suggested/mandated by outsiders (e.g. politicians). What strikes me most of all are the similarities between the world of medicine and the world of education, in which I spent 40+ years, working from K-graduate schools.

    Although the history, dynamics, and focuses are different,
    healthcare and education get pushed around by folks who don’t know what the hell they’re talking about, from Presidents, Congresspeople, media, on up, and the bottom line is always the bottom line, not the needs of patients and students.

    Your tirades against administrators parallel my feelings about the “consultants” and “foundations” who infest educational policymaking at every level. The last ones consulted are the frontline teachers and docs. And of course, the politicians and business moguls take no responsibility for the culture and economy they’ve helped create which lead to the problems in both areas.

    I don’t always agree with you (I’m adamantly for universal/single payer healthcare), but I appreciate your struggle. Keep up the good work.

    • Doug Farrago
      December 7, 2011 at 12:39 pm

      Thanks for some great feedback! And the similarities are eery.


    • Frank J. Rubino MD
      December 14, 2011 at 6:55 pm

      We do have much in common. “No child left behind” where the teacher is held responsible for the sucess of each and every child no mater how functional or dysfunctional is the child’s family.

      “Pay for performance” reguardless of how cooperative a patient is with diet & exercise and with their medication regimine for hypertension, diabetes etc.

      If one wants to make a lot of money in a short period of time, one should become a “consultant” to to school districts or to health care organizations. Expensive advice with out the responsibility. Charge a lot and then get out of town.

    • pat nagle
      December 21, 2011 at 12:50 pm

      Pardon me for doubledipping, but I forgot to mention that no legislator/congressperson has ever begged to be put on merit pay/pay for performance. Obviously, legislating doesn’t lend itself to factory models of evaluation. So why do medicine and education? The things that count aren’t measurable, and the measurable things don’t count.

      • Judy
        January 4, 2012 at 9:26 am

        hey, Pat, hope you don’t have a patent on your last line! that is about to become my ‘signature statement’ on my sign-offs!

        • Richard W. Mondak
          March 28, 2012 at 1:56 pm

          I think several of us are going to “borrow” that line (of course we’ll give credit to whomever coined that phrase — whoever that is)

  23. John Chase
    December 7, 2011 at 9:11 am

    I would prefer your stories to run in their entirety rather than “read more”. Very irritating to have to go back and forth

    • Doug Farrago
      December 7, 2011 at 10:08 am

      Ok, will work on it.

      • Greg Salard
        December 8, 2011 at 2:35 am

        I have to agree. Not only is it irritating, it can be confusing when you have to …

        Read More >>>

        • Doug Farrago
          December 8, 2011 at 3:31 am

          LOL. Will work on it

          • thea
            December 14, 2011 at 8:00 am

            Would like more written stories/blogs etc, do not have sound card on computer so can’t hear any of these videos..they kinda lose their punch without sound?

          • Doug Farrago
            December 14, 2011 at 8:14 am

            Understandable. I had some videos done already and needed to get out a few extra this week. Won’t always be like that.

          • Chris
            December 15, 2011 at 11:20 am

            Dear Doug,

            Not only do I want full articles on the page and written articles instead of videos, but I also want to have $100 deposited into my bank account each time I click onto your sight. And world peace.

          • Doug Farrago
            December 15, 2011 at 11:25 am

            Done and done.

          • tom walsh
            January 11, 2012 at 7:52 am

            These same people who can’t fathom going “back and forth” to read an article are the same ones who had difficulty with ‘butterfly” ballots in the 2000 elections in Florida.
            I have been enjoying your articles for quite a while and have no problems with the layout. Keep up the great work!! And, thanks.

          • Doug Farrago
            January 11, 2012 at 7:54 am

            Thank you, Tom!

          • Connie Severin
            February 8, 2012 at 1:09 pm

            Thanks for the new format! Jumping between responses and articles was a nuisance. I like being able to read everything in only one, maybe two spots at one read. It also makes it easier to check on new entries to the comments all at once, rather than having to check for each separate article.

        • Richard W. Mondak
          February 22, 2012 at 12:21 pm

          I have a short attention span, so reading part of the article and assuming I know what is being stated is par for the course for me. I often shoot par – 36 on the first 5 or 6 holes – so why play more?

          I don’t mind procrastining to READ MORE>> later

      • Ariel
        December 8, 2011 at 8:58 pm

        Agree with Mr. Chase. Thanks for looking into it!

        • Sharon
          December 28, 2011 at 10:10 am

          I totally agree with Chris!

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