July 2, 2009
Primary Care Wins, Imaging Loses, Under New CMS Proposal – ht to Vinny Arora who retweeted AbbieCitron – Twitter does increase the speed at which I learn about important articles.
Primary care physicians are cheering—and radiologists are jeering—a new CMS proposed change to the Medicare Physician Fee Schedule that will cut reimbursements for imaging services by as much as 30% and use the savings to raise reimbursements for primary care by as much as 8%.
“I am surprised. We all kind of knew this sort of thing was coming, but until you see it in writing you don’t believe it,” says Ted Epperly, MD, president of the American Academy of Family Physicians. “We’ve been there before and never saw it. Putting it out now in the heat of the debate is a big deal. It sends a strong message.”
“I’m impressed that CMS is actually doing stuff to reformulate the system toward primary care. Of course, the devil is in the details and we will see what the final product looks like, and it’s not a total fix, but it’s a step in the right direction,” he says.
The AMA has always argued that enhancing primary care should not come at the expense of other physicians. I have remained skeptical, because they have benefited at the expense of family physicians and non-procedural internists.
I like much of what CMS is proposing:
CMS is also proposing to:
- Remove physician-administered drugs from the definition of “physician services” in anticipation of enactment of legislation to provide fundamental reforms to Medicare physician payments. While the proposal will not change the projected update for services during 2010, CMS projects that it would reduce the number of years in which physicians are projected to experience a negative update. AMA President J. James Rohack. MD, called the proposal “a major victory for America’s seniors and their physicians.”
- Implement a mandate in the Medicare Improvements for Patients and Providers Act of 2008 that suppliers of the technical component of advanced imaging services be accredited beginning Jan. 1, 2012 by designated accrediting organizations. The accreditation requirement would apply to mobile units, physicians’ offices, and independent diagnostic testing facilities that create the images, but would not apply to the physician who interprets them.
- Implement provisions to promote improvement in quality of care and patient outcomes through revisions to the Electronic Prescribing Incentive Program and the Physician Quality Reporting Initiative. Professionals or group practices that meet the requirements of each program in 2010 will be eligible for incentive payments for each program equal to 2% of their total estimated allowed charges for the reporting periods. CMS is proposing to simplify the reporting requirements and is also proposing a new process for group practices to be considered successful electronic prescribers.
- Refine Medicare payments to physicians, which are expected to increase payment rates for primary care services. The proposals include an update to the practice expense component of physician fees. For 2010, CMS is proposing to include data about physicians’ practice costs from a new survey, the Physician Practice Information Survey, designed and conducted by the AMA.
- Stop making payments for consultation codes typically billed by specialists at a higher rate than evaluation and management services. Physicians will instead use existing E/M service codes when providing these services. The resulting savings would be redistributed to increase payments for the existing E/M services.
- Increase the payment rates for the so-called “Welcome to Medicare” visit to be more in line with payment rates for higher-complexity services.
- Refine how Medicare recognizes the cost of professional liability insurance in its payments. These changes would have a modest impact, but they will promote payment equity by redirecting the portion of Medicare’s payment for professional liability insurance to those physicians that have the highest malpractice costs.
Taken together, CMS says refining the practice expenses, eliminating payment for the consultation codes and revising the treatment of malpractice premiums would increase payments to general practitioners, family physicians, internists, and geriatric specialists by between 6% and 8%.
I have not read the CMS proposal, but this morning it looks very interesting.
Posted in Medical Rants 
2 Comments »
July 2, 2009
I always wondered why the SGR formula accelerated so quickly. Now I understand.
Medicare May Shuffle the Deck on Doctor Payments
Most of the money that Medicare pays physicians is for doctor visits, medical procedures and the like. But Medicare also pays physicians directly for drugs that are administered at doctors’ offices. Today, the agency that runs Medicare said it wanted to move the payments for those drugs out of the bucket of money allotted to physician payments, and into a different bucket.
The AMA has been pushing for this shift for years, because the cost of physician-administered drugs (which include expensive new cancer drugs, for example) has risen faster than the cost of doctors’ services.
But beyond making the a powerful lobby happy, the shift could make it politically easier for Congress to wade in, get rid of SGR and replace it with a new system, as many have called for.
If those drug costs are no longer included in the overall cost of payments to physicians, then Medicare’s total cost of paying physicians could fall by $87.5 billion over the next decade, according to a CBO estimate cited today by The Hill.
That would make any fix to SGR a bit easier to swallow — even if didn’t reduce Medicare’s overall spending.
I hope that helps others.
Posted in Medical Rants 1 Comment »
July 2, 2009
This editorial (HT to retired doc) makes a point that many bloggers have made over the past 5 years – Socialize medical care?
As I’ve argued before in this space, one result of this unduly heavy reliance upon third-party payers is that almost everyone who consumes medical care does so irresponsibly. That is, the typical American is unresponsive to the burdens that his or her medical-care choices impose on others. This unresponsiveness — this irresponsibility — exists because we’ve socialized too much of the costs of medical care. Why should I give close attention to the price of some recommended medical procedure if I, personally, am paying out of pocket none (or only a tiny fraction) of the price of that procedure or drug?
With everyone irresponsible, resources are wasted. And with massive waste comes unnecessarily higher costs.
It’s a mystery why medical care cannot be supplied in the same way that, say, accounting services and food are supplied. Like medical care, these things are valuable. (Indeed, food is even more essential to life than is medical care!) Also like medical care, some types of accounting and some types of food are more crucial than are other types — and accounting services and food are supplied on a fee-for-service basis.
And yet, America suffers no “accounting services” crisis or “food supply” crisis.
Some proponents of the idea that medical care differs so much from other products that it cannot be compared to things like accounting or food say that “in matters of life and death, people aren’t willing to make the trade-offs that they make when deciding how much of other things to buy.” The idea is that a person on his or her deathbed will not care about the price of the costly medical procedure required to prolong life.
This “deathbed” tale is likely true. But it’s difficult to see how it counsels that we socialize medical-care payments. Does anyone seriously suppose that decisions by government bureaucrats over who will get, and who will be denied, some expensive lifesaving procedure would be better than having such decisions made according to each patient’s willingness and ability to pay?
Supply and demand really works. If one has no restrictions on demand, then some will abuse that demand. I addressed this issue 3 years ago - The tragedy of the commons
Health care is rather following the logical path that the Tragedy of the Commons predicts. As long as neither physicians nor patients have economic accountability (because of the middle common ground) then we cannot possibly fix our system. Note that this explanation fits all one payor systems as well.
We should transform our health care system using solid economic principles. It will not happen because we would have to make financial decision making explicit. It will not happen because we have too long fed at the insurance trough.
Our health care crisis is economically predictable. The solution is likely too painful.
Posted in Medical Rants 2 Comments »
July 1, 2009
He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all – Sir William Osler
I believe most educators have known this since Osler’s time. As I reconstruct my career, I strongly believe that I have continued to improve as I have cared for more patients.
I have known of this study for some time, as several of the authors are friends. I have referred to the principles of this study often in this blog. Internal Medicine Clerkship Characteristics Associated With Enhanced Student Examination Performance
Results: In school-level analyses (using a reduced four-variable model), independent variables associated with higher NBME subject examination score were more small-group hours/week and use of community-based preceptors. Greater score increase from USMLE 1 to 2 was associated with students caring for more patients/day. Several variables were associated with enhanced student examination performance at the student level. The most consistent finding was that more patients cared for per day was associated with higher examination performance. More structured learning activities were associated with higher examination scores for students with lower baseline USMLE 1 achievement.
We should take these findings into appropriate context. If you are a learner, you want to train at places with sufficient patient volume.
Some have advocated “competency based training.” I reject that philosophy. Medicine is never learned. We all should grow each day. How can we establish arbitrary goals in learning medicine when learning medicine will always remain a process not an achievable endpoint?
I encourage students and residents to seek out patient care opportunities. Each patient brings valuable teaching.
I am encouraged that small group teaching also does make a difference, since I love small group teaching. However, I am cognizant that teaching is best when it builds on actual patients.
Several years ago we had our residents rate teaching sessions in the Department of Medicine. Morning report was the clear winner and Grand Rounds was the clear loser! The reasons seem obvious. Medicine is best learned when given a patient context. Morning report, when done best, explores the intellectual process of diagnosis and management. When linked to the patient presentation, most residents learn important texture, even when they know much about the disease or symptom.
So my advice to students persists. Do not choose “easy residencies.” Choose residencies with the appropriate volume to allow you to grow as a physician.
Posted in Medical Rants 3 Comments »
June 30, 2009
Back in November I made a commitment to improve my fitness. The Thanksgiving resolution – year 3. Fortunately, this year I have had no significant injuries and I have continued my resolution all year. April and May were a bit down due to excessive travel, but this month I have rebounded and probably have my most successful exercise month in history! I attribute my success to an addiction to The Expresso Bike. Early in June, after golf I went to my local YMCA to work out. I saw this bike and decided what the heck – time for something different than the elliptical machine.
The Expresso Bike allows one to register and connect to the internet so that one can store workout data. Each day you can work to improve our time, power, calories etc. on a variety of interesting bike rides. You have an LCD screen with simulated courses ranging from 1 mile to 20 miles. Most courses have elevation changes, and as you ride the bike, the pedaling resistance adjust for the slope (up or down.) You have 30 gears to choose amongst.
This month (I started June 6) I have these results:
Miles:333.45
Time:0d 20h 4m
Calories:14225
Yesterday, for example, I pedaled almost 19 miles in 65 minutes, burning almost 900 calories.
If one reads about practicing any skill, feedback is important. Each day on the bike I am competing with myself, trying to improve. The Expresso web site provides data that enables you to chart your progress. I know my speed on each course in the past, and even can race the “ghost” of my previous best ride on that course to gauge my progress.
This exercise bike pushes my competitive buttons. I look forward to competing each day.
So, I believe that I will last the entire year, and not need to do another Thanksgiving challenge, because I will just be continuing my continued commitment to exercise. I have a resting heart rate of 56, not bad when your resting heart rate is less than your age.
As a physician, I believe that I have a responsibility to embrace a healthy lifestyle. I believe my exercise obsession helps my health and provides a good role model for my students and residents. Perhaps I can even challenge you, my readers, to enhance your exercise program.
Posted in Fitness & weight 5 Comments »
June 30, 2009
Those who follow me on Twitter have seen these references. Here is the rest of my story.
One argument for health care reform involves comparing our health care provision (I will try to avoid the word system, because we do not have one) with that provided in other countries. These analyses point to the waste in US healthcare and opine that we should emulate other countries. We certainly should study the strengths and weaknesses of other countries. A medical economics article and a WSJ editorial strongly suggest that we should also look at malpractice in these “best practices” countries.
Malpractice: Do other countries hold the key? and How Other Countries Judge Malpractice
Litigation in the U.S. has at least four distinctive procedural features that drive up malpractice costs. The first is jury trials, which can veer out of control and in any case introduce significant uncertainty. The second is the contingency-fee system, which allows well-heeled lawyers to self-finance litigation. The third is the rule that makes each side bear its own costs. This induces riskier lawsuits than are undertaken in most other countries, such as Canada, England and most of Europe, where the loser pays the legal costs of the winner. The fourth is extensive pretrial discovery outside the direct supervision of judges, which occurs far more readily here than elsewhere.
Even these features aren’t the whole story. American judges frequently let juries decide whether honest mistakes are negligent. Judges in other nations are less likely to do so. American courts commonly think it proper for juries to infer medical negligence from the mere occurrence of a serious injury. European judges usually will not.
American plaintiffs are sometimes spared the heavy burden of identifying particular acts of negligence, or of showing the precise causal connection between a negligent act and an actual injury. Lastly, damage awards for lost income and medical expenses in the U.S. tend to dwarf awards made elsewhere — in part because governments elsewhere provide this medical care from their nationalized systems. In sum, the medical malpractice system provides incentives for plaintiffs that really do matter. Americans, for example, file claims about 3.5 times more often than Canadians.
I have not blogged explicitly about malpractice in the recent past, but I have many times during the past 7 years. I expect the usual harangues from trial lawyers, but they should first read this hilarious satire – Obama Plan Calls for Making the Health Care System More Efficient by Having Trial Lawyers Provide Medical Services More Directly. But then, I am giving these critics credit for a sense of humor.
Our malpractice environment likely has a major influence on costs. Trial lawyers will deny it, but ask almost any physician if they believe that expensive tests are done to protect against malpractice. Defensive Medicine at Work We all know it.
How do we really decrease health care costs? We must use technology more intelligently. We should not order tests just because we can – or worse yet – just to be sure.
I do blame our tort laws, which are clearly out of sync with our peer countries, for our over testing, especially in the ER. Unnecessary testing has both direct and indirect costs.
So I will state again that malpractice reform could save numerous health care dollars. I also believe that the Democrats (who seem to love the trial lawyers) will not include substantial reform in their bills. Do they want to improve health care and decrease costs or win political points?
Posted in Malpractice 8 Comments »
June 29, 2009
I made rounds today on 9 patients. I would categorize the issues:
- Stabilize acid-base status
- End-of-life discussion
- Nuclear medicine stress test in woman with recent NSTEMI
- Cellulitis which followed a traumatic amputation
- Hyponatremia secondary to psychogenic polydipsia and (perhaps) thiazides, presented as altered mental status
- Achalasia – needs myotomy
- Lung cancer with bony metatases – needs biopsy documentation
- Patient s/p below knee amputation for gangrene – awaiting rehab placement
- Severe tonsillitis – probably bacteremic – responding to clindamycin
Did I do a good job? Would any of the current performance measures apply?
I can provide a similar list almost every day I make rounds. What is the point of performance measures if they do not relate to the main issues that I see on daily rounds? How would you judge my quality?
Posted in Medical Rants 1 Comment »
June 29, 2009
In one of my must read blogs, Evan Falchuk cautions us over oversimplifying health care reform by using one New Yorker piece. The McAllenization of Health Care Reform
When we talk about health care reform, we are really talking about dozens of different issues. Is health care reform about covering the uninsured, or about cutting costs for employers? It is about having a publicly-funded health plan, or changing reimbursements to doctors? Is it about longer life expectancies or creating insurance cooperatives? Is it about caps on medical malpractice awards, or comparative effectiveness? Is it about healthier lifestyles, or cutting the cost of prescription drugs? Is it about cutting administrative waste, or incentives for more people to go to medical school? Is it about implementing new health care IT, or preventing insurers from making excessive profits?
It’s about all of these things, and more. And that’s the problem, if you’re an ambitious reformer. There is no simple way to get all of these things under one roof.
Well, until Atul Gawande introduced us to McAllen.
True health care reform should be complex. We have an illogical payment system that has perverse incentives. This has resulted in a maldistribution of our workforce – too little primary care (IOM definition) and too many subspecialists. We have divorced financial decision making from patients through an insurance industry that has not had incentives to really control costs, because they just increase their rates.
We have no free market in health care, and yet many worry that we will lose free market principles. We have accounting definitions of quality, and rarely explore the components of true quality health care.
We have an incredible plethora of expensive regulations, written under the guise of protecting patients and privacy. We are overwhelmed with unfunded mandates.
Too many physicians and entrepreneurs “game” the system, finding the profit opportunities without regard to our health. They can do this because they deal with bureaucracy rather than individual patients.
We have too many observers who do not understand that finding a way to provide care for the uninsured will actually save money. We will decrease ER visits and admissions through universal coverage. This likely would offset the costs (in my opinion), and it would be the right thing to do.
We have unreasonable documentation requirements that take the physician away from direct patient contact (our strength) and towards buffing the medical record. We have a tort system that worries almost every physician. Physicians clearly order unnecessary expensive tests because of their fear of lawsuits.
Yes we need health care reform, and I have no confidence that our current politicians will get more than 30% correct. They are bound to make mistakes that will make things even worse for patients.
Fortunately, we also have physicians who care deeply about patients. We will continue to do our best regardless of the changes. Some changes will be good and some will be horrid. And we have a responsibility to do our best for our patients.
Posted in Medical Rants 6 Comments »
June 29, 2009
Had a great time talking to family physicians at the Alabama Academy of Family Physicians. One conversation with an experienced family physician included the hospitalist phenomenon. He mentioned that a significant percentage of patients left his practice when he stopped making hospital rounds.
Patients are smart. They understand the value of having a physician who knows them well. I wonder how prevalent this sentiment really is.
Most articles about the value of hospital medicine focus on the hospital and the care received there. I am sensing a growing skepticism amongst patients.
I write this as someone who has eschewed the outpatient clinic. Most patients that I see really have no choice. I help care for “unassigned” patients in a community hospital and VA patients (who have never had comprehensive physician care.) My hospital experience is clearly skewed because of the patient population I serve.
But I do believe this is a legitimate concern. I hope that this rant will stimulate some commentary from hospitalists, outpatient physicians and comprehensivists.
Posted in Medical Rants 5 Comments »
June 27, 2009
Those who follow me on Twitter know that I went to the beach to give a talk this week. On the trip down (4.5 hours) and back I listened to my trusty IPod Nano. While at the beach I took a first listen to Wilco (The Album).
These were the key observations from all that listening.
Wilco (The Album) – for sale this coming Tuesday – if you are a Wilco fan you have probably found the First Listen stream on NPR All Songs Considered. If you are like me, you are smiling. Jeff Tweedy is a genius. This might not be their best CD, but I think it will be highly ranked.
Veckatimest – Grizzly Bear – I had heard of this group, but had not really listened to them. My son, he of great musical taste, told me that I had to check it out. Wow! The songs grab you with their beauty and complexity. They are inventive, musical and have gorgeous voices. Read this review – Veckatimest. I will warn you that this music is complex and not related to top 40 pop.
The Seldom Seen Kid – Elbow – I had this CD on heavy rotation about 6 months ago but had forgotten it. On Wednesday night I was watching a music station and saw them perform One Day Like This. I really enjoyed the performance, and while driving remembered to listen to the CD again. I found myself singing along on at least 4 of the songs. Here is a good review – The Seldom Seen Kid
That Lonesome Song – Jamey Johnson – I rarely listen to Country – and this is country. Jamey Johnson has a classic country voice and tells stories that you know – but you still smile the way he tells the story. Only a country singer could write:
I tell you
The high cost of livin’
Ain’t nothing like the cost of livin’ high
These were the top 4. I am also listening to Merriweather Post Pavilion by Animal Collective – have not listened enough to be certain – but certainly beautiful thus far. I listened to Sophie Milman – Take Love Easy – great young female jazz singer.
Listening to Wilco while writing this post – they are really good.
Posted in General 2 Comments »
June 26, 2009
The Family Doctor: A Remedy for Health-Care Costs? – of course I object to the title. This article champions the patient centered medical home, which the ACP and internists embrace. Internists or family physicians can lead adult medical homes. But then, I understand the most pundits and politicians do not understand what an internist is.
The article is good and includes this priceless paragraph:
As sensible as this routine may sound, it goes against the grain of most primary-care practices. Medicare and other insurers pay doctors on a fee-for-service basis that rewards quantity of care over quality. There are no reimbursements for discussing diabetes management with a patient, say, or talking over a case with a specialist. “The main hurdle to getting the medical home accepted more widely is the lack of compensation for cognitive work,” says Harvard Business professor Clayton M. Christensen, co-author of The Innovator’s Prescription: A Disruptive Solution for Health Care.
How many times have I written about this concept? We will have inadequate health care reform if we do not fix the payment system to encourage primary care physicians to spend extra time with patients. We will have inadequate health care reform if we do not fix the payment system to encourage physicians to become primary care physicians.
Posted in Medical Rants 1 Comment »
June 26, 2009
Again tip of hat to FutureDoc – House Reform Bill Would Redistribute GME Positions, Assess Curricula
Health care reform legislation proposed by Democratic leaders of the three committees of jurisdiction in the US House of Representatives would mandate a study of residency education and faculty expertise in subjects including patient care coordination, costs and benefits of diagnostic and treatment options, and work in inter-professional teams. The bill would also (1) redistribute unused residency positions to hospitals that agree to expand and maintain primary care training as well as (2) provide legislative authority for graduate medical education payments from the Medicaid system.
The curricular assessment is the most troubling aspect of the bill. The legislation articulates seven goals for physician training, including working effectively in non-hospital settings, implementing solutions to health care systems errors, and being “meaningful [electronic health record] users.” The bill does not mention development of medical knowledge or skills as goals for training. According to the bill, the aforementioned study, to be conducted by the Comptroller General, would include recommendations in two areas. First, the report would discuss if making curricula in the seven goal areas mandatory for Medicare graduate medical education payments would be effective in changing medical education. Second, the report would discuss if existing accrediting processes are effective in changing curricula to meet the goals outlined in the bill.
Policy wonks and politicians know less about medical education than they know about the automobile industry. Letting the Comptroller General influence graduate medical education is an idea whose time should never come.
But we do need more primary care physicians.
But more important we need to reform our payment system to encourage physicians to do true complex primary care.
Posted in Medical Rants 1 Comment »
June 26, 2009
Med School ‘Senioritis’ as suggested by FutureDoc in a tweet.
While Lyss-Lerman does not advocate getting rid of the fourth year, she said that it needs to be revised to be more useful. The study suggests a curriculum wherein students “have more authentic roles in patient care,” which, she said, will help them to develop their own identities as physicians and collaboratively practice the humanistic elements of medicine. Specific recommendations for fourth year curriculum additions include sub-internships in internal medicine, and rotations for critical care, ambulatory care, and emergency medicine. The idea is to make sure students are achieving competencies — a movement in medicine to assess students based on critical skills rather than memorized facts — even as they enter the home stretch of their education. The study suggestions were based on interviews with 30 residency program directors at San Francisco.
Having graduated in the 70s, I have heard the argument for 35 years. My medical school had a 3 year option while I was a student. Most students felt that the 3 year grads had missed important opportunities.
Now I have worked at 2 medical schools that have some 4th year requirements. All our students have to take a medicine AI. Invariably the students find this a very valuable experience. They have to take 2 other AIs during the year.
What does the 4th year provide? I believe that the competency movement has a flaw. It cannot measure wisdom and comfort. Being a physician is more than knowledge and more than skills. Being a physician requires wisdom.
Wisdom only comes through experience. Those who teach residents know that residents continue to grow throughout residency. They often can do well enough on the test as interns to pass the boards, but they still pale compared to senior residents when approaching patient care.
I believe the 4th year is a consolidation year. I agree with the need for required acting internships. I advise students to take some electives related to their field of interest and some complimentary electives.
Yes tuition is too high, but that should not become a reason to short change education. Students benefit from the 4th year. The 3 year experiments in the 70s were not great successes.
Posted in Medical Rants 1 Comment »
June 25, 2009
Atul Gawande: The Cost Conundrum Redux
Gawande answers many of his critics, but I wonder if we really understand the issues. As I look over his many tables – this response is much more academic than the original article – I see that the most expensive community is also the most “under doctored.”
I wonder whether McAllen has many family physicians or general internists. I would bet not.
Adequate primary care (using the IOM definition) decreases unnecessary health care costs. Having less physicians in the community does not necessarily decrease health care costs.
Clearly there are many reasons for high health care costs. The most important health care reform that would help is re-aligning the incentives for physicians, because we do create many health care costs.
Important and interesting read.
Posted in Medical Rants 3 Comments »
June 24, 2009
I have a recent history of disagreeing with IDSA – Pharyngitis Management: Defining the Controversy. They have outdone themselves in my opinion.
Free Offers of Antibiotics Raise Concern for Some in Public Health: Resistance Feared
I do a significant amount of attending at a community hospital. We serve insured patients and “safety net” patients. Given the significant number of patients who we discharge on antibiotics and the inability of many of them to pay, the free antibiotic option is a blessing. Ask any of our attending physicians or residents and they love this option.
The free antibiotics:
-
Amoxicillin
-
Cephalexin
-
Sulfamethoxazole/Trimethoprim (SMZ-TMP)
-
Ciprofloxacin (excluding ciprofloxacin XR)
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Penicillin VK
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Ampicillin
-
Erythromycin (excluding Ery-Tab).
I cannot see any bad here. Free antibiotics decrease the tendency to use newer more expensive options, reserving them for resistant organisms.
But here comes the IDSA:
Promoting free antibiotics at a time when the nation faces a growing crisis of antibiotic resistance “does not make good public health sense,” according to the Infectious Diseases Society of America, which criticized the giveaways.
“Most doctors know better than to prescribe antibiotics when they are not needed,” said Anne Gershon, MD, president of the Infectious Diseases Society of America. “But many find it hard to say ‘no’ to sick patients who think antibiotics will make them feel better. We are concerned that these pharmacy marketing efforts will encourage patients to ask for antibiotics prescriptions.”
Antibiotic resistance is “one of the key microbial threats to health in the United States,” according to the Institute of Medicine, which has recommended curbing the inappropriate use of antibiotics — such as using them for illnesses they do not treat, like colds or the flu, or using them to enhance growth among livestock.
I may get in trouble for this post because I am going to say what I really feel. I have removed my frontal lobe for the next few minutes.
The IDSA is consistently critical of outpatient antibiotic use. In the hospital, confronted with a sick patient, infectious disease specialists often become very liberal in antibiotic use.
I believe the problem is a lack of respect for outpatient medicine. This list of antibiotics helps my patients actually take their antibiotics. Money does matter.
I am astonished that IDSA has made this an issue. I wonder if they also object to $4/month prescriptions.
Still shaking my head in disbelief.
db putting frontal lobe back into cranium – signing off
Posted in Medical Rants 7 Comments »
June 24, 2009
I appear to have a comments problem at this time. I will continue to try to fix it – but may be without comments for a few days.
Apologies – this started because of a major blog spam insertion – slowly fixing that also.
!!!!Update – I figured out the problem – the comments database was corrupted and I figured out how to repair it.
Trying a new spam filter – hope it works better.
Posted in Medical Rants 1 Comment »
June 23, 2009
Movin’ meat writes Work Hour Restrictions and challenges me to critique his analysis.
Dr Bob of Medrants has some thoughtful comments on the matter, mostly pleading for flexibility in the new rules. I would mostly agree, excepting that flexibility is best given to those who have proven themselves trustworthy, and residency directors (especially but not exclusively of surgical training programs) have repeatedly and flagrantly flouted the rules thus far imposed. Flexibility is fine, but accountability should also be demanded.
I would also take issue with Dr Bob’s comment that this "training system that has served our profession well for many years." I look at the statistics on physician burnout, substance abuse, divorce, depression and suicide. They are terribly concerning. I would not lay all of this at the feet of residency, but I would say that the abusive (I’m sorry, "rigorous") environment of residency training sets the tone for the culture of machismo that harms physicians as much as it harms patients. Nobody is well-served by the current system.
I love being challenged. Perhaps intellectual challenge is the greatest reward for blogging.
Let me define flexibility. I have worked with interns and residents who I know cheated on their work hours. The program and this attending reminded them of the work hour requirements. Yet they sometimes stay too late and violate the strict rules. They do comply with the intent of the rules.
Should you punish the program? Should you forcibly make them leave the hospital?
I love these things about the new rules:
- 80 hour work week
- average 1 day off each week
- efforts to avoid sleep deprivation
While I believe my training benefited from over night call, I can see a logic for avoiding this tradition. At the family practice program where I am regional campus dean, we are going to a strict night float system July 1. In this system, we are restricting residents to 14 hour shifts. We do have a challenge. We still owe the night shift physicians education and we owe the patients good care.
We will start with the night float residents working from 7:30 p.m. and leaving at 9:30 a.m. From 7:30 a.m. to 9:30 a.m. we will have "overlap" rounds. During those rounds the night float residents will present their new patients and their old patients. The other resident on the team will participate and know the plans – handling day time cross coverage. The family medicine program has designed a system in which the night float admitters keep patient care responsibility for those patients that they admit.
We hope it works well. We hope that we can provide adequate education and supervision. This new system does put new stress on the attending physicians and that does concern me a bit.
We are trying to limit handoffs. One problem with most work hour plans is that they do not balance handoffs as a risk factor for poor patient care.
Where we need flexibility is on the precise leaving time. I can imagine situations in which a resident wants to stay an extra half hour for good reason. Do we push them out the door?
I am also concerned that too many programs have not considered that one needs adequate patient exposure to expand knowledge and attain wisdom. I do not want to go back to the old days; I only want the new days to be designed to produce the best possible physicians.
Posted in Medical Rants No Comments »
June 22, 2009
I go to an unusual source for this post – The grinch who stole a homer
I hate this kind of crap. There’s nothing cheaper than using some tiny, unconnected technicality to rob somebody of her rightful moment of glory, won fair and square. It’s the cheapest thing in sports: an adult pencil-whipping some kid just because she can. And my e-mail box fills up with these kinds of stories all the time.
I lost the pine box derby because a den master said I didn’t fill out the form right.
They DQ’d our team because the coach found out I failed math class two years ago.
They said the goal didn’t count because my jersey was out.
Makes me want to chew a hole through my desk.
I always get frustrated when common sense should trump rules. The sports examples make the point dramatically. The same is true in medicine.
Posted in Medical Rants No Comments »
June 21, 2009
I saw this somewhere recently – apoligize that I cannot give direct attribution.
We have socialized payments with free market expenses.
I do believe that this is the big problem for developing the proper workforce.
Posted in Medical Rants 7 Comments »
June 21, 2009
So I thought about the problem overnight. The key here was the persistent respiratory acidosis. The patient clearly did not have COPD. I did mention his weight, and then I decided he must have obesity hypoventilation syndrome.
So we go into the room the next morning and he is now alert and his wife is in the room. I turn to her and ask if he snores – and then the floodgates open. He had a history of sleep apnea, and was supposed to be using CPAP, but his mask had broken.
When he came to the emergency department, he had altered mental status, and thus the history was incomplete. We initially blamed his hypoventilation on the hyperosmolar state. However, the hypoventilation persisted after his blood sugar came down to normal and he awoke to normal mental status.
My family medicine interns put it best. They related that this patient re-emphasized the importance of continuing to take history. History taking does not end during the intial evaluation. We should take cues and clues and revisit the history regularly.
To restate the presentation:
41 year old man with left hemipareis s/p right brain aneurysm surgery in the past. Now presents with increasing obtundation, increased urination and abdominal discomfort. Labs follow:
On 2l nasal oxygen:
| ABG |
| pH |
7.41 |
| pCO2 |
47 |
| pO2 |
95 |
| Electrolyte panel |
| Na |
128 |
Cl |
83 |
BUN |
8 |
| K |
4.2 |
HCO3 |
24 |
creat |
0.7 |
| Blood Sugar |
742 |
The patient is a large man (110 kg) who now admits to 4 weeks of increased urination and recent constant thirst with a marked increase in water intake.
Now for the hard part, figure out the acid-base problem. Next I will give you his labs 2 days later, then my interpretation.
At this point I see:
- anion gap of 21 – therefore anion gap acidosis
- pCO2 = 47 – hypoventilation thus respiratory acidosis
- Delta gap supports bicarbonate of 33 (add 9 to 24 – the 9 being the difference between the observed anion gap and the expected anion gap)
- Thus when first presented I assumed a mild ketoacidosis (or possible mild lactic acidosis), a respiratory acidosis and a metabolic alkalosis
- I wondered if his obtunded state was causing hypoventilation
- I assumed significant volume contraction (and probably total body potassium depletion) from his glucose induced osmotic diuresis
The next day we have these numbers:
| ABG |
| pH |
7.35 |
| pCO2 |
48 |
| pO2 |
68 |
| Electrolyte panel |
| Na |
139 |
Cl |
106 |
BUN |
5 |
| K |
4.4 |
HCO3 |
26 |
creat |
0.6 |
| Blood Sugar |
321 |
Posted in Acid-Base & Lytes No Comments »
June 20, 2009
Abraham Verghese is a skeptic – The Myth of Prevention The article reacts to the now famous Gawande article. He argues that prevention does not save money.
Yet, we know that high quality primary care does save money. I believe Verghese is making the classic mistake of defining prevention only as primary prevention. Those who study epidemiology and health services research understand that the real value occurs in secondary and tertiary prevention.
Time for some prevention definitions:
- Primary prevention avoids the development of a disease. Most population-based health promotion activities are primary preventive measures.
- Secondary prevention activities are aimed at early disease detection, thereby increasing opportunities for interventions to prevent progression of the disease and emergence of symptoms.
- Tertiary prevention reduces the negative impact of an already established disease by restoring function and reducing disease-related complications.
The value of good comprehensive care is in decreasing costs and improving value once you have disease. The major health care advances in my career come in tertiary prevention. Some examples should make this concept clear:
- ACE inhibitors for patients with CHF decrease hospitalizations, improve quality of life and improve mortality.
- So do appropriate beta blockers
- Statins decrease progression of coronary artery disease
- Antibiotics decrease recurrent spontaneous bacterial peritonitis
- Home oxygen improves COPD mortality and morbidity
- ACE inhibitors or ARBs slow progression of proteinuric CKD, as does aggressive blood pressure control
Most physicians can add to this list. The reason that I want universal coverage is to provide care to those with disease, not for those who are healthy. We provide value if we prescribe appropriate medications which patients can afford and willingly take. Those medications generally save health care dollars through decreasing hospitalizations and emergency department visits.
One final criticism of this provocative paper. The main value of EMR will result when a universal medical repository provides information on previous imaging studies, and allows us to avoid repitition. They also should decrease medication errors – a big financial and health care cost.
So I disagree with the premise of this paper. What do you think?
Posted in Medical Rants 11 Comments »
June 19, 2009
Taking Time for the Self on the Path to Becoming a Doctor
While in training, I always had 3 priorities for my off time. I played basketball most every off day – even post call. As an addicted basketball player during that time, I knew that i need the sweat.
I always read fiction. For some reason I did not feel guilty that I did not just read medicine.
I always listened to music. Music made me happy then, and makes me happy now.
And my major priority was my wife, and during residency my daughter.
For some reason, I always kept things in balance. For many years I have give students and residents this advice. During clinical training I believe hobbies are very important. Many benefit from exercise, others benefit from singing, or playing an instrument. The key point is that you cannot let medicine be your entire life. Medicine should be an important part of your life, but too much medicine does lead to burnout.
According to a study from the Johns Hopkins University School of Medicine in Baltimore, I am far from the only doctor who has behaved this way. The researchers interviewed residents, or doctors in training, from seven different specialties and found that they set themselves up for burnout by accepting, even embracing, what they believed would be a temporary imbalance between the personal and professional aspects of their lives. While the young doctors interviewed defined well-being as a balance between all those parts, many felt that their medical training was so central to their ultimate sense of fulfillment that they were willing to live with whatever personal sacrifice was required, even if it meant a temporary loss of a sense of self.
This study should be remembered throughout our professional lives. I still try to maintain good balance. Tomorrow morning I will play golf. Tonight before bed I will read my current novel for 10-15 minutes.
I worked hard on a paper today. I’ve learned to work very hard when I work, but to try not to overwork. Hobbies help you stay balanced. Time to read a bedtime story to my grandson.
Posted in Medical Rants 2 Comments »
June 19, 2009
If you click on a post now, you will get 2 added features – 5 related posts and buttons for sending my post to twitter or facebook or several other places.
Posted in Medical Rants No Comments »
June 19, 2009
Hats off to Pauline Chen whose tweet alerted me to this article. Health Care Rationing Rhetoric Overlooks Reality
Here are the key thoughts:
“Just because there isn’t some government agency specifically telling you which treatments you can have based on cost-effectiveness,” as Dr. Mark McClellan, head of Medicare in the Bush administration, says, “that doesn’t mean you aren’t getting some treatments.”
Milton Friedman’s beloved line is a good way to frame the issue: There is no such thing as a free lunch. The choice isn’t between rationing and not rationing. It’s between rationing well and rationing badly. Given that the United States devotes far more of its economy to health care than other rich countries, and gets worse results by many measures, it’s hard to argue that we are now rationing very rationally.
On Wednesday, a bipartisan panel led by four former Senate majority leaders — Howard Baker, Tom Daschle, Bob Dole and George Mitchell — will release a solid proposal for health care reform. Among other things, it would call on the federal government to do more research on which treatments actually work. An “independent health care council” would also be established, charged with helping the government avoid unnecessary health costs. The Obama administration supports a similar approach.
As DrRich tells us repeatedly, we currently use covert rationing. Covert rationing is usually irrational from a patient perspective. We should become transparent to proceed with honest rationing. Perhaps we will start paying for value rather than glitz.
Posted in Medical Rants No Comments »
June 19, 2009
To restate:
41 year old man with left hemipareis s/p right brain aneurysm surgery in the past. Now presents with increasing obtundation, increased urination and abdominal discomfort. Labs follow:
On 2l nasal oxygen:
| ABG |
| pH |
7.41 |
| pCO2 |
47 |
| pO2 |
95 |
| Electrolyte panel |
| Na |
128 |
Cl |
83 |
BUN |
8 |
| K |
4.2 |
HCO3 |
24 |
creat |
0.7 |
| Blood Sugar |
742 |
The patient is a large man (110 kg) who now admits to 4 weeks of increased urination and recent constant thirst with a marked increase in water intake.
Now for the hard part, figure out the acid-base problem. Next I will give you his labs 2 days later, then my interpretation.
At this point I see:
- anion gap of 21 – therefore anion gap acidosis
- pCO2 = 47 – hypoventilation thus respiratory acidosis
- Delta gap supports bicarbonate of 33 (add 9 to 24 – the 9 being the difference between the observed anion gap and the expected anion gap)
- Thus when first presented I assumed a mild ketoacidosis (or possible mild lactic acidosis), a respiratory acidosis and a metabolic alkalosis
- I wondered if his obtunded state was causing hypoventilation
- I assumed significant volume contraction (and probably total body potassium depletion) from his glucose induced osmotic diuresis
The next day we have these numbers:
| ABG |
| pH |
7.35 |
| pCO2 |
48 |
| pO2 |
68 |
| Electrolyte panel |
| Na |
139 |
Cl |
106 |
BUN |
5 |
| K |
4.4 |
HCO3 |
26 |
creat |
0.6 |
| Blood Sugar |
321 |
After some thought the solution became more clear. I believe that I can explain what happened now. Your turn to try.
Posted in Acid-Base & Lytes, Medical Rants 3 Comments »
June 18, 2009
41 year old man with left hemipareis s/p right brain aneurysm surgery in the past. Now presents with increasing obtundation, increased urination and abdominal discomfort. Labs follow:
On 2l nasal oxygen:
| ABG |
| pH |
7.41 |
| pCO2 |
47 |
| pO2 |
95 |
| Electrolyte panel |
| Na |
128 |
Cl |
83 |
BUN |
8 |
| K |
4.2 |
HCO3 |
24 |
creat |
0.7 |
| Blood Sugar |
742 |
Now for the hard part, figure out the acid-base problem. Next I will give you his labs 2 days later, then my interpretation.
Posted in Acid-Base & Lytes 4 Comments »
June 18, 2009
Solo Dr writes:
In my area, quality doctors, according to hospital administrtors and other doctors, are the ones who make lots of money by seeing 40+ patients a day and doing lots of procedures to make the hospitals wealthy. I personally don’t see the conveyer belt medicine helping patients in the long term. I also find that my capitated colleagus are good at talking healthy patients out of screening colonosocpy after age 70 and are good at pushing the sickest patients onto other doctors to keep their efficiency and quality ratings high.
Quality should not be measured in time but on outcomes. Providing rapid short visits has a risk of the doctor missing things. Only the large items will be addressed at each visit, max 1-3 things per visit and times is up.
Outcomes are the holy grail, but like the holy grail elusive. Here is the problem. If you want to measure my quality you must measure outcomes for all my patients. And you must measure outcome rather than process indicators. We have too many examples of logical process indicators failing or leading to harm.
How do you measure outcomes when our goals differ so greatly with each patient? Some patients present a diagnostic problem. Some require chronic management of one problem. Some require juggling 6 problems. Some patients come for a routine check up. What parameters should we measure?
We should not provide quality measures using only a minority of patients. We definitely should not provide quality measures which encourage us to select patients (cherry pick.)
Having done "outcomes" research, I believe that such research can provide interesting information for improving practice, but not for judging or ranking physicians.
My point from the previous post is that our current payment system detracts from quality. The mere existence of our coding discourages spending appropriate time with patients.
Posted in Medical Rants 2 Comments »
June 17, 2009
If physicians answer this question – please clarify that you are a physician.
When you consider physician quality, what attributes do you consider?
I would love several attributes from each reader. I am considering writing an article on quality, and am asking for help in framing my comments.
Thanks in advance,
db
Posted in Medical Rants 9 Comments »
June 17, 2009
Full disclosure – I am on the faculty of the Academic Hospitalist Academy. This is a wonderful course for new academic hospitalists.
Posted in Medical Rants No Comments »
June 16, 2009
Remember this:
People are stupid; given proper motivation, almost anyone will believe almost anything. Because people are stupid, they will believe a lie because they want to believe it’s true, or because they are afraid it might be true. People’s heads are full of knowledge, facts, and beliefs, and most of it is false, yet they think it all true. People are stupid; they can only rarely tell the difference between a lie and the truth, and yet they are confident they can, and so are all the easier to fool.
—Chapter 36, p.397, U.S. hardcover edition of Wizard’s First Rule
You can imagine how this pertains to medicine and health care.
Posted in Medical Rants 3 Comments »
June 16, 2009
According to a 2006 study, patients want their doctors to be “confident, empathetic, humane, personal, forthright, respectful and thorough.” But in the age of conveyor-belt medicine, and the standard 15-minute office visit, it’s becoming apparent that today’s physician will have trouble fitting that mold.
From Kevin MD What do patients want from their doctors?
I am astonished. Patients did not talk about performance measures! Kevin talks about "tricks" for short visits.
Why do we insist on short visits? Our payment system discourages physicians from these desirable characteristics – because time is money.
This story should give the quality chiefs food for thought.
Posted in Medical Rants 3 Comments »
