db's Medical Rants

Our favorite Dinosaur starts her rant by praising me and then (using a wonderful debating technique) totally disagrees with me – Palliative Care: An Unnecessary Specialty

True palliative care — the management of symptoms — is part and parcel of everyday medicine. Itching; nausea; constipation; pain. Work them up to make sure there is no serious underlying problem, of course, but for crying out loud, don't tell me you now need another specialist to actually come TREAT them! This is fragmentation of care taken to outrageous extremes.

As for talking to patients and families about difficult decisions when curative treatment is no longer an option, that too is part and parcel of my job. I do it every day in my office, and the only reason I don't come to the hospital to do it is because I can't get paid for it, and I can't afford to work for free.

So I must disagree partly with the Dinosaur.  While I agree that excellent primary care physicians and hospitalists can and should provide the same care that palliative care physicians provide, I still find palliative care very valuable.

What makes our palliative care physicians special?

First, they can take the necessary time to talk to the patient.  I am talking about at least an hour for an initial evaluation.  Our hospitals help support them to perform this function.

Second, they have ongoing relationships with all the relevant agencies, giving them the ability to pull things together much more seamlessly than I can.  They have the team, and the team has great value.

Third, we have an inpatient service that caters to palliative care patients.  The palliative care docs have worked with the nursing staff to encourage them to be comfortable with all the details of palliation.

Finally, they provide the home services that I could provide, but that I find difficult to provide.

Is this a specialty?  I consider that a moot question.  I would rather focus on the value that our palliative care physicians provide to our patients. 

Primary care physicians can do this, but probably not quite as well due to the time commitment involved.  I have done much palliative care during my career, but sometimes having that specialist involved does make a difference.

Residency Match Results Not Encouraging for Adults Needing Primary Care

This is old news.  Students love our rotations much more than they choose internal medicine. 

According to the 2010 National Resident Matching Program report, 2,722 U.S. seniors at medical schools enrolled in an internal medicine residency program, a 3.4 percent increase from 2,632 in 2009. The internal medicine enrollment numbers are similar to 2008 (2,660), 2007 (2,680), and 2006 (2,668). In comparison, 3,884 U.S. medical school graduates chose internal medicine residency programs in 1985.

So we should be honest and evaluate the problem.  Is internal medicine a poor career choice?  Is the material uninteresting?  Why do our graduates not choose internal medicine?

Dr. Weinberger sees the world clearly:

“Because it takes a minimum of three years of residency after four years of medical school to train an internist, it is critical to begin making careers in internal medicine attractive to young physicians,” said Dr. Weinberger. “As America's aging population increases and more people gain access to affordable coverage, the demand for general internists and other primary care doctors will drastically outpace the primary care physician supply.”

Increasing Medicaid and Medicare payments to primary care physicians, expanding pilot testing and implementation of patient-centered medical homes, and increasing support for primary care training programs are ways to increase the number of primary care physicians, according to ACP.

ACP remains concerned about the rising cost of medical education and the resulting financial burden on physicians who choose careers in internal medicine, Dr. Weinberger noted.

As I write repeatedly, we are getting the workforce that our payment system encourages.  We know that excellent internists decrease costs and increase quality, but they are shown no respect from private insurers and CMS. Those payers reward procedures out of proportion to pure cognition and patient relationship.  Those who do procedures certainly use cognition in addition to their procedures, but it appears to this observer that the payment for the procedure greatly outweighs the payment for excellent outpatient or inpatient care.

We can have the desired workforce if we made drastic and necessary changes.  If is a huge word, and therefore I remain skeptical.

This post is by request from a comment.

I have a very short set piece concerning the indications for parathyroidectomy.  There are 2 indications in Primary Hyperthyroidism – symptoms related to the hypercalcemia – "stones, groans, moans and broken bones" or significantly decreased bone density.

I leave secondary hyperparathyroidism decisions to the nephrologists – perhaps a nephrology reader can send me a paragraph to add to this post.

Many articles in the NEJM seem arcane and eclectic to this blogger.  However, the best articles in this esteemed journal are really great.  So it is today with the early release of this article – "Lenient" as good as "strict" ventricular rate control in permanent AF: RACE-2 trial 

When pursuing a rate-control strategy in patients with "permanent" atrial fibrillation (AF), it's just as clinically effective and a good deal easier, for patient and doctor alike, to treat with beta blockers, calcium-channel blockers, and other agents until the resting heart rate is <110 bpm as to aim for <80 bpm, a prospective study suggests [1].

In the randomized Rate Control Efficacy in Permanent Atrial Fibrillation (RACE 2) trial, more patients were able to achieve the higher "lenient" heart-rate target than the lower "strict" target, and they required far fewer doctor visits. Yet symptoms attributable to AF and drug side effects were about as prevalent in one group as the other, and the lenient strategy was "noninferior" (p<0.001) to the strict approach for a composite primary end point that included CV death, heart-failure hospitalization, stroke, and other major events.

Actually there were more end points in the strict control group.

We live in an era in which we forget that medications carry impacts.  We focus too much on targets, too often ignoring the cost of reaching those targets.  A few examples should resonate with physician readers: tight glucose control in ICU patients; anemia in CKD; and now rate control in atrial fibrillation.

Too often we worry about numbers rather than patients.  This study should both guide our rate control targets in atrial fibrillation and remind us that treatments are rarely benign.  I welcome this study and its findings.  I will immediately adopt the findings. 

Today I hope to make you think.  Today I will rant against rampant subspecialization.  Today I will make some readers mad.

Pauline Chen has a wonderful article in the NY Times – Learning to Keep Patients Safe in a Culture of Fear.

In this article she writes about the problems we have in improving patient safety in hospitals. 

But a recent study indicates that current doctors-in-training may still be hesitant to document errors. Last month, The Joint Commission Journal on Quality and Patient Safety reported that the majority of residents have never written up an incident report. And according to a paper issued this week from a committee of leading experts in medical education and health care working with the Lucian Leape Institute of the National Patient Safety Foundation, young doctors are still going out into practice with little education or training in patient safety.

Changing a health care culture that undermines some of the most important principles of error reduction — trust, teamwork and communication — has proved to be much more difficult than a safety checklist would lead one to assume.

“Young doctors are being educated in a toxic culture,” said Dr. Lucian L. Leape, a leading patient safety expert at the Harvard School of Public Health who was chairman of the report’s committee. “The current environment is hierarchical, stressful for the individual, driven by the fee-for-service payment system and humiliating, all of which works against improving patient safety.” To ensure safer health care, doctors-in-training need time to reflect on their actions, a sense of community with colleagues and other health care workers, and the support to engage freely in disclosing errors.

Earlier this week the NEJM published a report on coronary angiography – Diagnostic Angiography Catches Few Cases of Obstructive CAD.

Now you are probably scratching your head now (if you are still reading this rant) and wondering how these 2 articles fit into one rant.  Here is my hypothesis:

I believe that our rampant subspecialization has led to physicians focusing too much on disease and not enough on patients.  As Osler reportedly said, "The good physician treats the disease; the great physician treats the patient who has the disease"

What has happened to medicine in the last 40 years?  We have had an explosion of knowledge acquisition, primarily funded through NIH.  NIH research focuses primarily on diseases and the biology of diseases.  We have had the development of huge subspecialty divisions in internal medicine (and pediatrics, and ob-gyn, and surgery, …).  These divisions have members who quickly focus on the diseases of that subspecialty and forsake their generalist training. 

The power structure in academics exists either through NIH funding or bringing in "business" due to one's expertise in a specific disease.  We have "product lines" in cancer, cardiology, liver disease, etc. 

The focus on disease unfortunately can take the focus away from the patient and the process of care.  The angiography example recalls the not funny joke that most non-cardiologists tell.  What is the indication for coronary angiography?  A groin (the catheterization starts in the femoral artery which is in the groin).

Those who focus on patient safety are considering the entire process of care, regardless of disease.  They rarely receive grant moneys.  They rarely get major publications.  They merely work hard to prevent tragedies by understanding either tragedies or near misses.

I submit that our focus on disease (btw this is just as bad in community hospitals as in academic medical centers) leads to the culture that does not focus on the entirety of patient care.

I recently heard a story about a patient on multiple medications with multiple physicians who had altered medical status.  One of the consultants insisted that his medications not be changed because he finally had the patient's disease under control.

Our job should focus on the patient and not the disease(s).  If we focused on patients then we would all embrace safety.  And we should.

If you reread my post, I was talking clearly about patients in the hospital with a clear cause of pain.  For example, a patient with pancreatitis from gallstones or a patient with a hip fracture or a patient with painful osteomyelitis.  I was making a point about inpatient pain control.

I appreciate the difficulties related to pain control in outpatients.  I did not mean to have my comments have any impact on any situations other than the specific one that I outline.

Primary care doctors need financial independence

Nice article but it does miss one important point.  I believe the way we pay for primary care causes the problems.  Paying for a visit with a fixed price has so many unintended consequences that I do not believe the model can work.  Our payment system encourages shorter visits.  Our insurance companies place hurdles on spending.  Those hurdles have a huge negative impact on the daily life of primary care physicians.

If we do not look at how we pay for primary care and develop a more logical system, we will continue to have flight from primary care.  With apologies to many well meaning colleagues, the problem has nothing to do with training.  The problem is the job and how we pay for the job.

Money is the answer, but just as important as how much we pay we must consider how we pay.

Had a great conversation with an outstanding intern yesterday.  He is bright, thoughtful and has a great bedside manner.  He also is self aware and understands that he still has much to learn about being a great physician.  He will get there because he cares, he reads and he learns from his attendings everyday.  He is in a program that will expose him to enough patients that he can develop expertise.

I am personally tired of the competence movement.  We have only one necessary competency – becoming great physicians.  We spend too much time worrying about systems based practice, which can distract from learning how to make diagnoses and decide treatments.

Becoming an expert physician can not occur from a textbook.  It can only happen when one follows learning with experience.  Many physicians fear that we have forgotten that truism.

Yesterday, we had a CPS for Grand Rounds.  I had a colleague from Birmingham come to Huntsville and present me 3 unknown cases.  For 1 hour I opened my thought processes – warts and all – making a few mistakes and having some successes. 

In Birmingham we have done this monthly for several years.  Our students and residents love the conference and tell us it is the best learning experience.  Yesterday after the conference I heard incredibly positive feedback and several requests to do more of that style of Grand Rounds.

As a leaner, but also as a colleague I find these exercises extremely useful.  The audience plays along, sometimes getting ahead of the discussant.  But I believe the unmasking of the thought process has the greatest benefit for all.

Often medicine requires a cerebral approach.  We too often teach facts without making explicit how to incorporate those facts into decision making.  Medical decision making is dynamic not static, yet traditional teaching focuses on the static information.

NEJM regularly publishes CPS cases.  The Journal of General Internal Medicine has just added a similar exercise.  I believe that these exercises allow us to teach wisdom in addition to knowledge.  As physicians we continuously strive to improve our wisdom for wisdom requires us to use knowledge.

”“Wisdom is not a product of schooling but of the lifelong attempt to acquire it” – Albert Einstein

I missed this back in December – The rediscovery of pharyngitis in adolescents and Arcanobacterium hemolyticum

Yesterday I was seeing a new admission in the ER and ran into a colleague admitting a sore throat patient.  You can imagine that I rarely miss the opportunity to examine and take a history from sore throat patients.  Yesterday's patient has a small tonsillar abscess.

Medpedshosp talks about my Annals article and adds a nice description of Arcanebacterium pharyngitis.  He writes well, and the article is well worth reading.

There is a new trend in pharyngitis that has taken hold amongst emergency physicians – the use of steroids to provide symptom relief.  Two recent articles address this issue:

• Corticosteroids for pain relief in sore throat: systematic review and meta-analysis
• Steroids as Adjuvant Therapy for Acute Pharyngitis in Ambulatory Patients: A Systematic Review

I was asked to write a comment on the second article – scroll to the end of the article to find the link.  These articles do not include enough patients to really know about complications due to steroids masking worsening symptoms.  Maybe I am a curmudgeon, but I worry about potential downsides for minor upside with steroids.

Wordpress has a wonderful "add on" program that would allow us to create a forum.  On the one hand running a forum would be interesting, but would readers want a forum.

If you think it is a good idea, please let me know and particularly what topics we would put into the forum.

Thanks

A colleague just sent me this information – The Sore Throat Symptom and Complication Study: DESCARTE

We hope that analysing the data will show differences in the signs and symptoms of those patients developing a complication or worsening symptoms versus those who recovered quickly. If we find a difference we can create a ‘Decision Rule’ which, after being prospectively tested, GPs and nurses could use in the future to identify patients likely to get complications or extended symptoms. This could help with targeting antibiotics to those most likely to benefit and help reduce antibiotic prescribing for sore throats.

Bravo – the study is apparently complete.  I look forward to reading the results.

Evidence That Little Touches Do Mean So Much

Regular readers know that I have a great interest in bedside manner.  I have written often about how one role models bedside manner, and thus how one helps learners improve their bedside manner.  One habit I have (that of course I believe is a good one) is to use appropriate touch.

For several years, I have felt strongly that holding a patient's hand or feeling their pulse, while discussing their medical situation, provides reassurance and makes a clear statement of empathy.  I generally shake hands with patients when entering their room.  I often check pulses, or examine their neck for accessory muscle use.  These touches convey something important to the patient.

A sympathetic touch from a doctor leaves people with the impression that the visit lasted twice as long, compared with estimates from people who were untouched.

What do other physicians think?  What do patients think?

$295,000 In Medical School Debt

I am currently a third year medical student and already $226,000 in debt because I'm out-of-state and have no other means of funding my education except through loans. I'll graduate with at least $295,000 in debt, an amount that will only increase as interest accumulates during residency training and over my 20 year repayment period.

The thought of starting life with such a huge debt is very frightening, especially since I plan on going into primary care and not a lucrative medical specialty or subspecialty. Primary care physicians are grossly underpaid compared to many specialists, yet they work longer hours and have to deal with the administrative burden associated with insurance companies. As a result, the number of medical students choosing to pursue primary care as a career is declining each year. More and more, students are taking debt load and lifestyle into account when making career choices.

My goal is to help increase the public's awareness of medical student debt and its impact on health care. The American Medical Student Association (AMSA) has implemented legislative proposals for creative solutions to medical student indebtedness and the growing shortage of primary care physicians.

Why do medical schools charge students so much money?  Frankly, they do it because they can.  We have enough students who want to become physicians that we can increase tuition rates yearly.

It was not this way when I went to medical school.  I paid an average of $1000 per year in the early 1970s.  Using an inflation calculator, that would become around $5000 per year in current dollars.  Yet that same school and most state schools charge 3 times that much.

What has changed?  I believe that medical schools and universities have become an industry.  I understand medical schools better than universities, but it is clear that you can understand the implicit mission if you follow the moneys. 

Student debt has an insidious influence on our physician workforce.  Students clearly will often choose a specialty that has double the income, even when they do not have a strong attraction to that specialty.  Money does matter, and it contributes implicitly to student decision making.

The AAMC should address this.  I applaud AMSA for making this issue one of high priority.

"Bending the Curve": What Really Drives Health Care Spending

A major source of these spending increases is a third-party payment system that often leaves the physician and patient insulated from and even unaware of the costs of the various treatment options. Often, the patient faces the same co-payment regardless of which treatment is chosen, and the extra costs are passed along to the insurance company, Medicare, or Medicaid. These payers may appear to have an incentive to encourage efficient use of resources, but ultimately they do not pay the price for inefficiency. Insurance companies offer "generous" benefits and pass on the increased spending to patients (and often their co-workers) through increased insurance premiums, and government programs pass on the spending increases to taxpayers.

To a large extent, increased health care spending is a consequence of this third-party payment system. In recent decades, the percentage of health care spending paid "out of pocket" by patients has fallen substantially, from 52 percent in 1965 to only 15 percent in 2005, which means that third-party payments have increased from 48 percent to 85 percent. As third-party payer spending has risen as a percentage, total spending has grown even faster. Since 1965, real per capita health care expenditures have increased approximately sixfold.[47]

In short, neither the patient, the doctor, the insurance company, nor any government program has much incentive to spend health care dollars efficiently. A system that determines prices through administrative procedures rather than market processes disconnects the prices paid for health care services and products from both the costs incurred to provide them and their value to patients. A tax code that rewards employees who purchase insurance through their jobs and punishes individuals who purchase health insurance in the outside market further distorts these incentives. A litigious tort system that encourages doctors to order unnecessary tests and procedures at no cost to themselves in order to forestall lawsuits exacerbates the problem. However, the main problem is a system that insulates both patients and producers from normal market incentives to reduce prices and spending.

While I might agree with the entire analysis presented in this long and erudite analysis of health care costs, the authors echo a common belief in the medical blogosphere.  The current payment system encourages increased spending.  We are getting exactly what our system design would predict.

I wish we could have nationally available health insurance plans without state mandates.  We could have competition through a system of transparent definitions.  Workers could decide the level of health care they want to buy.

I understand all the arguments against this approach.  I suspect some of my friends will bring out the health care is a right argument.  I will argue that food and shelter are rights, but everyone does not eat the same food or live in the same space.

There are challenges in developing a system that encourages workers to make rational decisions about their insurance.  I believe that we could do this, but the Democrats will never pass a bill to allow this.

Please read as much of this article as you can.  It is thoughtful, referenced and thought provoking.

My friend and twentor, Vinny Arora, has this insightful blog post today – Resident Duty Hours: Take for a Wake-up Call

Of course, no one wants a tired doctor. But, the more relevant question is whether you prefer a tired doctor that knows you or a well rested doctor that doesn’t know you? Acknowledging the tradeoff makes it harder to answer. My answer – it depends. For a simple procedure, I would choose the well-rested resident (the one that’s most experienced in fact). But, for a more complex decision where familiarity with the patient matters, I prefer the resident who may be tired, but knows me better. Of course residents can’t work 24/7 (like they did when they were truly lived in the hospital hence ‘resident’) so handoffs will occur and limits on hours are needed. But, to arrive at the best solution, we must present this debate in a more informed way for the public.

Vinny avoids answering the questions she poses, but she very nicely paints a complete picture of the problems.  This year we have changed our family medicine residency call to a maximum of 14 hours (to allow for 10 hours off each day).  The new system has overlaps scheduled for careful handoffs.

Here is the problem, not everyone can sleep during their time off.  This system seems to particularly disadvantage women residents with small children.  They work all night (in our system for either 3 or 4 nights consecutively) but do not get enough sleep during the days.  Some residents clearly prefer the 30 hour shift and several day recovery.

This question has no correct answer.  The sleep proponents have the classic sub-specialty prism – everything is about the sleep.  But patient care does not just involve sleepiness.  Many residents working days will come to the hospital sleepy the next day because they do have a social life (as Vinny discusses clearly).

I believe the IOM report is not balanced.  The sleep researchers have overinfluenced the conclusions.  But read the article from FutureDocs to really understand.

A comment yesterday pooh-poohed the combined Happy Medrants checklist discussion.  This physician does understand that students and interns learn all these things.  But as a medical student points out – that is not the point of a checklist.

The point of checklists comes when we have a complex day and many detractors to our thinking.  We know everything on a checklists, but a checklist makes us consider each detail each day or each time we do that procedure.

I know how to care for diabetes, but do I remember every detail every time?

Reading The Checklist Manifesto made me think.  When an activity is repetitive, I believe using a checklist will decrease errors.

Happy wrote in a comment:

Why not a daily checklist for medical patients. It works in the ICU. It works in the OR. It should work on my medical patients.

I envision a mostly IT data gathering process with some RN driven process. I wish to make it voluntary. But as a physician, I should WANT a daily checklist reminder of what I may be forgetting for my patients. I know of know initiative within SHM along this path. I’m starting from scratch at my hospital.
Now the question is what should I include on my cost and quality saving mission. I have some empiric ideas on what I believe can save money and reduce complications. I have not researched it. It is just based on experience.

Urinary cathers: Present or absent
Telemetry: present or absent
Central line: How long has it been there
patient status: General care or progressive
IVFs: If present, what are they
Weights: Admit weight and what’s the current weight
IV medications: can they be converted to po?
VTE prophylaxis: present or absent

Happy has made a great start.  If you read Gawande's book, the challenge of checklists is making them usable.  I visualize 3 steps – develop an extensive list, edit the list, test the list.  Here are some of my thoughts.  We can all help here through comments.

First let me comment on the list.  I would add to the first three elements on the list – are they still necessary if present?  We sometimes forget to remove urinary catheters because they make hospital care easier.

I would omit patient status from a checklist.  Since we are revisiting IV fluids, we should review them in the context of the basic metabolic panel.  Generally patients receiving IV fluids need basic metabolic panels daily. 

I love the idea of weights, and find them very difficult to obtain. 

IV medications and whether the patient is ready to convert to oral raises an important associated problem.  We should generally have a "game plan" for the patient.  Discharge planning should begin on day 1.  My mental checklist always includes an explicit understanding of why the patient was admitted, what needs to be done, and what the eventual discharge plans will be.  Another comment suggested PT/OT and I agree.  Trying to develop the proper checklist for this concept is challenging.  I often ask my residents and students, "Where are we going".  I would rather get social work and case managers involved a day too early than a day too late.

VTE prophylaxis is part of our checklist at admission.

Addendum:

We need an antibiotic checklist:

1. How many days out of how many total days?
2. Any evidence that we can move to more narrow coverage?
3. Any reason to consider broadening antibiotics?
4. If on IV antibiotics, will the patient need IV antibiotics at discharge?

I will think about this checklist carefully during my rounds this week.  I may post more on this topic later this week.  Hopefully Happy will have more thoughts in response to my screed.

Twitter often leads to thinking.  Thinking is good.  Therefore, twitter is good.

I read this tweet: "Talked with a doc, chief of emergency, today who has great data about how standardizing practices improves patient care"

Now this tweet comes from the LeanBlog.  The author is a big fan of Gawande and Provonost, but I believe not a physician.

Here is our challenge – what can we standardize and when do we reject the standard.  Gawande discusses this problem eloquently in his book.  Checklists can help greatly with health care and airplane flying, but sometimes the checklist does not apply.

Standardization has the same problem.  We can standardize the management of a COPD exacerbation, but only once we know that we treating standard COPD management.  The danger of standardization is when we treat COPD perfectly but the patient has pulmonary thromboembolism.

Standardization probably has the most value when doing procedures as in Provonost's work.

We should embrace standardization with the proviso that we first have a firm diagnosis or situation that fits the context of the standardization.

Readers know that I have spent my career teaching students and residents.  As one observes two interesting worldviews occur simultaneously.

Many students and residents develop some cynicism concerning a subset of our population.  These patients participate in self-destructive behavior that negatively impacts the rest of society.  We recognize those who seek narcotics, those who use illicit drugs excessively, those who drink excessively, those continue to smoke despite cigarette related disease, those who eat to excess and those who abuse others.  We provide care for those people, but most of us will admit to anger about their illnesses.  We do become cynical over time.

But at the same time we care for the unfortunate.  Some have serious mental disorders; some were dealt a bad hand; some are just unlucky.  We have great capacity for empathy.  We worry about our patients and rail against a health care system that does not allow these unfortunates to receive adequate care.

As a clinician we develop an interesting combination of cynicism and empathy.  Mostly we care.  We really do get angry when patients take advantage of us (or try to take advantage of us).  We will do almost anything to help the unfortunate.

We see the world a bit differently because we interact daily with the people whom our socioeconomic peers rarely meet and interact.

Talk to any 3rd year student this time of the year.  They see people differently than they did.  The challenge is that it is really difficult to share our feelings with our friends and family who are not involved in health care.  We see the world through a different lens and that is good and bad.

Some readers have (in my opinion) misinterpreted the CMS adjustment to overhead calculations.  This really is what happened:

1. The RVU calculations include a overhead cost
2. Overhead costs had not changed in many years
3. The AMA commissioned an independent study to provide more accurate overhead costs for the formula
4. Imaging studies (having a major impact on cardiology and radiology) had overhead overestimated.  As I understand the problem, CMS had originally estimated that an imaging machine would be used 50% of the time.  When measured the machines actually had over 90% usage.  Since depreciation of the machines is part of the overhead calculation, in fact the overhead was markedly overestimated for many years.
5. Therefore the decrease in cardiology and radiology payments is an adjustment.
6. The total amount that CMS pays our has not changed.
7. Because of that adjustment, and a recalculation of primary care office costs (they were markedly underestimated), primary care is getting a bit more (as one commenter points out with dollars)

This is not a conspiracy to decrease physician payments.  This is a cold calculation.  The commissioned study led to winners and losers.

Primary care has been unfairly penalized for many years.  The increasing overhead in primary care had no adjustment for many years.  Now we do have an adjustment that helps primary care a bit.

If you graph the primary care/specialty income gap since RBRVS started, the gap has grown every year.  The gap makes clear one of the reasons that few students and residents choose primary care.

As I say often, our payment system has major problems.  Cardiology and radiology still will more than double primary care in income.  CMS has used AMA data to make an adjustment.  There is no conspiracy here.  The adjustment has actuarial soundness.

Dr. Wes has become a bit too hyperbolic for me.  Cardiologist cuts taking their toll

More than 10 employees for this group have lost their jobs. More layoffs loom. More than half of cardiology patients are on Medicare, but some specialists may stop accepting new Medicare patients.

“At some point, doctors are going to tell their Medicare patients ‘you know, I really can’t afford to keep taking care of you,’” Rabinowitz predicted.

His practice is handing out a letter about its concerns to patients, using them to contact their Washington representatives, calling for action to sop what they consider devastating cuts.

At the risk of being obnoxious, please recall that cardiologists are receiving lower pay for imaging procedures not for office visits.  Look at the ever growing discrepancy between cardiology pay and family medicine or internal medicine pay.  Cardiologists still make multiples of our salaries.

Methinks the lady doth protest too much.

This line of reasoning seems disingenuous at best.  I do not see a flight from cardiology amongst residency graduates – it is still very popular.

Physicians do deserve solid incomes.  Do we deserve extraordinary incomes?

Of course I would like to abandon fee for service, as I do believe FFS influences physicians in negative ways.

Timeout, I need to blow my nose and wipe the tears from my eyes.

This report should not surprise any practicing physician.  Only those who study data and have left the bedside could imagine the concept of never events (other than a few obvious ones that the article acknowledges).

'Never Events' Not Always Preventable

Analysis of some 890,000 surgeries performed in 1,368 hospitals showed that patient age and pre-existing conditions such as weight loss and chronic renal failure greatly increased the risk of "never event" complications including surgical site infections and decubitus ulcers, reported Donald E. Fry, MD, of the consulting firm Michael Pine and Associates in Chicago, and colleagues.

Rates of such complications also varied dramatically by the type of procedure, the researchers indicated in their report, published in the February issue of Archives of Surgery.

Colon resection appeared particularly vulnerable to "preventable" complications. It was associated with C. difficile enterocolitis, methicillin-resistant Staphylococcus aureus infections, surgical site infections, and decubitus ulcers with odds ratios of 2.4 to 21.3 relative to the least risky procedures, the researchers found.

Other procedures were associated with relatively high rates of certain complications as well.

Fry and colleagues argued that the findings demonstrate the unfairness of Medicare's policy, increasingly followed by private insurers as well, to deny all reimbursement for costs associated with treating "never events."

"Calling these complications never events and refusing to pay for their treatment may advantage high-quality caregivers, but it also will penalize providers that care for the most vulnerable patients or that perform procedures with higher-than-average risk," the researchers wrote.

Those who wonder why practicing physicians so often feel outrage when Medicare and insurance companies make rules should read this piece.  We understand that "The best laid schemes o' mice an' men Gang aft agley".  We who care for patients must do everything to maximize safety and provide high quality care.  But we do not operate on machines.  Our patients have great complexity and that complexity can lead to complications.  We should do our best to minimize complications, but only a bureaucrat could image a lack of complications.  The editorial to this article states it well:

In an invited critique accompanying the report, Jana B.A. MacLeod, MD, of Emory University in Atlanta, agreed that risk adjustment is a better approach than the one taken by the Medicare system.

"This study provides an evidence base to discuss whether unconditional preventability of complications, even in the environment of evidence-based treatment guidelines, actually exists," MacLeod wrote.

"In our attempt to eliminate the avoidable, we cannot allow the public and private health care funding groups to punish us for the inescapable."