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Worcester Medicine The
Changing Face of Primary Care (revisited)
Hospital
Based-Medicine An Advance or a Retreat? The
Use of Hospitalists is Unwise
The Impending Collapse of Primary Care and What It Will Take To Prevent It
Internal Medicine Primary Care - Is the Obituary Premature?
The Changing Face
of Medical Student Education: The Call to Primary Care Physician-Educators
The Future of Primary
Healthcare Delivery
Do No Harm: From
Hippocrates to the I.O.M. Excerpted from the 2006 Annual Oration Legal Consult: Apologies
Accepted
Financial Advice for Physicians: Use State Exemptions to Begin Your Asset
Protection Science Corner: Where
Did the Pseudoephedrine Go?
Massachusetts Medical Society 6th Annual Creative Writing Contest
Gerald F. Berlin
Prize for Creative Writing Off Call: Winetasting The
Changing Face of Primary Care (revisited) Four years ago in Worcester Medicine, Dr. Kenneth Kronlund and I wrote an article entitled “The Changing Face of Primary Care.” In that article, we stated, “The biggest drivers of changes in primary care are finances, insurance, and the workforce. For physicians starting practice, educational debt load can be a significant factor.” Fortunately, although these issues have not been resolved, at least politicians, government regulation bodies and professional societies are looking for solutions to them. Dr. Goroll’s article points out that reimbursement favors procedure-based practices and does not reward the cognitive work that the primary care physician performs. The current system pays only for face-to-face encounters; thus the birth of the hospital-based internist, a topic so well debated by Dr. Susan George and Dr. Robert Lebow. The drastic decline in the number of medical students choosing primary care as a career choice is highlighted in Dr. Joel Popkin’s article. The time demands, regulatory constraints and the staggering emotional ~ not to mention financial ~ cost of malpractice all enter into an equation that adds up to 1% of Internal Medicine residents choosing General Internal Medicine for a profession. Student debt, now at $200,000, drives students into the more lucrative fields of medicine. As documented in Dr. Michele Pugnaire’s article, the medical schools have already put in place several measures aimed at increasing student interest in primary care. Students are spending more time in the outpatient setting and most of the “hot topics” listed by the AAMC are related to primary care. Dr. Robert Baldor’s thoughtful article discusses the evolution of managed care, new payment schemes such as Pay-for-Performance, and the informed consumer. These changes, aimed at cost containment, influence the way we practice medicine. I will end with a quote from our previous article: “Despite the complex problems above, there are reasons for hope and optimism in Central Massachusetts. The medical community here is fortunate to have the University of Massachusetts Medical School as a resource for new and existing primary care physicians. While providing continuing education for local physicians, the faculty also has an excellent track record for placing their graduates into primary care residencies…We have an active medical society, both at the local and state level, which advocates for medical providers in both regulatory and legislative arenas. Perhaps most importantly, we are endowed with scores of dedicated, talented, and well-trained providers who have made the Worcester area their home.”
Hospital
Based-Medicine An Advance or a Retreat? While the concept of inpatient medicine has been around for some time, especially in Europe and Canada, organized hospital medicine gained momentum in the US health care scene in the late 1990s. Hospital medicine is currently the fastest growing medical specialty in the US, with the number of hospitalists expected to exceed 20,000 by the year 2010. The specialty initially evolved in response to health care market trends, demands for more efficient inpatient care, and cost pressures to decrease length of stay. Inpatient medicine has now become an indispensable part of quality patient care. As with any major transition, there are pockets of resistance and skepticism in the medical community as to the role of the hospitalist. A hospitalist is defined as a physician who spends at least 25% of his or her professional time serving as the physician-of-record for inpatients, during which the entire responsibility of care is handed over from the primary care provider (1). The purposeful “hand-off” of care raises concern regarding discontinuity of information flow between office and hospital and again upon discharge. The only way to minimize this potential issue is to maintain an open channel of communication between the hospitalist and the primary care physician at the time of admission, discharge and with any major change in the patient’s status. The input of the primary care physician is invaluable in the care of the patient. The means of transmitting information could include telephone, fax or secure electronic mail, but personal contact is always preferred. Another area of concern is potential patient dissatisfaction caused by assignment of a new physician to provide care when the patient is most vulnerable. Studies however have shown otherwise ~ that satisfaction of inpatients under a hospitalist’s care is at least as great as under the primary care physician (2). Data indicates that patients may be willing to sacrifice familiarity for availability. Social visits or calls by the primary care physician are encouraged to enhance patient satisfaction. The primary activities of a hospitalist include research, providing quality patient care, providing leadership related to hospital care and teaching medical students and residents. Several studies have demonstrated that patients managed by hospitalists had lower total costs or charges primarily by reducing length of stay and improving efficiency (3). Because hospitalists are in-house full-time, they are able to respond more expeditiously to test results, consultations and any sudden change in patients’ condition (4). On the other hand, the primary care physician, because of time demands in the office, may be able to make rounds in the hospital only once a day. The hospitalist would also be more adept at obtaining the various services required to expedite discharge. The improvement in quality of care is most likely due to an improved ability to respond to needs and service demands rather than special medical knowledge. A major area of involvement is that of perioperative medicine. A study published in the Mayo Clinic Proceedings showed that the hospitalists’ involvement in the medical management of patients undergoing hip fracture surgery was associated with a decrease in time to consultation, time to surgery, length of stay and total hospital costs (5). Another study showed that the co-management of patients undergoing total hip or knee arthroplasty by medical hospitalist-orthopedic teams had lower rates of minor complications (6). The higher satisfaction rating by orthopedic surgeons and nursing staff reflects the team approach that hospitalists bring to multidisciplinary care. Many hospitalists assume responsibility for quality assessment, utilization review and development of hospital policies and procedures in order to improve clinical outcomes and efficiency of the institution. Internal medicine residency programs have also experienced a boost in teaching with increased supervision by hospitalist attendings, which offsets any perceived loss of autonomy. Trainees reported more effective teaching and more satisfying inpatient rotations when supervised by hospitalists (7). While there is no statistical difference in the quality of care or patient satisfaction (3), dedicated hospitalists allow the busy primary care physician to spend more time in the office. With 5% of the gross domestic product being spent on hospital care, there are significant savings to be harvested with more efficient inpatient care. Rather than being viewed as a competitor or threat, patient care will improve if both outpatient and inpatient medicine physicians complement each other. Quality patient care can be ensured only if there is communication between physicians so that the transition between inpatient and outpatient care is seamless. The race is not between us; rather, it is to ensure that together we get our patients to the finish-line (without dropping the baton). References:
The Use of Hospitalists is
Unwise The common “wisdom” is that the use of hospitalists leads to improved quality and lower cost ~ witness the growth in their numbers from about 7,000 in 2003 to about twice that today. But the common wisdom can be wrong ~ just ask anyone who jumped on board the Enron investment “miracle” (before its Dec., 2001 bankruptcy declaration) ~ not to mention those who believed that the Titanic was unsinkable. Plato’s “Gorgias”1 cautions us to look for the underlying truth rather than to allow ourselves to be swayed by slick rhetoric; this is applicable both to Dr. George’s pro article and to this one. The issue of hospitalists is a complex one which does not easily lend itself to a simple answer. The use of full-time hospital doctors (now called hospitalists) was implemented in this country largely to improve hospital income by shortening the average stay. It was not intended to improve quality-of-care nor to please patients (it doesn’t ~ but admittedly opinions vary). When I’m in the hospital I want to see MY doctor ~ but I’m not given the choice. Primary care doctors soon learned they’d make more money (and save more time) by staying at their offices seeing patients rather than by traveling and fighting Boston (or New York City or wherever) traffic. Then there is also the time they would save by avoiding hospital-associated hassles including the obligation of serving on hospital committees. But shouldn’t continuity-of-care for patients trump higher income? The term “hospitalist” was first used by Drs. Robert Wachter and Lee Goldman2 in 1996, but the use of full-time hospital doctors precedes the coining of the term. Note that there are many variations of the hospitalist model. If I’m a member of a 12 doctor group, each of whom takes a one-month turn as ward/hospital attending and teacher, does that mean I’m a 1/12 hospitalist? Some problems associated with hospitalists:
Our hospital of about 100 beds estimates that a full-time, around-the-clock hospitalist seven days per week would cost about $1.1 million/yr. (five individuals; for each about $160K/yr. salary plus $45K for malpractice insurance, fringe benefits and other costs ~ plus about $100K for administrative costs), most of which we would not make up in savings. We have an ad-hoc committee looking for a middle ground (perhaps only one doctor who’d cover only 35-40/hrs. per week) as this is something that the newer primary care doctors appear to want (Oops! ~ I’ve slipped out of the “con” mode). The use of hospitalists appears to be growing. Whether this is good or bad is a complex issue. Whether or not to have a hospitalist service is less pro/con than “Does it fit?” One size does not fit all (and there are many variations of the hospitalist model). The reader is cautioned to look for the underlying truth rather than be swayed by rhetoric (Plato’s “Gorgias”). For more information please go to the websites of medical journals (www.NEJM.org and www.annals.org), insert “hospitalist” into the Search box, and read. References:
The Impending Collapse of Primary Care and What It Will Take To Prevent It Allan H. Goroll, MD, FACP, is Professor of Medicine Harvard Medical School; Physician, Massachusetts General Hospital; and Massachusetts Governor, American College of Physicians Modern primary care in the United States was founded over three decades ago on the premise that coordination, comprehensiveness, and continuity of medical care are essential to the effective functioning of our health care system. Ironically, at the very time that strong evidence is accumulating on the essential contributions of primary care to our health care system, the field faces imminent collapse. Anecdotal data abound about the abandonment of primary care practice by accomplished clinicians years before normal retirement age. This trend is compounded by survey data on the career plans of physicians in training, which indicate that only a fraction of the necessary numbers plan to enter primary care practice. A well-functioning health care system requires between 50% and 75% of its practitioners to be primary care physicians. At present less than 20% plan to enter the field and their numbers continue to decline annually by double-digit amounts. The reasons for this abandonment of primary care are numerous and multifaceted, rooted in the nature of modern practice and how its services are paid for. Our current payment system richly rewards procedures and technology and devalues so-called “cognitive” work (regardless of who performs it). Moreover, payment is awarded only for face-to-face encounters and not for all of the off-line effort that goes into ensuring coordination and comprehensiveness of care. Net result: Much of the essential work performed by primary care practitioners goes unpaid or underpaid. Consequences of this disconnect between work and payment are the financial collapse of primary care practices and the desertion of the field by its practitioners, present and future. Primary care practices have tried to adapt to these financial pressures but the approaches commonly used to maximize revenue have proven counterproductive and/or professionally dissatisfying. For example, many practitioners have abandoned caring for hospitalized patients because they cannot afford the time away from the office. At the very time their patients need them most, they are forced to be absent. Instead, their office schedules are packed with as many face-to-face visits as possible, including large numbers of short visits, which are the most financially advantageous. This leads to scheduling lots of visits for patients with minor problems, leaving inadequate time for proper assessment and management of elderly and complex patients and encouraging high rates of referral and over-reliance on expensive testing (especially imaging studies). Primary care doctors feel frustrated because they don’t have the time to do their job properly; patients feel shortchanged and abandoned. The resultant patient anger and loss of collegial respect have demoralized the entire field. A few practitioners have adopted novel approaches for regaining financial solvency. Some have turned to performing lucrative office procedures (e.g. administering Botox). Others have resorted to personally charging patients a large retainer fee in return for offering “concierge” service. While these adaptations provide short-term relief to beleaguered practitioners, they are fraught with serious shortcomings (e.g. encouraging provision of unnecessary care, firing patients who cannot pay). The current untenable situation begs fundamental reform of primary care. Two important responses are in the works: 1) Redesign of primary care practice and 2) New models of payment for delivery of primary care. The former is exemplified by the “advanced medical home” concept being promoted by the American College of Physicians (ACP) and others. Features include an electronic health record/decision-support infrastructure, multidisciplinary team practice, a population health focus, and patient-centered care. The latter is characterized by proposals for major payment reform that range from a substantial management fee for coordinating the care of complex patients to substituting the current visit-based RBRVS system with a program of comprehensive payment for comprehensive care. Massachusetts ACP is exploring a demonstration project to test these models. A strong primary care base is essential to the well functioning of our medical care system. Its current unraveling is due to a combination of outmoded practice methods and a dysfunctional payment system. It will be fixed because it must be fixed. The only question is whether we do it now or later, before or after the meltdown of our health care system.
Internal Medicine Primary Care - Is the Obituary Premature? In 1985, fifty students graduating from the University of Massachusetts Medical School, a number of whom presumably went on to primary care, chose Internal Medicine as their career track. This year, a record low number of grads ~ seventeen ~ chose Internal Medicine and, if current trends persist, possibly none will go on to primary care. At St. Vincent Hospital, none of our current fourteen senior internal medicine residents or three chief residents will be practicing primary care. Just five years ago, we could count on a 50:50 mix of primary care and subspecialty interest. Is this an isolated Worcester phenomenon? Were that only true. The latest national data we have from the American College of Physicians confirms what all of us in the graduate medical education business have obsessed about for several years now; not only have we reached the precipice, but we may be hanging on by our thumbs. Annual residency questionnaires have shown an extraordinary decline in the percent of graduating internal medicine residents who choose generalist careers. While in 1998 54% of internal medicine graduates were seeking primary care, in 2005 the number shrank to 20%.1 Predictions for this year are that we may be looking at 1%. The ACP labels this phenomenon as “…the impending collapse of primary care.”2 It is urgently pressing for “…a national workforce policy for internal medicine, critical changes in undergraduate and graduate medical education and training, and reforms in physician payment and delivery systems to reverse the downward trend in primary care.” Never mind that “…the consequences of failing to act will be higher costs, greater inefficiency, lower quality, more uninsured persons, and growing patient and physician dissatisfaction."2 The basics are these: Our very elderly, age 85 and over, those with the greatest complexity of problems and most in need of coordination of complex care, will increase 50% from 2000 to 2010 and are expected to more than double by 2030.1 The current predicted shortage of physicians in the United States is 200,000 by 2020.4 Who will be left to care for us medically when we most need it? And at a time when a nationwide shortage of physicians in training is looming, particularly in primary care, it is notable that a jump ~ a leap, really ~ from established careers in general internal medicine is also taking place.5 The reasons are straightforward. Primary care has evolved into a grossly undervalued specialty in which the service demands are continuously increasing, the regulatory environment and the financial and emotional costs of malpractice are numbing, and the compensation has withered. More than ever, internists simply “Don’t get no respect.” Role models of enthusiastic internists have become a rarity, and by their second year most medical students have already turned off to the idea of a potentially rewardless career. Realistically, what student with a typical $200,000 debt would pursue Internal Medicine even if the desire hadn’t already been quashed? Between 1985 and 2005, Internal Medicine crashed with the same impact nationally as locally. Some 412 three-year Internal Medicine programs were whittled down to 364, while preliminary medicine programs (the source for dermatologists, ophthalmologists, radiologists, and the like) increased from 201 to 285.6 The untold part of this story is that the number of positions in preliminary medicine essentially doubled. Where is everyone going? As the percentage of US grads inexorably declines in Internal Medicine, Anesthesiology and Radiology have become the wunderkinds of the decade. Mind boggling now in competitiveness is Dermatology, deliberately limited to a handful of select grads who will never once have to worry about job security or lifestyle. Of the few left who have entered Internal Medicine residency, the great majority are now swamping formally less competitive subspecialties such as Hematology/Oncology, Endocrinology, and Rheumatology. Meanwhile, Cardiology and Gastroenterology continue to enjoy hundreds of applicants for each available position. So why the question about a premature obituary if the funeral is already underway? Having been in the business of graduate medical education for more than 15 years and the practice of Medicine for nearly 30, I have lived through the sine waves of physician supply and demand:
Am I predicting a similar shift in primary care? In short, yes. Like it or not, capitalism is still what drives American medicine. Kaiser, or for that matter any large medical group practice, cannot survive without a primary care base. Without new primary care docs coming down the pike, ACP’s “impending collapse of primary care” could be upon us within a year ~ two at most. But stand back. A bidding war for primary care physicians is about to start. And in two to three years my medical residents will be saying, “Ya know, I hadn’t really thought much about primary care before, but I could see myself doing this for a career. And those loan forgiveness deals aren’t so bad either…” References:
The Changing
Face of Medical Student Education: The Call to Primary Care
Physician-Educators Michele Pugnaire MD is Associate Professor of Family Medicine and Community Health and Vice Dean for Undergraduate Medical Education, University of Massachusetts Medical School. Now more than ever before, medical schools nationwide are calling on primary care physicians to serve an expanding role as teachers and role models for our students. UMass is no exception, and our medical school is fortunate to have both a founding mission and a nationally recognized tradition of excellence in primary care education that contributes substantially to the quality of training for all our graduates, whatever their chosen specialty. Looking back over the past two decades, the evolving trends in medical education reveal a compelling picture of how far primary care has come not only as a core component of medical student learning, but also in the development of primary care physicians as faculty and teachers. Looking forward, the direction and pace of change in patient care, medical science and clinical practice will ensure the ongoing expansion of primary care in our teaching programs and the “primacy” of primary care physicians as teachers and role models for our students. Perhaps the best illustration of the changing face of primary care in our medical schools has been the recognition that primary care experiences are essential for quality clinical training of all medical students, regardless of their choice of specialty. As a requirement for accreditation, medical schools must now provide clinical experience in primary care as part of the required curriculum. At UMass, clinical rotations in the primary care setting total about 17 weeks beginning in the first year of medical school. This number represents a nearly three-fold increase in primary care teaching in the past two decades. This increased exposure has been fueled by the recruitment of new primary care preceptors throughout Worcester and across the Commonwealth providing our students with a rich array of primary care experiences in diverse settings, including rural, urban, group, and solo practices. Students consistently rate their primary care experiences most highly, and particularly value the one-on-one mentoring and role modeling provided by their primary care preceptors. The changing face of primary care in our medical schools is also exemplified in the educational standards supported by the Association of American Medical Colleges (AAMC). Each year, the AAMC issues its Graduation Questionnaire; included in it is a growing list of guidelines for assessing the quality of our educational programs and promoting the advancement of medical student education. In its 1980 Graduation Survey, the AAMC listed 20 different content areas as “Hot Topics” to be addressed during the 4 years of medical school. In the most recent 2005 AAMC Graduation Survey, this list had grown to 65 items, with primary care-related topics leading the way. For example, in the area of student’s clinical experiences, topics on this list include “primary care” itself as well as diverse patient care issues that are consistently encountered and best taught in the offices of our primary care preceptors: “Patient follow-up,” “long-term health care,” “continuity of care,” “disease screening,” “risk assessment and counseling,” “human sexuality,” “family dynamics,” “domestic violence,” “drug and alcohol abuse” and “women’s health.” In the area of population-based care, the AAMC has developed a comprehensive list of topics that reflect the growing needs of our underserved and vulnerable populations, groups who are largely served by primary care physicians in our community-based practices. The list includes: “Health issues for underserved populations,” “culturally-related health behaviors,” “culturally appropriate care,” “health disparities,” “social determinants of health,” “cultural competency” and “the role of community and social service agencies.” Recognizing the need to keep pace with the science of medicine and medical informatics resources, the AAMC is also advocating that our students be knowledgeable and skilled in evidence-based practice, specifically noting “evidence-based medicine,” “cost effective medical practice,” “decision analysis” and “quality assurance” as key areas for development in medical school. In all of these areas, primary care physicians provide valued expertise for teaching our students and have been recognized as educational leaders both at UMass and nationwide. The AAMC has also acknowledged the growing importance of systems for health care delivery in the education of medical students and has defined a number of curricular areas for development including “medical record keeping,” “patient privacy/HIPAA,” “health care systems,” “medical economics,” “practice management” and “law and medicine.” As experienced practice managers, primary care physicians are well-prepared to teach these topic areas, serving as active participants in our educational programs on health care systems. The AAMC has also been a strong advocate for promoting the development of curricular programs that address and promote professionalism in our students. Areas of focus include “biomedical ethics,” “teamwork with other professionals,” “physician-physician communications” and “physician patient communication.” Our students’ one-on-one relationships with primary care physician-preceptors provide the ideal opportunity for primary care physicians to serve as role models of professionalism and to participate as much sought-after teachers in our professionalism curriculum. Over the course of the past two decades, the changing face of medical education has established primary care as an essential and highly valued component of medical student teaching. Today’s challenge for primary care education is to continue the expansion of this teaching in our classrooms, clinical practices and diverse community settings despite the looming workforce shortages resulting from falling recruitment in the primary care disciplines. Through their role as teachers, primary care physicians have a unique opportunity to proactively respond to our workforce needs by informing, motivating and supporting student interest and career decision making in primary care. And for all students, regardless of their career interests, the changing face of primary care in medical education must ensure that future physicians appreciate and respect primary care as the backbone of our health care system and as an essential part of their medical education. The Future of
Primary Healthcare Delivery Robert Baldor, MD is Professor and Vice-Chairman of Family Medicine & Community Health; Director, Community-Based Education in the Office of Medicine Education; and Chairman of the Eductional Policy Committee, UMass Medical School. The delivery of Primary Health Care services has changed over the years and will continue to evolve to meet the challenges of providing high-quality, accessible health care. However, before looking to the future, it is useful to reflect on the changes that have occurred over the past 50 years. Prior to World War II, the majority of physicians in this country were General Practitioners (GPs). While the development of the specialties pre-dated WWII, medical advances on the battlefield accelerated the interest in specialty techniques, encouraging returning medical personnel to pursue medical specialties. Additionally, many generalists who went to war found that when they returned home they were denied the hospital privileges that they had previously held. As the majority of physicians entered into specialty fields during the 1950s, concern rose that the GP appeared to be a “dinosaur.” In response, the Millis Commission was formed to make recommendations regarding the physician workforce. The Commission findings were reported in 1967, formally recognizing the concept of “Primary Care.” It was acknowledged that advances in medical care necessitated a primary care physician undergoing more comprehensive training than what was formerly provided during a general practice internship. The new specialty of Family Medicine was established. The Millis report also recommended increasing the number of primary care physicians. This growth was fuelled by the development of new state-supported medical schools with mission statements devoted to such training. UMass was one of these schools. The decade following the Millis Report saw a slight renaissance in primary care as more medical students pursed primary care residencies. Primary care practice had changed from simply providing comfort and symptom relief to providing cure by integrating specialty medical advances. Additionally, the focus changed from conducting home visits to providing care in the office. Two decades later, the annual spending on healthcare surpassed a trillion dollars while concerns were being raised regarding access and quality. A new means of health care delivery, “Managed Care,” was proposed. Managed Care called for the delivery of coordinated, high quality, cost effective health care services. The primary care physician (PCP) was placed at the heart of this new medical system. The focus of the doctor-patient relationship became more complex as, for the first time, physicians were asked (and financially incented) to be concerned about cost containment in the course of providing care for their patients. In addition to providing comprehensive primary healthcare services, PCPs were required to verify the need for specialty referrals, adhere to guidelines and formularies, pre-authorize diagnostic procedures, and minimize the use of hospital-based services. Challenging payment mechanisms such as capitation placed physicians “at-risk” for the care they prescribed, requiring primary care groups to look carefully at how they ordered tests, cared for patients in the hospital, etc. Further, as care moved from a focus on acute problems to the management of chronic disease, “report cards” such as the HEDIS program began to illustrate the flaws in an older delivery system. Without the tools to actively manage chronic illness from within the practice, physicians were finding that their patients were being enrolled in disease management programs by the insurance companies, far removed from the practice. The turn of this century has seen a significant push back against restrictive reimbursement mechanisms such as capitation and as a result many of these processes have been relaxed. However, health care costs are again on the rise and attention continues to be focused on medical errors and quality. Renewed calls are heard for measures to control costs, enhance access and improve quality. The latest tactic to control health care costs aims at asking the patient to become more actively involved in the medical decision-making process. New payment schemes such as patient-directed “health savings accounts” and varying co-pays for “tiered practices” are being implemented. Pay-for-Performance (P4P) has also arrived. While P4P and “tiering” measures attempt to assess the ability of a practice to incorporate chronic disease management and preventive standards, the concept also introduces patient measures of satisfaction such as the quality of the doctor-patient relationship and the convenience of office hours. We are clearly moving into a future of informed consumers, those who use the internet to research their health care, communicate via email, and demand that their physicians be accessible and cost-conscious. Thus, primary care is again challenged to change. Figuring out how best to approach this change is triggering a number of experiments in health care delivery. Those primary care clinicians who rely on the basic tenets of their primary care training will do well. It will be important to embrace the concept of the “medical home,” which requires the provider to enter into a partnership with patients. Not only will a patient know where to turn for medical care, but the practice will know who “lives” in the home ~ in essence, the practice will assume responsibility for the health care of a specific panel of patients. I believe that there are 3 key components to the future success of primary care practice: The provision of chronic disease management, a robust focus on health promotion and disease prevention, and accessible acute care management.
The current demands of providing optimal care require re-engineering of the primary care office. Studies have demonstrated that primary health care delivery is cost effective and provides quality equal to that delivered by specialist care. Primary health care is an important component in addressing many of the issues that are so difficult today ~ cost, quality and access. The future success of primary health care delivery entails a well-trained primary care medical corps practicing in a patient-centered, electronic office. Do No Harm: From
Hippocrates to the I.O.M. Excerpted from the 2006 Annual
Oration Physicians have been debating and defining for millennia what constitutes appropriate medical care. Indeed, the evolving discussion over medical appropriateness and effectiveness mirrors the history of Medicine as an art, a science, and a profession. In this article, we will examine three themes which have informed that debate over the centuries and which today remain issues with both great intellectual and emotional significance to physicians, patients and public policymakers. These three themes are:
The “Re”- mergence of Do No Harm In the 18th and 19th centuries there were multiple and competing schools of practice subscribing to radically divergent views of therapeutics and consequently of medical appropriateness. The so-called Heroic School of Practice adopted an activist-interventionist position on medical therapy and believed that it was immoral for a physician confronting disease to do nothing for his patient. In contrast, the Skeptics were troubled by the seemingly dangerous interventions many practitioners were willing to apply and felt that Nature’s powers to heal were at least as effective as many of the Heroics’ remedies and that therefore one ought to do nothing to a patient unless there were good reason to believe the intervention was more likely than not to be beneficial. The differing philosophies of Medicine were captured in this quote: “The Heroics believed better something doubtful than nothing, whereas the Skeptics believed better nothing than something doubtful.” Over time, of course, the ancient notion to “do no harm” prevailed. Indeed, as science and measurement asserted their dominance over medical training and research, practitioners began to utilize the Proportional Calculus to judge medical effectiveness and to guide clinical decision making. The Proportional Calculus states the now-familiar concept of Risk versus Benefit: One ought not to intervene unless the intervention is more likely to be beneficial than is non-intervention. By basing medical decision making on a more rational foundation, the Proportional Calculus provided a common basis upon which competing schools of therapeutics could be compared and patients’ welfare better protected. The Recognition of Iatrogenic Illness With a now secure grounding of medical therapeutics in scientific rigor, coupled with dramatic growth of knowledge in basic science and applied technology, the mid 20th century witnessed the penetration of technology into all areas of healthcare. Indeed both the profession and the lay public developed an almost unfaltering belief in the ability of technology to bring about miraculous benefits across a broad spectrum of medical conditions. Additionally, however, during the 1950s the concept of iatrogenic illness began to be recognized as an important public health problem. Studies indicated that as many as 5-8% of hospitalized patients sustained serious or fatal reactions to treatment. Nevertheless, so great were the confidence and pride in modern medicine that such medical harm was seen as the price we paid for the benefits of technology. Medical risk was considered a necessary cost of receiving good care. Challenges to the Profession’s Role The 1960s and 70s were notable as decades during which American society established a civil rights agenda and during which concepts of self-fulfillment and self-determination affected many social institutions including the family, the school, corporations, churches and so forth. Institutions in general were increasingly suspect. In this context, the growing awareness that medical science, despite its wonderful works, was inflicting a substantial burden of suffering on patients in the name of promoting health gave rise to a backlash against the disproportionate authority and independence physicians had enjoyed in the United States. Virginia Sharpe, in her book Medical Harm, relates that the ethos of patient self-determination arose in challenge to this then-prevailing spirit of professional paternalism and virtual autonomy. The doctrine of informed consent arose as the vehicle that would bring about a new power balance in the physician-patient relationship and a new paradigm under which treatment decisions were to be made. In cases of law and philosophy the message was clear, that self-determination was a value that was independent of the particular medical outcomes in any situation. Standards of care, if they were to be regarded as universal and sustaining, had to encompass ~ in addition to the profession’s belief in what constituted sound science ~ a consideration of the individual patient’s view of what constituted harm and benefit. No physician could decide among options in isolation from the patient and his/ her unique needs, concerns and circumstances. In addition to including personal ethical, spiritual and psychological dimensions in evaluating medical appropriateness, the latter part of the 20th century brought us face to face with the economic realities that challenge our ability to continue to provide accessible, high quality healthcare. For the first time, physicians were asked/told to consider resource utilization as one criterion upon which to base medical decision-making. The physician’s traditional duty to avoid biologic harm to the individual patient whom he was treating had expanded to include a duty on the part of the practitioner to affirm the psycho-spiritual well-being of his patient and to make a good faith effort to steward the healthcare resources of society as a whole. Clearly our roles as physicians have become increasingly complex and the task of providing consistently excellent care more challenging. We serve many agendas simultaneously and it is often tempting as a profession to feel burdened and victimized. Nevertheless, despite the limitations placed on our autonomy and the hurdles we have been asked to overcome in the daily practice of our art, we continue to enjoy immense power to do good and equally great authority to help direct the course of and assure the continued vitality of our healthcare institutions for our fellow citizens. References:
Legal Consult: Apologies Accepted Press reports about some of the most difficult
conversations a physician Recent state legislative action around the country to
pass “apology laws” seeks to create a space safe from legal liability in
which a As of the end of 2005, at least twenty states had
passed apology legislation. One of these was Maine, which passed a law
making ina A similar law exists as of the beginning of this year
in New Hampshire. There, a “…statement, writing, or action that expresses
sy Vermont recently passed legislation that will become
eff There is at least one bill pending before the
Massachusetts legislature that includes an apology provision. That
provision, proposed by Senator Moore, is offered as part of a larger medi This Massachusetts proposal, perhaps be
If this
proposal becomes law in Massachusetts, physicians will be afforded new legal
prot Financial Advice for
Physicians: Use State Exemptions to Begin Your Asset Protection Are your neighbors, the investment manager working on Congress Street in Boston or the software engineer running his business in Franklin, worried about being sued by their customers? Should they be concerned? If they see risks, what can they do to protect themselves, their businesses and their families? The resources (their time and money) dedicated to protection should be commensurate with the risks they face. As a physician, your exposure to lawsuits is significantly greater than is your neighbors’. In order to analyze the magnitude of your lawsuit or asset protection risks, it is helpful to introduce the idea of your personal economy. Your personal economy has an income statement and a balance sheet. Balance sheet assets like your home, investment real estate, practice assets, qualified and non-qualified retirement accounts, and savings and investments are the first items to protect because they are the assets against which lawyers seek judgments. Asset protection of your personal economy is not a binary system where you are protected or you are not protected; it is a continuum from not protected at all to well-protected. Asset protection can come in many forms: How the asset is owned, the type of legal structure, “shielded” financial products, and state and Federal laws and exemptions. Assets owned by you individually, jointly, or in partnership are highly exposed. Well-protected assets, such as IRAs, profit sharing plans, and 401k plans have federal or state exemptions. Real estate assets which have had the equity stripped out of them by a debt shield are also well- protected. Permanent “Whole Life” insurance policies have their detractors, but in some states, including Massachusetts, they can provide valuable asset protection. State-provided exemptions, which can shield some of your assets from potential lawsuits, should be a foundation of your asset protection planning. According to asset protection attorney Gideon Rothschild, in Massachusetts the cash value of life insurance policies is shielded from creditor claims. Beyond this creditor protection, life insurance policies also lessen your income taxes. Finally, the growth of cash value within a permanent life insurance policy is income tax deferred like the deferred growth within a qualified retirement plan. Because of your increased exposure as a physician, shielding your net worth from creditor claims is more critical to you than it is to your neighbors. Utilizing life insurance to protect some of your assets should be considered an essential component of your financial planning. Because of your almost systemic exposure to liability concerns, exempt assets are good tools for building your financial foundation. State law protects certain investments All States have laws which define “exempt assets”, that is, those assets that are shielded from seizure in a lawsuit or in bankruptcy. These assets can be an IRA, a Qualified Retirement Plan or a “homestead exemption” on a portion of your primary residence. In many states, life insurance policies and annuity contracts are exempt to a degree. Exempt life insurance policies are “cash value” policies that provide permanent insurance. These permanent policies have a cash value account or investment component which can be considerable. These policies can have hundreds of thousands, if not millions, of dollars in cash account value which enjoy all of the asset protection and tax-deferral benefits under the state law. Under tax law, the growth in these policies builds up income tax-deferred. Also, withdrawals and policy loans can be taken against the cash account tax-free. In this way, cash value life insurance enjoys superior tax treatment compared with other liquid investment. Life insurance policies have exemptions in all 50 states but the exemption amounts do vary greatly from state to state. Annuity contracts are issued by insurance companies and have exemptions in many states ~ but not most. Working with an attorney familiar with your state’s creditor laws is necessary to achieve your asset protection goals. Case Study: John chooses between mutual funds and a variable annuity John is a cardiologist concerned about asset protection. John now has $50,000 to invest and is in a state where variable annuities are protected. His decision is whether to invest the money in mutual funds or in a variable annuity. He knows that annuities have higher charges than mutual funds. However, for that higher expense, John would enjoy tax deferral and asset protection. Let’s assume that the difference in charges is about 1.5% annually. Is it worth it for John to use the annuity rather than the mutual fund when it is protected and grows tax-deferred? We can’t say for sure without knowing more about John’s goals and portfolio, but ask yourself the question, “Would you pay an extra $750 per year to protect that $50,000 from all potential lawsuits and grow those funds tax-free?” Conclusion If asset protection and tax reduction are important to you, learn what assets are protected in your state. Once you do, you will have a better idea of how such investment options can be used to optimize your financial plan. Michael Halloran is a PIAM Representative, Certified Financial Planner™, and Wealth Protection Alliance Member. He holds a Bachelor of Science degree in Electrical Engineering from Cornell University and a Masters in Business Administration from Harvard University. He can be reached at 8 Grove St., Suite 300, Wellesley, MA 02482, (781) 431-8800 and mike@halloranfinancial.com. Science Corner: Where Did the
Pseudoephedrine Go? Pseudoephedrine (PSE) is an adrenergic agonist used to relieve the symptoms of nasal or sinus congestion associated with allergic rhinitis, sinusitis or the common cold. Pseudoephedrine is available in many cough and cold products both alone and in combination with other agents such as antihistamines, antitussives, and analgesics. The controversy regarding PSE relates to its structure, which is both similar to and is easily converted to methamphetamine, a widely abused CNS stimulant. Methamphetamine use induces feelings of euphoria and pleasure; it is highly addictive and is associated with many detrimental health consequences. The removal of the oxygen from the hydroxyl group on PSE converts it to methamphetamine. This chemical manipulation is inexpensive, quick and easily achieved using household products and little equipment. As such, home “meth labs” have flourished creating a methamphetamine drug epidemic.1 New federal regulations limiting the sale of all pseudoephedrine products (single source and multi-ingredient) were recently enacted. The Combat Methamphetamine Epidemic Act of 2005 was incorporated into the USA Patriot Reauthorization Act in March, 2006. This legislation was to be implemented in two phases effective April 8, 2006 and September 30, 2006. The first phase restricts consumers’ purchases of PSE to a daily limit of 3.6 grams and a monthly limit of 9.0 grams. Mail-service pharmacy customers are restricted even further to 7.5 grams per 30 days; mail-order facilities must also verify each patient’s identification prior to shipping PSE. In addition, all non-liquid forms of PSE must be sold in blister packs or in unit dose packets or pouches. The second phase that begins on September 30, 2006 will require retailers to store PSE-containing products behind the pharmacy or front store counter or in a locked cabinet; they will also need to maintain a written or electronic logbook to track all sales of PSE. The logbook must identify the following: the product name, the quantity sold, name and address of purchaser, and date and time of sale. The patient is also required to present a photo ID and sign the log book. The legislation further states that retail organizations must train their employees about these regulations. This phase will also limit mobile sellers to monthly sales of 7.5 grams. The regulations will not apply to prescriptions for products containing PSE.2 The DEA will be responsible for enforcing these laws.3 Local Massachusetts retailers vary in their methods for complying with this current law. Most are storing all PSE- containing products behind the counter either in the pharmacy department or at the front store checkout. Some are manually or electronically logging all sales while others have not yet begun logging. By September 30, 2006, PSE will not be readily available over the counter; instead, all PSE products will be placed behind the pharmacy or front store counters.3 References:
Massachusetts Medical Society 6th Annual Creative Writing Contest James T. E. Chengelis, M.D. is currently the Associate Medical
Director of Boston Emergency Service Team and does Consultation/Liaison
Medicine in Psychiatry at Boston University Medical Center, Boston. Finding St. Elsewhere A spring day in Boston, the air has a ruminant of winter, yet the cool essence of new and freshness. A typical day on the consult/liaison psychiatric service, as I entered a room to start a new consult for “depression.” Who is this person? The room was dark. I saw Mr. A lying in his bed, with his sheets tightly bound around him almost like a mummy. He lay in bed staring out the window. He lay there quietly, while outside the glass window there were men walking the steel girders of a new cancer building arising. A bird sat on the windowsill looking in, almost as if he had a message. Rain has fallen, Simple drops The hallway was loud between the medical teams rounding, patients’ moaning and just the general chaos of the hospital. I felt surreal. I am, The patient greeted me and stated he was waiting to see me. As I pulled the hard plastic cold chair closer to the steel/plastic bed, the floor shined with wax and was reflecting the skeleton of the new building growing. As I sat, I felt the blanched white coat against my colored clothes, as I too greeted Mr. A. There was silence. I am alone Only the men outside the window in a
muffled noise of commands and orders being said can be heard. I was born on the third floor, The world is round, I felt lost in a desert Alone, He started to tell me all of his medications and treatment. He knew them well. One can assume that he had been through this drill many times. He further stated that he was prepared for what could happen. Mr. A seemed to be in a rote fashion explaining himself and then he stated in an articulate, clear and animated manner, “Always keep going, and find your St. Elsewhere.” At that moment I am not old At this moment, his medications were brought to him…He did not want to take them, he simply said, “No, not now.” The nurse and the patient were engaged in conversation at this point, and my mind wandered off… How poignant, We search daily, from The stars and moon dance Gerald F. Berlin
Prize for Creative Writing The competition is the Gerald F. Berlin creative writing prize, established by psychiatrist and poet Richard Berlin, MD in honor of his father, Gerald F. Berlin and open to all students, residents and fellows at UMass Medical School and its educational affiliates. The grand prize winner was Mike Zacchilli, UMass Medical School, MSIII (class of 2007).
“Dialogue: An Empty Hospital
Corridor” It wasn’t supposed to be like this. On the wall, the clock’s hands grudgingly surrendered a few more millimeters. It was 3 o’clock in the morning. I looked through the wire-latticed window, banged the hard metal plate next to me, and sighed in accord with the whirring motor as the doors to the Cardiac Catheterization Lab swung outward into the empty corridor. The doors’ hazy reflections passed wearily across the polished hardwood floor and their shadows drifted across the newly painted walls ~ a failed attempt to shade the tactless reality of the fluorescent lights overhead. Across the hall, a man faced the wall silently, his hands pressed tightly over his eyes ~ they dropped suddenly at the sound of the doors. To my left, in a mocking attempt at comfort, a womb-like recess in the wall supported a thin cushion and the huddled form of a second man. His arms were locked around his chest in a pitiless embrace as he rocked slowly back and forth in that somber asylum. Then he looked up, eyes pleading silent prayers. It was not supposed to be like this. The corridor was empty. “Time out of OR: 5:45 PM. Here’s the last patient from Room #2…we’re done for the day.” The hospital bed drifted slowly to rest in the PACU like a boat to dock, leaving a host of nurses, residents, and myself standing listless in its wake. The heavy-eyed passenger slowly scrubbed his face with his hands, and I found myself doing the same as I stepped out into the lounge. My legs willed me to the nearest seat, unceremoniously abandoning me as I dropped onto the hard plastic. I ripped off my surgical mask, uncaring as the blue straps tore into my skin before snapping free. It had been eight hours, one pelvis, and three femurs since I had stepped beneath those hot lights ~ somehow that last knot just wasn’t worth the effort. My roommate burst out of the PACU behind me with a smile on his face. “Hey man…we’d better hurry home. This is our last Friday for the rest of surgery,” he said, clapping me on the back. “Oh wait, I forgot, you’re on call tonight.” His already broad smile grew wider, and he laughed as he jogged out the door, leaving me alone. Tonight would be my first general surgery call. A chief resident, an intern and I would be covering more than seventy patients from now until morning rounds. My stomach clenched and spun ~I was hungry; not nervous, just hungry. I took a breath, stood up, and began the trek to surgical sign-out. As I entered the room I grabbed a copy of The List ~ the pulse of a hundred lives laid out in stark monochromatic Times New Roman. The chief from each service briefed us and my spidery scrawls quickly adorned the orderly register: Unfinished tasks, recent labs, general concerns, basically everything about which I needed to worry. For the next seven hours, I roamed the hospital doing postoperative checks. Sinking comfortably into the repetition ~ recording urine outputs, listening to hearts and lungs, asking about pain ~ I was finally beginning to feel useful. I finished writing my notes, neatly placed the charts back into their racks, and decided to page my intern. And that is how I found myself sprinting to the nearest stairwell, my short white coat flapping behind me, spilling forgotten index cards and leaving them to flutter helplessly down into the dark void. It was my first night on-call for surgery, and one of my patients ~ one of those anonymous names on my list ~one of my patients was coding. But I was the medical student, so everyone had justifiably rushed to their responsibilities caring for the patient. They had never thought to page me. I paused outside the doors to the catheterization lab. I was safe in the corridor…I knew what was happening in the corridor. I had no idea what was behind the door. I had never met this woman. Everything I knew about her life was in an 8 cubic inch block of typed script. I didn’t even know her full name (the computer had decided that Jorgensen, M 67F was sufficient), but she was my patient, and she was dying. Nobody had put that on The List. I decided it was time I tried doing something about it, and banged through the doors. The scene that greeted me was unexpected. I had envisioned a team surrounding the bed, someone yelling frantically for some vital piece of equipment, the nurses looking on in horror. That is precisely not what was happening. It seems that in the life of a third-year medical student, reality always finds a way to humble you, a way to bluntly testify to your ignorance…In short, reality explains why nobody remembered to page you. And so, instead of standing at the center of chaos, I found myself observing from the edge of a dead quiet room. The anesthesia team quickly finished the intubation and began oxygen, glancing nervously at each other. My intern was anxiously writing admission orders as the resident spoke with the ICU nurse in hushed tones over the phone. But I didn’t need to hear desperate cries. I didn’t need to see desperation. Looking at their steeled expressions, glancing into their eyes, I saw hesitation, and I knew things were not good. And then everything happened at once. The phone clicked, the chart closed, and the anesthesiologist unlocked the bed with a snap. Each person grabbed a portion of the bedrail as they began rolling towards the patient transportation elevator. “Hey…” My chief resident spoke clearly ~ a staccato plea suddenly penetrating the dull fog of the surreal nightmare. “Hey, I’m sorry to have to do this to you. We need to get this patient to the ICU now, and she’s going to need everyone here when she gets there…Her sons have already been called. They should be out in the corridor. We need to help her…and that means you need to help them. There are three things they need to know: One, the situation is serious, two, their mother has been intubated and is moving to the ICU, and three, we are doing everything we can for her right now.” He carefully noted each assertion on his fingers, marking my cadence. “Now go, answer the questions that you can, and send them up to the ICU waiting room with the ones that you can’t.” I watched silently as the elevator doors slid shut, swallowed that moment of certainty, and left me alone. And so I stood for a moment, my thoughts accompanied by the irregular beeps and dimmed light of the abandoned catheterization lab… There is an unspoken lore in most hospitals. It’s a theory unexplained by science, unproven by any systematic review, but people believe it nonetheless. It’s like a sixth sense. In fact, it’s not at all uncommon in any hospital to hear it: “Patients just know when it’s time.” And you need only look as far as the Pediatrics ward to learn that sometimes, despite all odds, they decide to get better. It seems that occasionally this intuition extends beyond personal concern ~ at times of truth, when thoughts and perceptions are stripped down to raw emotion. And so it was that Mrs. Jorgensen’s sons knew every word I would speak before we ever met. The doors swung outward in perfect arcs and swept doubt from the eyes of the two men facing me ~ And just as swiftly, their piercing gazes shattered my trepidations. For a few moments we stood in silent dialogue, frozen in that empty corridor. I remember it distinctly. The words that followed were nothing but formality. Fifteen minutes passed, and then they clasped my hand, thanked me, and disappeared into the vastness of the dark stairwell. Despite all my efforts that night and in the coming days, I would never see them again. I walked away down the empty hall and soon found myself sinking once again into the sedating repetition of postoperative checks and discharge plans. I wanted to numb my mind, to blanket and smother my doubts beneath mounds of patient education forms and lab printouts…but every checkmark I placed on The List, every completed task, stood in stark contrast to my uncertainty. What happened in the ICU? Had I been realistic enough in my explanations? Hope had a way of rising, and the fall was so much longer from the 7th floor ICU… I finally left the hospital a few hours before dawn. It seemed a singular period of time, a fleeting undefined moment when the world walked wearily between dreams and consciousness. The ground was blanketed in a thick white sheet and snowflakes danced brightly in the halo of the streetlights. They seemed infinite…a million tiny stars. To the eye, it was impossible to follow any single path for more than a moment ~ they all moved a thousand directions at once, up and down, each at its own pace and heading ~ but watching the ground, as the pure white drifts grew slowly, it was impossible to deny the truth. They all stopped eventually. Regardless of that frantic dance, despite the beauty of their chaotic journey, they all ended finally in quiet repose. I walked on in solitude, a million tiny crystals lighting gently on my wool jacket…they felt heavy. I walked on through the cold until, slowly, my unquiet mind was tamed by the night’s unbounded silence, by its relentless truth. Eventually the night, this night, seemed somehow natural. The strong wind pushed me, shook me, carried me in its currents…and I walked. Off Call: Winetasting “Would you write an article on your interest in wines?” asked “Off Call” editor Dr. Brinnig. Why not traveling, golf, skiing, sleeping, snorkeling, spelunking, etc.? No, after a suitable bottle of good wine was promised as incentive, an article on winetasting was agreed upon. While I am no expert, I do have considerable experience and spend a good bit of “off call” time on winetasting activities. So, let’s start with my introduction to winetasting. It was 1969, my first year at Georgetown School of Medicine. There was an informal talk on winetasting at the freshmen dorm given by Dr. Marchetti, OB-Gyn professor, originator of the Marshall-Marchetti bladder suspension procedure and an oenophile. Perhaps a strong bladder is important if one is drinking a lot of wine. I remember his opening words: “Wine is as old as mankind and civilization, it defies chemical analysis, it contains antibiotics. It made water safe to drink in early times. Wine has many uses. It is a social activity, and makes life more enjoyable. Wine was entertainment before the printing press or television. It is well worth knowing.” He offered several different wines to taste and discussed them in then unfamiliar but detailed and descriptive terms. Those first samples of wine and his enthusiasm kick started my lifelong interest. Over the years, I have found winetasting to be an appealing hobby ~ practical, fun and interactive. Winetasting attracts interesting people from all walks of life. It has its own body of knowledge, both general and specific. Winetasting has its own jargon. Discussing wine requires lots of adjectives and descriptive language. It appeals to those who like details, who enjoy complex subjects. It ties into many other life activities including dining, social events, and travel. You know what to order in restaurants. Friends call you for advice. Learning about wine can be serious and formal if you like. There are academic degree programs available, bona fide experts who write extensively, and the occasional wine snob. Through wine you meet many complex people who are accomplished in their day jobs and bring that focus to their interest in wine. It is fun to interact with them with wine as a common thread. There is always something new to learn and to share with others. Some people invest in and collect rare wines. Some make their own wine at home. Others buy and operate wineries. But be cautious, the best way to make a small fortune in wine is to start with a large fortune. Interested yet? It is easy to “get into wines.” Read some basic books on how wine is made, the different grapes, and the major wine-producing regions. Take a course or join a wine group. Go to winetastings at restaurants or attend large wine and food events. You will be able to taste many more wines than you could possibly do on your own. Besides, they’re social and fun. Get to know the local wine experts, ask them questions, hear what they recommend. You have to taste many different wines to really learn. Tasting is different than drinking. Serious winetasters examine, smell, taste and then spit it out. You can get most attributes of a wine without swallowing. The nose is very important in evaluating a wine, providing hints of what is to come on the palate. By spitting out, you can taste more and different wines with a clear, critical mind. Next, start a wine cellar. It can be a few bottles in a dark closet ~ or better yet, in a cool basement. Begin with a plan, talk to your local wine merchants as they are usually quite knowledgeable. Buy an assortment of different wines ~ and by “different” I mean wines made from different grapes. Begin with Chenin Blanc, Pinot Gris, Sauvignon Blanc, and Chardonnay for white wines. For red wines have some Merlot, Pinot Noir, Syrah (Shiraz), Cabernet Sauvignon, and Zinfandel. Try some inexpensive bottles to get to know the grapes, then (with advice) buy some good wines at value prices. The individual grapes yield very different wines. Buy a few bottles of the same wine you like (a red wine), and see how it ages by trying another bottle a year later. Keep records of good wines that you have enjoyed. Get to know the local wine experts. The Worcester area has many such aficionados and there are many wine-related groups. Then take your hobby on the road. Visit a winery, see how wine is made, taste it at the source. Exploring wines is an excuse to travel, to taste the local wines, to remember the experience and enjoy the memories. Travel to the wine’s country of origin ~ go to Napa Valley, Europe, or Australia. There are cruises and barge trips. Work in a vineyard during the harvest. Go with friends or to meet new people with similar interests. One of my best trips was a bicycling tour through Burgundy, France, burning off the calories between vineyards. What is the downside of an interest in wines? Not much, I think, unless Prohibition returns or your old wines go bad before you can enjoy them. But there are always people with other opinions, those who rally against all drinking. Fortunately, there are articulate defenders of the grape. So I will leave you with a favorite quote, attributed to Henny Youngman: “When I read of the evils associated with drinking wine, I had no choice in what to do, I had to stop reading!” |