I am writing because I’m frustrated with the current and proposed state of healthcare in the United States. My concerns include malpractice liability and insurance coverage; the lack of tort or legal reform as evidenced in the current healthcare bill; the diminution of the primary care physician; and the potential loss of the primary care physician’s guidance and control over a patient’s health regimen. I regard primary care physicians as “gatekeepers.” In such a scenario, the primary care physician has overall guidance and supervision of patient care. Another major concern is the disconnect regarding payment solutions for physicians. Such solutions appear headed for a downward trend over the next few years. My greatest concern is the projected future shortage of primary care physicians- a shortage that could be detrimental to our profession. The question of change in American healthcare is moot- change is manifest- but as part of that change I see no solutions for the problems I’ve noticed.

I’m compelled to write about my personal experience and describe a case that reflects my concerns. Recently, a consultant- a colleague to whom I referred a patient- admitted my patient. I find it ironic- as of this writing- that the doctor-patient relationship has changed, and I am now considered the consultant in this case and not the attending physician. The patient is one of the eldest I see, I’ve seen him for several years and he is quite ill. Several consultants- nephrologists, hematologists, and gastroenterologists- are treating him, as well as me the family practitioner. The specialists saw the patient and documented that he was “dizzy” in the progress notes. Period. When I examined my patient I listened to his heart and heard an irregular rhythm. I ordered a stat EKG which showed positive couplets of PVCs. I ordered isoenzymes, a cardiology consult, a magnesium level, and transferred the patient to ICU. His blood pressure was less than 90/50. In a situation like this, there is no question in my mind that the primary care physician must follow his patient on a daily basis to ensure complete perspective of treatment- be the “gatekeeper” as I like to call it.

As a family practitioner, I’m going out of business. Why? I don’t get paid. NBC’s Robert Bazell asked me, “Doctor, since the economy is so bad, are you ordering more tests? Trying to improve your income?” I replied, “No, Mr. Bazell, when any tests are done at my office, I pay for them upfront. I send the claim to the insurance company and in two-three weeks-maybe- I will get paid or perhaps incur other administrative responses such as additional requests for my records or other clarifications. It may take months before I get paid-if ever. Who paid for the x-rays, the EKG, the radiologist, employees, insurance, etc.? If we in primary care were surgeons and we paid for the sutures, anesthesia, bandages, etc., would we remain in our profession? We in primary care pay for all of that and if we ever get paid, it will be at the insurance price, for example, $1.95 for drawing a patient’s blood. As a result of this administrative “nightmare,” primary care doctors are referring out more, not following their patients in hospitals, retiring early, giving their practices away to hospital corporations for free, and so on. This is a dangerous ‘erosion’ of our chosen field.”

I recently received a denial from Medicare for a patient seen in 2007. The patient came in for medical clearance before surgery, complained of chest pressure, and had an abnormal EKG. I couldn’t ignore this and okay the patient for surgery- that would be irresponsible. I did a cardiac evaluation. To further explain the Medicare reason for delay or nonpayment, the stress test proved to be negative. Medicare focused on that result in its conclusion, which further explained Medicare’s reason for delay or nonpayment. Had I known the stress test would be negative, I would not have ordered it, however, I am a doctor not a magician. I must test to verify concerns and protect the patient.

Now, three years later, a woman presented to my office with chest pain and an abnormal EKG. She needed clearance for surgery. This time, I referred her to the Emergency Room. The ER doctor recommended that the patient be admitted. A cardiac consult was called and a evaluation was done, which included a stress test. The stress test was questionable, so a cardiac catheterization was done. The catheterization was negative and the patient was cleared for surgery, albeit with an additional financial liability close to $40-50,000. The patient I saw three years ago incurred expenses approximating $1,500. I didn’t get paid for that procedure, and I no longer can pay for such tests upfront, so I referred the recent patient out for the evaluation. Who ultimately pays these bills? The U.S. taxpayer.

To summarize my points:

  1. Legal reform must take place.
  2. Primary care doctors should get paid for evaluating patients in their offices. This will cut healthcare costs by 50 percent.
  3. We need more primary care physicians. Residents are not choosing Family Practice. (Can you blame them?)

Whenever I’m asked if I want healthcare for every citizen, my response is yes. Do I want coverage for pre-existing conditions? Affirmative. But everything comes down to payment solutions – and it is there in which my major concerns lay.

As always, not only as a doctor, but most important, as a patient, I am very concerned for medicine today.



As the nation starts to transform its approach to healthcare, there are clearly more questions than answers regarding what the future will bring. For the research community, the questions are no less compelling than they are for healthcare professionals, institutions, employers and prospective patients. Funding is the obvious engine that drives all research endeavors. Traditionally, funding for medical research comes from four sources—the drug and device industry, the NIH or other governmental agencies, private charitable sources and academic university budgets. In recent years, tightening reimbursements and uninsured care have placed increased strains on university hospital budgets, limiting the funding formally available to support the development of young researchers. The financial recession has certainly taken its toll on available charitable sources, although many foundations and organizations are in fact weathering the storm and will likely remain a limited but durable resource in the future. The two big “players” in the arena are industry and NIH. It is here that uncertainty, at least for now, reigns.

In general, industry support is essential in order to bring promising ideas into clinical reality. Before introducing a new medication or device, it is quite obviously necessary to demonstrate to some reasonable degree that the medication/device is both safe and effective. Since no therapy is either 100% safe or 100% effective, the key is to define the knowable limits of safety and efficacy sufficient for an educated and reasonable judgment to be made regarding release and marketing (hopefully by the FDA). In order to accomplish this, testing must be completed in numerous stages, at first in the laboratory setting, then in an animal population, then in a very limited population of normal volunteers, then in a gradually expanding population with the condition which is being treated. All of this takes time and, you guessed it, dollars. It is not unusual for the total cost from drug discovery to clinical release to accumulate to the billion dollar range. The price of failure becomes challenging at best. It is for this reason that patent laws protect the drug manufacturers’ ability to recoup their investments (which must include not only the successes, but all the failed investments as well), so as to encourage future development. If new legislation restricts or taxes the drug and device industry in order to raise much needed funds (and we are not saying that it shouldn’t), industry will likely respond by being more risk averse. If the bar for acceptance of new therapies is raised to demonstrate not only safety and efficacy, but also comparative advantage over currently available therapeutic options (a highly reasonable request), the incentive for industry-sponsored clinical research will be diminished. Perhaps a contraction and/or refocusing of this industry are not so bad in the big picture of how a country allocates its healthcare dollars. However, in the short run, there is likely to be a “cooling” of available funding for clinical research.

The real question that remains unanswered is the impact that health care reform will have on the NIH. Traditionally, the NIH has been the bastion of basic science research. Somewhat risk averse because it is distributing large sums of public money, the NIH process has nonetheless been remarkably free of political directive. Aside from the issue of embryonic stem cell research, NIH funding has largely been based on broad research strategies and rigorously evaluated by experts in the various fields being studied. What is currently being discussed with regard to comparative effectiveness research is a shift in this approach, from a research community-based approach to a governmental agency/policy approach to setting priorities and making funding decisions. (see VanLare’s article in the March 18, 2010 New England Journal of Medicine). This shift would signal a major shift in research funding, one of huge political significance. Not least amongst the major unsettled issues that such a change in direction would raise is who is left that is committed to medical research based upon scientific validity rather than commercial or political consequence? It is in just such a scenario that rare institutions such as the Florida Heart Research Institute, with its unbiased and independent commitment to stopping heart disease through research, education and prevention, take on added importance and significance.



Before construction can commence in a hospital environment, proper consideration must be given to the isolation and control of contaminants that may arise due to construction-related activities. The control and remediation of these contaminants are addressed in project specific Infection Control Risk Assessment (ICRA) Plan, the development of which is critical to the elimination or minimization of risk to hospital patients and staff. The development of a project specific ICRA plan involves the careful coordination of a hospital’s Infection Control Practitioner, Safety Officer, Director of Facilities, Director of Construction, representatives from departments adjacent to affected areas, and the contractor employed to perform the work.

The first step in developing a cohesive ICRA plan is to identify the invasiveness of the construction activities that are to take place based on scope and duration, typically identified as type ‘A’, ‘B’, ‘C’ or ‘D’ activities. Obviously, a project involving the repainting of walls (type ‘A’) or replacement of telephone/computer cabling (type ‘B’) will be less invasive than one involving demolition of partitions (type ‘C’) and relocation of major mechanical systems (type ‘D’), or one where the envelope of the building is compromised for an extended period due to the potential for water infiltration (type ‘D’).

Once the scope of work is adequately understood, the risk level of the areas affected must be evaluated, commonly referred to as identifying patient risk groups. Risk assessment is based on the sensitivity of patients in adjacent areas and described from ‘low’ risk to ‘high’ risk. Less stringent measures would be required in a Radiology Department (‘medium’ risk) as compared to one where there are heavily immune compromised patients, such as Oncology (‘high’ risk).

Once the scope of work is defined and the risk level to patients assessed, preventative measures can be adequately delineated. Low risk projects might simply require the isolation of areas with fire retardant plastic sheet barriers and the cleaning of the space during and after completion with an approved disinfectant. A high risk project might involve such extensive measures as isolating the mechanical system, keeping the space under negative pressure using HEPA filtration units, incorporating anterooms where workers can be cleaned before re-entering active hospital spaces, requiring workers to wear shoe/clothing protection (“bunny suits”), etc. Whatever the measure may be, they must be clearly and effectively specified so they may be properly carried out by the construction team. It is quite common to use an “ICRA Matrix” to assist in identifying the above-mentioned types and risks when implementing an ICRA plan. Not only will this ICRA Plan become the most critical part of the preconstruction planning between the General Contractor and Subcontractors, but it will also serve as a rubric by which the site must be continually graded for effective infection control.



As I write this, New Orleans, Mississippi, and Alabama are still reeling from Hurricane Katrina and Texas is bracing itself for an unwelcome visit by Hurricane Rita. We Floridians are no strangers to the potential devastation of a hurricane. So these are not fun times for any of us who share the Gulf Coast.

When faced with a storm of such magnitude, you cannot help but be forced to put things in perspective. In pure size, both Katrina and Rita were massive storms, bigger than any of the states they threatened and, in fact, dwarfing even Texas. The power of their winds and rushing water overwhelmed anything mere mortals could devise to stop them. All anyone could do was get out of the way (if possible), wait it out, then go back to see what, if anything, was left to rebuild. It made us, masters of the known universe, seem small indeed.

These storms had a message for everyone, even those of us fortunate enough—at least this time—not to be directly in their paths.

To begin with, they made many of us think about what we would do if we were caught up in the devastation. One day you have a house, a car, a job, a routine … the next, everything you have come to know and to rely on has been swept down the street, literally. How many of us could face such a prospect and have the courage and the fortitude to recover?

But it also gave us another perspective. In the Felix household before Katrina and Rita, many of life’s annoyances would dramatically affect Carol and me: everything from a blown fuse to someone taking the last Diet Coke from the refrigerator. How unfortunate or ill timed such nuisances would seem.

But now, in the aftermath of these hurricanes—and realizing that more will come and, like a frustrating game of Russian Roulette, some might turn their frightening power on Florida—we’ve adopted a new attitude. Our code phrase to invoke is “No Biggie.”

The cable guy didn’t show up for the third time in a row. No Biggie. Let’s turn off the TV and play Canasta.

One of our old pipes sprung a leak and we need to call a plumber? No Biggie. At least we have fresh water. And it’s not covering everything we own.

Flat tire? No Biggie. Let’s call the Auto Club and relax. Wherever we had to go, it’ll be there tomorrow.

I appreciate that we humans have short attention spans, so I know it won’t be long before once again I ’m upset because the pizza is delivered late, or it rains after I’ve washed the car, or I spill something on my laptop …

But for now, all of those are No Biggies. No matter what minor irritant befalls me, I’m feeling pretty fortunate right now.

Charles Felix, Publisher



While working for HospiceCare of Southeast Florida, Caren Bock realized the need for a children’s book that could prepare, inform, and guide children through the experience of a loss. Inspired by her husband John, family, and dear friend Susan G. Telli, Caren created Wings: A Story of Transformation, a delightful children’s book about the transformation of life and death. This unique story is about a young boy named Christopher and his friend, a caterpillar named “Fuzzy”, who through transformation becomes a beautiful butterfly leaving Christopher to cope with his change. As a critical care pediatric RN, Caren feels this book will help many families through difficult times. Wings offers care and support to children, parents, grandparents, guardians and families, counselors as well as healthcare providers as they face end-of-life, and deal with the issues that come after the death of a loved one.

All proceeds of this book will be donated to HospiceCare of Southeast Florida, Inc.

HospiceCare of Southeast Florida, Inc. will be celebrating their 25th Anniversary with the Book Launching of Wings, on November 17th from 5:30-8:30 p.m. For more information, call (954) 467-7423 or visit www.hospicecareflorida.org.