db's Medical Rants

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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

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, [...]

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 [...]

$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 [...]

"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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

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 [...]

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

The RVU calculations include a overhead cost
Overhead costs had not changed in many years
The AMA commissioned an independent study to provide more accurate overhead costs for the formula
Imaging studies (having a major impact on cardiology and radiology) had [...]

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 [...]

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 [...]

You probably can see that I changed the blogs look.  I change the look of the blog often.  I am looking for the perfect theme, but have not yet found it.  However, I like this theme today, it is clean and I believe easy to read.
I started a second blogroll today.  These are newer blogs.  [...]

Health care costs continue to spiral.  We have too much unnecessary testing and care.  The Wall Street Journal had a wonderful article yesterday that dissected the impact of the COURAGE trial.  For those who do not remember:

The study, known as "Courage" and published in the New England Journal of Medicine in 2007, shook the world [...]

First, the important stuff – I am a decent golfer, Bob is a very good golfer.  He beat me convincingly.
I gave my pharyngitis talk yesterday morning at UCSF.  After that I spent 90 minutes discussing careers with primary care residents.  We had a delightful discussion that combined realistic observations and hope for the future.
In the [...]

I am currently reading Linchpin by Seth Godin.
The section I read yesterday gave outstanding advice.  Perfect is the enemy of excellent, set a deadline and ship it.  By this he means, blog posts, articles, abstracts, products, memos. 
I know too many academicians who obsess over perfect.  His advice is brilliant.
It is good enough – SHIP [...]

Newt Gingrich and John Goodman have a thought provoking piece in the WSJ today.  Ten GOP Health Ideas for Obama
All ten ideas are worthy of thought, but I will focus on the two I feel are the most important.

Allow doctors and patients to control costs. Doctors and patients are currently trapped by government-imposed payment [...]

 An SGIM colleague has just published another book.  Danielle Ofri wrote this fascinating story about writing her book – 'Medicine in Translation': Pens & Stethoscopes

I wrote lots of the novel–more than 300 pages worth–and had a wonderful time doing it. It was about a fictional internist in a fictional city hospital, and the wildly diverse [...]

Obama Plans Bipartisan Summit on Health Care
Morning Joe had a nice discussion of this plan.  I agree with two of his three points.
My agenda (if anyone cares)

True tort reform.  I would not go after caps, but rather focus on health courts.  Tort reform would attract several Republican votes.  Can the Democrats vote for a [...]

Gawande’s “Checklist Manifesto”

Instead, I’d like to focus on the subjects that don’t come through in reviews and interviews (such as Atul’s charming appearance on The Daily Show) but, I believe, are much deeper and more valuable.
“For nearly all of history, people’s lives have been governed primarily by ignorance,” Gawande writes. But in healthcare, he [...]

The best way to lower health care costs and improve outcomes is to spend more on excellent primary care.  The data are consistent, and the concept has great face validity.
This article is intriguing – For Diabetes, P4P Improves Patient Care, Outcomes
As one reads the article, skepticism about the title enters.

High-quality care — defined as receiving [...]

When I wrote earlier this week about peer review, I did so from the heart and from my observations over the years.  My timing was somewhat random.  Apparently my post was somewhat prescient.  I will present 2 links that make the point much better than I did.
Peer review trickery?

Two researchers — Robin Lovell-Badge, who spoke [...]

Those who have read my rants for almost 8 years can guess my answer.  Either we have worshiped Flexner too reverently or we have misinterpreted his recommendations.  These primary physicians blame the Flexner report on our current imbalance between primary care and subspecialty care.
Flexner Report Linked to Growth of Specialty Medicine
This paper focuses on several [...]