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Urogynecology We're Not LIKE a Good Neighbor, WE ARE the Good Neighbor Alliance

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Urogynecology We're Not LIKE a Good Neighbor, WE ARE the Good Neighbor Alliance Volume 92 No. 1 January 2009 Urogynecology We're not LIKE A Good Neighbor, WE ARE The Good Neighbor Alliance 56 52 Specializing in Employee Benefits since 1982 Health Dental Life Disability Long Term Care Pension Plans Workers' Compensation Section 125 Plans The Good Neighbor Alliance Corporation The Benefits Specialist AffiAffiliatedliated with with RHODE ISLAND MEDICAL SOCIETY rhode isl and medical society 401-828-7800 or 1-800-462-1910 P.O. Box 1421 Coventry, RI 02816 www.goodneighborall.com UNDER THE JOINT VOLUME 92 NO. 1 January 2009 EDITORIAL SPONSORSHIP OF: Medicine Health The Warren Alpert Medical School of Brown University HODE SLAND Edward J. Wing, MD, Dean of Medicine R I & Biological Science PUBLICATION OF THE RHODE ISLAND M EDICAL SOCIETY Rhode Island Department of Health David R. Gifford, MD, MPH, Director Quality Partners of Rhode Island Richard W. Besdine, MD, Chief COMMENTARIES Medical Officer 2 Reimbursement for Experience-Based Medicine Rhode Island Medical Society Joseph H. Friedman, MD Diane R. Siedlecki, MD, President 3 I’ve Got a Little List…I’ve Got a Little List EDITORIAL STAFF Stanley M. Aronson, MD Joseph H. Friedman, MD Editor-in-Chief Joan M. Retsinas, PhD CONTRIBUTIONS Managing Editor SPECIAL FOCUS: Urogynecology Stanley M. Aronson, MD, MPH Guest Editor: Deborah L. Myers, MD Editor Emeritus 4 The Role of Urogynecology In Women’s Pelvic Floor Disorders EDITORIAL BOARD Deborah L. Myers, MD Stanley M. Aronson, MD, MPH John J. Cronan, MD 5 Pelvic Organ Prolapse James P. Crowley, MD Brittany Star Hampton, MD Edward R. Feller, MD John P. Fulton, PhD 10 Physical Therapy for Pelvic Floor Dysfunction Peter A. Hollmann, MD Wendy Baltzer Fox, PT, DPT GCS Anthony E. Mega, MD Marguerite A. Neill, MD 12 Minimally Invasive Approaches To Pelvic Reconstructive Surgery Frank J. Schaberg, Jr., MD Charles R. Rardin, MD Lawrence W. Vernaglia, JD, MPH 16 Urinary Incontinence Newell E. Warde, PhD Vivian W. Sung, MD, MPH OFFICERS Diane R. Siedlecki, MD 22 Interstitial Cystitis President Deborah L. Myers, MD Vera A. DePalo, MD President-Elect COLUMNS Gillian Elliot Pearis, MD Vice President 27 ADVANCES IN PHARMACOLOGY – Effect of Zoledronic Acid on Bone Pain Margaret A. Sun, MD Secondary To Metastatic Bone Disease Secretary Porpon Rotjanapan, MD Jerald C. Fingerhut, MD 29 GERIATRICS FOR THE PRACTICING PHYSICIAN – The Practicing Physicians’ Guide Treasurer Nick Tsiongas, MD, MPH To Pressure Ulcers in 2008 Immediate Past President Rachel Roach, MSN, ANP, GNP, WCC, and Clarisse Dexter, MSN, FNP, GNP, WCC DISTRICT & COUNTY PRESIDENTS 32 HEALTH BY NUMBERS – Rhode Island HEALTH Web Data Query System: Geoffrey R. Hamilton, MD Death Certificate Module Bristol County Medical Society Annie Gjelsvik, PhD, and Karine Monteiro, MPH Herbert J. Brennan, DO Kent County Medical Society 34 PUBLIC HEALTH BRIEFING – Palliative Care – Evolution of a Vision Rafael E. Padilla, MD Anna Wheat Pawtucket Medical Association 37 PHYSICIAN’S LEXICON – Medical Words In Extremis Patrick J. Sweeney, MD, MPH, PhD Stanley M. Aronson, MD Providence Medical Association Nitin S. Damle, MD 37 Vital Statistics Washington County Medical Society Jacques L. Bonnet-Eymard, MD 38 January Heritage Woonsocket District Medical Society 39 2008 Index Cover: “Tender Moment,” is an award- winning watercolor by Antonia Marshall of Foxboro, MA. She is an artist member of the Rhode Island Watercolor Society, Medicine and Health/Rhode Island (USPS 464-820), a monthly publication, is owned and published by the Rhode Island Medical Society, 235 the North Shore Arts Association and has Promenade St., Suite 500, Providence, RI 02908, Phone: (401) 331-3207. Single copies $5.00, individual subscriptions $50.00 per year, and $100 per year for institutional subscriptions. Published articles represent opinions of the authors and do not necessarily reflect the official policy of the Rhode Island been juried into many national and in- Medical Society, unless clearly specified. Advertisements do not imply sponsorship or endorsement by the Rhode Island Medical Society. Periodicals postage ternational shows. Following a career in paid at Providence, Rhode Island. ISSN 1086-5462. POSTMASTER: Send address changes to Medicine and Health/Rhode Island, 235 Promenade St., graphic design, she dedicates her time to Suite 500, Providence, RI 02908. Classified Information: RI Medical Journal Marketing Department, P.O. Box 91055, Johnston, RI 02919, phone: (401) 383-4711, fax: (401) 383-4477, e-mail: [email protected]. Production/Layout Design: John Teehan, e-mail: [email protected]. painting. E-mail: [email protected] 1 VOLUME 92 NO. 1 JANUARY 2009 Commentaries Reimbursement for Experience-Based Medicine The editor of Annals of Neurology, the harder, see more patients for less money Should doctors be paid differently publication of the American Neurologi- than we used to. This means less time for based on experience or expertise? Do they cal Association, recently wrote an edito- journal review, attending conferences and do a better job? Evidently not by established rial trying to come to grips with insur- “keeping up” in general. This time-crunch measures. Are they less expensive, able to ance reimbursements being unrelated to means that those more recently trained have rely more on experience than expensive test- experience. As we all know, insurers pay less keeping up to do. Perhaps their skills in ing? We don’t know. In the academic work- flat rates depending on diagnoses, technical areas are better. Or they perform place, pay is based on seniority, and collec- whether the patient gets good care or better on the measuring scales because they tions. In private practice it is not. The Mayo not, so long as it is documented care. were trained with the measuring scales in Clinic, an academic-private practice, has a What I hadn’t realized until I read the mind. One of the major philosophical de- flat payscale that ignores seniority. I don’t article was that there is a body of pub- bates regarding “No child left behind” is think a flat reimbursement is right, again lished data that actually tracks “quality” whether teaching to score better on a stan- perhaps because of my age. Yet that’s what of care in relation to physician’s age and dardized exam is of any value other than insurers pay. One pays more to an experi- duration of practice. improving test performance. Some, but enced famous lawyer than to a newcomer. What surprised me was that these clearly not all, of these outcome studies may Yet if I go to a famous doctor or an un- data, perhaps not the best epidemiology reflect that. But, on the other hand, how known one, the fee is the same, unless the work extant, indicate that “experience” can one measure the physician-patient re- doctor refuses insurance. Yet psychiatric fees is not associated with improved care, and lationship? How can one compare the re- vary enormously in the big cities, with some is often associated with worse outcome. assurance a patient feels from a doctor who doctors charging $600/hr, and some $150. It’s not simply that I’m now an older has helped hundreds of patients cope with They can do this because they refuse insur- physician that makes me respond to this like the same problem to one whose experience ance. The patient pays out of pocket and I’ve heard nails on a chalkboard (a meta- is limited? Is there any way to compare the the insurance company pays whatever per- phor appropriate for an older person) but experience of returning to a doctor who centage they deem “reasonable.” Even rather that I wouldn’t have believed that has had a twenty-year experience with the when the economy was humming along, when I was younger, and don’t now. When patient and his family to that of a younger this would be impossible in most parts of I first started out I used to call my old men- doctor? The doctor-patient relationship is the country. And if we decide that quality tors frequently about troubling cases, refer sometimes more important than choosing is important, how is that to be determined? to the big academic centers for second opin- the first line treatment instead of the sec- I have thought of abandoning accep- ions, and send my EEGs for review. After I ond. These are intangible; and we are lim- tance of insurance, thus reducing overhead got my sea-legs, I reduced my second guess- ited, of course, to measuring what we can enormously and increasing my charges, but ing to a low level, as I learned that when I measure. then my patients, largely Medicare, almost didn’t know something and had an oppor- The various medical disciplines have all insured, would have to pay a lot more; tunity to research the area, chances were tackled the problem of keeping up to date and many of them cannot. Which is why, the other guy didn’t either. by re-credentialing exams every 10 years. of course, medicine is so different than law, The literature indicates that younger While I am an ardent supporter of this I have accounting or other businesses. cardiologists produce better results than not renounced my “grandfather” clause pro- If and when our disaster of a older ones, that younger PCPs follow guide- tection that lets me avoid the process. Am I healthcare system gets straightened out, lines better than older ones, and that by keeping up? How can I tell? In my own nar- this will be another issue that we should any criterion of quality or outcome, younger row subspecialty I’m pretty confident that I confront. physicians do as well or better than the older do and I have a number of objective mea- ones.
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