Saturday, December 10, 2011

To Fix Health Care, Help the Poor -

It's common knowledge that the United States spends more than any other country on health care but still ranks in the bottom half of industrialized countries in outcomes like life expectancy and infant mortality. Why are these other countries beating us if we spend so much more? The truth is that we may not be spending more — it all depends on what you count.

In our comparative study of 30 industrialized countries, published earlier this year in the journal BMJ Quality and Safety, we broadened the scope of traditional health care industry analyses to include spending on social services, like rent subsidies, employment-training programs, unemployment benefits, old-age pensions, family support and other services that can extend and improve life.

We studied 10 years' worth of data and found that if you counted the combined investment in health care and social services, the United States no longer spent the most money — far from it. In 2005, for example, the United States devoted only 29 percent of gross domestic product to health and social services combined, while countries like Sweden, France, the Netherlands, Belgium and Denmark dedicated 33 percent to 38 percent of their G.D.P. to the combination. We came in 10th.

What's more, America is one of only three industrialized countries to spend the majority of its health and social services budget on health care itself. For every dollar we spend on health care, we spend an additional 90 cents on social services. In our peer countries, for every dollar spent on health care, an additional $2 is spent on social services. So not only are we spending less, we're allocating our resources disproportionately on health care.

Our study found that countries with high health care spending relative to social spending had lower life expectancy and higher infant mortality than countries that favored social spending. While the stagnating life expectancy in the United States remains at 78 years, in many European countries it has leapt to well over 80 years, and several countries boast infant mortality rates approximately half of ours. In a national survey conducted by the Robert Wood Johnson Foundation, four out of five physicians agreed that unmet social needs led directly to worse health.

Unfortunately, instead of learning from countries like Sweden and France, we prefer the frantic scramble to recover money from one part of the health care system only to reallocate it toward retreads of previously failed reforms. We pretend that the fresh schemes are innovative, but they are usually long on promises, short on details and often marked with an annoying acronym: H.M.O., F.S.A., A.C.O. and so forth.

It's time to think more broadly about where to find leverage for achieving a healthier society. One way would be to invest more heavily in social services. This may be difficult for many Americans to swallow as it suggests a potentially expanded role for government. Out of respect for individuals' rights, our current social programs are mostly opt-in, leaving holes for the undocumented, uneducated and unemployed to slip through cracks and become acutely ill. Emergency rooms, though, are not allowed to opt out of providing these people extraordinarily expensive medical treatment before discharging them back to wretched conditions and their inevitable return to the E.R.

The impact of sub-par social conditions on health has been well documented. Homelessness isn't typically thought of as a medical problem, but it often precludes good nutrition, personal hygiene and basic first aid, and it increases the risks of frostbite, leg ulcers, upper respiratory infections and trauma from muggings, beatings and rape. The Boston Health Care for the Homeless Program tracked the medical expenses of 119 chronically homeless people for several years. In one five-year period, the group accounted for 18,834 emergency room visits estimated to cost $12.7 million.

We can learn from the star pupils in our analysis. Other countries have created government ministries that marry health and social care. Earlier this year, the Department of Health in Britain released plans to create health and well-being boards comprising local government representatives, primary care physicians, hospital administrators, children and adult-services specialists and public health directors, who will coordinate care for their constituencies across the health and social care spectrum. We should think expansively about how to construct similar programs that enable much needed integration of these mutually dependent sectors. The Department of Veterans Affairs is leading the way, with programs called "stand downs" that simultaneously address the health and social needs of retired service members.

It is Americans' prerogative to continually vote down the encroachment of government programs on our free-market ideology, but recognizing the health effects of our disdain for comprehensive safety nets may well be the key to unraveling the "spend more, get less" paradox. Before we spend even more money, we should consider allocating it differently.

Elizabeth H. Bradley is professor of public health at Yale and faculty director of its Global Health Leadership Institute, where Lauren Taylor is a program manager.

Medical Marijuana and the Memory of One High Day -

When my mother-in-law was in the final, harrowing throes of pancreatic cancer, she had only one good day, and that was the day she smoked pot.

So I was heartened when, at the end of last month, the governors of Washington and Rhode Island petitioned the Obama administration to classify marijuana as a drug that could be prescribed and distributed for medical use. While medical marijuana is legal in 16 states, it is still outlawed under federal law.

My husband and I often thought of recommending marijuana to his mother. She was always nauseated from the chemotherapy drugs and could barely eat for weeks. She existed in a Percocet and morphine haze, constantly fretting that the sedation kept her from saying all the things she wanted to say to us, but unable to face the pain without it. And this was a woman who had such a high tolerance for pain, coupled with a distaste for drugs, that she insisted her dentist not use Novocain and gave birth to her two children without anesthesia. But despite marijuana's power to relieve pain and nausea without loss of consciousness, we were afraid she would find even the suggestion of it scandalous. This was 1997, and my mother-in-law was a very proper, law-abiding woman, a graduate of Bryn Mawr College in the 1950s. She'd never even smoked a cigarette.

But then an older family friend who worked in an AIDS hospice came bearing what he said was very good quality marijuana. To our surprise, she said she'd consider it. My husband and I — though we knew nothing about marijuana paraphernalia — were dispatched to find a bong, as the friend suggested water-processing might make the smoking easier for her. We found ourselves in a head shop in one of the seedier neighborhoods in New Haven, where my husband went to graduate school, listening attentively to the clerk as he went over the finer points of bong taxonomy, finally just choosing one in her favorite color, lilac.

She had us take her out on the flagstone patio because she refused to smoke in her meticulously kept-up house. Then she looked about nervously, as if expecting the police to jump out of the bushes. She found it awkward and strange to smoke a bong, but after a few tries managed to get in two and a half hits.

And then she said she wanted to go out to eat.

For the past month, we'd been trying to get her to eat anything: fresh-squeezed carrot juice made in a special juicer, Korean rice gruel that I simmered for hours, soups, oatmeal, endless cans of Ensure. Sometimes she'd request some particular dish and we'd eagerly procure it, only to have her refuse it or fall back asleep before taking a bite. But this time she sat down at her favorite restaurant and ordered a gorgeous meal: whitefish poached with lemon, hot buttered rolls, salad — and ate every bite.

Then she wanted to go to Kimball's, a local ice cream place famous for cones topped with softball-size scoops. The family had been regular customers starting all the way back when my husband and his brother were children, but they hadn't been there since her illness. My husband and I shared a small cone, which we could not finish, and looked on in awe as my mother-in-law ordered a large and, queenishly spurning any requests for a taste, polished the whole thing off — cone and all — and declared herself satisfied.

We were of course raring to make the magic happen again, but it never did. The pot just frightened her too much. She was scared her friend would be arrested for interstate drug trafficking, that my husband and I would be mugged in New Haven; she was afraid she'd become addicted or (à la "Reefer Madness") go insane. It was difficult watching her reject something that had so clearly alleviated her nausea and pain and — let's admit it — lightened her mood in the face of the terrible fact that cancer had invaded nearly every essential organ. And it was even worse to watch her pumped, instead, full of narcotics that made her feel horrible. The Percocet gave her a painfully dry mouth, but even ice chips made her heave. We were reduced to swabbing her lips with little sponges dipped in water, and waiting out her agony.

My husband and I have dredged up the memory of that one good day many times since, how she smiled and joked, for the last time seeming a little like her old self.

After the funeral, saying goodbye to all the family and friends, supervising the removal of the hospital bed, bedpans and related paraphernalia, one of the last things my husband and I did, under the watchful eyes of the hospice nurse, was destroy her remaining Percocets. We opened the multiple bottles and knelt in front of the toilet to perform this secular water rite, wishing there had been other days, other ways, a softer way for her to leave us.

Marie Myung-Ok Lee, the author of the novel "Somebody's Daughter," teaches writing at Brown University.

Wednesday, December 7, 2011

How Doctors Die « Zócalo Public Square

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient's five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn't spend much on him.
It's not a frequent topic of discussion, but doctors die, too. And they don't die like the rest of us. What's unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.
Of course, doctors don't want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They've talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that's what happens if CPR is done right).
Almost all medical professionals have seen what we call "futile care" being performed on people. That's when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, "Promise me if you find me like this that you'll kill me." They mean it. Some medical personnel wear medallions stamped "NO CODE" to tell physicians not to perform CPR on them. I have even seen it as a tattoo.
To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they'll vent. "How can anyone do that to their family members?" they'll ask. I suspect it's one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it's one reason I stopped participating in hospital care for the last 10 years of my practice.
How has it come to this—that doctors administer so much care that they wouldn't want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.
To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They're overwhelmed. When doctors ask if they want "everything" done, they answer yes. Then the nightmare begins. Sometimes, a family really means "do everything," but often they just mean "do everything that's reasonable." The problem is that they may not know what's reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do "everything" will do it, whether it is reasonable or not.
The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I've had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who'd had no heart troubles (for those who want specifics, he had a "tension pneumothorax"), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.
But of course it's not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.
Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman's terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.
Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn't restore her circulation, and the surgical wounds wouldn't heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.
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Tuesday, December 6, 2011

N.F.L Sued by Ex-Players Over Painkiller Toradol -

In the latest lawsuit based on medical issues against the N.F.L., a dozen former players have accused the league and its teams of repeatedly administering the painkiller Toradol before and during games, worsening high-risk injuries like concussions.

The players also contend that the league and its teams failed to warn them of the consequences of taking the drug, a blood thinner that, according to the suit, "can prevent the feeling of injury" and therefore made it harder for players to recognize when they had concussions.

"The plaintiffs have described the situation as one of being in a pregame locker room with players lining up to receive injections of Toradol in a 'cattle call' with no warnings of any sort being given, no distinguishing between different medical conditions of the players, and regardless of whether the player had an injury of any kind," the suit alleges.

The dozen retired players, including Joe HornMatt Joyce and Jerome Pathon, played in the late 1990s and early 2000s and say they now have anxiety, depression, short-term memory loss, severe headaches, sleeping problems and dizziness, according to Christopher A. Seeger, the lead lawyer for the plaintiffs.

"We took it like clockwork," said Horn, a receiver who played 12 years with the Kansas City Chiefs, the New Orleans Saints and the Atlanta Falcons and who says he now experiences bouts of dizziness and blackouts. "They don't meet with you to tell you what will happen five years later. Had I known that there were going to be complications, I wouldn't have taken the shots."

In accusing the league of negligence, fraud, fraudulent concealment, negligent misrepresentation and conspiracy, the former players are seeking an unspecified amount of compensatory and punitive damages, and the reimbursement of their legal costs.

The league disputed the suit's claims.

"The N.F.L. has long made player safety a priority and continues to do so," Greg Aiello, a league spokesman, said in a statement. "Any allegation that the N.F.L. intentionally sought to mislead players has no merit. It stands in contrast to the league's actions to better protect players and advance the science and medical understanding of the management and treatment of concussions."

The suit, which was filed in United States District Court in New Jersey, also alleged that the N.F.L. was late to acknowledge the problems raised by repeated concussions, and its efforts to combat the issue were half-hearted.

In recent years, the league has instituted a number of changes to protect players, including penalizing helmet-to-helmet hits. Commissioner Roger Goodell said he would not rule out other rule changes to minimize the potential for head and neck injuries.

In October, the league said it would broaden its study of the effects of concussions after an earlier study was scrapped because of problems in how the data was collected. The new study will include about 1,400 people, from 45 to 59 years old, and divided into three groups. The first group will be retired N.F.L. players; the second will be people who played college football but no professional football; and the third will be a control group of nonathletes who have some medical commonalities with the first two.

Monday, December 5, 2011

Nerves or Something Worse? -

It felt like a knife slicing through his right side. The young man lay in bed and tried not to move. He'd had this pain off and on for years — usually when he was nervous, and he was very nervous that Sunday morning. He was supposed to start a new job the next day.


The pain had never been that bad before. A hot shower helped, but not for long; afterward, he couldn't bend at the waist without gasping. Slowly the pain began to ease, and the next day, he was well enough to start his new position — as a doctor, training for a specialty in cancer.

Although he felt comfortable with his self-diagnosis of a jittery stomach, his wife — also a doctor — did not. At her insistence, he made an appointment with the primary-care doctor he'd been assigned at the Mayo Clinic.


When Dr. Eric Tangalos met his new patient, his impression was that he was a pretty healthy guy. Tall and slender, he had a ready smile and an earnest, easygoing manner. "Tell me what brought you in," he asked the patient.


a) Abdominal pain: Normally it was intermittent and manageable, but it became quite severe that one time. He didn't have diarrhea or blood in his stool, and other than that one day, the pain hadn't interfered with his activities. He hadn't lost any weight.

b) Hypercalcemia: A routine blood test the year before showed too much calcium in his system.

c) Rash: He had some red spots on his nose that were bothersome and, he thought, unattractive. And he was getting more of them every year.


Other than these complaints, the patient told Dr. Tangalos, he had no medical problems. He'd never been in the hospital, was rarely sick and had not even broken a bone. He was married and had a daughter who was 2. The patient didn't smoke and rarely drank. He was physically active.

On examination, the patient certainly seemed healthy. The bumps on his nose were small, firm and slightly red. Tangalos wasn't sure what they were and decided to send the young doctor to a dermatologist. Then he turned his attention to the elevated calcium level. Should he refer him to an endocrinologist, too? In either case, he definitely needed to order some tests to help find where that came from.


Cancer: Metastatic spread of the cancer to the bone can cause calcium in the blood to rise.

Vitamin D intoxication: Calcium increases when there is too much vitamin D, often the result of taking too many supplements.

Sarcoidosis: A disease in which immune-system cells cluster to form lumps called granulomas in various organs. These granulomas create too much activated vitamin D, which leads to the absorption of excessive amounts of calcium.

Familial hypocalciuric hypercalcemia: An inherited inability to get rid of calcium in the urine. It's rare but will cause high calcium levels (also known as hypercalcemia). It rarely causes any other symptoms.

Hyperthyroidism: Too much thyroid hormone often leaches calcium from the bones, causing hypercalcemia and osteoporosis.

Hyperparathyroidism: This is the most common cause of elevated calcium levels. The parathyroid gland helps regulate the amount of calcium in the blood. Small tumors can form on these tiny glands, which makes them produce too much of the hormone and thus too much calcium.


There was one more thing the young man wanted to bring up, but it was a little embarrassing. Sometimes medical students or doctors will convince themselves that they have the diseases they are studying. This patient spent the past couple of years reading about cancer in preparation for his fellowship, and now he wondered if he had one.

Both his father and his father's brother died young from cancer. His uncle died at 52 from a tumor of the pituitary gland. His father — a nonsmoker — died at 49 of lung cancer. And his father also had high calcium levels.

There are only a couple of inherited diseases that can cause increased calcium levels. One in particular, the patient explained, seemed to fit: MEN — multiple endocrine neoplasia, a rare, inherited predisposition to develop tumors (or neoplasms) — seemed a likely diagnosis for his father and uncle and, uncomfortably, for himself as well.

Could he have MEN, he asked his new internist. The doctor was interested but not convinced. "This is unlikely but not outlandish," he told the patient. Although an unusual presentation of a common disease is far more likely than even a classic presentation of a rarity, Tangalos had to admit, the young man's story was compelling. But first he would have to look for the usual suspects.


The internist ordered a chest X-ray and a series of blood tests. The chest X-ray was normal — it wasn't sarcoidosis or Hodgkin's disease. The blood tests showed that it wasn't too much vitamin D or hyperthyroidism. Indeed all the blood tests were normal except for high calcium levels. And the parathyroid hormone level (PTH) was normal, but it shouldn't have been. PTH should be low when calcium is high. That suggested there was something wrong with the parathyroid gland.

When he saw these results, Tangalos was glad he had arranged for the young man to see an endocrinologist. Hyperparathyroidism and a family history of cancer certainly suggested MEN. The endocrinologist tested the patient for the gene. It was positive. He and his father, and probably his uncle, all had the disease.


There are three types of multiple endocrine neoplasia. MEN Type 1 — the kind this patient had — is the most common.

Current thinking is that patients with MEN 1 are missing one of the genes that suppress the formation of tumors. Almost everyone with MEN 1 will have high calcium levels because of tumors in the parathyroid gland. Around a third will also develop tumors in the pancreas or, as in this young man's uncle, in the pituitary gland. Other types of tumors are also seen. The patient's father had a characteristic type of lung cancer. The bumps on the young doctor's nose are also common in those with this rare disease.

The goal in treatment is to catch and, when necessary, remove tumors as they arise. Patients with MEN 1 should get regular CT scans and other studies to monitor body sites that may be affected.

The patient had multiple tumors on his parathyroid glands; he recently had surgery to remove them. Small tumors were also found in his pancreas. So far, these are too small to do any damage — and there's a good chance they will stay that way.

And what about the abdominal pain that brought him to the doctor's office in the first place? Once Dr. Tangalos had the results of the blood test, it seemed obvious enough. There's a mnemonic that doctors use to help remember the classic symptoms of high calcium: stones, bones, abdominal groans and psychic moans. High calcium can cause kidney stones, bone pain, abdominal pain and a variety of neurologic and muscular problems. Current thinking is that the abdominal pain is caused by gas and constipation — two common problems in those with high levels of calcium.


For this patient, the greatest challenge is that his children have a 50-50 chance of inheriting his tendency to grow tumors. His daughter was tested when he received his diagnosis. She tested negative. He and his wife wanted another child but weren't allowed to adopt because of his genetic disease. After long deliberation, they decided to have a second child. They haven't decided when to test their son, now 9 months old.

Bring Health Care Home -

One of my patients called me with a high fever, chills and dropping blood pressure. He was 48 and had been a quadriplegic since he was shot during a robbery in the hardware store he owned. I called an ambulance and admitted him to the hospital, where we soon brought his urinary tract infection under control. But he developed a bedsore, which became infected with an antibiotic-resistant bacterium that breeds in hospitals. He didn't survive the hospitalization.

This was in 1998. Ever since, I have struggled to treat my patients in their homes and avoid hospitals except when absolutely necessary. I practice general internal medicine on Roosevelt Island in New York City's East River, where many of my patients are elderly and homebound: survivors of the polio epidemic, people with multiple sclerosis, paraplegics, some on respirators.

Patients who are treated at home by a doctor and nursing staff who know them intimately and can be available 24/7 are happier and healthier. This kind of care decreases the infections, mistakes and delirium, which, especially among the elderly, are the attendants of hospital care. And it is far more efficient. According to a 2002 study, for the patients treated by the Veterans Affairs' Home Based Primary Care program, the number of days spent in hospitals and nursing homes was cut by 62 percent and 88 percent, respectively, and total health care costs dropped 24 percent.

I had one 83-year-old patient whose arthritis kept her from moving around, but she loved to talk about her career as a rocket scientist — working on weather rockets, not military ones. One day, a well-intentioned neighbor dropped by and called 911 after finding her feverish and dehydrated from diarrhea.

My patient had never been treated before at the hospital she was taken to, and as a Russian immigrant, had no family here for the hospital to contact. She became disoriented; the hospital assumed she was demented and transferred her to a nursing home. It took me two months to track her down and many more to get her home, where, among well-known attendants and friends, she became lucid again. If she had lived out her days in an institution, she would have cost Medicare a great deal of money, and her life would have been shorter and far less happy.

All too often, ambulances take people to the nearest hospital, not to the one where their doctor is on staff. State laws make it difficult to administer simple treatments in the home. Emergency rooms want to admit patients, and hospitals want to discharge them to nursing homes, rather than send them home.

The good news is that last year's health care reform act included provisions for the creation of Independence at Home Organizations — groups of doctors and nurses who treat patients in their homes — and incentives to make that work appealing. The organizations can invest in extra services and home visits (for which Medicare typically will not reimburse them) because they will share in a cut of the savings that result from avoiding hospital visits and expensive procedures. The program is to go into effect no later than Jan. 1.

However, Medicare is behind schedule and has not yet issued the rules or applications to begin the process. It has been focusing instead on another provision of the new law intended to deliver more efficient care, creating accountable care organizations — groups of hospitals, doctors and nurses who work together to treat patients. But Medicare should make getting the Independence at Home Organizations up and running a priority.

We have the technology. Electronic medical records can give a doctor with an iPad as much information as any institution. With hand-held machines and a few drops of blood, doctors can get test results in seconds at a patient's bedside. Portable X-ray and ultrasound equipment can be wheeled into homes. Monitors can alert doctors to any change in a patient's heart rate.

The fact that this care is possible at home means that the role of hospitals must change. Acutely ill patients who need operating rooms or intensive care will still be brought to hospitals. But they should be quickly discharged to the care of the doctors and nurses who know them best.

For too long the institutions that make up our health care system — hospitals, insurers and drug companies — have told us that "more is better": more medicines, more specialists, more tests. To rein in spending and deliver better care, we must recognize that the primary mission of many an institution is its own survival and growth. We can't rely on institutions to shrink themselves. We need to give that job to patients and their doctors, and move health care into the home, where it is safer and more effective.

Jack Resnick has a solo internal medicine practice.