Funniest and Coolest Bar Stool Ever: Carved Testicle Ball Sack

Who thinks of this stuff. It's got to be the funniest and coolest bar stool ever with it's  carved testicle ball sack in it.? Is this a luxury line of bar stools?

see more funny videos, and check out our Insanity Wolf lols!

What Does Universal Coverage (Really) Mean?

What does universal health coverage really mean for health care? 

FREE=MORE will eventually = MORE=LESS. It's only a matter of time. If you promise everything, eventually, you will get nothing. Why? Because the more you promise to provide on the backs of the few, the more the few must pay to provide for the many. Eventually, the few will quit trying and join the many who will then wait for their gravy train to come to town.

Why work harder than everyone else when you can do less and get more. From No Oil for Pacifists:

We have FREE=MORE for 250 million Americans now. What makes you think we can have FREE=MORE for 300 million Americans and have it cost less? If you think you can, you aren't thinking. The problem isn't too little insurance, it's too much insurance.

Funny Health Care Bumper Sticker: Just Wait Till It's Free Bumper Sticker

Heres' a funny health care bumper sticker to pass your days away.  

"You think healthcare is expensive now? Just Wait Till It's FREE!

Yes folks, FREE=MORE lives in bumper sticker infamy

Overweight Dancing Troupe: 340 Pounds Of Dancing

Here's an overweight dancing troupe you don't want to miss.  The average weight is 340 pounds.

I think that's great. Exercise is wonderful, no matter how you do it. Plus, what I find incredibly impressive is their requirement to perform leg splits and flips in the air. That is one Hell of a skill to master.

Happy Doctor's Day 2009 To me

Happy Doctor's Day 2009 to me.  I bet you didn't know there was a Doctor's Day.  I didn't know. 

Doctors' Day observances date back to March 30, 1933 when it was started by  by Eudora Brown Almond of Winder, Ga. The date marks the anniversary of the first use of general anesthesia with surgery.  1991 marks the  T first celebrated National Doctor's Day.

Hallmark suggests you send your doctors a card of appreciation

I didn't get any cards this year. Bummer.

Inflation vs Pay Cut: Which Would You Chose? See the Fascinating Research

Here's some fascinating research that discuss how we think about inflation vs a pay cut.    If you had to choose between a 3% pay cut or 3% inflation which would you choose?   The answer lies deep inside your brain.

We The People Stimulus Package Video: You're Sucking At the Hind Tit of a Dead Cow

This is great video titled We The People Stimulus Package.  It doesn't get any better than this.  The only problem is when you buy off the majority with free money, nobody cares.

Hospitalists Decrease Costs And Improve Quality

Once again showing the value we bring to the table research suggests hospitalists decrease costs and improve quality.  

This time it's the Mayo Clinic Proceedings that reports on these general trends. I don't need a study to tell me what an incredible asset hospitalists are to a hospital system. All you have to do is ask every player that comes in contact with a hospitalist, from nurses and techs to subspecialists to patients to administrators.

Oh yeah, and a well run hospitalist group definitely brings a hospitalist advantage to the hospital's bottom line.  There is a reason why 2010 hospitalist compensation and salaries are thriving. Because hospitalist medicine model works. 

Pay It Forward, Kidney Transplant Style

This is an amazing pay it forward chain, kidney transplant style.  This is just amazing.

Insulin Drips In the ICU: Tight vs Liberal Control Pendulum Swings Again.

Insulin drips in the ICU seem to swing the tight vs liberal control pendulum every few years.   In the last 10 years of my medical life I have gone from putting no one on an insulin drip to putting everyone on an insulin drip in the ICU with the goal of perfect control.  New research suggests that it is time to back off. A large international randomized trial sets the bar at a blood sugar of <180 mg/dl, not a normal blood sugar. I had the journal linked, but the link has since died.  You'll just have to trust me, or continue your search elsewhere.

Handicap Parking Spot For Motorized Scooters (Fail Picture)

Funny stuff from Fail. Here's a motorized scooter parked in a handicap parking spot.  Someone's got skills.

Read On

Assess Your DVT Risk Tool

You can find the assess your DVT risk tool at the bottom of this post. Did you know it's DVT awareness month? DVT (deep venous thrombosis), or now more appropriately named VTE for venous thromboembolism is a condition that can kill you. How? Because blood clots form in the legs, break loose and travel north into the lungs. They're called pulmonary emboli, and they can kill you instantly. I see scores of people every year that are admitted with VTE. Some with barely a symptom. Some close to death. Some are dead on arrival

I just found out that one my mother's good friends died suddenly while visiting New Zealand this month. A healthy lady otherwise, after death she was found to have two blood clots in her lungs presumed secondary to her long trip in the airplane. The condition went unrecognized at the hospital, resulting in her demise. A sad sad story indeed.

The prevention of VTE is a national patient safety initiative. I am on Happy's hospital VTE prevention quality committee. After a bit over a year on the committee, and a very strong participation of VTE prevention by our hospitalist group AND a growing recognition by most (not quite all) of the physicians at Happy's hospital, I was told we have data indicating a rate of hospital acquired VTE lower than the last five years of available data.

Something all physicians should be very proud of. For the few docs who still believe their patients don't get VTE, I have to say only that I hope you are not that healthy, active patient one day who refuses their lovenox shot. I hope you are not that father who travels to New Zealand on a family vacation, only to return in a body bag. Your patients are at risk whether you want to believe they are or not, no matter how good your surgical skills are and no matter how much you yell at the nurses to ambulate your patient 4X a day. Your patient will still be at risk. Because they are in the hospital. You should never deny your patient the right to a VTE free experience.

For more information on this deadly disease you can search about David Bloom, a journalist who died in Iraq from a deadly pulmonary embolism, is memorialized by his wife, Melanie Bloom, who continues to fight the fight. I had the opportunity to meet Melanie several years ago.

Risk of Diabetes Tool Calculator

Want to know what your risk of diabetes is? You can use this risk of diabetes tool calculator.

Read On

Iatrogenic Death Spiral Makes the Top Ten Causes of Death In American

The Top 10 Causes of Death

1.  Heart Disease 
2. Iatrogenic Death Spiral 
3.  Cancer
4. Stroke
5. COPD
6. Accidents
7. Diabetes 
8. Alzheimer's 
9. Pneumonia
10. Kidney Failure

For the rest of the world, two things are certain: Death and Taxes.  The only thing certain in America are taxes.

Define Primary Care

Define primary care.  Over at Are You A Doctor, the increasing need for PAs to provide care in rural America with indirect (code word for no) supervision is addressed. A noble undertaking for the PA field. But then the question is posed:

Should PA programs have mandatory residencies if PAs practice outside of primary care?

The question you ask is deeply flawed. The basis of your question assumes that PA school can train PAs to provide primary care services with indirect (code word for no) physician over site. When you conclude that PAs should be required to complete a residency for all practice styles except primary care, you make the assumption, in my mind, that somehow PA school can train one adequately to provide the entire scope of primary care services with minimal oversite.

I hear specialists say all the time how much easier their roles in care are than primary care. As a subspecialist, it's often far easier to answer the question being asked than it is to figure out what the question even is. Often I admit patients in which the question isn't even defined. That's internal medicine for you.

I'm here to tell you that your logic of primary care being easier is all backwards. This assumption has been perpetuated by government, insurance and patients by a lack of understanding of what the scope of primary care actually is. The practice of primary care is far more complicated than a focused specialty such as cardiology or gastroenterology. The scope and breadth of information required to practice competent primary care without reliance on subspecialists for basic problems of internal medicine is far more complicated to master than you give credit to. Every medical subspecialist has finished a residency in internal medicine. Ask any of them and most would agree that the practice of general internal medicine is far more complicated than their focused specialty.

I can tell you categorically, without a doubt that it would be impossible for any scientifically honest extender, whether it is a PA or a NP, to wake up in the morning, look themselves in the face and tell themselves that they are competent to practice in the same scope of primary care as a board certified, residency trained, internal medicine physician, with indirect (code word no) over site.

I can assure you that a graduate of PA school (or even a NP residency) would be incapable of evaluating and managing patients in a scope of practice which meets the expectations of an independent physician provider of internal medicine. Why? Because they aren't trained to do so. You don't just wake up one day and practice internal medicine. No matter how hard you bang the gavel about experience as an EMT or a PA or 40 years of nursing experience. Experience in other fields does not equate to experience as a minimally supervised provider of internal medicine. I could never claim to be competent as an ICU nurse simply because I worked as a hospitalist for 15 years with ICU experience. The training I received as a physician trained me to be a physician, not an ICU nurse.

And my education allowed me to practice from day one with no over site. Are you a doctor, I'm concerned that you believe PAs, who you stated are more frequently trained with little to no prior experience in anything, could magically finish their 2 1/2 years of training and get shipped out to rural America to practice with indirect supervision (code word no supervision). I am concerned that you don't get it.

I can only assume that you feel a body is better than no body in rural America. Which is fine, as long as we accept access as your driving force in determining policy, not competency. That's not to say that those providers who have not received the training that physicians have are incompetent. But they are less competent in matters of patient care. Can you measure competency? Of course. My competency is certified by my status as board certified in my field of expertise. Based on a physician level standard of care.

One has to assume that indirect care of patients in rural America by PAs with no residency training (or even an NP with with the current NP residency standards) must be easier than I am lead to believe. My definition of primary care must be far different than yours.

It appears you make an assumption, by excluding residencies for primary care tracks, that you believe primary care to be a field in which PA school would adequately train one to practice with indirect supervision (code word no).

So I have to ask the question: What exactly do you think primary care is? If it is capable of being practiced with indirect (code word no) supervision, without any type of physician level residency, without the medical school experience, I can only assume that your definition of primary care is vastly different from mine. In which case this whole argument is moot. What I do is provide primary care in the hospitalist setting. I take care of everything. This PA explains my position well (in the comments section).

Anonymous said...

After pa school, i was able to work as a mid level hospitalist and soon realized how much i had to learn-and that's an understatement. I believe every pa graduate should have a mandatory internal medicine 1.5-2 years training after pa school (and i mean in an inpatient hospital setting), where a pa learns how to manage a patient in the ER for admission, round on the different floors-medicine, surgery, cardiac step down, telemetry, and yes..you know it-ICU!!!-i mean c'mon; what if the icu nurse calls you at 2am and tells you that the obese pt with s/p lap chole-and a hx of copd, htn, dm, cvd, previous mi, and possible chf now has a blood pressure of 70/40! I also now work in a family practice and urgent care setting, and believe you me, i have met pas with 10-12 yrs experience who are freaking clueless on a lot of significant clinical presentations. I believe our profession need to wake up to the reality that a new pa graduate is a walking time bomb!

The only thing I would add is that 1 1/2 - 2 years is not enough. Not even close. Not without the medical school experience, if you want to practice with indirect (code word no) medical supervision.

The real question you should be asking is not whether or not PAs should be doing residencies on non primary care tracks, but rather the question should be exactly what is your definition of primary care. I think that is the real question that should be asked. So what is your definition? And America, how do you define primary care?

By the way, I heard a surgical PA once explain  to a nursing student what they do:

"They've trained me well. I operate. I do everything that the surgeon does. I'm like a second surgeon. Almost, but not quite."

Huh.  Addendum: I just found Dr Centor over at DB's Medical Rants discussing the same thing.

Nurse Practitioners as Hospitalists?

Nurse practitioners as hospitalists?  A reader asks the question.

Computer Condom Protection

I hope your computer is wearing a condom come April Fools day

From the NYT

Conficker,

Consider this my  public service announcement of the day.  I hope your computer is wearing its condom.

How to Define An Alcoholic?

A reader, Neon, poses the question on how to define an alcoholic:

So, when you see a patient that admits to consuming a 6 pack of beer and 2-3 whiskey's per day, do you automatically label that individual an alcoholic?  Where is the line drawn?  Is a glass or two of wine acceptable?  Is it ethical to label an individual an alcoholic in their medical file with the claim of drinking the above beverages without actually documenting other criteria of dependence?  

In my documentation, I never document alcohol addiction.  If they get admitted intoxicated, I label them as alcohol intoxication. Many folks suspected of drinking more than three drinks (my criteria) a day gets an automatic consultation from the alcohol nurse specialist?

Why?  Because that's what they do for a living.  Most of the time patients lie about their alcohol consumption anyway (in residency I was taught to take what ever number I am given by the patient and double it).  That's what addicts do.  They lie.

I let the alcohol nurse ask all the important questions about their alcohol history, legal, financial and marital problems related to their alcohol.  And most of the time the alcohol nurse labels them as dependent, the patient refuses treatment and we all go on our merry way.

I once had a patient that I got called into to consult at 2 am for profuse sweating, tachycardia and fever and elevated blood pressure in a post operative patient. Hypertension causes me to act just as hypotension causes me to search for an answer. The patient swore up and down he didn't drink.   I told him and his wife flat out that if they  were lying to me he could die.

Sure enough, the wife comes of the room minutes after I left and told me her husband was drinking heavily.    In less than two hours the patient was on a ventilator in the ICU.

I never believe how many drinks a drinker tells me they drink.  I assume they will withdraw until they don't.  And I let the alcohol nurse label them as alcohol dependence.

Race Toward Mediocrity

We are in a race toward mediocrity. 

I have to admit, I sit here every day watching company after company tank in one of the biggest recessions of a lifetime. The faster they rise, the harder they fall. Nobody talks about the out of control rise in home prices over the last decade. The basis of the false economy built around a house of cards. Only when the house collapsed did the greed really become an issue.

The thing with greed is that it causes a rise in quality of life for everyone. When Bill Gates started his company. When Henry Ford started his. The desire to become financially successful drove them towards their goals. That's greed. Greed is natural. FREE=MORE is a type of greed. It doesn't have to be economic greed, but we usually associate greed with money. It is a part of the human race. We are all greedy in one way or another.

We want a raise. We want more vacation time. We want that flat screen TV. We want higher interest rates on our savings. We want more time with our family. We want that iPhone. We want that new car. We want security for ourselves and our family. Some look to be independently wealthy through hard work and determination. Some look to the government to support all of their needs. Both are greedy. The motivations are the same. The pathway of achievement is not.

Most of us strive to improve our quality of life through the concept of greed. I don't think greed is not a bad thing. Greed is a fundamental quality that drives innovation, desire, and success. I would even say that greed is a type of survival instinct.

With that said, I don't think we can legislate greed out of the market, no matter how hard we try. Nor should we want to. Without greed, the individual desire to succeed would be replaced by the concept of social and economic equality, where all people would strive for mediocrity. Mediocrity is bread and cultivated in socialistic government societies. Without the success of greed, one has only mediocrity to look forward to. And mediocrity is the death of achievement.

So when does greed become a problem? When decisions are made without regard to the risk of extreme failure. Even extreme greed is not bad, when greed gets it right. Extreme risk taking can be a good thing for economies. But it must be balanced with the fallout of extreme failure. In fact, I think too much success must be balanced with too much failure. Without extreme failure extreme risk taking becomes the norm. And the extreme failures would be intolerable. It is the act of failure that keeps extreme greed in check. Just enough to advance science and technology. Not to much to cause failure.

What we have witnessed before us in the last year ten years is both sides of the pendulum. Millions of people become very rich in the exploding housing market. This extreme greed was not limited to any class. People making $18,000 a year buying $500,000 homes that doubled in value. Mortgage brokers walking out with million dollar bonuses. Bankers receiving millions in dividends for their efforts. The party went all the way to the top. Wall street executives taking home billions in profits.

Extreme greed on the way up. What we see in every step of the process is failure to analyze the risk of that extreme greed. Failure to analyze the downside of that extreme risk taking. The only possible solution to this failure of risk analysis is failure itself.

The only solution to extreme greed is extreme failure. The only thing capitalism has to protect itself from bad risk analysis is failure. Without the risk of failure, there is no risk to extreme greed. It makes no difference how many laws you pass, how many bailouts you pass, how many trillions of dollars you throw at the players who lost in the game of extreme greed, you will never be able to legislate greed out of the market. Greed is a fundamental part of all of us.

Now that Bush and Obama and Co have decided that you can legislate greed, how do you legislate a fundamental driving force out of capitalism?

You can't. And that's why bailing out any individual or private industry that failed because of their own inability to price risk is doomed to failure. The only solution to keep extreme greed in check is to have a real risk of extreme failure. Now that we have chosen to legislate extreme failure out of the market by legislating greed (which will fail miserably) we are stuck with failed companies and failed individuals that will be in the race toward the ultimate endpoint.

Mediocrity.

That's Why You're The Doctor

That's why you're the doctor.  

That's what I heard from an ICU nurse after I chose watchful waiting after extubating my formerly drunk, possibly high patient that stopped responding to a sternal rub and developed a disconjugate gaze. Concerned about stroke? Possibly.

An hour later, he was walking out the door. Motivation? I have no idea.  Sometimes the best thing to do is nothing.

Excercise and Depression: Taking That First Step To Feeling Good

So I took care of a really depressed young female. She'd been through a lot in her young life. Medically. Physically. Emotionally. She was suicidal. Very pleasant. Married with children. And she was on a boat load of psychiatric drugs.

She was also overweight. I spend 30 minutes talking with her about the benefits of exercise. How I believe she could do more for herself for feeling good with exercise than all the psychiatric medications and electroconvulsive therapies combined.

She thanked me for my time and told me she would do it. I think a saw a glimmer of hope in an otherwise severely depressed young female.

The only in-patient doctor (even outpatient for that matter) you will ever find talking to a patient for 30 minutes about the benefits of exercise is a hospitalist.

If you are depressed, you need to exercise. It should be first line therapy, in front of medications. Comparative effectiveness should prove that. It should be required for any insurance to cover any type of antidepressant. Antidepressant medications should be third line, behind exercise and cognitive therapy.  Healthy lifestyles does wonders for mental health.

Medical Decision Making and Perceived Risk.

Dr Wes talks about how even the perceived risk and  threat of litigation drives medical decision making. I want to come out and say. Absolutely.  100%.  No doubt in my mind.

The threat of litigation, perceived to be real by reason or not, rational or irrational, drives decision making. It is without a doubt at the front of many, if not most physicians' minds when they formulate a plan. It is the threat of delayed diagnosis. It is the threat of a missed diagnosis.

Physicians do not walk into a day of work wondering if they are going to get sued for chopping off the wrong leg. Physicians do not walk into work thinking they are going to get sued for administering a lethal dose of heparin.

Physicians do walk into work with a daily fear of missing a deadly diagnosis. Of missing that case of nonspecific headache that turns out to be meningitis or an aneurysm. Physicians do walk into work daily with a fear of missing that case of chest pain that turns out to be Prinzmetal's angina. They do walk into work on a daily basis with a fear of missing that case of a C1 fracture.

Physicians walk in fear daily with the fear of the unknown. Medicine is a big unknown. How unlikely is it that the old man with chest pain has a ruptured aortic aneurysm? How unlikely is it that the young lady with atypical chest pain is having a massive MI? How unlikely is it that the asymptomatic old lady who fell out of her hospital actually has a subdural hematoma?

The answer to the question is: It doesn't matter.

In our current state of health care, the standard of care is the perceived standard of perfection. And until that community standard changes, Dr Wes and I will always error on the side of caution rather than the side of comfort or the side of expense. The legal standard is the community standard. And the community standard is an impossible standard of perfection.

Example in point. I took care of a woman found unresponsive at a local park. It was unknown how long she was down. She was resuscitated from a PEA arrest and was admitted to my ICU with severe anoxic brain injury, status seizures, ARF, cardiogenic shock with an EF of 5% and recurrent VTach. I determined that this 79 year old lady's chances of survival was 0% for discharge from the hospital alive.

No known family. No DNR. No guidance on what to do. Except my clinical judgment. I wanted to withdraw medical care to allow natural death but ran into concerns by other physicians regarding Happy's Hospital's futile care policy. The simple act of trying to do the right thing and let this lady die peacefully was interrupted by an overwhelming concern for the correct legal interpretation of Happy's state laws. Death should be natural, not legal.

In this situation, like so many, the legal ramifications will trump the right medical decisions. But it happens. And it happens on auto pilot all across this country. Every day. Every single day.

I would even say that so much of medicine is legally driven, that if you have ever been a patient, you will have been exposed to unnecessary tests and prolonged evaluations to protect a physician from the possibility of preventing a missed or delayed diagnosis, no matter how unlikely the probability.

It shouldn't have to be that way.

Four Pack A Day Smoker Spends 6 Million Dollars

This is freakin' nuts.  Four pack a day madness in middle America.

2 packs per day for the patient

2 packs per day for the husband.

$6/pack.

$24/day

$168/week

$720/month

$8,760/year.

That's four packs a day madness.  That's enough to take out a 30 year mortgage with a loan of $120,000 at 5% and enough left over to pay for the taxes and home owners insurance.

How much money are they losing to potential investment? Let's assume for the sake of argument that the long term rate of return for your money placed in the stock market is about 10% (the S&P returned an average close to 10%/year) over the last 40 years. Subtract from that the long term CPI average yearly increase of 3%. So let's assume that your post inflation money is gaining 7% per year. How much money will you spend over your career as a professional smoker?

Let's say that the price of a pack of cigarettes only rises 5% a year ( a conservative estimate). How much money could you save up by not spending a four packs a day habit of $8,760 on cigarettes and instead investing it with a post inflation return on average of 7%?

After 10 years? $153, 716

After 20 years? $521,304

After 30 years? $1,277,508

After 40 years? $2,806,917

After 50 years? $5,815,495

This is post inflation dollars (pre tax).

Imagine, if you started smoking, you and your wife, two packs per day, starting at age 25. By 75 years old, had you invested that cigarette money, and made just 7% per year, after inflation, you could have almost 6 million dollars in the bank you could have spent on your family.  Instead you smoked four packs a day.

My, how foolish we are as a nation. Looking for ways to pay for the health care of its citizenry, when the answers are staring us in the face.Perhaps it's time for a little free Chantix and an Apple computer.  UPDATE:  Chantix lawsuits, here we come.

See my other record clinical findings.

Pubic Hair In a Cop's Wendy's Burger

This cop got a mouth full of pubic hair while eating a cheeseburger at a Wendy's.  That's terrible.  Have you ever messed with someone's food you served them?  I've also heard stories, locally, from the chef none the less, about families served steak that was dropped on the ground.  Brush it off and serve it, they said.  Why?  Because cooking it again would have delayed all the food by 15-20  minutes.  

Hmmm...

How Many Times a Week Should I Wash My Hair? You'd Be Surprised

You'd be surprised at how many times a week you should wash your hair. 

Some suggest you shouldn't shampoo more than two or three times a week.  I don't think Americans are quite ready for that.  I'm sure women who missed a day of shampoo are already on the phone with their hair restoration expert. 

Chiropractor vs Primary Care: An RVU Analysis of My Experience

Who makes more money?  I did my own RVU analysis from a recent visit comparing the chiropractor vs primary care. 

As you know, I experienced acute onset back pain last week. I think it was an L5-S1 disk problem. I went to the chiropractor. I went back for a repeat visit several days ago and asked for an itemized billing statement. Are you curious to find out what how a chiropractor pays in comparison to a primary care doc?

I looked up the Medicare CPT/ RVU payment rates for my city. I came in at 3:03 pm. He asked me about 2 minutes worth of questions, if that. I laid on a chiropractor table for about 2 minutes. He moved the base of the table up and down as he palpated several spinal regions. Then he wound me up like a pretzel and realigned my facet joints. Two maneuvers. A total of 2 minutes. I would say I spent a total of six minutes tops on that table with history.

Then I went and lay for about 7 minutes, by myself, with an electrical stimulation device hooked up to my back. When I was done, the secretary took it off my back and I paid and left. I asked a couple of questions, he showed me the spinal model and explained what he did. How much did the chiropractor get paid for his 10 minutes of work (tops). ( I added in 4 minutes for the time he took to answer my questions).

My insurance is Blue Cross. I compared what they paid with what Medicare would pay.

CPT 99201 New patient, lowest level: Blue Cross paid $43 Medicare would pay $34

CPT 98941 Adjustment of 3-4 regions: Blue Cross paid $47 Medicare would pay $33

CPT 97014 Electrical stimulation: Blue Cross paid $18 Medicare would pay $12

So how much did he make for his 10 minutes? That's $65 for 10 minutes of work. If I had been a Medicare patient, $45.

Not bad. Not bad at all. How much would a hospitalist make for a 99232 spending 25 minutes documenting, talking with family, ordering studies, xrays, interpreting labs, calling specialists, filling out family medical leave act paper work? About $60. How about a high level, complicated patient with multiple medical conditions worsening condition for which I may spend 45 minutes or more on? A 99233 pays $90.

How about a primary care doc stuck in clinic evaluating granny complaining of dizziness, on 20 medications with 10 chronic medical conditions. A 99213 (mid level outpatient visit) will pay you under $60 (expected 15 minutes). The step up, a 99214 will pay about $85 (expected 25 minutes). None of these expected times include uncompensated work which will always take you past these time variables. Prescriptions, phone calls, referrals, preauthorizations...

In either case, whether you are dealing with hospitalist or clinic follow ups, it is clear that E&M cognitive codes are getting the shaft even when compared to codes being billed by chiropractors, who complete their training in 4 years with no residency.

The complexity of cognitive evaluations from the review of systems to the past medical history, medication review, side effect profiles, multiple simultaneous system complaints, vague and unusual symptom complexes. It doesn't matter. It all gets treated like the step child of the RVU world.

A chiropractor makes more, on a time based axis, with far less complexity than a primary care doctor. Even the lowest level new patient clinic visit, the 99201 paid the equivalent of the actual manipulation. And the time involved was double.

The payment reform necessary in this country, for there to be any chance of success will have to find a way to value cognitive evaluations in line with procedural compensation. With out an admission that cognitive interventions are equal, if not more important, than the technical based procedural intervention, there will be no payment reform. And therefore, no health care reform.

Dog Walking and Peeing Forever Hilarious Video. Laugh Out Loud Funny!

Check out this hilarious video showing a  dog walking and peeing forever.  You don't see that every day. 

Hospital Advertisements Truth in Advertisement Claims? Oh The Horrors.

Will there be a new truth in advertising push for claims made in hospital advertisements?

New rules are just around the corner that will change, forever, what advertisers can claim in their advertisements.  No longer can we watch Jared, of Subway fame, claim to lose hundreds of pounds without also being shown  a picture of a typical results person.  That means if you show Jared, you will also have to show someone who doesn't' lose weight.  Probably some portly gentleman with a spare tire hanging over his belt.

I can only imagine what this means for hospital advertisements.  You know, the ones that show a person in extremis showing up at The Hospital On The Lake and walking out to play golf in a week.  Talking up their cath lab and fancy schmancy MRI machines.  Happy families giving testimonials about how they wouldn't be alive today if it weren't for The Hospital On The Lake.

Imagine if hospitals also had to show another patient getting their ribs crushed with CPR, in a bed of poop and urine as nurses and doctors try to revive them from their STEMI.  Imagine if hospitals had to show grandma debilitated, wheelchair bound and getting shipped off to a nursing home, instead of back to her bungalow in the city to play bridge with her neighbors.  Imagine if hospitals had to show 85 year old ladies being transported off to the morgue  instead of walking out on their own two feet.

If you want to advertise to the world how great your Hospital On The Lake is, you will have to represent what real health care outcomes usually entail.  And that ain't usually a pretty picture.  Now that's truth in hospital advertisements. 

Bailout Cartoon: Dishonest vs Honest

How's that for a bailout cartoon that speaks the truth:  dishonest vs honest.  That about sums it up.  You do realize that you also got 170,000 million dollars in free cash money last year  to bail you out.  Also known as the stimulus check.  Look how far that got us.  Every bailout is a blatant waste of taxpayers money.   Why are you not outraged at yourself for cashing your $600 portion?

Writing Liquid Prescriptions Rant: You Tell 'Em Angry Pharmacist!

Do you write liquid prescriptions as mg/kg?  If you do, the Angry Pharmacist has some words for you.

I write Lovenox in the hospital as a 1 mg/kg dose all the time.  I wonder if  should I round to the nearest 10mg.  Come to think of it, I don't even know what doses the prefilled syringes come in for writing liquid scripts upon discharge.  

Should I Become a Drug Rep? Be Careful. Future Drug Rep Numbers are Declining.

Are you asking yourself, "Should I become a drug rep?".  If you are, be careful.  You might soon find yourself out of a job.  I seem to see much fewer drug reps these days than I did as a resident.  Where did all the drug reps go? 

From American Medical News comes this piece about the changing landscape of pharmaceutical detailing in the doctor's office.  With many blockbuster drugs going off patent, few in the pipeline, new rules regarding "gifts" and a recession, it appears that the days of the drug rep might be limited.  Peaking at 102,000 reps in 2007, the industry expects no more than 75,000 by 2012.

When I was a resident, we used to see drug reps all the time.  They'd bring  hospital food.  Some would bring a waffle iron and a griddle and make us eggs, bacon and waffles right in the resident lounge.  What self respecting resident would turn that down?  They would try and get us young uns to use their drugs.  They are salesmen.    At the end of the day, their main goal is to get us to use their drug.

I rarely see drug reps as a hospitalist.  I don't generally find I have the time.  Occasionally they come for other groups and I may stop by briefly.  Of course, they have food.  It really is a giant sales job. A while back, word got out that a hospital  formulary interchange for a major drug was in the works.   It was no more than a week later that all us hospitalists and other docs were invited to an upscale bar for free food and drink.  It was a giant pimp session to try and understand exactly what was going on and if we would consider changing drugs.

I found it comical.  Drug reps running scared.  It really was unbecoming of their profession.  It turned me off completely to their plight.  It's all about money.  Medicine is no different from every other business.  Why we fail to accept that and structure reform around that basic principle is beyond me.  The day of the drug rep is limited.

Getting It Right Every Time: Is that Reasonable?

I think the public generally believes that doctors must get it right 100% of the time, every time.   It is their right as a patient to expect perfection, much like we expect our bank to get our account balance correct 100% of the time.

 A Country Doctor writes about a personal experience.  A relative who had a delayed diagnosis of melanoma, ultimately resulting in her death.  Family members saying the doctor should be sued, that their license should be revoked.

To watch over your fellow human beings’ health is a tremendous responsibility, especially on the front lines of Primary Care. Every bellyache is a possible appendicitis, every headache a possible brain tumor, every case of indigestion a fatal heart attack, and every mole a potential melanoma. We have the technology to correctly diagnose these conditions, but can we use all of it in every situation? Does every bellyache require an exposure to the high doses of radiation of a CT scan or the risks involved in an exploratory laparotomy? Does every headache justify an MRI, and does every case of indigestion warrant a hospital admission to the cardiac intensive care unit to rule out a myocardial infarction?

I don't have any idea where the belief that medical care and medicine/medical technology had the capability of getting it right 100% of the time.  There is nothing in medicine that is black and white.  Medicine is a big field of grey.  Even obvious diagnoses like heart attack or stroke have large fields of gray in the diagnosis and management.  What kind of heart attack? How extensive?  Which vessel?  Even the technology in diagnosing it isn't perfect.  Heart catheterizations depend on the clinical expertise of those doing them and the interpretation component.  Even strokes require a clinical impression from the radiologist reading the scans, the vascular surgeon reading the Doppler ultrasounds, the cardiologist reading the echos the hospitalist  making the daily judgment on better or worse.

Even the technology itself has limitations.  MRA is not the best study for evaluating blood vessels in the brain.  Obese people make cardiac echos difficult to interpret.  Even technique on doing the echo can change the clinical report and can change the management of the patient. Even MRIs, CTs and x-rays come with a clinical judgment call.

In every step of the diagnostic tree, from obvious diagnosis to nothing more than a sign or a symptom for which to base an evaluation on, clinical expertise and judgment calls are being used to make patient management decisions.

Even management of a known diagnosis has an element of clinical judgment.  Should you treat that pneumonia with Levaquin or Merrem?  Should that MI get stents or bypass surgery?  What chemotherapy is appropriate for that case of breast cancer?  Guidelines may guide, but they can't give you the answer for individual patients.

Even complications of disease states come with their own clinical judgments.  What should you do with that 85 year old patient admitted with pneumonia who now has a NSTEMI and acute systolic heart failure?  What do you do with that lymphoma patient being treated with chemo who shows up in your ED with severe septic shock?  What do you do with that hip fracture patient who gets delirious and aspirates into severe hypoxemic respiratory failure?

In every step of the way, clinical judgments are being made in the evaluation, diagnosis, treatment and management of disease and complications of disease.  This is not protocol driven medicine.  This is real world clinical medicine.  I have yet to manage a patient that could be described perfectly in a start to finish How To Manage book.  This is where years of medical school training, years of residency and patient contact experience and long hours in the office come into play.

Will a physician get it right every time?  Of course not.  Nor would I expect them to.  Should they be sued for it?  Should they get their license pulled?  Of course not.  Even if someone dies.   Bad outcomes happen.  It's part of being in a field where perfection can not be the expected outcome.   Even if some one has a delayed diagnosis.  Even if bad outcomes occur.  Even if someone dies.  Medical care is a field of judgment calls, from start to finish.  Can you give guidance in some areas based on evidence?  Yes, but even those guidelines are based on studies that are often difficult to extrapolate on an individual basis.  All we have are pools of data.  We cannot individualize therapy based on protocols and guidelines.

What we have is a system of educational rigor.  Starting with the weed out process in college.  The demand of good grades and excellent MCAT scores as a prerequisite for entrance.  Proceeding to a series of very difficult tests, massive volumes of information a very structured curriculum of normal and abnormal.  Frequent testing followed by rigorous medical school clinical years filled with long hours and frequent patient contacts.  Each experience with their own national standardized clinical exams.   Add to that Step 1, Step 2, and Step 3 national licensing exams that must be passed to proceed to the next level.  That all must be passed to be called an MD.  And after the medical school experience comes the residency experience.  Thousand upon thousands of hours of structured educational didactic experiences and patient contact hours that create doctors.  And ultimately to take an exam generated by the board of their specialty, the questions of which are generated by leaders in their field of practice.  To become physicians certified by their specialty board as experts in their field of practice.

Physicians who have passed through all these hoops have earned the right to be called an expert in their field of practice.  At no way along the way is perfection achieved. I have never received 100% on any test in medical school.  Never.  I know of no student in my class or residency that ever got 100% on their tests, national exams, or even their board exams.

The expectation of perfection is generated by the public and perpetuated by lawyers who have convinced the public that anything less than perfect is grounds for a lawsuit.  Perfection in medicine does not exist.  It is not reasonable to get it right 100% of the time, even if patients die.

We have built a system of medical care around an unattainable assumption that the standard of care is to get it right every time.  It's irrational.  It's impossible.  And it's unfortunate that we expect it.

Little Red Riding Hood Explained By a Van on Vimeo

Here's a cool video explaining Little Red Riding Hood by a van.

Shaken Baby Cases On the Rise Due to Recession

It looks like cases of Shaken Baby Syndrome are on the rise, potentially due to the recession. sinking economy.  How sad is that.

Popcorn Lung Disease Caused By, You Guessed It, Popcorn.

I heard about popcorn lung  awhile back.  Diacetyl, a chemical used to give microwave popcorn its buttery flavor, is apparently causing popcorn factory workers' lungs to fail.  It sounds like workers in these popcorn plants are inhaling this compound which causes them to get Popcorn Lung, a form of bronchiolitis obliterans.  The only supposed treatment is a lung transplant.  OSHA under the Bush administration refused to set standards for exposure to diacetyl.  That position has now been reversed under Obama's Kingdom.   Right now 300 popcorn workers have lawsuits pending, some have won multimillion dollar settlements.  

Popcorn Workers Lung

Ouch.

Hands Free Feeder For Infant? It's Like A Bird Feeder?

This comment about a hands free feeder for an infant is over the top.  This is almost like a bird feeder.  Reality Rounds left this comment regarding entitleditis gene.

March 22, 2009 8:38 AM

I don't know what to say.

Colorectal Surgeon Song (Video). Good Times!

The Colorectal Surgeon Song (Video Fun!)

Via Medical Pastiche. You've got check him out. He's got some funny stuff. Like the Colorectal Surgeon Song.

What Happened To The Nursing Profession?

One of my biggest irks about the nursing profession is their failure, at times,  to use critical thinking skills. Some nurses are much better than others. Some floors are much better than others and in fact, some floors I give rock star status.  I would trust them with my life to do the right thing.   And then again, some nurses are incapable of comprehending what critical thinking is.  I'm not sure if this is because of the rules and regulations by the hospital or government imposed safety regulations or simply something that isn't remembered from their school days or even that it isn't taught anymore (a scary thought).

Regardless, from a training track that is advancing their agenda into areas of independent patient care via NP level training, there must be at least a basic foundation of learned critical thinking for all nurses in order to communicate effectively and efficiently on patient care. Nurses must be capable of handling some basic critical thinking skills. You don't have to be a super star. Just come to work with your thinking caps on. I get frustrated with the robotic nature of many nurses these days who turned in their thinking caps at the front door to hide behind the safety of the telephone notification.

Take for example being called at 4 am with a "critical lab value". It's would be interruptive to my daily schedule had the call happened in the middle of rounds at 1 pm.  It's especially interruptive during the few hours of sleep I may get (if I'm lucky) on a night shift.  What was that critical lab value?  An elevated calculated bicarb level on an ABG of 43. Bicarb will always be elevated in someone who has chronic compensated CO2 retention (ie COPD) . Something that can be determined by looking at the ABG and using basic science skills to determine the acid-base chemistry. There is nothing critical about an elevated calculated bicarb level on an ABG of someone with a chronic compensated respiratory acidosis. It's only critical because the hospital must have a critical lab value cut off to report.  Again, this is all legally driven medicine.  Used to prevent lawsuits under the guise of quality.

I can actually understand calling me once with this non critical, critical lab value. I can't expect a nurse to always know such basic science skills and to differentiate the difference between a critical on paper and a clinically critical value, although it would be nice that their training gave them the critical thinking skills to figure it out on their own.  It is quite scary to think that nurses graduating from nursing school going on to NP school have difficulty interpreting basic blood gas measurements.  Incapable of making judgement calls between things that are critical and things that are not.

Regardless of the science, critical thinking skills should be used by the nurse to help them differentiate a critical value by definition from one that is really critical.  And they should be allowed latitude in making the decision to contact the physician or not in regards to non critical, critical lab values.

But it appears that they are not.  Maybe nurses must call all critical lab values, even though critical thinking would allow them not to do so. I explained to the nurse that this elevated calculated bicarb isn't critical, it's expected. I gave a telephone order not  to call me the critical calculated bicarb level on the ABG and while she's at it, not to call me the actual measured bicarb on the BMP, because certainly, I was going to get a call about that as well.

The following morning at 4 am I got another page from the same nurse with a "critical lab value". An elevated calculated bicarb level on an ABG of 41. I asked her why she was calling me again. That this isn't critical. That an order was given the night before not to call me this noncritical critical lab value.

"I thought that order last night was just a one time order", she says.

Can anyone explain to me how taking an order not to call me a critical lab value that isn't critical can be a one time order when I have already been called?

What happened to critical thinking in the nursing profession? Is the nursing profession to blame for turning some nurses into robotic like documenteurs, void of any critical thinking skills? Or is it the toxic malpractice environment that drives robotic like activity?

How do you fix this? And how do you prevent nurses incapable of critical thinking from entering into master's programs that require one to use critical thinking skills on a regular basis to prevent patient death? If nursing school no longer teaches critical thinking, what is the value in nursing education requirments? We can hire med aides and nurse techs to follow orders. That seems to be the road down which we are heading for. What happened to the nursing profession? Is it dead in the water?

Swerving Car On the Interstate: What Should I Do? Would You Call 911?

We took a little road trip to Atlanta a few weeks ago. While driving near the city at night we almost got taken out by a truck that was swerving all over the place on the interstate. We followed him for a while while he almost took out a couple other cars. Then I called 911 and guided the State Patrol in. I stayed on the phone for a good 10-15 minutes while the dispatcher guided the patrol in based on our mile markers. They pulled in behind the guy and flipped on the cherries. The guy pulled over immediately. We hung up and kept going on our way.

Would you call 911? We thought the guy was drunk. Maybe he was just tired. Maybe he was just texting someone. Regardless, It felt like the right thing to do.

Nurse Practitioners Are Dangerous And Should Be Avoided

Nurse Practitioners are dangerous and should be avoided, according to this pharmacist as a nurse practitioner tears into generics and a pharmacist lets her have it.  You be the judge

 Nurse Practitioners are dangerous

Are generics dangerous? I prescribe generic warfarin. I only prescribe generic of a lot of things. Myself, I take generic levothyroxine. I must admit I take brand name Advil in the gel capsule because Mrs Happy won't buy anything else. I'm not quite sure what kind of patients this NP is practicing on. I just don't find myself discouraging the use of generics.

Do you tell your patients to avoid generics? Or as a patient, do you try and avoid them?

Hubless Motorcycle Technology (Cool Video)

Check out this picture of hubless motorcycle. You can read about the hubless technology over at Geekologie. But first, check out the video.

Six Pack Beer Tattoo. Crazy and Hilarious FAIL.

Check out this crazy and hilarious six pack beer tattoo. That's America for ya. Forget about healthy lifestyles.  It's all about the crazy six pack beer tattoo. 



see more funny videos, and check out our Foul Bachelor Frog lols!

Politicians are Scoundrels.

 scoundrels

Robot Condom Sex Machine: This Coital Machine is "Physiologically Accurate"

Why do condoms break? Yes folks, it's actually been studied with this robot condom sex machin, aka a coital machine.  Physiologically accurate? Really now. Can you imagine being the graduate student doing that research?

The Value Of Stupidity

An interesting read regarding graduate students and the value of stupidity in science.   I think it applies well to the medical school and residency experience as well. I can relate to my educational experience thinking just when I thought I had a grasp on things, I didn't. And not only that, but I felt I had less of a grasp on things than the day before. This went on for years. Until one day, I didn't feel so stupid anymore.

I guess in one way or another, we are all stupid, some more than others. I know the farther I got into my education the dumber I felt. It wasn't until one day realized that I know about as much as my professors that I wasn't as stupid as I used to be. There was no a-ha moment. It just happened. One day, everything just made sense.

I can stand in front of a patients chart. Review their history, their past medical history and their acute data and everything just clicks. Almost invariably it makes sense. It's like the Rain Man. You have a thousand data points and all the dots just connect. I don't' know how it happens. It just does.

There is still a lot I don't know. Medicine is constantly changing and keeping up with the ever changing therapies can be a challenge. I think what medical school and residency does better than all other medical training tracks is it gives one a very strong foundation from which to ask the question why? Science is the pursuit of answers to questions. There is no better question in medicine than the question Why?

Smoking Is Too Expensive

When I asked my kidney transplant patient if she smoked.

"Yes. But I've got to quit. It's becoming too expensive"

People respond to money. They always will.  I know this because I had a schizophrenic patient tell me he had to quit smoking (and did) because it was getting too expensive. And schizophrenic patients NEVER quit smoking. Money is a powerful motivator in this world we live in.

Economic Differential Diagnosis

Here's something you may not think of every day. Having insurance may actually be at the root of defensive medicine. I speak from personal experience, but I'm sure there are many docs out there that will rationalize their decisions in the same way. So here goes.

Let's imagine for a moment that you knew before hand whether the patient had the platinum insurance plan that paid for everything with no deductible or whether the patient had no insurance at all and was responsible for 100% of the charges on their own. Let's imagine for a moment how this would affect your decision making.

In my experience the patients without insurance will get less care. This does not mean worse care. Why? Because there may be more discussion in the decision making process. I have gone down this road before, and it can be intellectually and clinically satisfying.

Let's imagine for a moment that I am moonlighting at a local adult only urgent care center that has access to all the latest technology, CT's MRIs, EKGs X-ray, lab, Doppler. As a physician I could order just about anything I saw fit for any possible scenario that walked into my door.

Let me give you the following hypothetical clinical scenario.

A 35 year old female on birth control pills comes to your moonlighting urgent care center with shortness of breath. She has a history of anxiety. She is recently recovering from a viral illness. She has no other medical problems. She takes no other medications. No family history of clotting disorders. She does however have pain with inspiration. Her exam is normal, including lung exam. Her BP, HR O2 sat and temp are all in the normal range.

What happens next? How aggressive are you with the patient? After taking a history and physical examination a differential diagnosis is created based on your available information. Asthma? Bronchitis? Pulmonary embolism? Heart Failure? Pneumonia? Coronary disease? Drugs? Anxiety? GERD? Pleuritis? Lupus? Scleroderma? Fibrosis? PPH? DKA? Sepsis? Stachybotrys Atra? You could go on and on and on with possibilities in your differential diagnosis. The question is, where do you end?

I'll tell you where you end. You end where the community standard says you end. And in many communities, the standard is to do everything because that's what everyone does. And that's what everyone does because someone else is paying for it. And because someone else is paying for it, there is little hesitation to restrain ones work up both from the physician's perspective and the patient's perspective.

When you are working up a sign or a symptom, medical evaluations deal with probabilities and possibilities. The key to being a great clinician is to be able to understand what the likelihood that any given patient has any given condition on any given day. And to get it right every single time.

However, I contend that the mentality of the medical work up is different based on the payment model you function within. I contend that two things happen when we operate our practice in a third party insurance system.

1. Physicians spread the cost of minimizing malpractice risk from one patient encounter over many healthy patients by way of defensive medicine practices. This means over testing in the belief that the standard of care IS to over test, and failure to do so would result in liability for failure or delay in diagnosis. Over testing has the believed effect of decreasing risk of malpractice exposure by decreasing the risk of failure or delay in diagnosis. The more you test, the more conditions you exclude (whether perceived or real) and the smaller the expected risk of delayed diagnosis. Physician's practice in this way because of a selfish desire to limit their exposure to malpractice risk, perceived to be real and present. It is human nature to protect one's economic self interest. Physicians are no different. While the duty of the physician may be to the individual patient, physicians are, in fact, practicing medicine in a selfish desire to limit their exposure to risk. They have to. The community standards have been set so high. And they have been set so high due to the unlimited funds available for over testing in third party payment models. Over testing has established irrational standards of care. And those standards drive further testing in a vicious circle of defensive medicine. Physicians accept the practice of defensive medicine by rationalizing that the cost of minimizing their malpractice risk is spread over millions of premium paying patients, both private and government, who then absorb the cost by way of premiums that rise every year at inflationary rates that exceed CPI or population growth.
   
2. Patient's have a selfish desire to limit their risk of unknown by allowing the cost of their expensive testing to be spread over millions of other premium paying customers. What do patients want?   Patients want to limit their risk, just as physicians do. The third party model treats individual patients as consumers of unlimited resources. Whether they are passive or active players in over testing, patients also believe that their risk of harm is limited by over testing. The brunt of the cost of this belief is born by others which allows patients to rationalize the expense in the selfish desire to limit their own perceived risk of failure or delay of diagnosis.

Points #1 and #2 above are the basis for a FREE=MORE health care delivery system. It does not matter if the delivery system is a government single payer or a private insurance company, the perceived cost to both physician and patient of over testing is "free" because the brunt of the cost for the physician to reduce their malpractice exposure and for the patient to reduce their risk of unknown is spread over millions of other premium paying patients. Both parties allow, and quite frankly expect over testing as a selfish desire to protect their own economic self interest. It will ultimately be unsustainable no matter how many EMRs you build or how many PQRI programs you create or how many ways you rearrange the Titanic. You cannot legislate economic self interest out of health care delivery. All third party payment models are doomed to failure 100% of the time. The selfish economic self interest of all the players will force it to. I personally don't believe that you can centrally ration any third party payment model and still maintain a functioning health care system. Picking and choosing which services to ration would be socially intolerable, open to the political whims (like the TARP bank fiasco) of power hungry politicians greased and bribed by the lobby interests that keep them in power. Ultimately, the process would be incapable of limiting costs. Where some costs disappear, others would explode. Medicare and Medicaid costs are proof positive that only the market is capable of determining price. You cannot legislate a price without unintended consequences of health care reform at every turn. Price must be determined by market forces for the supply and demand for equilibration. Those who believe in central planning need only look towards the failed policies of communism to understand why government cannot artificially price services, being both the buyer and the seller of their goods.

So, how do you get limits back into health care? Health care that is rationed based on individual decision making?I like to call it the economic differential diagnosis,a process based on a combination of financial and medical decision trees. I contend that knowing whether someone has insurance or not will force both physician and patient into a mental state of economic and medical decision trees based on how much risk the patient is willing to accept for the unknown. As an expert in the medical field, the duty of the physician should be to provide the patient with information required for the patient to make informed decisions on the amount of risk they are willing to accept of the unknown. That means the risk of delayed or missed diagnosis should be born by the patient, based on how much risk they are willing to accept. And that risk should be determined by how much financial burden they are willing to bear.

Removing the threat of malpractice for delayed or missed diagnosis allows the physician to practice medicine based on sound medical principles instead of a selfish desire to protect their own economic self interests through defensive medicine. When you free a physician from the risk of economic suicide in the current malpractice climate, you free the physician from requiring them to practice defensive medicine. A practice built on irrational community standards of care, financed with an unlimited supply of insurance dollars. When you put economic forces into the equation you get a shared decision making process where ultimately the patient is able to decide how much risk they are willing to accept. And the physician does not feel compelled to practice defensive medicine.

The cost savings alone from this action would allow for a fund to be established to assist patients in need to pay for their health care bills. Billions of dollars in savings as defensive medicine disappears. A fund, not insurance, that would be available on a grant basis to pay for expenditures who's price is determined in the open market with transparency. Competition based on price, not price based on insurance dollars. If we insist on having others pay for minimizing risk, both patients and physicians, we will all bankrupt each other in a flaming ball of glory.

85% of Americans who have health insurance are quite satisfied remaining fully uninformed in the decision making process. I suspect that most insured patients choose not to be fully informed, opting instead for reducing their risk of the unknown by having others pay for it in a third party model. And physicians choose to over test to reduce their malpractice risk (either real or perceived), the cost of which is spread over millions of patients.

Whether third party is defined as private or government, the third party model is a destructive force as it prevents the overt rationing of a finite resource. All resources in every aspect of our lives are rationed, except health care. It is an irrational assumption that health care should not be rationed. Everything is. I don't believe we can ration health care from a position of central power. I think everyone needs to ration their own health care based on their own special needs and desires. The political will is missing to even attempt centralized rationing. But even if it was, I don't believe that centralized rationing would be capable of showing significant cost controls. It must be the patient who ration's himself based on the value system of their own self interest.

Supply and demand is determined by market forces. The supply and demand curve of an unlimited resource will price it to a value of zero in an open market situation. If the demand is unlimited, the price will be valued towards infinity for a finite resource. What we currently have is a finite resource with unlimited demand. A demand that is artificially created by a third party system that operates on the assumption that supply is unlimited. For 50 years, the centralized pricing system has failed to find an appropriate pricing model that is sustainable. The reason being is it doesn't exist. At least not a sustainable model. Only the open market can match buyers and sellers of goods and services and find a price that works.

With all that said, let's go back to my 35 year old with shortness of breath. How does the work up differ between a patient with insurance that pays for 100% of the cost vs a patient who pays 100% of the cost?

1. The patient has insurance that pays for everything. If you are a physician worried about malpractice risk, you will over test. The patient will get labs, EKG, CXR, probably a CT chest, perhaps an echo. The patient will likely get a prescription for antibiotics. There is minimal downside risk of malpractice exposure for a physician to do more in fully insured patients. And patients accept more testing as a way of minimizing the risk of the unknown. And the whole process is paid for by spreading the payment out over millions of other premium paying customers. Patients turn a blind eye of responsibility for the costs incurred by the testing, as do physicians, both for their own selfish reasons.
2. What if the patient had no insurance? What if the physician was allowed to freely discuss their thoughts, probabilities, likelihoods and concerns without worrying about their own selfish desire to minimize malpractice risk? What we should see is more conversation between physician and patient regarding the risk of medical disease combined with an economic analysis of the situation. If the patient was bearing the brunt of the cost, and accepted the risk of unknown based on a thorough informed consent process regarding testing options, cost, probabilities, clinical suspicions, they could decide how much testing they wanted to pursue. And say no to over testing. And physicians would not feel obligated to pursue low probability high cost testing. My short of breath patient may accept pleuritis or anxiety as an acceptable diagnosis and defer more aggressive testing with CT scans, echo's and Doppler's in favor of conservative management. The physician will not feel obligated to order everything, but rather feel obligated to discuss their clinical opinion on the likelihood of pathology being present.
   

Being able to discuss my clinical opinions with patients based on the probabilities of disease being present or absent is quite satisfying. By putting patients in control of their economic destiny, they have the ability to ration their own health care and save our country from the current course of economic disaster. If patients understand that their own financial and medical welfare is at risk by smoking, drinking, eating poorly and failing to exercise, that they have within their power to make changes in themselves to minimize their economic differential diagnosis, we may be able to have real reform in how health care is delivered. The way I see it, insurance is a root cause of defensive medicine by creating an unsustainable demand curve that is met with ever greater supply. We are on a course of economic suicide.

For any sustainable model to be achieved, there will have to be large component of personal financial risk involved. Only then will overt rationing price health care in a way that can sustain it. We need the ability to generate economic differential diagnoses in order to self ration the care we deliver. We need new decentralized, innovative concepts for the self rationing delivery of health care. How to achieve that? That's where the money is.

Sense of Entitlement Runs Deep: The Entitled Gene

An extreme sense of entitlement:  I present you the entitled gene.

What do you think? $60,000 (USD equivalent) a year in benefits not enough for a family of four? What kind mentality are you teaching your kids. You're fat because I'm fat and there isn't anything you can do about it? Give up? The government owes you? Other tax payers owe you?

I suspect this cycle of entitleditis is carried down through generations of helpless souls who feel everyone is to blame for their predicament and everyone else owes them for their failures. Maybe there is even an entitled gene that they can blame it on. We are a nation of great enablers. Always in the victim role.

You may carry genes that make you susceptible to obesity, but you have the ability to change your course of history through your actions. To put it crudely, how many obese concentration camp victims were there? How many obese famine ravished Somalians do you know?

Obesity is a mathematical equation. Calories in = Calories out. Obesity is an imbalance of the equation (of course this excludes certain true genetic/iatrogenic conditions). Some people have to work really hard at the calories in part. Some people have to work really hard at the calories out. It may not be easy. But no one ever said life was supposed to be. Expecting others to pay for your easy way is a Ponzi scheme. Once everyone decides they also want the easy way out, there will be no one left to pay for anyone. This is the America we are rapidly achieving.

Thanks to a reader for the heads up on this sad gem.

Vitamin K in Nonbleeding Patients: Yes or No?

Is it time to stop giving vitamin K in nonbleeding patients with an elevated PT INR testing?  One study suggests so.    It's no better than placebo AND it makes reinitiating anticoagulation quite difficult in the post vitamin K period of time.  I see this too many times.   Just stop it.