Contemplating medicine and the health care system
The Obama Health Plan Emerges
I expect significant, if not radical change, in health care payment over the coming year. This WSJ article gives useful perspective on some possible directions.
If the Obama White House decides that reorganizing the 17.1% of the economy that the U.S. is likely to spend on health care in 2010 is [...]
The rift between ER docs and hospitalists
This rift does not just involve hospitalists. Rather, I see problems between the ER and everyone else.
Back in the old days, when I was a resident, we had no specialty of ER medicine. We had this same problem back then. I would love to blame the problem on the [...]
A reader writes:
The Physician Extender (Ex: Physician Assistants, Nurse Practioners, Nurse Anesthesist, Radiologist Assitant, etc). This career has been around since the 1960’s offering a time saver to MD’s, maintenance of quality patient care, as well as as being dramatically cost efficient. These health care workers are stae/nationally certified and ready to take on the [...]
Our country must answer an important question - are we willing to take the steps necessary to make primary care available to our population. This survey raises the stakes significantly - Half of primary-care doctors in survey would leave medicine.
And as Ray mentioned, med school students are shying away from family medicine. In a survey [...]
A relatively new web site - Opposing Views - serves as a platform for debates on various issues. The debate categories include health. They asked me to participate in a debate on universal health coverage. So here is my take.
The question posed can serve as a Rorshach test. I could just as easily debate one [...]
Love that #1 Dinosaur - More on Hospitalist Economics
Dino makes the argument once again -
I recognize that hospitalists are here to stay, so all those commenters warning of dire consequences if the positions were eliminated are completely off-base. I am just pointing out that they are not immune from the basic economic principles [...]
Senator Baucus’ Answer to Who Should Pay for Primary Care? As usual, Bob Doherty nails the issue. Baucus completely understands the problem. These are the highlights:
A process would be created to reduce payments for services found to be overvalued under the Medicare physician fee schedule and redistribute them to increase payments for undervalued primary care [...]
Kevin has all the links - all free text - The New England Journal of Medicine focuses on primary care
Please spend the 30 minutes to watch and listen to the video discussion.
Then tell me if you learned anything that we have not discussed in the blogosphere. Several excellent bloggers have been addressing these issues with [...]
Proceduralists *SHOULD* make more because their training requires more time in order to become proficient at high risk procedures. Access to comprehensive care should be improved by increasing mid-level providers in primary care specialties. Cognitive specialties are not well reimbursement because cognitivists did not advocate well for themselves at RUC and CPT meetings.
I received this comment [...]
Since this seems to be an opportunity for internists to crap on specialists, I would like to retort.
Since orthopaedic surgeons are an apparent target of your ire, let me inform you that hip and knee replacement, well documented as providing high value in terms of QALY, as well as risk/benefit, has seen reimbursement drop 40% [...]
The Happy Hospitalist took a shot a humor yesterday … and failed miserably. Happy Vetrad’s Day
The problem with humor is that it often is based on ones true feelings. Humor is obviously differs amongst readers, but in this case Happy’s humor speaks to me of his disdain for veterans.
Disclaimer - I receive some salary from [...]
Happy doesn’t care; he says he’ll just find another job at another hospital. (See Addendum) And I’m sure he will. There will always be other, richer hospitals with more cash lying around to offset the loss-leader services of hospitalists. My point is that if he cannot produce enough income to cover his salary, benefits, etc. [...]
As per KevinMD, Dr. Wes writes Final Rule Hieroglyphics
Is there any wonder that the guys who do the work are completely and utterly baffled by such a payment system? In every instance, the system obfuscates and confuses while supporting it’s own network of highly-paid sycophants to decipher the hieroglyphics.
What an absolute and utter mess our [...]
Health care reform will soon reach center stage. I (and many others) believe that the Obama administration will develop a health care reform early in their tenure. Bob Doherty provides a sobering view of AMA discussions on this issue - Who will pay for primary care?
I share Mr. Goldsmith’s view that policies to rebuild [...]
This study will change our thinking. This study will change primary cardiac prevention. This study gives us wonderful clues, but we need more data.
Probably sentence #3 is the most accurate, but the Jupiter study should change our conversation. Statin use ‘may benefit healthy’
The results are published in the New England Journal of Medicine.
The patients [...]
A Positive Approach to Doctors-in-Training
“People have a natural desire to do good, physicians especially,” she said. “But the problem,” she continued, “may be a training system that encourages not how I can improve but how I can survive.”
Doctors-in-training, Dr. Reed maintained, want to know how to improve. But many of their teachers, individuals like [...]
Hat tip to Dr RW - Hospitalists as rolling stones
Dr. Ford says he thinks those data point to a migratory mindset among at least some hospitalists.
“Physicians want to work as a hospitalist,” he explains, “but those data tell me that there are doctors who want to get one or two years of experience [...]
Bob Doherty (in his must read blog) beautifully captures the likely scenario of health care reform coming this winter. Will single payer advocates get behind Obama-style health reform? He provides the most important insight to the coming political battle:
One reason why President Bill Clinton was unsuccessful in his effort to reform health care is that [...]
I personally dislike using the term primary care for internists, because of the misuse of this word. Those who do not understand the value of outpatient internists use the label primary care, and then opine that we could get nurse practitioners to do primary care. Obviously we have a problem of semantics.
Semantics are powerful. The words [...]
If they asked me, these are the initial steps I would take to repair health care:
Scrap RBRVS - this is a failed model. The concept was well considered, but the devil of the details outweighs the purity of concept. We have no good way to evaluate relative value of billing codes. We have bean counters [...]
As readers know, I fear that the best solutions for health care reform will not likely come from politics. However, we must play in the political arena, for it is the only arena that we have.
I have many hopes. I hope that we can develop a rational billing system, one that values time spent with patients [...]
So yesterday afternoon I was browsing the medical literature, and I discovered that my choice of colon cancer screening was well supported. This editorial refers to several articles in the current Annals of Internal Medicine. These articles discuss colon cancer screening guidelines. Screening Guidelines for Colorectal Cancer: A Twice-Told Tale
Two guidelines and a modeling study support [...]
I had my second routine colonoscopy today as this is a preventive medicine measure that makes great sense.
I blog about this because I hope that will encourage others to undergo this procedure.
For those who do not really understand the procedure, I will explain some of the details.
Yesterday was all liquids (clear liquids) and then [...]
Primary care shortage dooms universal health care
Primary care doctors spend more time talking with patients and managing health care without expensive procedures and tests. The reimbursement for these cognitive services are not keeping up with the costs of running a practice and young doctors are walking away from this type of practice in favor [...]
Lactic Acidosis Very Rare During Current Use of Oral Antidiabetes Drugs
During current use of oral antidiabetes drugs by 50,048 type 2 diabetic subjects, there were 6 identified cases of lactic acidosis. Crude incidence rate was 3.3 cases per 100,000 person-years in metformin users and 4.8 cases per 100,000 person-years in sulfonylurea users. All case [...]
A valuable reader/listener found my error - which I have fixed. Thanks!
I am posting this to stimulate discussion. The author has good reason to maintain anonymity and I have good reason to publish his/her opinion. The following should make you think:
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I have heard Democrats say it many times before, and Obama said it again tonight: "a right to affordable health care."
Do we really have this right? [...]
Bob Doherty has advocated for internal medicine for many years, first with ASIM and more recently with ACP. He just started a blog, which I believe will be a must read - ACP Advocate. His first post addresses an issue very familar to the blogosphere - is health care a right? Is health care a privilege, [...]
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Anion Gap Acidosis
This represents the first in a series of 7 lectures that I plan for understanding acid-base problems. Please provide feedback and questions. I plan to collect questions over a few days and then prepare an audio addendum.
I like this BBC News piece - A guide to the Hippocratic Oath
This whistle-stop tour of the Oath gives some idea of the content and spirit of this ancient text.
In an age of technological developments, cosmetic surgery, complementary medicine, drug companies, and many other temptations for patients and doctors alike, the spirit of the [...]
This comment starts with a good idea, but the naivete of the solution is telling. We Should Stop Paying for Diagnostic Failure and its Downstream Consequences
Here is the problem, the well meaning author wants physicians to take responsibility for false positive tests. Medicine does not have enough precision to avoid false positive testing. We learned [...]
"For every complex problem, there is a solution that is simple, neat, and wrong." - HL Mencken
"I hear and I forget. I see and I remember. I do and I understand." - Confucius
"The good physician treats the disease; the great physician treats the patient who has the disease" - Sir William Osler
"Those are my principles, and if you don't like them - well, I have others." - Groucho Marx
"It is hard enough to remember my opinions, without also remembering my reasons for them" - Friedrich Nietzsche
"Anyone can make the simple complicated. Creativity is making the complicated simple." - Charles Mingus
"Not everything that can be counted counts, and not everything that counts can be counted." - Albert Einstein
"A foolish consistency is the hobgoblin of little minds, adored by little statesman and philosophers and divines. With consistency a great soul has simply nothing to do." - Ralph Waldo Emerson
"This ain't no party, this ain't no disco, this ain't no fooling around." - Talking Heads, Life During Wartime
"What is hateful to you, do not do to your neighbour. This is the whole Torah; all the rest is commentary. Go and learn it." - Hillel, Talmud, Shabbath 31a
"You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing." - Thomas Sowell
"An idealist is one who, on noticing that a rose smells better than a cabbage, concludes that it will also make better soup." - HL Mencken
"If you only have a hammer, you tend to see every problem as a nail." - Abraham Maslow
"A great teacher is one who realizes that he himself is also a student and whose goal is not to dictate the answers, but to stimulate his students creativity enough so that they go out and find the answers themselves." - Herbie Hancock
"There are no facts, only interpretations." - Nietzsche
"An education isn't how much you have committed to memory, or even how much you know. It's being able to differentiate between what you do know and what you don't." - Anatole France
