As the authors of this commentary -- a vascular surgeon from New York and a cardiologist from Texas -- waited in an airport boarding area, we pondered why healthcare costs in the United States are out of control. Here are some dollar-wasting examples that we have both observed:

1. The Building of Shrines for Hospital Administrators. We have both witnessed the building of expensive and unneeded new healthcare facilities to satisfy the desire of an institution to provide a monument to a hospital executive who is nearing the end of his or her career. In one case, architecturally spectacular new hospital buildings costing billions of dollars were erected within a few hundred yards of similar facilities belonging to a competing institution. In another case, a specialty hospital was constructed despite the fact that 2 other similar specialty facilities existed within a few miles. In both instances, as large as the costs of the new buildings may have been, they were dwarfed by the costs of the duplicative staffs required for the new facilities. Moreover, to keep both new facilities acceptably occupied, substantial additional monies continue to be spent on advertising and public relations campaigns.

2. Unnecessary Duplication of Services. One large city had 3 excellent transplant programs, each associated with a different university hospital. Administrators at a fourth university hospital decided they also wanted a transplant program to enhance their institutional image and prestige. When the relevant state agency determined that there was no need for a fourth transplant program in the city, there was a rumor that a top officer at the medical center interceded personally with a high-ranking elected state official. Whatever the truth of the rumor, the unneeded fourth program was quickly approved. The costs for the complex and extensive additional staffing and equipment for the extra program were borne by our healthcare system. Because the number of organ transplants in the area is totally dependent on the number of donor organs and not on the number of programs, no increase in quality or number of patients treated could accrue -- only an increase in the overall cost. The sole purpose served by the additional program was gratification of the egos who served the institution.

3. Absence of Medical Malpractice Tort Reform. It is well known that medical liability costs are out of control in New York State. Abuses are rampant because the system depends on contingency payments to trial lawyers and "hired gun" expert witnesses who are often nonexpert and who are paid handsomely for their biased opinions -- a pure example of conflict of interest.

Numerous studies have documented that most awards, some of which are larger than lottery payouts, do not correlate at all with actual malpractice and that most instances of actual malpractice do not result in awards. Clearly the system is fueled by the greed of trial lawyers who contribute large sums of money to the campaigns of federal and state elected officials so that they will block reform of a system that is nonfunctional and frighteningly expensive. The billion dollar insurance premium burden is, of course, passed on to our overall healthcare system.

Worse still are the staggering costs of defensive medical practices, such as adding unnecessary tests, hospitalizations, and consultations. These defensive practices are estimated to increase healthcare costs by 65-200 billion dollars every year.

Texas and a few other states have passed sensible state malpractice reform laws that protect patients' rights to seek redress for real malpractice, while limiting liability to reasonable amounts rather than lottery amounts. President Obama, however, who originally advocated medical liability reform as part of his healthcare federal legislative package, has inexplicably backed away. If we are serious about cutting healthcare costs, how can we not address this problem on a national level?

4. Need for Hospitals to Be in the Black. Hospitals need to survive. To do so, they cannot operate at a deficit. This requires hospitals to admit enough insured and paying patients to maintain their income stream. Tremendous pressure, therefore, is placed on physicians and surgeons to increase hospital admissions. In one New York institution, salaried staff surgeons were ordered to increase their admissions and operations by 20% or face a cut in salary. Because most surgeons normally operate on all patients who have appropriate indications for such aggressive treatment, the only way these surgeons could possibly increase their operative load was to perform procedures that were not indicated. Such behaviors subject patients to unwarranted risks and increases costs.

5. Decreased Physician Reimbursement Leading to Unnecessary Procedures. Physicians, like other humans, do not like to take a cut in pay. Physicians who do procedures are paid on the basis of the number of procedures performed. If the compensation per procedure is decreased, as is happening, the only way for a physician to maintain his or her income is to do more procedures. Accordingly, a cut in procedural reimbursement will inevitably motivate physicians to do more procedures. For reasons already mentioned, this will result in more unnecessary operations and procedures. Increased costs and unnecessary risks to patients will result.

6. Pay-for-Performance Systems. In an effort to improve the quality of healthcare and physician performance, financial incentives have been introduced. These provide additional income to physicians who can perform procedures with lower mortality and morbidity rates.

It is well known that patients who most need certain procedures are at higher risk for death and complications than patients whose indications are weaker or nonexistent. Physicians are therefore incentivized to add easier cases, even if some of the people do not need the procedure, so that their mortality and morbidity rates will be lower and they will receive higher reimbursement rates. This adds to the current trend of treating patients who do not need treatment, and it increases costs. In addition, as we have both observed, pay-for-performance systems motivate physicians to deny interventional or operative treatment to patients who need it most.

Conclusion

These are just 6 of many reasons why healthcare costs are rising uncontrollably. Suggesting detailed ways to address these issues is outside the scope of this article. However, we should recognize that some of these problems are inherent to a system in which compensation is based on the number of procedures performed. Others relate to the nature of man and the fact that humans are strongly motivated by self-interest, greed, and ego gratification. If these system and motivational factors are recognized, it is likely that measures to offset them can be developed. Healthcare costs are more likely to be brought under control.

Welsh Rhapsody by William German.  "Men of Harlech"

The 13.65 Basis Point Portfolio

Written by Matthew Hougan

Tuesday, 04 December 2007 20:05  |  Related ETFs: BND / DJP / VGK / VNQ / VPL / VTI / VWO

As many of you know, I've been keeping track of just how low you can drive your expense ratio on a broadly diversified portfolio of ETFs. I published my first blog about this in June, when my portfolio of low-cost ETFs had a blended expense ratio of 16 basis points (0.16%). That fee dropped to 15 basis points (0.15%) in July, as expense ratios came down on certain funds. The Wall Street Journal was kind enough to cover that portfolio in October. Now, the portfolio has gotten even cheaper—down to 13.65 basis points—thanks to fee reductions on three Vanguard ETFs. Vanguard recently announced that it was lowering the expense ratio on its Emerging Markets ETF (VWO) from 0.30% to 0.25% and the expense ratios on its Europe (VGK) and Pacific (VPL) ETFs from 0.18% to 0.12%. With those changes, the portfolio now looks like this:         Asset Class Weight Fund Ticker ER U.S. Stocks 40% Vanguard Total Market VTI 0.07% European Stocks 20% Vanguard Europe VGK 0.12% Asian Stocks 10% Vanguard Pacific VPL 0.12% Emerging Markets 5% Vanguard Emerging Markets VWO 0.25% Fixed Income 15% Vanguard Total Bond Market BND 0.11% REITs 5% Vanguard REIT VNQ 0.12% Commodities 5% iPath Dow Jones AIG Commodity ETN DJP 0.75% Blended Expense Ratio 0.1365% I'm not recommending this as the right portfolio for anyone, and I'm not saying that these are the best ETFs in their respective asset classes (although many of them are). But the portfolio makes an important point: You can now buy a diversified portfolio that includes everything from Emerging Markets stocks to commodities futures ... for 13.65 basis points. That's amazing. And it is a testament to the benefits ETFs bring to investors.

Last Updated ( Wednesday, 05 December 2007 20:24 )

Frank Shostak is an adjunct scholar of the Mises Institute and a frequent contributor to Mises.org. Send him mail. See Frank Shostak's article archives.

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Asset Class Weight Fund Ticker ER U.S. Stocks 10% Vanguard Total Market VTI 0.07% Non-US Stocks 30% Vanguard Ex-US, Small Cap. VSS   Fixed Income 10% Foreign Bond BWX ?     10% Foreign Bond, Inflation-Protected WIP   ?   Gold 10%   IAU   Commodities 10%   DBC 0.78% Cash 10% Foreign Money Market FXE   Cash                                        10%              Vanguard Inflation-Protected Fund                               I'm not recommending this as the right portfolio for anyone, and I'm not saying that these are the best ETFs in their respective asset classes (although many of them are). But the portfolio makes an important point: You can now buy a diversified portfolio that includes everything from Emerging Markets stocks to commodities futures ... for 13.65 basis points. That's amazing. And it is a testament to the benefits ETFs bring to investors.

Last Updated ( Wednesday, 05 December 2007 20:24 )

Introduction

On average, the United States loses the equivalent of at least one entire medical school class each year to suicide (reliable estimates are as many as 400 physicians).

Sadly, physicians globally have a lower mortality risk from cancer and heart disease relative to the general population, presumably relating to self-care and early diagnosis; however, physicians have a significantly higher risk of dying from suicide. Depression is a leading risk factor for myocardial infarction in male physicians. Although, as a profession, physicians seem to have heeded their own advice about avoiding smoking and other common risk factors for early mortality, they are decidedly reluctant to address a significant risk of both morbidity and mortality that disproportionately affects them.

In all populations, suicide is usually the result of untreated or inadequately treated depression coupled with knowledge and access to lethal means. Depression is at least as common in the medical profession as in the general population, affecting an estimated 12% of males and 18% of females. Depression is even more common in medical students and residents, with 15-30% screening positive for depressive symptoms. Self-reporting likely underestimates the prevalence of the disease in both populations.

Perhaps due in part to knowledge of and ready access to lethal means, completed suicide is far more prevalent among physicians than the public, with the most reliable estimates ranging from 1.4-2.3 times the rate in the general population. More alarming is that, after accidents, suicide is the most common cause of death among medical students. Although female physicians attempt suicide far less often than their counterparts in the general population, completion rates equal those of male physicians and, thus, far exceed that of the general population (2.5-4 times the rate by some estimates). A reasonable assumption is that underreporting of suicide as the cause of death by sympathetic colleagues might well skew these statistics, so the real incidence of physician suicide is possibly somewhat higher.

The most common psychiatric diagnoses among physicians who complete suicide are affective disorders (eg, depression and bipolar disease), alcoholism, and substance abuse. The most common means of suicide by physicians are lethal medication overdoses and firearms.

Depression in Physicians

Reticence to recognize physician depression is imposed by other physicians, who may be well intentioned, chronically emotionally distanced, and/or feeling temporarily vulnerable themselves. Physicians are notoriously reluctant to ask for help of any kind. When depressed and feeling less than adequate, asking for help is even more difficult, and sadly, sometimes remarkably difficult to actually obtain.

Physicians are demonstrably poor at recognizing depression in patients let alone themselves. Furthermore, physicians are notoriously reluctant to seek treatment for any personal illness. Research suggests that 1 in 3 physicians has no regular source of medical care. Although everyone knows that "a doctor who treats (himself or) herself has a fool for a patient," we also know that most physicians treat themselves anyway, at least on occasion. This is especially likely when the physician believes that the consequences of seeking treatment might subject him or her to shame or worse (see Problems With Treatment in Physicians).

Some physician reluctance to reach out is self-imposed. Physicians feel an obligation to appear healthy, perhaps as evidence of their ability to heal others. Inquiring about another physician's health can shatter this mutual myth of invulnerability. Volunteering assistance may seem like an affront to a colleague's self-sufficiency. Thus, the concerned partner may say nothing, while wondering privately if the colleague has become impaired. Unconsciously defending against this painful vulnerability, colleagues or partners may fail to notice significant depression or withdrawal, attributing behavioral changes to stress or overwork. Nearly every article or obituary about a physician's suicide contains a quotation from some close contact, occasionally a spouse, similar to "I never had any idea that he/she was suffering." Of course, many physician obituaries omit the fact that the "sudden death" was a completed suicide.

Those physicians who do reach out may find limited understanding or sympathy demonstrated by colleagues. For many experiencing depression, the first symptoms experienced are physical. A physician unable to diagnose his or her own symptoms commonly feels incompetent. To admit inability to diagnose oneself to another colleague is an admission of failure. When this tacit confession is met with avoidance, disbelief, or derision, it can only reinforce feelings of worthlessness and hopelessness. Physicians find it painful to share their experience with others; therefore, published accounts are nearly impossible to find. However, in the author's experience, private consultations with a trusted counselor reveal that symptoms of depression among physicians are surprisingly common.

Whether the incidence of divorce among physicians is higher than that in the general population is not known, but marital problems are common, perhaps in part due to the tendency of physicians to postpone addressing marital problems and a general conflict avoidance. Marital problems of course can contribute to depressive symptoms, which can increase the likelihood of suicidality if unaddressed.

Litigation stress can precipitate depression and occasionally suicide. The suicide note of one Texas emergency physician the day after he settled a malpractice case read, "I hope that my death will shed light on the problem of dishonest expert testimony." Physicians have completed suicide upon first receipt of malpractice claims, after judgments against them in court, or following financially motivated but unjust settlements foisted upon them by malpractice insurers to cut the insurer's losses. Others have attempted or completed suicide due to employment discrimination relating to judgments or settlements and/or upon the realization that they are no longer able to practice because of discrimination by liability insurers who refuse to insure them due to past judgments or settlements.

Problems With Treatment in Physicians

Many clinicians are uncomfortable treating fellow physicians, especially in the realm of mental health. The "VIP syndrome" of well-intentioned but superficial or inadequate treatment based on collegiality and concerns about confidentiality can detract from the effectiveness of therapy.

Mental health experts studying physician depression and suicide have stressed that immediate treatment and confidential hospitalization of suicidal physicians can be lifesaving more so than in other populations. Yet, this very specter is often the major impediment to a physician's reaching out in time of crisis. The fear of temporary withdrawal from practice, the lack of confidentiality and privacy in treatment, and the loss of respect in the community hampers physicians from seeking effective treatment.

Physicians who have reported depressive symptoms (even those for which they are receiving effective treatment) to their licensing boards, potential employers, hospitals and other credentialing agencies have experienced a range of negative consequences, including repetitive and intrusive examinations, licensure restrictions, discriminatory employment decisions, practice restrictions, hospital privilege limitations, and increased supervision. Such discrimination can immediately and severely limit physicians' livelihoods as well as the financial stability of their families. For this reason, well-meaning colleagues or family members sometimes discourage physicians from seeking help.

Regulations governing some state physician health programs allow a physician who is compliant with treatment to check "no" on the mental health questions on licensure applications, but this is not generally known by physicians who are contemplating or in need of treatment. Any lack of disclosure on an employment or credentialing application can be cited as grounds for termination or decredentialing.

Discrimination in obtaining insurance coverage is a common but little publicized problem for physicians with mental illness. Health, disability, and liability insurance may all be denied to a physician who admits to depression. Even if disability insurance has previously been procured, its use may subject physicians to repetitive humiliating and invasive examinations by detached and dubious "independent medical examiners" for the insurer, whose motivation is to cut company losses. Many physicians affected by mental illness feel that insurers expect adherence by them to the standard prescription of "physician, heal thyself."

Despite the protections offered by law to citizens and other professionals who have disabilities, the potentially devastating effects triggered by a physician's self-reporting of depression may delay or in effect preclude appropriate treatment. A depressed physician, whose thought processes are clouded because of the illness and the anticipated consequences of seeking treatment, may honestly believe that self-treatment is the only safe option. However, attempts at self-treatment are often unsuccessful. Failure to obtain consultation and treatment of depression significantly increases the risk of physician suicide.

Depression in Medical Trainees

Prospective medical students and residents are unlikely to report a history of depression in selection interviews. The prevalence of depression in these populations and in medical student and postgraduate trainees is unknown, but it is estimated in the range of 15-30%. After accidents, suicide is the most common cause of death among medical students. A recent report has suggested that depression is not uncommon in pediatric residents (up to 20% self-reported in 3 programs). This preliminary study found that residents who experienced depression may be as much as 6 times more likely than nonaffected controls to make medication errors. 

Stressful aspects of physician training, such as long hours, difficult decisions with the potential for errors due to inexperience, learning to deal with death and dying, and frequent shifts in workplace could add to the tendency toward depressive symptoms in trainees. Even positive workplace changes such as translocations to secure further training or job advancement could contribute to job-related stress.

Education and Resources

Depression, like substance abuse in physicians, is not only more common than in the general public, it usually is more readily treatable. This is because of the strong self-motivation to continue successful pursuit of a professional calling, which is an important source of a physician's self-esteem.

More education is needed regarding this disease and its disproportionate and needless toll on the profession of medicine, beginning in the earliest stages of physician training. In addition, there is an urgent need to change the attitudes of those in health care, including those in the regulatory system, as well as the general public, toward mental illness. This might encourage physicians to be more receptive to a diagnosis of depression and enable them to feel free to seek treatment without the fear of repercussion. Physicians themselves need to be aware of the existence of Physician Health Programs in nearly every state and province, which allow a physician who is compliant with treatment to avoid disclosure of depression or other stable illness that does not interfere with ability to practice to licensing authorities. 

Please consult the American Foundation for Suicide Prevention available at www.afsp.org and www.physiciansuicide.com for further information and resources about physician depression and suicide. Litigation stress and related materials and resources can be found at www.mdmentor.com.

References

1. Adams D. Physician suicide: Searching for Answers. American Medical News [serial online]. April 25, 2005;Available at http://www.ama-assn.org/amednews/2005/04/25/prsa0425.htm.

2. Andrew LB. Depression and Suicide. eMedicine from WebMD. 2008;[Full Text].

3. Andrew LB. Litigation Stress. eMedicine from WebMD. 2006.

4. Andrew LB. Survey Says: Many EPs Suffer in Silence. Emergency Physicians Monthly Online [serial online]. March 2006;13:3:1-7. Available at http://www.epmonthly.com/index.php?option=com_content&task=view&id=226&Itemid=15.

5. Andrew LB. PHPs Are in Your Corner. Emergency Physician Monthly Online. 2006;13:6:[Full Text].

6. Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA. Jun 18 2003;289(23):3161-6. [Medline].

7. Charles SC, Frisch PR. Adverse Events, Stress, and Litigation: A Physician's Guide. New York: Oxford University Press; 2005.

8. Frank E, Dingle AD. Self-reported depression and suicide attempts among U.S. women physicians. Am J Psychiatry. Dec 1999;156(12):1887-94. [Medline].

9. Goldsmith SK, Pellmar TC, Kleinman AM. Reducing Suicide: A National Imperative. Institute of Medicine Monograph. National Academies Press; 2002:[Full Text].

10. Gross CP, Mead LA, Ford DE, et al. Physician, heal Thyself? Regular source of care and use of preventive health services among physicians. Arch Intern Med. Nov 27 2000;160(21):3209-14. [Medline].

11. Hendin H, Maltsberger JT, Haas AP. A physician's suicide. Am J Psychiatry. Dec 2003;160(12):2094-7. [Medline].

12. Holmes VF, Rich CL. Suicide Among Physicians. In: Blumenthal SJ, Kupfer DJ, eds. Suicide Over the Life Cycle. Washington, DC: American Psychiatric Press; 2004:599-618.

13. Lehmann C. Aggressive Intervention Urged for Depression in Physicians. Psychiatric News. November 17, 2000.

14. Miles SH. A piece of my mind. A challenge to licensing boards: the stigma of mental illness. JAMA. Sep 9 1998;280(10):865. [Medline].

15. Myers M, Fine C. Suicide in physicians: toward prevention. MedGenMed. Oct 21 2003;5(4):11. [Medline].

16. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. Dec 2004;161(12):2295-302. [Medline].

17. Sessions S. Dr. Ticktin and the Expert Witness Industry. 2005;[Full Text].

18. Shaw DL, Wedding D, Zeldow PB. Suicide among medical students and physicians, special problems of medical students. In: Wedding D, ed. Behavior and Medicine. 3^rd ed. Hogrefe and Huber: 2001:78-9 (chap 6).

19. Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. Mar 1 2008;336(7642):488-91. [Medline]. [Full Text].

20. Noonan D. Doctors who kill themselves. Newsweek. Apr 28 2008;151(17):16. [Medline].

21. Bender, Eve. Suicide-Awareness Project Targets M.D.s, Med Students. Psychiatry News. April 2008;43:8:14. [Full Text].

22. Schwenk TL, Gorenflo DW, Leja LM. A survey on the impact of being depressed on the professional status and mental health care of physicians. J Clin Psychiatry. Apr 2008;69(4):617-20. [Medline].

23. Worley LL. Our fallen peers: a mandate for change. Acad Psychiatry. Jan-Feb 2008;32(1):8-12. [Medline].

24. Hendin H, Reynolds C, Fox D, et al. Licensing and Physician Mental Health: Problems and Possibilities. Journal of Medical Licensure and Discipline. 2007;93:6-11.

25. Hawton K, Malmberg A, Simkin S. Suicide in doctors. A psychological autopsy study. J Psychosom Res. Jul 2004;57(1):1-4. [Medline].

26. Middleton JL. Today I'm grieving a physician suicide. Ann Fam Med. May-Jun 2008;6(3):267-9. [Medline].

Keywords

physician suicide, doctor suicide, medical student suicide, depressive illness, mood disorder, suicidal, suicidality, suicide ideation, suicide attempt, suicide attempts, self-destructive acts, self-murder, suicide gesture, major depressive disorder, MDD, bipolar affective disorder, BPD, unipolar depression, unipolar affective disorder, alcoholism, substance abuse, myocardial infarction risk, self treatment, VIP syndrome, physician health programs, medical licensure boards, medical license, licensure restriction, insurance discrimination, liability insurance denial, disability insurance denial, employment discrimination, litigation stress, malpractice associated stress, medical malpractice stress, malpractice stress syndrome, frivolous malpractice litigation, unethical expert witness, dishonest expert testimony, medical regulatory system, American Foundation for Suicide Prevention, Struggling in Silence, Physicians Who Kill Themselves

Contributor Information and Disclosures

Author

Louise B Andrew, MD, JD, Medical-Legal, Risk Management and Trial Consultant, Litigation Stress Counselor
Louise B Andrew, MD, JD is a member of the following medical societies: American Association of Women Emergency Physicians, American College of Emergency Physicians, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Dana A Stearns, MD, Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital
Dana A Stearns, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Robert Harwood, MD, MPH, FACEP, FAAEM, Program Director, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College of Medicine
Robert Harwood, MD, MPH, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 

Asset Class Weight Fund Ticker ER U.S. Stocks 10% Vanguard Total Market VTI 0.07% Non-US Stocks 30% Vanguard Ex-US, Small Cap. VSS   Fixed Income 10% Foreign Bond BWX ?     10% Foreign Bond, Inflation-Protected WIP   ?   Gold 10%   IAU   Commodities 10%   DBC 0.78% Cash</