Bradley M. Tipler, MD

I have an elderly, demented aunt in California for whom I am the responsible decision maker. Up until a few years ago, Aunt Doris was an intelligent, powerful, and forceful woman. Picture Nurse Ratched in 

 and you will be pretty close, although Doris was never so insidious. After a stint as an Army nurse, serving near the front in the European and Philippine campaigns of WWII, she was a head nurse in the VA psychiatric hospital outside San Francisco for 20 years. Ken Kesey was an orderly there for a year before writing 

. In typical Doris fashion, when I asked about him, her summary was “Good for nothing, lazy SOB.”

Every night I see scores of exams on elderly patients. Last night I read an unenhanced head CT, perfusion scan, and CTA head/neck on an 80+ patient. The clinical summary given was “history of dementia, confused tonight.” Three thousand dollars to prove the brain looks like a hybrid of Swiss cheese and a dried walnut.

If we are ever going to control healthcare costs, people will have to accept that dying is part of our life cycle, and those in authority will need to incorporate this understanding into our healthcare system. Doris, when she was lucid, understood this well, and did everything possible to document that she wanted to die in peace, not in an ICU bed with tubes in every orifice and vessel. And still, the system works against her.

We enroll her in hospice with a failure-to-thrive diagnosis, but if she gains any weight, her insurance company takes her out of hospice. Then she gets sick again and is transferred from the nursing home to the hospital and treated intensively until I can contact her doctors and explain her wishes. She goes back on hospice and the cycle starts again. Recent changes in California law may be ending this cycle, but very few states have significant laws related to-end-of-life options.

Why does our system make dying so hard, and why can’t we fix it? Like most tough questions, the answers are complicated. Our culture has made discussions of death difficult for doctors and patients. Some religious and political groups view such forums as death squads. I guess the logic here is, if we don’t talk about it, it doesn’t happen. Sounds like the military’s “Don’t ask, don’t tell” policy.

Financial factors also play a significant role. In the span of my lifetime, American healthcare has evolved from a profession based on personal relationships into a behemoth modeled on a corporate structure. While corporate America likes to espouse noble ideas and goals, the bottom line always wins. One third of Medicare expenses come in the last two years of life, about $66 billion a year. Hospital organizations know imaging and high-tech surgery/procedures are the golden geese, so how hard will they lobby for limits? Ditto equipment manufacturers. Publicly held companies and private investment funds are becoming major players in radiology. How much do you think these large, for-profit companies will spend lobbying Congress to rein in medical expenses, and bring rational limits and decision making into end-of-life care?

For years I have felt our nation needs an Oregon-style Death with Dignity law. Recent experiences with my Aunt Doris have only reinforced that belief. As a radiologist, I am on the receiving end of the current situation, but as a physician I see the waste, futility, and near cruelty involved. I support organizations like Compassion and Choices, which work to change this mess. It remains to be seen if corporate medicine will support such a concept, and the hit on their bottom line. I suspect they will sit back and ride the status quo all the way to the bank, while doctors and patients remain frustrated here in the cuckoo's nest.

Articles

I have an elderly, demented aunt in California for whom I am the responsible decision maker. Up until a few years ago, Aunt Doris was an intelligent, powerful, and forceful woman.

We spend on end-of-life care at expense of patients

I enjoy historical novels. Three of my favorites are 

. One of the details I enjoy is the names. Tom Builder and John Mason leave little doubt what these men do for a living.

Names like Tipperwink and Justindoodle make you chuckle every time you read them. You have to wonder how those names originated. I assume Tipler says something about my ancestor's social proclivities.

Alcohol is a prominent part of life in much of the world. In the U.S., it plays a large role in healthcare. Like tobacco, it directly causes a number of diseases. Unlike tobacco, it also indirectly affects medical care, especially in the ER.

 written on imaging requests from emergency rooms. It comes in an amazing array of contexts. Four simple letters are used to convey a wide range of clinical scenarios, imply an etiology for myriad problems, and explain away a textbook full of imaging shortfalls.

I wonder sometimes if such a lack of specificity is a good thing to have in the medical record. Not that we don't understand exactly what the situation is, but are we giving ammo to plaintiffs' attorneys? Given the Charles-Manson-likefervor The Joint Commission and hospital suits have for clear communications, I am surprised this is tolerated.

From across the country I see requests that say “AMS, etoh.” To me this translates as “altered mental status-the patient is drunk- we have no way of discerning if there is anything else going on in addition to his/her being drunk.”

Often I get an exam, usually a head CT, with motion artifact. The request will have some variant of “repeated scan, etoh.” To me this reads as “the patient is drunk and would not hold still for the exam. I tried talking to him and repeated the exam, but he still moved.” I think most radiologists would get the same message, and I think the communication is usually accurate in this setting.

Maybe it is my own personal bias, but sometimes I get the impression that there is an underlying attitude, an implied message, that the patient is not really ill, just drunk.

There is an undercurrent of maddening frustration that comes from having done everything right and someone else then screwing up your work. It is hard to put a finger on, perhaps the way it is phrased, or even the emphatic handwriting used on 

Still, many times a night, I get the feeling I am dealing with frustrated technologists who are trying their best to get good images on an uncooperative drunk who probably just needs to sleep it off. They do their best, working hard to get diagnostic exams, which often still turn out less than optimal. We all understand this. The trouble is, as a resident once told me “Even turkeys get sick.”

What happens when an intoxicated patient has a real illness, the imaging and physical exam are compromised by his actions, and the diagnosis is missed? Who is to blame? My own bias is toward personal responsibility. However, I think our legal system has gone to an extreme in the opposite direction, and that is where these questions are ultimately answered. This is my problem with 

. Does it in any way imply less than 100% effort by the caregivers?

 adds no information. In my mind it implies many things, but includes no facts. If the patient doesn't, or can't, cooperate for a scan, that should be written in the record, not etoh. If you repeat a scan for motion, that is what the record should say, not etoh. The first line of all my reports is the history written on the request, minus any reference to 

I leave the etoh for the days when I am not working. Mine is a hard name to live up to, but I'm trying.

I enjoy historical novels. Three of my favorites are London, The Forest, and Pillars of the Earth. One of the details I enjoy is the names.

Name my poison? ‘etoh’ in emergency room requests

I live on an organic farm. Not that I'm a huge believer in organic farming, but my wife is. We have cows, chickens, dogs, cats, and more species on the way. In the past decade I have learned about animals, organic farming, and organic solutions around the farm.

If you visit our farm, you will notice partially filled baggies of water and a penny hanging in front of every door of our house. This is an organic method of keeping flies out of the house. Scientific explanations for this method hinge on the fly’s dislike of water, and the fact that their eyes split images into thousands of parts, so one little baggie of water looks like an ocean. Makes sense-too bad it doesn’t work. Fortunately, it has the hidden benefit of making a nice house look like a mobile home, so we are less likely to be robbed.

It strikes me that medicine and organic farming are much alike in this respect. We do a lot of things because that is the way someone told us to do it. We develop elaborate scientific explanations for why it works, and then we continue to do it based on anecdotal support, even when national consensus says it is not the best way of doing things. Since I joined Nightshift Radiology, I have been exposed to the wide variations in practice patterns across the U.S.

If you look up vertigo in the ACR appropriateness criteria, the highest rated test (if you need one at all) is an MRI with and without contrast. CT is not quite so high. What is being done around the country is a little bit of everything. I cover some hospitals where coming to the ER “dizzy” will get you a CT head with CTA head/neck in a heartbeat. At some hospitals with 24/7 MRI coverage, you will have an MRI/MRA of the head and neck before you sit down in the ER. I was taught all you need in the ER is a noncontrast head CT to exclude blood and mass effect, a shot of Vistaril, and an appointment with a neurologist. How can there be so much variation in approach to one problem?

Organic farming techniques go back thousands of years, while “modern” farming only starts with the industrial revolution. Organic farmers will proselytize at length about the life-affirming qualities of their methods and the horrors induced by chemicals in farming. They are oblivious to the fact that since the development of modern farming techniques our lifespan and our food productivity have increased dramatically. They long to go back to the good old days when people died at 50. And they can give you compost piles of anecdotal evidence to support their favored methods.

When I talk to ER docs, it seems to me the most powerful influences on decision-making are how they were trained to do something originally and their most recent “oh my god” case. A diagnosis of pulmonary embolism used to require much more clinical judgment, and the diagnosis was often difficult. These days ER docs are ordering chest CTA at the drop of a hat. The threshold for the test changes every time they are surprised by a positive result with low pretest probability. They’re like organic farmers: If it worked once, it must be the way to go.

What is the best way to do this medicine stuff? The government wants and thinks it can all be standardized, which may happen, up to a point. But our personal experiences influence our judgment, which is the crux of medical decision-making. Applying ACR appropriateness criteria and the numerous published clinical scales may bring some national conformity. But what we really need is an absolute rule, similar to the one governing me and organic farming: “If mamma ain’t happy, ain’t no one happy.”

I live on an organic farm. Not that I'm a huge believer in organic farming, but my wife is. We have cows, chickens, dogs, cats, and more species on the way.

Is why we do what we do reason enough to do it?

Recently, there has been some debate in the radiology literature about the demise of general radiology, and with it people like me: general radiologists. The future of radiology is subspecialization, they like to say. “They,” coincidentally, are always subspecialists.

. “I want to say one word to you. Just one word: plastics.” The screenwriter hit the nail pretty squarely on the head. We use ever increasing amounts of plastic in our lives.

I bought a new Mazda, which is 99% plastic. Great for gas mileage, but turned out to be not so The car is when my wife hit a curb at 5 mph and destroyed the front end. Like plastic, subspecialization is ubiquitous in medicine. But also like plastic, it is not synonymous with quality.

There are definite advantages to subspecialization, which subspecialists love to point out. By limiting your field of expertise, you can concentrate your study and CME on that area. This is particularly helpful if you lack the will or capacity to stay abreast of radiology in general. Zing.

The corresponding clinical subspecialists find rapport with you more easily because you all speak the same language. Of course, if either you or they encounter a problem outside your narrow field, you would want to consult the appropriate subspecialists in that field and let them communicate precisely with one another. When that third problem arises you will need a committee meeting.

Or-here is a novel idea-why not have someone who talks all these languages and integrate the problems, a super subspecialist? Patients have a funny way of showing up with more than one problem, or one problem that affects several organ systems at once. We could call this new guy the multi–organ-system subspecialist, or MOSS for short.

The creation of MOSS radiologists has some other, less obvious, advantages. Academic departments could establish new subsections, thereby creating new job opportunities for younger radiologists. Whole new avenues for getting journal articles published, which is so important to many subspecialists and clearly makes you a better doctor, would be available.

Other radiology subspecialists would be able to communicate with MOSS radiologists without fear of stigmatizing themselves by associating with inferior beings. This new field, by combining a broad knowledge of radiology with the ability to integrate the total clinical picture and the total imaging spectrum, would be adding a unique value to the patient's care. This is especially important because value added has always been one of the best ways to assess the practice of medicine.

As we move closer to the corporate model in medicine, I foresee large healthcare organizations employing MOSS radiologists as chairs and central coordinators of imaging departments. Patients admitted to hospitals might have their imaging optimized and initial exams done by a MOSS radiologist, and, when necessary, additional studies could be preformed or interpreted by other subspecialists.

Large outpatient and emergency centers might use MOSS radiologists, comfortable as they are with the myriad of patient presentations, to initially read exams and then determine the course of subsequent imaging and appropriate subspecialty referral. MOSS radiologists would be a central, critical part of the radiology spectrum.

I have been a general radiologist for 25 years. The entire time subspecialty radiologists from various fields have been predicting and promoting my demise. In that same 25-year span I have never heard a single general radiologist call for the end of subspecialization within radiology. Why is that? Sure, you see my mistakes, but I see yours. Part of the problem may be you see more of mine than you see of your own, because you are not second reading your own work. Every general radiologist I know, myself included, has always seen a role for subspecialists in radiology and values their contribution. The difference between us may be an ego thing, like those two plastic surgeons on TV. Do some subspecialists consider themselves the rock stars of radiology?

Recently, there has been some debate in the radiology literature about the demise of general radiology, and with it people like me: general radiologists.

What's old is new again, and the world rolls on

It is interesting to hear advocates of healthcare reform describe their vision because big changes seldom go as predicted. Take the decision to have kids. We read books, watched videos, and had deep husband/wife discussions. We did not have a clue what we were getting ourselves into…for the rest of our lives.

After much thought and consideration, this year I left my hospital practice of 20 years to become a teleradiologist with NightShift Radiology. In talking to friends and family-and everyone had an opinion-I came to anticipate several obstacles the change would bring. Working nights and sleeping days were uniformly expected to completely screw my already borderline brain. How could someone as gregarious as I am work in isolation with no patient or physician contact? Was I really confident enough in my abilities to read every study alone, with no one in the next room to sweat with over tough cases?

None of these materialized. I have absolutely no problem reversing my circadian rhythm a week at a time. And, much to my chagrin, my wife is telling everyone she likes not being “bothered” for a week. The way NightShift is set up, I cover most of the same hospitals each week. And if a doctor or tech calls the company, it rings on my desk, not to an operator. I actually talk to more referring physicians now than I used to, we just don't have lunch together. Although the next room is empty, my PACS and phone are shared with six similar souls around the country, able to give me a second opinion in two mouse clicks. Just like my old group, we commiserate frequently.

What I didn't anticipate is the anxiety associated with having every single case I read being reread within 24 hours. This gives an entirely new meaning to the term “peer review.” When the final read does not agree with my reading, I get a fax the next afternoon containing my report, the final report, and the final reader's comments. These are good radiologists, and their tone is usually friendly and nonjudgmental, but I still feel lousy. Fortunately, most of them have been nonemergent findings, like a 2-cm parotid mass on the lowest slice of a trauma head CT. I still can't figure out how I missed a golf ball.

My new partners tell me this is the nature of the beast. These dreaded discrepancy faxes have had two completely unanticipated effects. First, it is making me a better radiologist. My error rate is around 0.2%, or two per thousand, which is typical for our group. This is a number I did not know for the last 20 years, and now lowering it is a major goal. Second, when I get a junk fax, like one of those travel ads offering a trip to Orlando and Antarctica for $189, I am happy.

So, I listen to all 50 sides of the healthcare reform argument, and I have no clue what to expect. Will my salary go up or down? Will there be more or less work? Is access to healthcare for my family going to get better, get worse, or just get more expensive? Is there anything I can do to affect the outcome? Do I find answers in The New York Times, on Fox News or among the tea leaves?

Like it or not, these decisions are being made in Congress, not in the public forum. And the reality is that in Congress, money talks. The outcome is not foreseeable, but those who are not walking the halls of the Capitol, participating in this process, will certainly feel more pain. That is why giving money to RADPAC, radiology's voice in Congress, is so important right now. Healthcare is going to change and, I hope, improve. RADPAC is trying to defend radiology in the process. Call 1-888-295-8843, or go to 

, get out your Visa card, and invest in your future today. Or just leave it to the tea leaves.

It is interesting to hear advocates of healthcare reform describe their vision because big changes seldom go as predicted.

Tea leaf readers see…um, change is coming

You are a bank teller. Someone points a gun at you and demands all the money in your drawer. You're going to give that person all the money-unless you're Bruce Willis, in which case you say something cocky and take the gun away. Doctors (with the possible exception of a few surgeons I've known) are seldom that stupid and would do as they are told rather than die protecting someone else's money.

Over the past few years, there has been an outcry from the government and insurance companies lamenting the overuse of imaging, especially CT scans. Seldom does a week go by without some article mentioning the “overuse” of CT in U.S. emergency rooms. The same forces that created the current system are now complaining about it. I'm reminded of the daily struggle getting the boys ready for school, followed by the whining when they have to walk into school late.

By not supplying universal coverage, payers and the government have turned ERs into national walk-in clinics. In our hospital, the true emergencies are probably outnumbered by faux emergencies 10 to one. At the same time, the government has mandated that anyone who presents to the ER is an emergency. He or she cannot be transferred or handled routinely.

The Joint Commission on Accreditation of Healthcare Organizations and similar groups use wait times in the ER as a measure of quality, demanding that all these self-defined emergencies be assessed promptly. Chronic problems demand a complete diagnosis simply because the patient chose to visit an ER instead of a primary care provider.

These same government and private entities, with the enthusiastic support of the legal profession, have created an artificial expectation of perfection. All mistakes, oversights, and misdiagnoses are subject to the retrospectoscope, with serious consequences. Because of an upcoming job change, I have been filling out credentials forms from a lot of hospitals. Every one of them asks if you have ever been accused of malpractice, been investigated by your medical staff or quality review committee, or had any investigation into your work by any organization. Tolerance for mistakes is not a hospital byword.

We may have a small problem with overuse of imaging by emergency physicians. But we have a big problem with overuse of emergency rooms and conflicting demands on physicians.

Every day, about five million people with headaches and/or abdominal pain walk into our ER. Only a small percentage of them have serious maladies warranting the term emergency. By virtue of walking through that door and climbing onto the gurney, however, they all assume the importance and the liability of a true emergency. The ER doc knows how to sort out true emergencies from routine problems on a clinical basis with reasonable accuracy. But reasonable accuracy is not what the powers that be expect. Besides, the time required to make such an assessment is considered unacceptable. What would you do?

I would get a CT scan on all of them. The system virtually demands it. We did not create this system; it has been thrust upon us. And the one true emergency in 100 patients might have grounds for a suit due to delay in diagnosis.

With the misguided goals of efficiency and economy, those controlling the purse strings have created a system requiring excess utilization of expensive ER services and medical imaging. Now they are generating more expenses and wasted staffing trying to decrease utilization without addressing the real issues. If the U.S. hopes to control healthcare costs and CT utilization, it needs to lower the guns aimed at physicians or start training a lot of Bruce Willis wannabes.

You are a bank teller. Someone points a gun at you and demands all the money in your drawer.

ER bellyaches lead to more CT bellyaching

Two years ago, my 70-yearold father-in-law decided his 3500-square-foot house was too big and his household needed to downsize. They bought a lot on the edge of our farm and built their new house of 5700 square feet.

I resist correcting him on the meaning of “downsize” for several reasons. First, it is very convenient when your eight- and 10-year-old sons can drive themselves to the baby-sitter in a go-cart. Second, their six-car garage includes a complete shop with a 10-ton auto lift. Finally, there is the 11th commandment, “Thou shalt not criticize thine in-laws if thou wantest anything from thy spouse.”

The house has a kitchen fit for Martha Stewart and a shower the size of her jail cell. My boys love it. It has handheld sprayers and nozzles on the walls and ceiling. While I like a shower big enough for two, room for eight does not really appeal to me. Still, if it makes the boys want to spend Friday night at grandpa's, I love it.

Recently, our hospital hired a new CEO. She has brought fresh approaches, new ideas, and new challenges for our hospital and my department. This is a good thing. It would be a great thing if I weren't facing so many different challenges and changes already. It seems everywhere I turn there are forces aimed at my practice, like those nozzles in the showersaurus.

The past few years have seen an onslaught of articles and editorials from radiology pundits on the impending demise of the general radiologist. Most are published by the radiology alphabet groups (the ACR, ARRS, RSNA), which seem to be dominated by subspecialists.

That doesn't mean they are wrong, they just need to be taken with a grain of salt.

Teleradiology has made access to subspecialists easier but not mandatory. I believe I add a lot to the overall care in my hospital by my presence. I answer questions about “the best test” for a clinical problem, and I give patients a professional to deal with when they have questions.

But it doesn't take much imagination to picture my eight-person group replaced by three onsite generalists and a network of subspecialists. The snag may be that this network wants to be paid.

This detail is another nozzle aimed at my back. In our hospital, the computer codes patients by insurance category. The fastest growing group is “sp” for self-pay, which, translated into English, means nonpay. How many teleradiology networks accept nonpay? Do the network neuroradiologists really want to read the 2 a.m. C-spine series on the migrant farmworker for free? As the economy worsens and the uninsured population rises, we'll see if the publicly traded nighthawk companies and specialist networks volunteer their services.

Fortunately, we have a new president. The poor guy is walking into a storm of guano, and he is expected to fix it all. How will President Obama handle healthcare? He is a lawyer. His closest friends are lawyers. We know upfront which issue in healthcare will not be fixed.

What about the rest? I like the idea of universal health insurance, and I hope he can make it happen. But I wonder if this will help my income or hasten the demise of general radiology. Finally, there are those guns aimed at us by other specialties who want to do their own imaging.

This is the most fixable cause of rising healthcare costs in the U.S. Just stop self-referrals and watch imaging volumes stabilize. And it wouldn't hurt general radiology.

The future of radiology, especially general radiology, is getting harder to predict, but given all the forces in play, I suspect we may get hosed.

Two years ago, my 70-yearoldfather-in-law decided his3500-square-foot house wastoo big and his household neededto downsize.

Radiology gets sent off to the washhouse

Like most radiology groups, mine is a diverse collection. This is good. It allows us to hear a wide range of approaches to any given problem, some of which are novel and some stupid. Mine are always novel.

On most issues, I have partners to the left and right of me. One of the more conservative subscribes to publications from the Cato Institute. Judging from those he shares with me, the institute's output falls somewhere between the John Birch Society and Attila the Hun.

The latest policy analysis from Cato he passed on is by Shirley Svorny, Ph.D., chair of the economics department at California State University, Northridge, entitled Medical Licensing: An Obstacle to Affordable, Quality Care. Definitely a different approach.

Prof. Svorny states, "Consumers would benefit were states to eliminate professional licensing in medicine and leave education, credentialing, and scope- of-practice decisions entirely to the private sector and the courts."

She argues that specialty boards, hospitals, insurers, and trial attorneys would do a better job of deciding who is qualified for a given aspect of medical care. Consumers, who are of course the best determinant of good care, would have a wider range of choices. Market forces will make everyone do better for less, and we will have better, cheaper healthcare. Uh huh.

While it's true that the politics of licensure often revolve around limiting competition, the practice also establishes a minimum level of performance, and then seen other specialty boards umbrella their members into the field with ridiculously low standards.

Hospitals look very hard at these changes, if the preempting specialty wants to do the exams somewhere else. When the exams are staying in house, and numbers will go up thanks to self-referral, the review seems a little less critical. We all know the reason cardiologists now do 75% of the cardiac nuclear imaging studies is because they read them so much better.

I'm sure when a board-certified internist does an ultrasound scan, savvy consumers know the competence and 'Licensure at least establishes a defines a scope of minimum level of competence training. Take the and defines a scope of training.' difference between our years of training and the "Certificate of Merit in Ultrasound"Joe Doc got from the Magic Mini-Ultrasound Co. when he attended its weekend course.

And, of course, insurers, those mighty defenders of patients' access to quality medical care, would never use the abolishment of licensing laws to their own benefit. All the money they saved outsourcing medical imaging, lab tests, and surgery to unlicensed practitioners in Bangladesh would be put right back into consumers' pockets.

I think Professor Svorny has a brilliant idea. Let's deregulate the entire process and give control to private enterprise and the free markets. Look how well it worked for the banking and mortgage industries.

Like most radiology groups, mine is a diverse collection. This is good. It allows us to hear a wide range of approaches to any given problem, some of which are novel and some stupid.

Freestyle healthcare enters the marketplace

For my two preteen boys, everyone is a dude, and most of life is awesome. I never really thought of myself as a dude, but life is all about changes.

My wife grew up with horses. She loves them and anything with four legs. Our boys have been taking riding lessons, and I'm being encouraged to fence off a field and build a stable. My lack of equine enthusiasm is a problem.

Every summer we go to the beach as often as possible, but never often enough for me. This summer "we" decided not to go to the beach at all. We planned an educational trip for dad. We went to a dude ranch, Twin Peaks Ranch in Salmon, ID.

As my boys said hourly, it was awesome. The food, accommodations, people, scenery, and wide range of activities were all amazing. And I got to be good buddies with Rudy, my horse. By the last day, Rudy and I were feeling pretty cocky herding longhorn cattle. Billy Crystal has nothing on me.

In addition to Rudy, I made some friends with two legs. Deana and I spent a great deal of time with Peter and Sylvie, from Cheltenham, U.K. Our kids are about the same age, and they are both physicians. Among other things, we spent a lot of time discussing the relative merits of various healthcare systems.

You're thinking, "What kind of idiot discusses healthcare systems on vacation?" But over a nice glass of chardonnay, looking at some of the most beautiful, unspoiled mountains in the West, I could enjoy a conversation about mud. 

When I entered medicine in this country, it was a profession. Medical priorities mandated most of the decision making. Now it is a business, and corporate values (oxymoron?) dictate many major decisions. 

While I understand the evolution and motivation for this change, I believe that our system has evolved to a point where too many people who provide not one iota of healthcare are receiving far too many healthcare dollars. I'm just not sure how to fix this problem. I really hate people who complain about the status quo but offer no reasonable alternative.

Talking to Peter and Sylvie about healthcare in Europe, I realized no one has the ideal system. While I have yet to come up with the perfect redesign of U.S. healthcare, however, I do have some specific suggestions.

Corporate profits, percentage bonuses, entrepreneurial spirit, and direct-to-consumer marketing do not benefit medicine or patients. All companies that receive any income from healthcare dollars need caps on salaries and profit margins. Not unreasonable caps, but the only way Blue Cross executives can compensate themselves $20 million a year is by denying someone care. I find it ridiculous that the guy on TV selling scooters to Medicare patients is swallowing millions of healthcare dollars. Ditto the guy making Viagra ads.

Universal coverage is not an attainable goal. Universal access to a high level of care is. The government builds roads. It does not give everyone a Cadillac or Maserati. We need to make some tough decisions about what we as a country can afford to provide for everyone, and then do it. Leaving the burden of the "uninsured" on providers is not acceptable.

Medical decisions and outcomes need to be completely divorced from the legal system. Bad outcomes are inevitable and very hard on patients and their families. Regardless of fault, help should be available for all. Bad doctors and hospitals need to be dealt with separately. We all know how much waste defensive medicine generates, because we often benefit from it.

Finally, people in the U.S. need to realize that death is part of life. I know that near the end, I won't want to give up. That is why it is so important for reasonable, compassionate leaders to set some end of life guidelines and restrictions. 

Whoever wins in November, I hope he is willing to make some tough decisions. A lot of European dudes are watching to see how we tackle this awesome problem.

Dr. Tipler is a private-practice radiologist in Staunton, VA. He can be reached by fax at 540/332-4491 or by e-mail at 

Dude sadly trades his seahorse for real thing

For as long as I can remember, both the American College of Radiology and the RSNA have emphasized communicating with patients. Personal contact and face time are the best ways. Clearly written instruction sheets, detailed descriptions of procedures, videotapes of complex interventions, and websites offering even more information are also available. In the case of mammography, the government has even mandated that a result letter be given to every patient.

I have embraced this approach for years in my practice. Communication is great, but there is a fly in the ointment-people ignore it.

I spend about half my workdays in our women's imaging center. I use the term "our" loosely, since the hospital owns it and we staff it. About 12 years ago, my partners and I designed and were going to open the first women's center in our area, as the hospital wasn't interested. At the last moment, the hospital board asked us to let them do it instead. In return, we would have an exclusive contract for all radiology services at our new regional hospital.

Of course, the next CEO chose not to honor this agreement and screwed us when the opportunity arose. I learned the half-life of a hospital administration's word is shorter than  F-18's (which is fodder for another column), and thus we staff a very nice women's imaging center in the hospital. Our center is busy. I think we do about three million mammograms a day, and one radiologist reads them. There are also biopsies, dual x-ray absorptiometry exams, and several thousand ultrasounds. Not surprisingly, I occasionally fall behind, and patients have to wait.

When patients schedule an appointment for a diagnostic mammogram, they are told to allow an hour or two, unlike a screening exam. They are sent an information packet that contains a different-colored sheet of paper printed with large type telling them to allow an hour or two for their diagnostic exam. The difference between screening and diagnostic exams is explained to them. When they check in, large signs warn that a diagnostic exam takes longer. Yet every day-not just occasionally but every day-some lady is mad because she thought she would be here only 20 minutes. She either leaves or files a complaint.

Like most radiologists, I do a lot of biopsies. Every prospective biopsy patient gets a preop interview. All are cautioned about anticoagulants. Even if we didn't tell them (and we do, many times), common sense would suggest you don't want to be anticoagulated for a biopsy.

But you know what happens, because it happens to you. Every week, someone shows up for a biopsy swearing he or she had no idea that bleeding like a stuck pig after a biopsy was not OK.

My hospital seems to be one of the last in the U.S. with a busy fluoro schedule. Yesterday, I did nine upper GIs. I'm told a lot of residency programs don't do that many. And yesterday, like every day in fluoro, at least one patient was rescheduled because he ate breakfast before he came and said no one told him not to. Either our scheduling staff picks one person every day to frustrate, or people are not listening. I suspect the latter, as we also have the daily sneak-someone who ate, denies it, and thinks I won't notice all that crap in the stomach.

I have four children and a rather amazing wife. I love them dearly, and I know they love me. I am the king of a wonderful castle. That I spend all this time and energy trying to communicate with patients who don't want to listen might seem frustrating. But, it doesn't surprise me. No one listens to the king either.