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    Dr. Marcinko is originally from Loyola University MD, Temple University in Philadelphia and the Milton S. Hershey Medical Center in PA; as well as Oglethorpe University and Emory University in Georgia, the Atlanta Hospital & Medical Center; Kellogg-Keller Graduate School of Business and Management in Chicago, and the Aachen City University Hospital, Koln-Germany. He became one of the most innovative global thought leaders in medical business entrepreneurship today by leveraging and adding value with strategies to grow revenues and EBITDA while reducing non-essential expenditures and improving dated operational in-efficiencies.

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    Dr. David E. Marcinko is past Editor-in-Chief of the prestigious “Journal of Health Care Finance”, and a former Certified Financial Planner® who was named “Health Economist of the Year” in 2010. He is a Federal and State court approved expert witness featured in hundreds of peer reviewed medical, business, economics trade journals and publications [AMA, ADA, APMA, AAOS, Physicians Practice, Investment Advisor, Physician’s Money Digest and MD News] etc.

    Later, Dr. Marcinko was a vital recruited BOD member of several innovative companies like Physicians Nexus, First Global Financial Advisors and the Physician Services Group Inc; as well as mentor and coach for Deloitte-Touche and other start-up firms in Silicon Valley, CA.

    As a state licensed life, P&C and health insurance agent; and dual SEC registered investment advisor and representative, Marcinko was Founding Dean of the fiduciary and niche focused CERTIFIED MEDICAL PLANNER® chartered professional designation education program; as well as Chief Editor of the three print format HEALTH DICTIONARY SERIES® and online Wiki Project.

    Dr. David E. Marcinko’s professional memberships included: ASHE, AHIMA, ACHE, ACME, ACPE, MGMA, FMMA, FPA and HIMSS. He was a MSFT Beta tester, Google Scholar, “H” Index favorite and one of LinkedIn’s “Top Cited Voices”.

    Marcinko is “ex-officio” and R&D Scholar-on-Sabbatical for iMBA, Inc. who was recently appointed to the MedBlob® [military encrypted medical data warehouse and health information exchange] Advisory Board.

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HUMANITARIAN WISDOM IN PATIENT CARE AS A MORAL IMPERATIVE AND …

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EDITOR-IN-CHIEF

***

In SECTION ONE, of our newest textbook, on medical practitioner personal risk management issues, let us all recall the Canadian physician Sir William Osler MD, one of the founders of Johns Hopkins Hospital in my hometown of Baltimore Maryland, and where I played stickball in the parking lot as a kid. He left a sizeable body of wisdom that has guided many physicians in the practice of medicine. So, allow me to share with you some of that accumulated wisdom and the quotes that have served me well over the years.

From Dr. Osler, I learned the art of putting myself in the patient’s shoes. “The motto of each of you as you undertake the examination and treatment of a case should be ‘put yourself in his place.’ Realize, so far as you can, the mental state of the patient, enter into his feelings.” Osler further stresses that we should “scan gently (the patient’s) faults” and offer the “kindly word, the cheerful greeting, the sympathetic look.”1

“In some of us, the ceaseless panorama of suffering tends to dull that fine edge of sympathy with which we started,” writes Osler in his famous essay “Aequanimitas.”2 “Against this benumbing influence, we physicians and nurses, the immediate agents of the Trust, have but one enduring corrective — the practice towards patients of the Golden Rule of Humanity as announced by Confucius: ‘What you do not like when done to yourself, do not do to others.’”

Medicine can be both art and science as many physicians have discovered. As Osler tells us, “Errors in judgment must occur in the practice of an art which consists largely of balancing probabilities.”2 Osler notes that “Medicine is a science of uncertainty and an art of probability” and also weighs in with the idea that “The practice of medicine is an art, based on science.”3,4

Osler emphasized that excellence in medicine is not an inheritance and is more fully realized with the seasoning of experience. “The art of the practice of medicine is to be learned only by experience,” says Osler. “Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone can you become expert.”5

Finally, some timeless wisdom on patient care came from Osler in an address to St. Mary’s Hospital Medical School in London in 1907: “Gain the confidence of a patient and inspire him with hope, and the battle is half won.”6

Osler has also imparted plenty of advice on the business of medicine. In “Aequanimitas,” Osler says there are only two types of doctors: “those who practice with their brains, and those who practice with their tongues.”7

***

Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

***

In a valedictory address to medical school graduates at McGill University, Osler suggested treating money as a side consideration in a medical career.8 “You have of course entered the profession of medicine with a view of obtaining a livelihood; but in dealing with your patients let this always be a secondary consideration.”

“You are in this profession as a calling, not as a business: as a calling which exacts from you at every turn self-sacrifice, devotion, love and tenderness to your fellow man,” explains Osler in the address to St. Mary’s Hospital Medical School.6 “Once you get down to a purely business level, your influence is gone and the true light of your life is dimmed. You must work in the missionary spirit, with a breadth of charity that raises you far above the petty jealousies of life.”

It is not easy for doctors to combine a passion for patient care, a knowledge of science and the maintenance of business, according to Osler in the British Medical Journal.9 “In the three great professions, the lawyer has to consider only his head and pocket, the parson the head and heart, while with us the head, heart, and pocket are all engaged.”

While some aspects of practice may fall short or be devoid of appropriate financial remuneration, the giving of one’s time, expertise and experience in improving patient outcomes and the quality of their lives may be the greatest gift. “The ‘good debts’ of practice, as I prefer to call them … amount to a generous sum by the end of each year,” says Osler.9

***

http://www.BusinessofMedicalPractice.com

***

MEDICAL Ethics for Challenging Times

[Finding Your Moorings in an Era of Dramatic Change]

Marcinko Ethics

By Render S. Davis MHA

By David Edward Marcinko

***

And so, as you read and reflect on the chapter of SECTION ONE, always remember the words and wisdom of Dr. William Osler, and keep patient welfare as your first priority.

Dr. David Edward Marcinko; CMP™ MBA MBBS [Hon]

[Chief Executive Officer]

iMBA Inc., Norcross, GA

References

  1. Penfield W. Neurology in Canada and the Osler centennial. Can Med Assoc J. 1949; 61(1): 69-73
  2. Osler W. Aequanimitas. Chapter 9, P. Blakiston’s Son and Co., Philadelphia, 1925, p. 159
  3. Bean WB. William Osler: Aphorisms, CC Thomas, Springfield, IL, p. 129.
  4. Osler W. Aequanimitas. Chapter 3, P. Blakiston’s Son and Co., Philadelphia, 1925, p. 34
  5. Thayer WS. Osler the teacher. In: Osler and Other Papers. Johns Hopkins Press, Baltimore, 1931, p. 1.
  6. Osler W. The reserves of life. St. Mary’s Hosp Gaz. 1907;13 (1):95-8.
  7. Osler W. Aequanimitas. Chapter 7, P. Blakiston’s Son and Co., Philadelphia, 1925, p. 124
  8. Osler W. Valedictory address to the graduates in medicine and surgery, McGill University. Can Med Surg J. 1874; 3:433-42.
  9. Osler W. Remarks on organization in the profession. Brit Med J. 1911; 1(2614):237-9.
  10. Jacobs. AM: PMNews, April, 2015.

***

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***

Developing New Medical Practice 2.0 “People” Skills

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The Times are Changing in …. 2015 and Beyond

[By Render S. Davis MHA CHE]

[By Dr. David Edward Marcinko MBA CMP™]

DEM white  shirtMedical practice today is vastly different from a generation ago, and physicians need new skills to be successful, and reduce liability risks while improving care delivery at lower costs.

In order to balance their obligations to both individual patients and to larger groups, physicians now must become more than competent clinicians.

Bedside Manner?

Traditionally, the physician was viewed as the “captain of the ship,” in charge of nearly all the medical decisions, but this changed with the dynamics of managed care and the health reform of the PP-ACA.

Today, the physician’s role may be more akin to the ship’s navigator, utilizing his or her clinical skills and knowledge of the health care environment to chart the patient’s course through a confusing morass of insurance requirements, care choices, and regulations to achieve the best attainable outcome.

Some of these new 2.0 “People” skills include:

  1. Negotiation – working to optimize the patient’s access to appropriate services and facilities;
  2. Being a team player – working in concert with other care givers, from generalist and specialist physicians, to nurses and therapists, to coordinate care delivery within a clinically appropriate and cost-effective framework;
  3. Working within the limits of professional competence – avoiding the pitfalls of payer arrangements that may restrict access to specialty physicians and facilities, by clearly acknowledging when the symptoms or manifestations of a patient’s illness require this higher degree of service; then working on behalf of the patient to seek access to them;
  4. Respecting different cultures and values – inherent in the support of the Principle of Autonomy is acceptance of values that may differ from one’s own. As the United States becomes a more culturally heterogeneous nation, health care providers are called upon to work within and respect the socio-cultural and/or spiritual framework of patients and their families;
  5. Seeking clarity on what constitutes marginal care – within a system of finite resources, physicians will be called upon to carefully and openly communicate with patients regarding access to marginal and/or futile treatments. Addressing the many needs of patients and families at the end of life will be an increasingly important challenge in both communications and delivery of appropriate, yet compassionate care;
  6. Supporting evidence-based practice – physicians should utilize outcomes data to reduce variation in treatments and achieve higher efficiencies and effectiveness of care delivery;
  7. Fostering transparency and openness in communications – physicians should be willing and prepared to discuss all aspects of care and treatment, especially when disclosing problems or issues that may arise;
  8. Exercising decision-making flexibility – treatment algorithms and clinical pathways are extremely useful tools when used within their scope, but physicians must follow the case managed patient closely and have the authority to adjust the plan if clinical circumstances warrant;
  9. Fostering “patient and family centered care – whenever possible, medical treatments should be undertaken in a way that respects the patient’s values and preferences, and recognizes the important role to be played by family in supporting the patient’s care and well-being. For details on engaging families in this process, visit the website for the Institute for Family-Centered Care at www.familycenteredcare.org.;
  10. Becoming skilled in the art of listening and interpreting — In her ground-breaking book, Narrative Ethics: Honoring the Stories of Illness, Rita Charon, MD Ph.D., a professor of Clinical Medicine at Columbia University’s College of Physicians and Surgeons, writes of the extraordinary value of utilizing the patient’s narrative, or personal story, in the care and treatment process. She notes that, “medicine practiced with narrative competence will more ably recognize patients and diseases, convey knowledge and regard, join humbly with colleagues, and accompany patients and their families through ordeals of illness.” In many ways, attention to narrative returns medicine full circle to the compassionate and caring foundations of the patient-physician relationship.

***

Masks

[The Masks of Change]

Courtesy SplitShire

*** 

Assessment

These represent only a handful of examples to illustrate the myriad of new skills that today’s savvy physicians must master in order to meet their timeless professional obligation of compassionate patient care; coupled with risk avoidance, assumption, transference and reduction mechanisms.

*NOTE: Health 2.0 is information exchange plus technology. It employs user-generated content, social networks and decision support tools to address the problems of inaccessible, fragmentary or unusable health care information. Healthcare 2.0 connects users to new kinds of information, fundamentally changing the consumer experience (e.g., buying insurance or deciding on/managing treatment), clinical decision-making (e.g., risk identification or use of best practices) and business processes (e.g., supply-chain management or business analytics.

About the Author

Render Davis was a Certified Healthcare Executive, now retired from Crawford Long Hospital at Emory University, in Atlanta, GA He served as Assistant Administrator for General Services, Policy Development, and Regulatory Affairs from 1977-95.  He is a founding board member of the Health Care Ethics Consortium of Georgia and served on the consortium’s Executive Committee, Advisory Board, Futility Task Force, Strategic Planning Committee, and chaired the Annual Conference Planning Committee, for many years.

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On Cultural Sensitivity in Education and Medicine

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A Modern Integral Component of Healthcare Training

[By Render S. Davis MHA CHE]

[By Dr. David Edward Marcinko MBA]

[By Hope R. Hetico RN MHA]

***

While America has often been called a “nation of immigrants,” it has never been more true than today. Consequently, the challenge for physicians and other health care providers, in both large cities and small communities, is meeting the health care needs of increasingly diverse and multi-cultural populations who speak different languages and have social norms, traditions, and values that may substantially differ from their own. Problems arise when clinicians expect, even demand, that patients and their families discard their cultural foundations and adhere to the health care provider’s view of the care and decision-making process.

Instead, the health care team should be more aware of and sensitive to the values and beliefs of patients who come from other cultures; working within to assure that the patient’s individual rights are supported and wishes honored to the fullest extent possible.

In her award-winning book, The Spirit Catches You and You Fall Down, Ann Fadiman chronicled this tragic clash of two cultures in medical care for a child of the traditional Hmong people of Laos, transplanted to California after the Vietnam War.

In the book, Fadiman recounts a conversation with Professor Arthur Kleinman of Harvard University, a highly regarded expert in multicultural relations and conflict, who noted that “If you cannot see that your own culture has its own set of interests, emotions, and biases, how can you expect to deal successfully with someone else’s culture?”

***

anatomy-254129_640

***

Former U.S. Surgeon General David Satcher, M.D., Ph.D., now Director of the Satcher Health Leadership Institute at Morehouse College of Medicine in Atlanta, Georgia, helped develop a special curriculum designed to foster greater cultural competence among physicians and health care providers.

Called the “CRASH Course,” the program emphasizes:

  1. Cultural Awareness. Acknowledging the diversity and legitimacy of the many cultures that make up the fabric of American Society;
  2. Respect. Valuing other cultural norms, even if they differ or conflict with your own;
  3. Assess and affirm. Understanding the points of both congruence and difference among cultural approaches to decision-making; learning how to achieve the best outcomes within the cultural framework of the patient and family unit;
  4. Sensitivity and self awareness. Being secure in your own values; while willing to be flexible in working through cultural differences with others;
  5. Humility. Recognizing that every culture has legitimacy and that no one is an expert in what is best for others; being willing to subordinate your values for those of another to achieve the goals of treatment.

There is little doubt that multi-cultural sensitivity will continue to grow as an increasingly integral component of medical education and risk management in health care practice.

Dr. Marcinko Teaching Philosophy

***

anatomy-254120_640

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About the Author

Render Davis was a Certified Healthcare Executive, now retired from Crawford Long Hospital at Emory University, in Atlanta, GA He served as Assistant Administrator for General Services, Policy Development, and Regulatory Affairs from 1977-95.  He is a founding board member of the Health Care Ethics Consortium of Georgia and served on the consortium’s Executive Committee, Advisory Board, Futility Task Force, Strategic Planning Committee, and chaired the Annual Conference Planning Committee, for many years.  

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Cost Conflicts-of-Interest in Medicine

Clinical Care versus Finance

By Render S. Davis MHA CHE

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Conflicts of interest are not a new phenomenon in medicine. In the fee-for-service system, physicians controlled access to medical facilities and technology, and they benefited financially from nearly every order or prescription they wrote. Consequently, there was an inherent temptation to over-treat patients. Even marginal diagnostic or therapeutic procedures were justified on the grounds of both clinical necessity and legal protection against threats of negligence. 

Costs Rarely Considered

While it could be construed that this represented a direct conflict of interest, it could also be argued that most patients were well served in this system because the emphasis was on thorough, comprehensive treatment – where cost was rarely a consideration.  It was a well known adage that physicians “could do well, by doing good.” 

Managed Care

In managed care, the potential conflicts between patients and physicians took on a completely different dimension.  By design, in health plans where medical care was financed through prepayment arrangements, the physician’s income was enhanced not by doing more for his or her patients, but by doing less.  Patients, confronted with the realization that their doctor would be rewarded for the use of fewer resources, could no longer rely with certainty on the motives underlying a physician’s treatment plans.  One inevitable outcome was the continuing decline in patients’ trust in their physicians.  This has been exacerbated to some degree by revelations of significant financial remuneration to physicians by pharmaceutical and medical products firms for their services as researchers or active participants on corporate-funded advisory panels, calling into question the physician’s objectivity in promoting the use of company products to their peers or patients.

Conflicts of Interest

Conflicts of interest may also create concerns at a much higher level, as evidenced by the issues raised in 2008 litigation against Ingenix, a company that for more than a decade, provided information to the insurance industry on payments to out-of-network physicians for their “usual and customary rates (UCR).” As noted in court documents, Ingenix was a wholly-owned subsidiary of United Healthcare and the UCR information sold by the company to insurers may have been fundamentally biased in favor of the insurers, causing patients to pay larger out-of-pocket fees.

Assessment

As a result, New York attorney general Andrew Cuomo filed suit against Ingenix.  This action was followed by suits brought against major insurers by the American Medical Association and several state medical groups for systematic underpayment to members, based on the biased data.  To date there have been monetary settlements, but the issue continues to raise growing concerns regarding conflicts of interest among the key payers for health care.

Conclusion

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Understanding Healthcare Conflicts of Interest

A Modern Ethical Dilemma

By Render Davis

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Conflicts of interest are not a new phenomenon in medicine. In the fee-for-service system, physicians controlled access to medical facilities and technology, and they benefited financially from nearly every order or prescription they wrote.  Consequently, there was an inherent temptation to over-treat patients.  Even marginal diagnostic or therapeutic procedures were justified on the grounds of both clinical necessity and legal protection against threats of negligence. 

Traditional Medical Care

While it can be construed that this represented a direct conflict of interest, it could also be argued that most patients were well served in this system because the emphasis was on thorough, comprehensive treatment – where cost was rarely a consideration.  It was a well known adage that physicians “could do well, by doing good.” 

Managed Medical Care

In managed care, the potential conflicts between patients and physicians took on a completely different dimension.  By design, in health plans where medical care was financed through prepayment arrangements, the physician’s income was enhanced not by doing more for his or her patients, but by doing less.  Patients, confronted with the realization that their doctor would be rewarded for the use of fewer resources, could no longer rely with certainty on the motives underlying a physician’s treatment plans.  One inevitable outcome was the continuing decline in patients’ trust in their physicians.  This has been exacerbated to some degree by revelations of significant financial remuneration to physicians by pharmaceutical and medical products firms for their services as researchers or active participants on corporate-funded advisory panels, calling into question the physician’s objectivity in promoting the use of company products to their peers or patients.

Higher Concerns

Conflicts of interest may also create concerns at a much higher level, as evidenced by the issues raised in 2008 litigation against Ingenix, a company that for more than a decade, provided information to the insurance industry on payments to out-of-network physicians for their “usual and customary rates (UCR).” As noted in court documents, Ingenix was a wholly-owned subsidiary of United Healthcare and the UCR information sold by the company to insurers may have been fundamentally biased in favor of the insurers, causing patients to pay larger out-of-pocket fees.  As a result, New York attorney general Andrew Cuomo filed suit against Ingenix.  This action was followed by suits brought against major insurers by the American Medical Association and several state medical groups for systematic underpayment to members, based on the biased data. 

Assessment

To date, there have been monetary settlements, but the issue continues to raise growing concerns regarding conflicts of interest among the key payers for health care.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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On e-Confidentiality Conflicts in Medicine

Understanding the Potential Role of eMR Compromise

By Render Davis MHA CHE

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Whether it is an employer interested in the results of an employee’s health screening; an insurer attempting to learn more about an enrollee’s prior health history; the media in search of a story; or health planners examining the potential value of national health databases, the confidential nature of the traditional doctor-patient relationship may be compromised through demands for clinical information by parties other than the patient and treating caregivers. 

Impact of eMRs

In addition, without clear safeguards the growth in use of electronic medical records may put personal health information at risk of tampering or unauthorized access.  Clearly, employers and insurers are interested in the status of an individual’s health and ability to work; but does this desire to know, combined with their role as payers for health care, constitute a right to know?  The patient’s right to privacy remains a volatile and unresolved issue.

Assessment

Counter to this concern is the recognition that electronic records may dramatically improve communications by offering greater accessibility of information to clinicians in the hospital or office potentially reducing medical errors through elimination of handwritten notes, increased use of built in prompts and clinically-derived triggers for orders and treatments, and development of pathways for optimal treatments based on clinically valid and tested best practices.

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. What do you think about this confidentiality conflict and the role of eMRs? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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ReThinking Medical Professional Autonomy in the Era of Obama Care

Eying Contemporary Medical Ethics in Healthcare Reform

By Render S. Davis; MSA, CHE

And, Staff Reportersbiz-book

Not so long ago, a physician’s clinical judgment was virtually unquestioned. Now with the advent of clinical pathways and case management protocols, many aspects of treatment are outlined in algorithm-based plans that allied health professionals may follow with only minimal direct input from a physician. Much about this change has been good. Physicians have been freed from much tedious routine and are better able to watch more closely for unexpected responses to treatments or unusual outcomes and then utilize their knowledge to chart an appropriate response.  

Restrictive Protocols

What is of special concern, though, is the restrictive nature of protocols in some managed care plans that may unduly limit a physician’s clinical prerogatives to address a patient’s specific needs. Such managed care plans may prove to be the ultimate bad examples of “cook book” medicine. While some may find health care and the practice of medicine an increasingly stressful and unrewarding field, others are continuing to search for ways to assure that caring, compassionate, and ethically rewarding medicine remain at the heart of our health care system.

Assessment

Link: For another opinion: http://healthcareorganizationalethics.blogspot.com/2009/09/obamas-speech-good-ethics-and-good.html

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated. How does the specter of HR 3200-3400 in the healthcare reform debate impact the concept of medical autonomy and professional ethics? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, be sure to subscribe to the ME-P. It is fast, free and secure.

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