Anti-Southern Bigotry

5

Category : General, Politics

In these days of political correctness and diversity training, some bigotry remains.  Too many Americans have a prejudice against International Medical Graduates.  But they one I cannot understand is the open prejudice against the South (and by extension Southerners).

Periodically I will read an op-ed that criticizes my state – Alabama – specifically or the South in general.  The Wall Street Journal has an interesting book review criticizing a book with an outrageous title – Better Off Without 'Em: A Northern Case for Southern Secession.  The review – A New Turn in the South: Northerners may hate its culture, but they at least ought to try to understand the nation's fastest-growing region

On the first page, the author wonders why the American electoral system must be "held hostage by a coalition of bought-and-paid-for political swamp scum from the most uneducated, morbidly obese, racist, morally indigent, xenophobic, socially stunted, and generally ass-backwards part of the country." You expect him to let up, to turn the argument around, to look at the other side of question. But he never does. For more than 300 pages, Mr. Thompson travels through the South observing customs, outlooks and people and subjecting them to an unremitting stream of denunciations.

"A Northern Manifesto for Southern Secession," says the subtitle. Although Mr. Thompson tries hard (often too hard) to be funny, he doesn't seem to be joking about secession: He really does want the U.S. to be rid of the South.

Think of an ethnic group.  Can you imagine a description similar to that in the first paragraph?  Can you imagine the outrage?

Why does this writer think that he can stereotype Southerners?  Why is this blatant prejudice different from other prejudices?

The reviewer does a wonderful job critiquing a book that I will never read.  But I remain angry since first reading this 12 hours ago.  Why is such trash even published?  Why do we not hear outrage from others who shout whenever other groups have such criticism? 

Having lived in the South since the age of 5, I love the people.  I love the attitude.  We Southerners look each other in the eye.  We are nice and polite to each other.  We show each other respect.

But not everyone should move here.  Please do not come to the South if you are so close-minded as to try to characterize all Southerners with a stereotype.

If you are open-minded, y'all come on down.  You will be surprised.  Living here allows you to daily have a pleasant quality of life.  Perhaps the writer does not like us because we are generally happy.

A political lament

1

Category : Politics

This is usually a medical blog. This weekend I have thought a great deal bout politics. As I tweeted earlier today, I greatly admire Joe Scarborough’s comments on Meet the Press yesterday.

I consider myself a Scarborough Republican in general, although, with reservations I hope we get meaningful health care reform. What I oppose is extremism on the left and the right. What I oppose is hate speech, obfuscation and hyperbole. What I oppose is Nancy Pelosi and Sarah Palin.

We desperately need a centrist party. We need politicians who understand the art and necessity of compromise. We need strength coming from the middle rather than from the sides.

Unfortunately, the passion resides in the extremes. We in the middle feel very strongly, but we do not express those feelings with passion. Our willingness to listen to both sides and compromise may be signs of maturity, but they are not characteristics that rally the troops.

The current health care shouting match (I refuse to call it a debate) epitomizes our governing problems. I hope some readers out there can provide solace for this blogger who finds the current discourse so unpleasant and without serious thought.

If you are still reading, thanks for allowing me to vent. We should resurrect Henry Clay – known as the Great Compromiser.

All government, indeed every human benefit and enjoyment, every virtue, and every prudent act, is founded on compromise and barter.
Edmund Burke

Do you favor a public plan?

4

Category : Politics

 

At the risk of jumping into the hornet’s nest, I will start by linking to Bob Doherty – Are the right questions being asked about the public plan?

For liberal and conservative true-believers, the debate over a public plan has become a surrogate for the broader debate over the role of government in our health care system. If you believe that the government needs to take on more responsibility for financing and organizing health care in the United States, you want a public plan. (Many of those who favor a public plan option would like it to be the only option – like Canada – but have decided that this is the best they can get right now.) If you believe that the problem with American health care is too much government and not enough private initiative and responsibility, then you are opposed to a public plan.

Largely missing from the discussion, though, are the details of the "it" that everyone is arguing over. There is general agreement among policy wonks that the current Medicare payment structure is dysfunctional – it undervalues primary care and rewards volume instead of value. If so, then, does it make much sense to create a new public plan that takes this same flawed payment structure and add 10%?

Would there be safeguards to ensure that payment rates under the public plan are competitive with private insurance and high enough to ensure sufficient participation by physicians and other "providers"? Or would it end up looking more like Medicaid, where low levels of payment have resulted in low levels of physician participation and generally, poor access to care?

Medicare also does not cover most preventive services. Does it make sense then to replicate this same benefit structure in a new public plan?

One could imagine a public plan that is better than Medicare. It would pay primary care doctors more, create incentives for value, rather than volume, and cover preventive services that largely are left out of Medicare. It would pay enough to ensure sufficient participation by physicians. It would compete with qualified private insurers, but on a fair playing field.
 

As Bob suggests (and I agree 100%), your perception of a public plan depends on how you interpret the phrase and your political economic belief structure. 

I could construct a public plan that I would support strongly, and a public plan that I would vote against.

Why might I favor a public plan?  If that plan actually forced the private insurers to compete, the public plan might encourage insurance plan transparency.  Have you ever tried to understand health insurance?  Comparing apples and oranges is simple compared to health insurance.

We need transparency and simplification.  If a public plan yielded that goal I would be happy.  Such a movement could lead to decreased administrative costs for physicians, and less hassle for patients.

If a public plan requires physician involvement, and provides inadequate coverage, then I do not believe we should be excited. 

A public plan is not necessarily a bad idea; as always the devil is in the details.  We should debate and try to influence the details before we decide that we like or dislike the concept.  Too many pundits have already set their opinions in concrete without knowing those details.  And you wonder why physicians dislike politics.

 

Nurse practitioners and the PCMH

10

Category : Medical Rants, Politics

 

Several comments to this blog have addressed the inclusion of nurse practitioners as possible leaders of medical homes (only if the state certifies NPs for independent practice).  Because of the first two comments, I must clarify that I am not talking about NPs working with physicians, but rather my comments refer to NPs in independent practice. Here is one physician comment:

Dr Block makes a good point. There seems to be some cognitive dissonance on the part of those trying to bolster primary care, while at the same time accepting a much broader role for midlevels delivering it.

Either the comprehensive care is complex, difficult, and best provided by an extensively trained (and expensive) physician, or it’s usually straightforward, algorithm driven, not particularly complex, and best provided by a less expensive midlevel (with much less training).

Arguing those providing comprehensive care should be paid more, then arguing that we should have midlevels delivering a lot more comprehensive care seems schizophrenic. And it’s not convincing.

A nurse practitioner answers:

An interesting topic and comments that follow. It is obvious that even many “medical people” do not understang the role of the nurse practitioner since their comments are minimalizing and denigrating – Jiffy Lube? Fine – keep on thinking that NPs are “simple” and can’t handle “complex” patients. We want to work together with you so that we can care for the many patients that don’t have providers. It’s ok for NPs to care for the un or underinsured but don’t let them care for the patients with real insurance. There is no evidence that NPs order any more tests or referrals than any other provider.

We as NPs will continue going into primary care when many physicians completely avoid it and are leaving in droves. We want to partner with you – not so that you can supervise us – but so that we can collaborate and bring best practices to our patients. Is it not possible that NPs have areas of specialty where we are better equipped to handle a certain situation or patient? Perhaps you all have worked with what you consider substandard NPs – has that not happened with your physician colleagues?

Bob Doherty addressed this issue on Friday – Do internists have confidence in their own training when compared to NPs?

H.R. 2350 goes beyond ACP policy, in that it would allow NP-led practices to qualify as PCMHs, not just for demonstration projects as proposed by ACP, but under a permanent Medicare PCMH benefit, starting in 2011. ACP’s top physician leadership made the judgment that H.R. 2350 merits the College’s strong endorsement, even with the more expansive NP language, since perhaps 95 percent of the bill is based on ACP policy.

In the days since ACP endorsed the bill, some ACP members have expressed concern that ACP’s support will further blur the lines between general internal medicine and advanced practice nursing, making it even harder to persuade young people to go through the extra years of training to become a physician But if internists truly believe in the value of their training, shouldn’t they also be confident that they will be able to show such value in a medical home model where the outcomes of care can be measured?

My bet is that the PCMH will help support the value of internal medicine training by providing a consistent way to measure the outcomes, effectiveness and efficiency of care provided by internists, even when compared to nursing-led PCMHs that operate within the limits of their licenses and against the same evaluation benchmarks. And, as I’ve written about before, our chances of getting primary care legislation could be irreparably weakened if physicians and nurses are viewed as being in competition with each other, rather than as allies on the need for more of both.

I understand the politics behind the inclusion of NPs as potential PCMH leaders.  As I have written many times, the problem stems from the semantic drift that the term primary care has undergone over the past 3 decades.  I recently wrote about the levels of primary care.  My rant was meant to emphasize our collective confusion over this term.

If we mean routine episodic care or routine chronic disease management then we probably have the primary care that politicians conceive.  Internists do these things as part of their overall more comprehensive care.

I will try to define the problem once again.  The value of a well trained physician comes from recognizing the long tail events. The long tail zone – when do I enter it

We do not measure long tail events as a quality measure, because it would be very difficult to enumerate such events.  So we have a classic important concept which is not easily measured.  I will continue to insist that diagnostic errors are extremely important.  I heard a colleague state that diagnostic errors are the most common reason for malpractice lawsuits.  Yet our current quality measures ignore diagnosis.

Well trained physicians excel at diagnosis.  I remember during training that the greatest praise for one of our heros was that he was a great diagnostician.

Our primary care debate often ignores this issue.  I doubt that many NPs have the diagnostic acumen of well trained internists and family physicians.  I might argue that long tail diagnosistics define a different level of expertise than the concept that primary care currently represents. 

So I am personally against the NP clause, but understand the political necessity.  Politics requires the art of compromise.  In supporting HR #2350 I am willing to compromise, but I do not have to be completely happy.

How large is the pie?

0

Category : General, Politics

 

My son has joined the world of blogging.  He blogs about urban planning and the economy.  I highly recommend this thought-provoking piece he wrote this week – Where is the pie?  It has nothing to do with medicine directly, but health care is part of the pie.

Should we have preferred the devil we knew?

2

Category : Politics

 

Tom Daschle had no choice.  He made a dumb, arrogant mistake.  His lack of tax paying would have become the story for the week and perhaps next week.  Neither he nor Obama could explain his error.

We knew where Daschle stood.  I agreed with many of his positions, and understood that he was a politician.  He understands compromise, and would have worked to get the most practical health care reform.

Now we just do not know what will happen.  As usual, Bob Doherty places this political happening into perspective. The road to health reform gets bumpier and bumpier …

 

If I were health czar – steps to decrease health care costs

15

Category : Fixing health care, Medical Rants, Politics

 

First, I would not want to be the health czar.  I like my current position.  Still, it is fun to provide advice from the sidelines.

Our job is to consider health care costs and which are unnecessary.  I have some candidate categories for potential health care savings.

Our biggest hurdle remains the privacy issue.  We could save considerable money in duplicated testing if we had a national medical record repository.  As I have experienced through the VA electronic medical record, I can save time and unnecessary testing through access to all VA records.

Too often I see patients have expensive testing repeated when they move from one hospital to another.  Too often the physicians at the new hospital do not "trust" the physicians or the technology at the first hospital.  Radiologists often do not want to read the images from the first hospital.

Too often we do not have access to old ECGs.  We do not have a master file of prescriptions.  Often we do not have records of previous surgeries. 

Any hospitalist will tell you the knowing old lab tests improves decision making.  Having access to old films and other imaging can save unnecessary repetition.

So my first major strategy would focus on making information available to all physicians.  The privacy concerns would require some consideration, but I believe the improvement in health care delivery and decrease in unnecessary repeat testing would trump those privacy issues.

The second major concern is over use of technology in the emergency department.  Ask any practicing physician about testing in the ED.  Patients have too many imaging studies.  I think we all understand why those studies are done, but a significant percentage are clearly unnecessary.

Now clearly, ER physicians have a high exposure to malpractice claims.  When in doubt, they image.  The emergency department is often overwhelmed with patients, so technology trumps the history and physical examination.  We need a multispecialty panel to develop reasonable standards for technology use in the ED.

The thrid concern is unnecessary use of newer more expensive drugs.  I am a big fan of comparative effectiveness research.  I want to choose appropriate drugs based on data rather than hype.  Unless we fund comparative effectiveness research, we really do not know how and when to use the latest entry into the pharmaceutical market.

My fourth concern is pharmacological education.  We need to do a better job of minimizing the number of medications each patient takes.  So often I see patients admitted to the hospital with >10 prescriptions. Usually, we can decrease the number of meds.

As the number of medications increases, so does the chance of interactions, side effects and decreased adherence.  We are not teaching pharmacology properly during the first two years of medical school, and we rarely focus on pruning medical lists during clinical training.

Today’s last concern is palliative care.  We should increase funding for palliative care training and delivery.  We spend too many unnecessary dollars during the last hospitalization.  Too often we cause unnecessary suffering for patients and their families.  We could do a much better job of treating patients rather than diseases during the terminal phase of illness.  We sometimes use ICU resources unnecessarily, because we do not have a palliative care mindset, and we just have not discussed these issues with the patient and the family.

I am certain that my outstanding readers have other suggests for the czar.  Please comment and I will respond.  Perhaps we could even develop a health care bloggers guide to decreasing health care costs!

 

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Answer to new acidosis case

7

Category : Acid-Base & Lytes, Attending Rounds, Audio, Medical Rants, Politics

I am trying an audio version of explanation for the case presented 4 days ago.  I need your feedback – do you like this strategy, or should I type out the answer. 

Acidosis discussion

 

49-year-old man, previously in good health, presents after a few weeks of progressive weakness and dizziness.  He admits to polyuria.  Your job is to extensively discuss his lab tests.

Electrolyte panel
Na 147 Cl 104 BUN 28
K 4.7 HCO3 16 creat 1.3
Blood Sugar 678
ABG
pH 7.3
pCO2 33
pO2 68
calc HCO3 16

 

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What is primary care? (revisited)

9

Category : Medical Rants, Politics

In response to a comment yesterday, for the first time I reprint a rant.  This rant is so important that I consider it classic for this blog.

 

A reader writes:

My question: Is there a plan to move MD’s away from primary care and turn this function over to NP’s and others who will cost the system less? I raise this issue since from an economic stand point if I wanted to create a massive change in the medical delevery system I would follow the patteren now being set by Medicare and the insurance companies. This may not be the best system for the patients, but when did we, or doctors, count when there is profit to be made by an insurance company, or cost to be contained by the goverment. Not trying to sound like a nut case but when you stand back and look at the system as a whole I see a trend that will result in MD’s becoming a refural service only and clinics providing most primary care. A great loss to everyone.

I am often accused of overemphasing semantics. However, I believe that that this concern revolves around semantics. Let us start by defining semantics – "The meaning or the interpretation of a word, sentence, or other language form" So to really answer the questions which the reader poses, we must use a common definition of primary care.

Defining Primary Care Since its introduction in 1961, the term primary care has been defined in various ways, often using one or more of the following categories to describe what primary care is or who provides it (Lee, 1992; Spitz, 1994). These categories include: * The care provided by certain clinicians—Some proposed legislation, for example, lists the medical specialties of primary care as family medicine, general internal medicine, general pediatrics, and obstetrics and gynecology. Some experts and groups have included nurse practitioners and physician assistants (OTA, 1986; Pew Health Professions Commission, 1994); * A set of activities whose functions define the boundaries of primary care—such as curing or alleviating common illnesses and disabilities; * A level of care or setting—an entry point to a system that includes secondary care (by community hospitals) and tertiary care (by medical centers and teaching hospitals) (Fry, 1980); ambulatory versus inpatient care; * A set of attributes, as in the 1978 IOM definition—care that is accessible, comprehensive, coordinated, continuous, and accountable—or as defined by Starfield (1992)—care that is characterized by first contact, accessibility, longitudinality, and comprehensiveness;

Dictionary.com defines primary care – "The medical care a patient receives upon first contact with the health care system, before referral elsewhere within the system." Which of these definitions do we mean? The big problem in discussing primary care stems from a misunderstanding of what physicians think primary care means. Some subspecialists, some policy wonks and some patients equate primary care with simple episodic care – e.g. sore throats, urinary tract infections, ear aches, runny nose, etc. When you discuss primary care with general internists and family physicians (I am restricting my comments to adult medicine because pediatrics is very different), they assume the primary care includes episodic care and the ongoing care of patients who often have multiple chronic diseases. Do we need a specialty trained MD (both GIM and Family Medicine are specialties) to deliver primary care? If you take the dictionary.com definition or the simple episodic care concept, or even add routine hypertension and similar single conditions, then specialists are not needed. However, the patients that General Internists and Family Docs see rarely fit the constrained definition. Most often our patients are complex (defining complexity either by number of significant diagnoses, number of medications or the addition of complicating psychosocial issues). I do not believe that the majority of patients are well served if they do not have a well trained specialist in the care of the complex patient (my definition of GIM and FM). As I see the problem that we face, many have perverted the meaning of primary care and the term no longer adds to useful discourse of our problem. I generally avoid using the term for this reason. I hope this discussion emphasizes the importance of the semantics.

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On perioperative beta blockers – another hole in the performance indicator movement

1

Category : Medical Rants, Politics

 

Once again a study challenges dogma – POISE Published, Debate on Perioperative Beta Blockers Continues

Publication of the landmark Perioperative Ischemic Evaluation (POISE) trial online May 12, 2008, in the Lancet has triggered another heated debate about the pros and cons of using beta blockers perioperatively in noncardiac surgery [1]. In one corner are the authors of POISE, which was first reported at the American Heart Association (AHA) 2007 Scientific Session and which found that beta blockers do more harm than good in this setting; and in the other, two accompanying editorialists, who suggest that it is the POISE protocol—specifically, the doses of beta blocker used and timing of initiation of therapy—that explains the findings and that a different protocol might shift the risk/balance back in favor of using beta blockers in this setting [2].

"What POISE says is that in the dosing we used, we see beta blockers have substantial risk in the perioperative setting," Dr Philip J Devereaux (McMaster University, Hamilton, ON) told heartwire. "And until someone demonstrates with a clear and large randomized controlled trial that an alternative dose is both effective and safe, it’s just not rational, not in people’s best interests, to be assuming—that’s how we got into this trouble in the first place."

I have not done preoperative and perioperative management for many years, and have not followed this literature carefully.  I did know that most experts thought that beta blockers markedly decreased MI risk during and after non-cardiac surgery.  So as a more casual observer, this article surprised me.

Devereaux first reported POISE—a randomized controlled trial in more than 8000 patients undergoing noncardiac surgery who were not on beta blockers, randomized to either the beta blocker metoprolol or placebo—at the AHA meeting last year. The results showed that the beta blocker reduced the risk of myocardial infarction (MI) but increased the risk of severe stroke and overall death in patients undergoing noncardiac surgery. It suggested that for every 1000 patients treated, metoprolol would prevent 15 MIs, but there would be an excess of eight deaths and five severe disabling strokes.

Devereaux told heartwire that the new analysis featured in the Lancet "helps to explain why death went up and stroke went up [with metoprolol]. Death was clearly driven by a hypotensive state, leading to shock, which we’ve recognized is so common in the perioperative setting, and that’s what tipped the balance and why we saw the excess death. Also it’s not that simple to predict who will develop shock, and many people who are going to get it are the same people who are going to get a heart attack also."

He and his coinvestigators conclude: "Patients are unlikely to accept the risk associated with perioperative extended-release metoprolol. Current perioperative guidelines that recommend beta-blocker therapy to patients undergoing noncardiac surgery should reconsider their recommendations in light of these findings."

I take several messages from this study.  First, we really do not know answers to complex clinical questions until we careful prospective studies, especially randomized controlled clinical trials.  Second, the performance indicator and safety movement which has a "ready, fire, aim" philosophy, must reevaluate their strategies.  One must wonder if our current push towards performance measurement has caused strokes and death in some patients.  Finally, 30 years after finishing my residency, I continue to reshape my medical knowledge.  As new knowledge appears we must quickly adjust our practice.  I am interested in the ability of the performance movement to adjust.  Of course, they will shrug off the unintended consequences that they caused here. 

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