Is the Swine Flu Turning Into the 1918 Pandemic That Killed Millions?

The swine flu racing across the world is an H1N1 strain, the same strain that killed 50 million in the 1918 pandemic. On April 29th, the CDC raised the alert to phase 5, indicating a pandemic is imminent. However, they also indicate the current virus is susceptible to common flu antivirals. There is no available vaccine. As of 10:30 this morning EDT, 109 cases and one death have been reported in the United States.

Here is what you need to know.

Here is what history has shown us.

Wash your hands people. Everyone. Everywhere. Wash Your hands.

The Bandaid Sign

One of my roles as a hospitalist is to assist other physicians in consultation for elevated blood sugars. Usually straight forward consults. Easy to address and quick to fix. Most of the time it's either a non compliant diabetic who either doesn't take their insulin or had a run of poor food choices or is uncontrolled due to acute illness. Every now and then something else is to blame.

Like the bandaid on their knee.

"Why Mrs Smith. What is that bandaid from?" I asked.

"I had a steroid injection in my knee yesterday", says Mrs Smith.

Another reason to lift up the covers on exam. It can make the diagnosis for you.

Quote of the Day

"If I Had A Shotgun, I'd Shoot You"--centenarian patient

Sometimes Physicians Just Get It Wrong

What an eye opening experience. I had an old man in his 70's sometime back experience a nonspecific complaint. What was that complaint? He broke out into a sweat one day while living out his peaceful life at the nursing home. This nondescript complaint in a diabetic resulted in an outpatient arrangement for a cardiac stress test by his family medicine physician.

However, these plans were aborted when several days later the patient experienced right upper quadrant belly pain that ultimately resulted in a diagnosis of gallstones causing blockage in his bile ducts. The patient was ultimately transferred to Happy's Hospital for further evaluation. It just so happens that the transfer was made on the day of the outpatient cardiac stress test.

I got a call from the stress lab asking whether I wanted to do the test as an inpatient. I said I didn't know. I would get back to them. So I went to talk to the patient. I asked him if he knew why he was getting the stress test. He didn't know. I asked him if he had any discomfort in his chest. The answer was no. I asked him about jaw and arm pain, shortness of breath, nausea. All negative.

I told him I couldn't think of any reason why his doc had ordered the cardiac stress test and that I was going to cancel it. He said, "Thank you. I didn't want to do it anyway."


I couldn't think of a reason either on why this nursing home gentleman without chest pain needed a cardiac stress test. So I called the family medicine doc and I asked him. He told me the patient had diaphoresis (sweating) and he was a diabetic and he wanted to evaluate the patient for ischemic heart disease.

I told the good doc that I think we have a sound explanation for the sweating (a gallstone attack) and that I was comfortable cancelling the stress test as I felt that the current information explained the episode of sweating.

And you know what the doc says to me?

"Make sure you explain the risks to him for not doing it and that it could still be his heart."


If this isn't defensive medicine at it's finest, I don't know what is.

Here's a patient who doesn't want the test and a doctor who is so scared of malpractice that they are willing to do unnecessary and expensive interventions on nursing home patients when alternative explanations clearly explain the science of the situation. With this irrational thought process, one could argue that the patient also needs adrenal vein sampling to rule out a pheochromocytoma. Or perhaps a bone marrow biopsy to exclude leukemia. Why not? If you're going to do unreasonable testing in the setting of rational science based medical decisions, why stop at just the stress test.

Sometimes physicians just get it wrong. Really wrong. At some point physicians will have to take ownership of their medical decisions, lawyers be damned, and make sound evidence based decisions on sound medical principles. If we test every nursing home patient with an episode of sweating with a $2000 cardiac stress test, then we physicians have just established irrational medicine as the standard of care.

We as physicians set the standards. And we have often set the standards which are not based on sound scientific principles. The question is, how do we as a profession change the standards so we practice based on science, not fear?

I for one believe in practicing science based medicine. If I'm going to get sued, I have to believe that science will prevail. A science, I have to believe, most juries would respect. If I practice with sound principles, regardless of irrational standards, I can go to sleep at night knowing I did the right thing, irrespective of nature's plans for the patient.

The Nocturnist Tax

I heard in the halls the other day about a premedical college student shadowing at the hospital. He was speaking with some nurses about his plans. They asked him what he wanted to do. And he replied that he wanted to be a general surgeon so he didn't have to "take call or work any nights."

If there are any general surgeons out there, can someone build a general surgery practice and referral base without taking call or working nights?

Perhaps someday all doctors will work in a shift based system where the day ends when the banks close and someone else picks up. I know hospitalist medicine in most in-house 24 hour coverage models work on a shift model. Emergency medicine is often shift based. And some programs even have nocturnists (only work nights). That's your no nights, no call model. Even outpatient physicians and many medical specialties arrange their schedules to work shifts.

In fact, many surgical groups also split coverage with shift based call. It looks like the days of being the patient's doctor at all times is done. Not only for outpatient family medicine docs and internists who use hospitalists, but also medical and surgical subspecialists who use shift based coverage models to limit their weekly work hour experience.

Who knows, Obama may someday decree that nobody can get sick after hours and if they do, they will have to pay a special fine sick tax to cover the additional expense of their night time care.

Perhaps a Nocturnist Tax is in order so the new crop of medical students can work no nights and no call when they enter the real world.

Are You Hungry?

Check out the menu at Grand Rounds

Don't Worry, You're Not Alone

During our daily ritual of morning report we talk to the "night guy" about the new admissions. We talk about issues during the previous day shift. We talk to the pharmD about drug interactions, dosing, po to IV interchange. We talk to the social worker about disposition plans.

We also talk about iPhone applications. It turns out, I've been missing a gem all these months.

FML. Here's the website. Here's what it stands for.

The iPhone has a free application for this site. So I downloaded it. Here's a few samples from my next favorite website

Today, my house got broken into. My brand new laptop was stolen, along with my flatscreen TV, digital camera, external hard drive and some clothes. Wanting to drown my sorrows in the Ben & Jerry's Phish Food ice cream in the freezer, I opened the door to find that it too had been stolen. FML

Today, I read a PostSecret that said "I'm afraid my thighs will start to touch soon." My thighs have always touched. I didn't even know thighs weren't supposed to touch. FML

Today, my girlfriend was complaining that we don't have "a song". Irritated, I told her that I'd put on the radio, and whatever song was playing was our song from now on. I switched on the radio, and "It's Not Fair" by Lily Allen was playing. Our song is about premature ejaculation. FML

The next time you're feeling down, don't worry you're not alone.

How Would You Manage Acute Diastolic Heart Failure In a 103 Year Old?

Walk me through your thought process.

My 40 Minute Jog

My heart rate during a 40 minute treadmill jog wearing the Garmin Forerunner 405 GPS watch with heartrate monitor

0-9 minutes: 6.6 mph zero incline
9-18 minutes: 6.7 mph 0.5 incline
18-27 minutes: 6.8 mph 1.0 incline
27-36 minutes: 6.9 mph zero incline
36-40 minutes: 7.0 mph zero incline
40-45 minutes: cool down.

Average HR 160
Max HR 180

750 calories burned

Feels incredible

The Hungry Addict Day #92

BEFORE







AFTER (April 24th, day 92)



Baby Got Pects

It looks like somebody turned an apple into an upside down wedge of cheese. Keep goin'

Make Sure You LIft The Covers

As a member of the venous thromboembolism prevention committee at Happy's Hospital, I try and remain aware of thrombosis prevention and prophylaxis at all times. In fact, I once had a patient with a GI bleed in which a partner of mine didn't order anything for prophylaxis.    Of course anticoagulation is not indicated in a GI bleeder. But sequential compression devices are.

Thinking it was an over site on the part of my partner, I went ahead and ordered them, then I went into the room to talk with the patient.  I discussed the plans for the day and left.

Shortly after, the nurse informed my that my patient was a bilateral AKA (above the knee amputation).

Learning Point of the Day:  Always lift the covers.

This reminds me of a patient of mine years ago who had a glass eye.   Every subspecialty service was documenting  pupils equally reactive to light.  If you are a medical student and you document equally reactive to light on a patient with a glass eye, you might as well quit that rotation and start kissing some major ass.   If you are an attending, God help you.

What's your biggest physical exam mistake?

How To Prevent The Flu

Go here.

Washington's Pork Barrel Spending

Is finally catching up with us.

It's Not About Insurance, It's About Lifestyle

People aren't dying because of a lack of insurance, they are dying because they fail to take action to improve their own health.  And that means exercise can do more for your health than all the insurance your government can buy.  Lay witness to this VA study.  Remember the VA?  That much touted socialized delivery of care for which we should all model after because of its great quality?  Well, you can't blame lack of access for these striking numbers from a VA study:

About 3,000 men were followed between 1986 and 2007 and classified either as low fit, moderate fit or high fit. Among African Americans, 46 percent in the low-fit group died, compared to 27 percent called moderately fit and 15 percent in the high-fit group. Among whites, 37 percent died in the low-fit group, 19 in the moderate-fit group and just 9 percent of those with high fitness levels.

You see, we spend all our time and energy figuring out how to insure everyone.  It's not about insurance.  It's about healthy living.  Almost half the blacks died despite all the insurance in the world.  Because they failed to act for their own benefit.

via Calorie Lab

Blaming the Obese For The Climate Crises

In fact, researchers say, the average overweight person contributes a ton more of potentially environment-destroying greenhouse gasses every year than a lighter person.

I never thought about it like this before.

Centers Of Excellence

Are apparently not so excellent.

It seems logical that a hospital labeled as a “center for excellence” in weight-loss surgery would be better than your run-of-the-mill hospital when it came to performing bariatric procedures, but a study finds that’s not the case. Centers for excellence had similar death and complication rates following surgery as other hospitals did, the report in the Archives of Surgery found.

Which then begs the question, why are they called excellent?

via Calorie Lab

Charging Obese Customers More

United Airlines has a new policy that would make large people buy two seats, if a flight attendant can't find two open seats together. The carrier is the latest of several airlines to adopt this policy.

Right or wrong?

Spiders On Drugs

via Blog Around the Clock

Cocky Nurse Learns A Lesson They Will Never Forget

A well written story on how education should occur, through the eyes of a cocky nurse who messed up.

"Because I'm here to teach you and you're here to learn. Knowing you, I'm rather confident that after today - you will never give any medication without knowing what it can and cannot do... and how to give it appropriately. Being a nurse is more than charting meds and giving them as ordered - as you've no doubt learned today."

How true this is.  This is a residency experience in a nutshell. Mistake after mistake that will never be made again. Because of the hierarchy of protection from supervising resident all the way to attending that are there to protect student and the patient from ignorant but learning interns, residents and fellows.

How To Make A Baby

I had no idea.  

Have You Ever Been Stuck By A Needle?

Getting a needle stick is never fun.  It brings up the worst case scenario in your mind.  I once stuck myself as a medical student at 3am on an ED rotation.  Yes, part of medical school it to work late into the night and take call.  It was a needle stick from an unknown source.  I got tested for all the nasty stuff and actually took HIV suppression drugs for awhile.  It's never a fun thing to go through.  

Have you ever been stuck?  And if so, what was going through your mind?

Tattoo Avoidance

Conclusion Tattoo disruption by surgical incision may cause distress especially in female patients who had their tattoo recently. Tattoos should be avoided where possible by alternative port site placement.

I suppose next someone will do a study on sunbathing areas and the stress it causes.

Read Aggravated Doc Surg's conclusions

Twitter Is Perfect For Orthopaedic Doctors

At least to document their physical exam.

This is a normal occurrence in the post operative notes I see.  With bundled surgical payments, it doesn't matter what you write.  In fact you don't have to write anything to get paid.  A patient could be in the hospital for two weeks after a surgery with complication after complication being managed by the hospitalist and the daily surgical note can be nothing more than 

"surgical site stable"

If I was able to document one and two sentence notes to get paid, I could double, triple, or quadruple the number of patients I see in a day.  That's how you cut costs and make health care delivery more efficient.  As it stands now, I spend 70% or more of my time documenting worthless information just to get paid and not be accused of fraud via the government mandated Evaluation and Management rules.

How Do You Define Primary Care?

That's it.  Just answer the question.

Missing The Appendix

Buckeye Surgeon discusses an interesting scenario.   A surgeon discovers after taking out a patient's appendix that it wasn't the appendix removed, but rather a piece of fat.  Buckeye Surgeon describes how this can happen when everything is so inflamed it's nearly impossible to tell the difference in tissues.  I have had heard of  experiences at Happy's Hospital where surgeons have done end to end anastomosis in metastatic cancers where the anastomosis ended in a blind loop because the tissues where so matted down that the surgeon could  not tell the difference on what was what.

In Buckeye's case, the patient ended up going back to surgery to have the ruptured appendix removed.  They lived and everything was fine.  BUT, I ask you America, had the patient died and a lawsuit was filed, and you were on the jury,  would you considered this negligence/malpractice?  Or would you consider it a complication of illness  in a small percentage of patients?  

I think it's the latter and that the patient's estate should not be compensated for anything, even though a bad outcome occurred.   Unfortunately, in America, patients view any outcome other than success as somehow negligence on the part of the physician.

Sigmund Freud's Grandson Tells A Funny Joke

via Boing Boing

80%

From the ACP Blog, The American College of Physicians (ACP) has some recommendations for Congress regarding how much primary care physicians should earn.

As a starting point, ACP recommends that the target be set at 80% of the annual compensation received by the median or average compensation of all non–primary care specialties.

b. Medicare fee-for-service payments to primary care physicians should be increased over a 5-year period to account for the program’s proportional contribution to achieving the target annual compensation level. This should be implemented as soon as practicable through an adjustment to payments, as determined by the existing fee-for-service methodology. The adjustment each year should be no less than one fifth of the amount needed to reach the 80% threshold over the 5-year period.

This is good stuff.

Read the rest here.

I Am A Specialist In Hospital Medicine

It's getting better, but anytime I  walk into a room and introduce myself, I have stopped telling patients and families I am hospitalist.  It's too complicated for many of them.

Instead I just say simply.

Hi Mrs Smith.  I'm Dr Happy.  I'm a specialist in hospital medicine.

And move on from there.  I know I'm a primary care trained internist.  But this way the patient doesn't think I don't do anything but consult other doctors (which many patients believe is my role) and using the word "specialist" gives me credibility in an America  where everyone expects some sort of magical specialist with genie powers to march in at my calling to make them better.

I have stopped telling patients that I do what their primary care doctor does, only I do it in the hospital.  Most patients have a belief that their primary care doctor doesn't do anything but screen, prevent and refer actual medical care to other doctors.  For many patients this is their reality because many primary care doctors do send everything to specialists, sometimes out of ignorance, sometimes out of laziness, sometimes out of economic necessity and sometimes out of legal necessity.  And patients suffer.

I figure, if the patient considers me a specialist from day one, it makes my ability to do my job so much easier.  And they aren't asking me every day when the specialist is going to come.  And if they do, I tell them that's me.

Health Care Reform Is In Reach

This is an op-ed from a week ago.  One thing stuck out in this article that I strongly agreed with

Moving closer to a health care model where patients are rewarded for living healthier

In FREE=MORE, the patient is rewarded for incurring costs.  They have no incentive to do less because everything is paid for.  The same goes for physicians who bill on a fee for service.  Do more, get paid more.

Having systems in place where you are rewarded for doing less seems like an obvious way to control costs.  People respond to money.  Either we have to bribe people to stay healthy or we are going to have to simply stop paying for care.  

Which would you rather have?

Using Television To Feel Better About Yourself

How so you ask?  

Would You Let An Optometrist Do Surgery On Your Eyes?

There seems to be a push in many states to expand the scope of practice for optometrists, including apparently surgery. Optometrists go to optometry school.  They don't go to medical school or do residencies that train them in surgical interventions on the eye.

The American Optometry Association says:

In a statement, the AOA said: "Although a decision on whether to seek expansion of scope of practice is left up to each state, the AOA encourages all states to take the necessary measures to ensure they are able to treat patients to the full extent of their education and training, and expand as they feel necessary to ensure access to quality care."

Interesting,  I think I've seen this before, somewhere else.  I just can't seem to pin it down.  Perhaps ophthalmologists should all abandon medical school and four year residencies in favor of the four year optometry model.  Cheaper.  Quicker.  More access.  Why do you need all that extra education anyway?  It seems like it does nothing but increase costs and decrease access to care.

There is a portion of America that lets street artists do this, so you never know.

Make Sure Your Patients Know As Well

I suggest that two professionals practicing within the same scope of practice should be certified by the same standards.  In the comments section anonymous responds

I think you're missing the point here. NPs will practice advanced clinical nursing skills not medicine. So I don't think your argument that NPs be certified to the "same standard" is valid.  

This is a new one for me.  I had no idea that a 78 year old with chronically uncontrolled DM, chronically uncontrolled HTN, AFib, chronic systolic heart failure, CAD, hypothyroidism, 3V CABG, COPD, OSA, chronic stasis edema, immobility and  morbid obesity  who comes into the "primary care" nurse practitioner clinic with a complaint of dizziness and shortness of breath was going to get an "advanced clinical nursing skills" evaluation and not a medical evaluation.

I stand corrected.  Please excuse me for my ignorance. Now please explain to me how you plan on evaluating the patient without employing the process of the medical differential diagnosis, the part you say you don't do.  I'm curious beyond all belief on how advanced clinical nursing skills will solve the answer of why grandma is dizzy and short of breath from an advanced clinical nursing skill set.

Are you going to tell her everything is OK and give her a hug?  That seems to be the mantra of NPs who claim compassion trumps the all unimportant "medicine" as you call it.  Or do you just send them to the ED to get a medical evaluation by a doctor and wait for your next patient, the healthy 50 year old man with hypertension. 

If you're not practicing medicine, perhaps you should let your patients know as well.  And Medicare and Medicaid.  And all other insurance companies as well.  The E&M codes you bill are certainly medical evaluation codes.  Remember the third component is "medical decision making", not advanced clinical nursing skills evaluations. 

How To Phone In A Prescription

It's a good thing I never have to do these. 

3.  Say the patients name in a way that we can understand.  You may be proud of your Mexican accent and the way you say Mexican names, but the non-Mexican pharmacist on the other end of the phone has no idea how to spell your ooplahs, n-yays and tongue-rolls.  Most pharmacists will want you to spell the name anyways due to the outrageous and stupid names people are making up for their kids now-days.  Say it like a white-boy and you should be safe.

A Love Vaccine?

This is crazy stuff.  And who goes to oxytocin sniffing parties?

In a New York Times article responding to Young’s essay, John Tierney argues the practicality of a love vaccine. This isn’t science fiction - an oxytocin blocker does turn normally monogamous female voles into philandering playgirls. What having blocked oxytocin would actually feel like is hard to imagine. Would the females be enjoying that sex or would it feel emptier?

Fascinating article. Via

Living Arrhythmias

Like You've never seen them (it's a silent video)

via Blog Around the Clock

I Nominate This Asset For TARP

Beautiful Two Story With A View.   Large Open Air Second Floor Bathroom. Professionally Remodeled.



I snaped this photo during a stroll down the pretty streets of Atlanta. I look at this picture and I'm reminded of the trillions of dollars Obamesiah is flushing down the tube trying to prop up assets that have no intrinsic value. Perhaps he would like to buy this troubled asset so the tax payers can smell the hope and change first hand.

We might as well rename it the CRAP program.

Just Put The Lotion In The Basket

I haven't had a camping patient in a long time. Come to think of it, I don't even know when it's indicated. If a nurse calls asking me for an order to go camping, there must be a good reason. The whole thing just seems to Hannibalesque.

Beauty From The Hands of a 97 Year Old

Born October 27, 1911.

Needle work from the hands of a ninety seven year old lady.

This is just amazing. And all done in one day.




Now, are you really as disabled as you say you are?

What Did You Do On Earth Day?

I tilled the field. Happy's getting a garden this year. Here I am tilling up the clay with a 40 year old tiller. It's old but works like a charm.

Here's the plan. Carrots, tomatoes, cherry tomatoes, cucumbers, red peppers, peas, yellow squash, cantaloupe and beans.





Tillin' the field



What are you planting this year?

Truth In Marketing

Perhaps a Little Controversy Erupting?  

I like Dr Val's site.  She has some good original content and content aggregation.  I didn't know she was claiming 11 million viewers a month.  Perhaps a contribution from Happy could make that 11,022,731 viewers a month.

Here's my truth for the month of March, according to  Google analytics, which I consider highly relevant and accurate data.  It seems to under count by about 10-15% what I see on other stat counters embedded on HH, but so be it.

Month of March

Visits 22,731

Page Views 36,100

Pages per visit:  1.6

Average time on site:  2 minutes 16 seconds

Traffic sources

Referred from other sites:  42%

Search engines:  30%

Direct traffic:  28%

I don't have any idea what this all means.  I don't know what the "industry" standard is, what's excellent or  what's poor.  I suppose if people keep commenting, good or bad, at least my little domain keeps for some interesting reading.

What do advertisers like to see?  Any ideas?

How Do You "Brush Up"?

A reader asks the question: How do you go back to hospital based medicine after eight years?

Happy,

I have followed your blog for some time now. I have always been a hospitalist at heart, but have been doing "traditional" internal medicine for the past 8 years. I have been working with a group who only does outpatient medicine and I have now made the plunge and just signed on to a new position with a new group in my town.

Any recommendations on getting back up to speed? I'm not too bad rusty, but it couldn't hurt to brush up on a few things.

Thanks!

A lot has changed in eight years. I wouldn't even know where to begin. I suppose many things are like riding bicycles. But so much as changed. Even the documentation games that we play change yearly. Hospitals don't like you outpatient guys much because you don't play the documentation games hospitalists do. Games that bring in millions of extra dollars a year in pure gravy. Quality initiatives that are required for hospitals to get their full cash cow as well.

From a medical standpoint? You need to decide if you're going to do ICU medicine. If you are, realize it's hard to practice ICU from the clinic. Also figure out if you are going to be one of those docs that just show up to write consults for other docs. Are you going to be that doc at 2 am that tells the ED doc to have GI admit for a GI bleed or have renal admit for ARF or have cardiology admit for chest pain? If you are that doc, you will bring no value to your patients care.

Eight years is a long time out of the hospital. Any readers have some suggestions on how to get rid of the rust?

This Is Why the Words Primary Care Need To Be Abandoned

From a PhD. Presumable someone who is highly educated and capable of logical thinking skills. The lack of critical insight into what defines primary care is striking. Here is the comment in its entirety.

I just thought I'd jump in here with an outsider's opinion. I'm a different kind of "Dr" (PhD in astrophysics). I'm also married to a Nurse Practitioner, to whom I would happily entrust my primary care over most physicians that I know.

While I am well aware that many NPs are not "fully qualified" to be primary care providers, I would submit that neither are many MDs. I would further assert that, from my experience, what many NPs lack in training, they often make up for in diligence and compassion, making them preferable by far as providers than a well-trained but apathetic physician who thinks himself (or herself) superior to the task at hand (not meant to be a blanket condemnation, but rather a description of certain individuals I've encountered).

But that is not the point I wanted to make. It seems to me that much of your argument depends heavily on an erroneous definition of the term primary care. You speak frequently of inpatient primary care, and I would submit that there is no such thing. Once a patient has been admitted to the hospital, they are no longer undergoing primary care. An inpatient is, at the very least, undergoing secondary, if not tertiary, care. As a hospitalist, you are not a primary care physician. By definition, primary care represents the first contact of a patient with the health care system, and one of the most important characteristics of a good primary care provider is knowing when a patient's condition is beyond his/her scope, and it is necessary to refer them on to the second tier of health care.

As a doorway to the health care system, different primary care providers may be able to handle a wider or narrower scope of care, and thus one provider may be comfortable handling patients that another would choose to refer to a specialist. As a rule, I would expect an NP or PA to have a lower threshold of acuity for referring patients than a DO or an MD, and I think that is entirely appropriate. It should be viewed not as a weakness of the practitioner, but rather as a strength in the recognition and acknowledgement of their own limitations.

As MDs have abandoned the field of primary care in favor of more challenging (and lucrative) specialties, mid-level practitioners have moved in to fill the gap that they have left. In doing so, they have provided an efficient and cost-effective alternative, for which they should be applauded, not vilified.

First of all, let me say, I have no doubt in my mind that there are good doctors and there are bad doctors. And there are some really, really bad doctors out there. Doctors who have no business practicing medicine.

With that said, I would counter that preferring to pay someone for compassion instead of a medical evaluation is like paying for sex. And that makes you a John. In the appropriate situations, both should be free 100% of the time. If you aren't getting compassion from your family, your friends, your church or your priest, then paying a nurse practitioner $75 because your husband won't listen to you is the same as paying a prostitute $75 for sex because your spouse cut you off.

Compassion is not something I would ever consider paying someone for. And anyone who accepts money just to dish out compassion is no different than the prostitute selling their body.

Before you slam me, this isn't to say that health care workers shouldn't be compassionate. They should be. But to pay someone because they make up in compassion what they lack in clinical evaluation and management skills is simply ludicrous. I would take an apathetic but competent clinical evaluator 100% of the time. I would kindly get my compassion for free from those who aren't being paid to dish it out. Exchanging money for compassion is a denigrating proposition in and of itself. It turns something which should be free of financial interference into nothing more than a service.

You are also sorely mistaken when you believe that inpatient medicine is not "primary care" Primary care is not the doorway you like to believe. It is the house. Primary care's role is not to screen the patient to see what other subspecialists can get involved. The role of the primary care physician is to be the physician that takes care of them. I take care of many patients from start to finish with no subspecialist consultation. What does that make me if not the primary care physician

What you seem to believe is that NPs, in general, have a lower threshold to refer. I would agree with that, in principle. Certainly in practice, variation in referal patterns are influenced heavily by payer mix and volume models. Perhaps what you envision is a system where all patients are shuttled through NPs who siphon off the "easy" patients (by MD standards) and move the more complicated patients on to subspecialists. Patients that many internists could handle without referral.

What you seem to be saying is that it's OK for NPs to have a lower threshold of referral. I'm saying it's not. It's not OK for us to create a medical system where complicated patients are farmed out to multiple subspecialists in a never ending game of pin the tail on the procedure. I am saying that such a model increases costs by increasing FREE=MORE medicine. The role of the primary care "provider" is not to farm out complicated patients. It is to manage complicated patients. If primary care was simply there to be the glorified triage artist, primary care's value is zero. Perhaps this is the model of care you invision, one who's value is zero.

Any model of care that has, as its basic foundation, a provider who's main duty is to consult with others is a model doomed for economic failure, UNLESS, you ration with unfettered impunity, the costs associated with the proceduralization of such a model. If you want a model that uses subspecialists and not internists as the foundation of comprehensive care, be prepared for the most expensive model of care known to man. That which has no boundaries or limitations. Good internists define that boundary for which to work with.

What you seem to be saying is that internists have abandoned their field for highly lucrative procedural fields and therefor the solution is to allow NPs and to take over their role.

This is so completely backwards on so many levels, it's frightening to suggest that the solution to better care is to have providers who have a lower threshold to seek subspecialists who have entered the field because of the lucrative procedures. What NPs cost less on the front end, they loose exponentially on the back end, assuming you believe they have a lower threshold to refer than internists (at least good ones).

The solution is not to replace internists with NPs who have a lower threshold for referral. The solution is a model where fewer referrals are made. Where primary care is not viewed as a front line access to care, but rather the care, in its entirety. Until internists are paid for their time to take care of complicated patients, they themselves have become nothing more than triage artists farming out their patients in a volume mill of economic survival. And in fact bring little value to their role.

As for your assertion that subspecialties are more challenging. Hardly. Here's my experience with community based "more challenging" cases. If a case is really hard or time consuming, they get referred to the academic mecca where the "real experts" in the field get to tackle the latest and greatest case of reallyhardandtimconsumingitis. It is a rare subspecialist in Happy's Hospital who thrives on the interesting case. Rather the bread and butter pays the bills. And the bread and butter procedures pay for thrills.

Your entire thesis as to the appropriate role of "primary care" provider is why those two words need to be abolished from any association with internists and comprehensive care. Primary care is not the doorway to care. It is the care.

On Risk and the RVU Scam

Here's my position. I am no more risky as an internist admitting a patient through the ED than is a neurosurgeon performing a craniotomy for a head bleed. As it stands, somehow, somewhere bad outcomes became linked to risk. Because a patient dies or becomes disabled from illness does not mean that malpractice occurred. Yet our current malpractice model seems to link bad outcomes with risk and creates irrational premiums based, not on the practice of good or bad medicine, but rather on good or bad outcomes.

With that said, Medicare has fallen into the trap of subsidizing this irrational malpractice market. I discussed risk here. Which lead to a discussion on Medicare and RVU here...

jb said...

The malpractice component of the RVU is based on the relative insurance premium paid by the specialty, not any vague gestalt of the risk of a procedure or episode of care. It's the most reality-based component of the RVU system.
As I have said previously, ad nauseam, it's not exactly a secret that I as a surgeon get paid more than you as an internist, and that has been well known by everyone in medicine since approximately the Year One. You say that it doesn't bother you, but you complain about it so much...

April 20, 2009 5:27 PM

The Happy Hospitalist said...

jb. Blogging about an irrational payment model is not complaining, it is blogging about an irrational payment model. By the way, you don't know how much I make as a hospitalist. I blog constantly about how hospitalist medicine has left the constraints of the irrational RVU restrictions. Not that it matters, nor do I care, but since you brought it up, I may just make more than you, considering my hours in the trenches.

As for your assertion that the malpractice component is the most rational RVU component, I would believe that if the actual malpractice model was rational.

If malpractice insurance was based on actual risk, than I can only assume that you as a surgeon are more risky as a physician than I as an internist. And by risk, I don't mean the types of care you provide are more risky, which they aren't, but the quantity of poor care you provide is greater, which makes you a riskier physician.

You see, if you are a poor surgeon and I a poor internist, both our risk would be equally high and both our insurances would be equally high. If we both practice stellar care and carry no lawsuits, both our risks should be equally low and both our premiums should be minimal.

As it stands now, you could go your entire life without losing a lawsuit and pay vastly higher premiums for no reason at all but to perpetuate the fraud known as malpractice insurance.

You as a physician are no more a risk to your patients than am I, if we both practice evidence based medicine. Yet we are priced by vastly different standards. Your work is perceived as more risky, when in fact not such risk exists.

That Medicare rewards you by paying your higher malpractice premiums is a sham and perpetuates the fraud that some how you carry more risk because you are a surgeon.

Besides, if you were the worst surgeon that ever lived, and your actual malpractice premium was 10x higher than the average surgeon in your geographical district, you would not get 10x the payment in RVU for your malpractice coverage. Which means that the malpractice component is not a true practice expense component. It's just a sham.

But all this is a moot point. Why? Because Medicare has no business being in the business of reimbursing physicians for their practice expenses. When I buy toilet paper, the grocery store doesn't charge me based on how many pleats I use each time to wipe my ass. Some people may go through one role a month. Some may go through one role a day. It's not the grocer's problem how often I go through toilet paper. Should they charge me less if I use 20 pleats per wiping rather than 10? Of course not. That Medicare pays you more to cover your malpractice insurance is a sham. Perhaps they should pay you more in practice expense because you opened an office in Trump Towers as opposed to a small building of bricks 20 miles from the shopping district. It's none of Medicare's business to pay you based on how much your business costs to operate. In no other field can I think of will the government pay based on how much it costs to run your business. Only in America does the government pay based on a self reported survey of how much you say it costs to run your business. Talk about a conflict of interest.

The RVU payment system is a scam, through and through. A scam hospitalist medicine has left in many ways. Medicare has no business paying anyone based on how much it costs to run their business. It's up to the physician to control costs however they see fit. And if they can't survive on the Medicare fee, they should drop out of the program until Medicare raises their prices, or they can create a leaner practice environment.

April 21, 2009 11:13 PM

Are You Thinking About Starting A Rural Hospitalist Program?

A reader asked me the question:

Do you have advice for a small rural hospital that wants to start a hospitalist program?

The most important component to a successful hospitalist program, whether rural or big city, is to have a strong backing by administration. An administration that understands more than revenue in = revenue out. In Happy's neck of the woods there are major big city hospital systems that have been trying to get hospitalists up and running for almost 10 years and have failed miserably. Why?

Because administration believes, and continues to believe that the only way to run a program is to look at front door revenue generation (physician billing) as the only parameter to determine success or failure of a program. These are the programs which are based only on revenue generation targets. And they will almost always fail because revenue comes at the expense of efficiency and value in every other aspect of the value tree.

The most successful programs are those in which the administration understands the vast tentacles of value that hospitalists bring to their medical system, independent of physician billing. Tangible and intangible parameters that can make or break the fiscal health of the institution as a whole.

Many hospitalist programs are doomed to failure because administration fails to understand the dynamics of hospitalist medicine. They fail to staff appropriately. And when hospitalists leave for greener pasteurs, they are left with a high likelihood of burnout by those remaining.

Rural has it even harder because it is hard to staff. Nobody wants to do rural. Here's my advice

1. Only administrations that appreciate physician billing as a small component of determining success of a program will survive. If your administration believes that physician billing is the most important sign of success and they make their decisions accordingly, the program is doomed to failure.
   
2. Don't under staff. Many programs try to skimp by. When one doc leaves (and they will), it puts the others on the road to burnout real quick. If you can't fully staff with enough physicians plus buffer for growing pains and the quitters, then start the program part time. Perhaps no weekends or no nights. Whatever, if you don't have enough physicians to run the program, it's doomed to failure from the start.
   
3. Be flexible. The larger your pool of candidates, the more successful you will be in starting the program.
4. Keep lines of communication open between docs and administration. Hospitalist jobs are everywhere. Administration in rural America must understand that they don't run the show, the docs do. Why? because the docs can leave and land a job just about anywhere they want. It's a buyers market for hospitalist medicine. It will be for quite some time. We are only getting started.
   
5. You're going to have to pay more than you think. It's rural. And it's hospitalist. Think big.

It's A Birthday Party

Over at Grand Rounds

Expect Little and You Get Little In Return

I got this comment from, I can only assume, a burned out nurse. It was in regards to a post some time back about nurses calling me non critical critical lab values.

I had to laugh when I read about your night shift nurses calling you at odd times......... Welcome to the world of MD. I wish I had a dollar for every time I had to save a doctors butt for things they didn't order or do. You as a MD agree to be on call at night we don't make them. There are hospital policies that we have to abide by, but obviously you did not look these up before you wrote this article. Hmmmmm.......If I don't call "your" Critical, "non critical lab, and your patients dies from it, will you go to court for me and cover me? Think not! Like I said, maybe you should check your hospital policies so you can at least "sound" educated. Or not. I bet your one of the md's that go assess their patients without washing their hands first, with no stethoscope in hand,think you know exactly everything after being in the room 2 mins. Don't dare grab my stethoscope with your dirty ear wax on them that you don't even bother cleaning.

In answer to your questions. I would go to court for and testify in your defense if you used your critical thinking skills to make educated decisions based on sound scientific principles. If a patient dies with their noncritical critical platelet count of 30K I would defend your decision not to call me. If a patient dies with their non critical critical Hgb I would defend your decision not to call me. If a patient dies with their non critical critical HCO3 I would defend your decision not to call me. I say this because I know that the cause of death would not be a non critical critical lab value.

When you are allowed to use your thinking cap to make educated decisions on what is critical and what is not, you have proven yourself to be worthy of your training. Patients do not die from noncritical critical lab values. By definition, they are not critical. How's that for defending your ability to be a nurse.

As for hospital policy, I have already made an inquiry into the standards at Happy's Hospital with the hopes of changing the policy on calling noncritical critical lab values to allow nurses to be nurses and not just robots.

Now, hospital policy also works in the other direction, protecting the hospital from uneducated robot nurses who can't tell me what the "bicarb" level is when they are looking at a BMP. Who can't tell me the difference between Lovenox and Coumadin or how both are used in the prevention of VTE on an ortho floor.

Hospital policy should not be set on the lowest common denominator. If you expect little, you get little in return. Making hospital policy based on the least capable nurses is like organizing medical school around the capabilities of its most educationally challenged students.

I presume, based on my experience, that there are a lot of nurses who have no business being nurses. They have some how forgotten how to think and have become nothing more than documenteurs of facts for legal based chart medicine, hiding behind the hospital policies that protect them from their own horrid lack of skills. These are the nurses who scare me to death. Not because I think they are bad people, but because they are incapable of understanding basic science principles necessary to recognize healthy from sick. These are nurses who should not be nursing, no matter how big the nursing shortage.

Training nurses to just be a body to collect facts will make for worthless nurses. If that's all you do, you could be a nurse's aid in four weeks at the community college. Allowing incompetent nurses to take care of patients is an embarrassment for the nursing profession. And something you,as a nurse, should be ashamed of. If you are going to be a nurse, know what you are doing and do your job well, don't just do it.

And shame on hospitals for establishing their protocols for the lowest common denominator. By doing so, you are just begging for the lowest denominator of care as well. Expect little and you get little in return.

SOLD OUT!

The Society of Hospital Medicine International Conference has sold out. I find this amazing. In the deepest recession in over half a century, you should be too. You should be amazed at the strength of the hospitalist movement. While outpatient primary care is falling apart. While general surgery is slipping away. While most subspecialists are leaving hospitals for the safety of their own invitation only hospitals, we have hospitalist medicine thriving on the merits of the strength of the value it brings to the table.

Walmart didn't become the biggest retailer in the world because they had nothing to offer. Hospitalist medicine is proving to be the Walmart of the medical world. Bringing value to everything it touches.

What? No Helicopter? How Dare Thee

It's easy to look at a life flight helicopter program and say it's too expensive to fund. Few will look at this as overt rationing. But it is. And look at the drama created by one simple act of trying to control a state budget when you choose to ground one of two flight helicopters because the state is millions of dollars in debt

“I heard about it and I was like, ‘Are you kidding me?’ How can they possibly put a value on a life?’ ” said Debra Moran of Preston, who credits Life Star helicopter with helping to save her 16-year-old son last summer. He was critically injured in an ATV crash in Ledyard, 55 miles from Hartford and the nearest trauma center. “Would they say a respirator is too expensive and they are not going to have an I.C.U. anymore?” she said.

How can they possibly put a value on a life? I can answer her question. When you put no value on life, then paying for all care without consideration for cost will eventually make no care the only feasible outcome for all. Unless restrictions are placed (rationing) FREE=MORE health care will always implode on itself when given enough time.

Folks, this is overt rationing. And it's just the beginning. If you want the government to pay for your health care, you had better start donating to the lobby arm of the Match Made For Heaven Committee, a congregation of humans entrusted with the role of playing your God with your tax money). Or start saving all your money for your future health care expenditures. Look at this fight over a couple million dollars. This is peanuts compared to the tens of trillions of federal tax dollars mandated without funding in the next several decades.

If one state can't even decide on how to cut a couple million dollars in health care spending, I have no doubt that our country is not ready to make the difficult choices. One more reason to stay healthy. Eat right, exercise and don't smoke. Because one day the Match Made For Heaven Committee will decide it's your time.

Unmanaged Expectations

We live in a society where the expectations of the outcomes by physicians are so often met head on by the unmanaged expectations of families who believe that their 87 year old grandma with Alzheimer's is going to live forever. A lot of families get it. But a lot don't.

I think the unmanaged expectations for a lot of those that don't get it are guilt driven, financially driven, culturally driven, media driven and technology driven. I've heard it all.

1. "I'm not going to be the one to pull the plug"
2. "Keep grandpa alive until midnight so I can collect his disability check for the month."
3. "We are entitled to immortality"
4. "Everyone walks out of the ICU on television"
5. Dr House
   

We live in a country where so much of our medical care and by default, expenses are directed toward saving what's already dead. Cells that we can crush, squeeze, stent, cut, kill, radiate, burn, and medicate. All our tissues are on a life long journey from life into death. We can't create healthy tissue out of the dead stuff. Yet we spend all our money trying. Almost 2.5 trillion dollars a year. When are we going to wake up and stop paying for death and start funding life. Processes that are proven to prolong active quality lifestyle?

1. Calorie control
2. Exercise
3. Not smoking.

Trying to change the unmanaged expectations of a culture in denial is like trying to get an orthopaedic consultation on a patient at Happy's Hospital without insurance. It will never happen. The madness will end, one way or another. It will end.

The Perception of Risk

I wrote about my thoughts on risk. I believe so much of medicine is driven by a perceived risk that does not exist. A perceived risk that drives irrational standards of care that self perpetuate themselves in a spiraling unsustainable economic death spiral.


I don't think I'm alone when I speak the truth about my own perceptions of risk. I am much more likely to view a young patient as carrying more perceived risk than an older patient. I am much more likely to view a previously healthy patient as carrying more perceived risk than one with multiple chronic medical conditions and an acute toxic surgical abdomen.

Why? Because my perception of risk has more to do with my (correct) expectation of recovery from illness than it does with the actual recovery itself. My perception of risk hinges on my expectation of recovery, not the actual recovery itself. This is a critical point to remember so let me give you two examples of patients to ponder.

1. An 87 year old Alzheimer's patient (and no other medical problems) presents with a three day history of fever, shortness of breath and cough. ED evaluation shows a BP of 85/50, HR 120, Temp 102.9, WBC 20K, Cr 4.5, BUN 110, gluc 220, Hgb 11.2, platelet count of 78K, shaking rigors and a very large RLL pneumonia.
2. A 35 year old healthy married man, gainfully employed, with no medical problems presents with three day history of fever, shortness of breath and cough. ED evaluation shows a BP of 85/50, HR 120, temp 102.9, WBC 20K, Cr 4.5, BUN 110, gluc 220, Hgb 11.2, platelet count of 78K, shaking rigors and a very large RLL pneumonia.

I ask you only one question.

1. Which patient is more risky?

The answer is neither. Practice good medicine and the risk of both patients is zero. The risk of a bad outcome is much higher for patient #1 who carries a much higher chance of death. A natural death.

However, I contend that the perception of risk is far greater for patient #2. Not because they have a higher chance of death (which they don't) but because the expectation of death and disability is far less. And therefore, any bad outcome is perceived (inappropriately) as negligence and not a progression of the disease process.

The perception of immortality lives on for the young and healthy and any deviation from that expectation is a perception of negligence and therefor a perception of risk by the physician, even if no risk exists.

Both patients presented with the exact same scenario. But I would view patient #2 as riskier (which is only perceived) every single time, in spite of patient #1 having a much higher rate of mortality based on nothing more than their age. This is what I mean by actual risk vs perceived risk.

A physician's expectation of recovery for patients of advanced age or with a heavy burden of disease is far less than young and otherwise healthy patients. Which explains why two patients with identical presentations will be triaged within the mind of the physician as having far different expectations of outcomes and by default, risk (or perception of).

Do Different Doctors Have Different Risk?

I attempted humor, suggesting surgeons are the only ones hanging around the doctors lounge because they see 1/3 the patients and charge 5x as much. Suggesting they have plenty of time to watch TV and eat free food in the lounge. A reader (physician?) responded:

They kind of take more risk though. Let them sit back and chill. I would never want to be in their shoes. I love my safe little clinic...

"They kind of take more risk though"

I disagree with that assertion. I don't think any physician, who is trained in their scope of practice, takes on anymore risk than any other physician, regardless of what field of medicine they practice in. In the current malpractice market we know as American medicine, I see an irrational linking of bad outcomes with bad medicine. Higher rates of bad outcomes does not mean that more bad medicine or more negligence is occurring. Or that there is more risk involved. It is simply the nature of the disease process or the limitations of the procedural/surgical intervention when bad outcomes occur.

Yet, physicians are charged accordingly on their med mal insurance rates. More bad outcomes? Higher insurance, regardless of the natural disease process.

Let me give you several examples. Neurosurgery has some of the highest malpractice rates, especially cranial privileges. In some parts of this country, you cannot find a neurosurgeon on call for cranial trauma because of malpractice coverage rates. If you are in a car accident in the middle of the countryside, sometimes you have to bypass major population centers because neurosurgeons have given up their call in favor of elective outpatient based interventions.

Let's say you are thrown from a car because you are drunk and you weren't wearing your seat belt. Let's say you have a large intracranial hematoma in urgent need of intervention. Let's say you make it to a neurosurgeon, who does everything right but the patient turns into a vegetable anyway. Let's say the patient develops a rebleed two days later and dies.

Compare this with an outpatient internist who is managing a patient with heart failure and chronic kidney disease. Treatment with potassium, lasix, ACEi, beta blockers, digoxin, statin. The patient presents to the ED in a sinusoidal heart rhythm as a direct result of life threatening hyperkalemia due to progressive renal failure from medication, diet, and natural progression of the disease process.

In both cases, the physician has performed their duties appropriately and both patients have died despite appropriate care from vastly different patient experiences.

The question I ask now is, who carries the greater risk? Is a neurosurgeon, practicing within their scope doing anything more risky than an internist practicing within theirs?

No. Both patient populations carry a risk of death. Both patient populations carry a chance of bad outcomes. So how can you define one as more risky than the other?

Risk is me practicing neurosurgery or a neurosurgeon practicing internal medicine. Practicing medicine you are not qualified to handle is risky. Doing what you are trained to do, despite bad outcomes is not. Yet we continue to link outcomes with risk.

If bad outcomes was a measurement of risk, then doctors who specialize in palliative care should have the highest malpractice premiums of all, as their chance of bad outcomes, defined by death, approaches 100%.

This is another reason why I contend the RVU system is a sham. Part of the payment of the RVU system (relative value unit) is the a malpractice RVU component. One RVU is worth about $35 according to Uncle Sam. For every encounter, a small number of RVUs are paid based on the perceived malpractice risk of the encounter. Every encounter I face has risk as long as I am not practicing sound medicine. Now, how many RVUs does Medicare pay for a 74 minute critical care patient, on their death bed with severe septic shock?

1/5 of 1 RVU in my community. About 0.2 RVUs. About $7.

How many RVU's does medicare pay for a craniotomy?

over 5 RVUs. About $175. This is more than the 74 minutes of critical care time I spend on a patient with severe septic shock and multi organ failure. A surgeon gets paid more just in malpractice expense than I do in all my efforts, even though their risk of a bad outcome is no different than mine, and in many cases, far less.


I contend that the Medicare payment model of risk, is in no way linked to the actual risk involved, and instead is being paid for on the basis of perceived risk driven by a backward malpractice legal system that self sustains the perception of risk. When in fact, minimal to no risk actually exists (as witnessed by the low rate of med mal payouts.)

If you are practicing sound medicine within your scope of practice, the risk is zero. Unfortunately, our entire med mal system is built around an irrational perceived risk that does not exist.

And this perceived risk has created an irrational standard of care that feeds irrational medicine and creates standards that are not achievable, even based on sound scientific principles.

With that said, my risk as an internist/hospitalist is no different than the risk of a neurosurgeon. The perceived risk is however, what matters. And that has driven entire insurance industries and med mal lawyers that self sustain themselves if for no other reason than to perpetuate their massive fraud on physicians and the general public at large.

A Tree Growing Inside A Lung

Part of your expanded differential diagnosis

And so to the Urals, where medics are reported to have removed a tiny fir tree from a man's lung, after he complained of chest pains. Before doctors opened him up, they were convinced he had lung cancer. Now, they're convinced he inhaled a seed, which sprouted inside him.

Tree lung. You don't see that everyday.

I bet the guy was a smoker. Lots of soot and toxic gases for the tree to thrive on.
via Boing Boing

How To Perform CPR On A Lemur

This is a great story.  Baby lemur falls into water.  Mama and Papa lemur look frantically as baby goes under.  Zookeeper finds baby lemur  and performs CPR.  Watch this dramatic rescue unfold.  I once tried to perform the Heimlich maneuver on my dog when I was young.  But I've never had to try CPR.  Your pets really are part of your family.  

"I Am Not Your Enemy"

What do you do when you walk into a room and family members start yelling at you? I know that the family cares deeply for the health and safety of their loved one. A loved one they feel nobody is looking out for. Someone they feel is being ignored. Someone they feel is suffering at the hands of a dysfunctional system where communication is non existent.

I recently had an encounter with a patient's family, transferred from the nursing home with acute exacerbation of a chronic medical condition. As soon as I walked in, I saw close to ten family members standing there ready to pounce on anyone with anything to say. I could tell, based on nothing more than the looks in their faces that this was going to be

one of those times.

One of those times where family is ready to unleash a tidal wave of anger onto the physician that just happens to show up to do their job. That physician just happened to be me. One thing I have learned in the last six years as a hospitalist is not to take anything personal. But also, not to accept verbal abuse as being OK out of frustration. I have no more a right to yell at family as they do to me, no matter how frustrated they are. I will not allow myself to be abused by a patient or a family. For any reason.

The whole idea of respect for the medical community left long ago when patients and families began their quest for irrational expectations. When patients and physicians a like became hired hands of third party systems where the delivery of medical care became nothing more than a a service that needed to be managed.

I cannot imagine for a moment that a physician would be treated with such disrespect thirty or forty years ago. I'm not even certain if the cultural acceptance toward verbally assaulting physicians is an entitlement for just Americans or if the experience is one of world wide acceptance.

We live in a performance driven world based on money. And the current reality is one of volume over time. Where a medication exists for everything. And a lack of improvement is taken as a physician's ignorance and not as a natural progression of the disease/aging process.

So what do I do when a family or patient starts to assault me with their words? I tell them simply

"I am not your enemy. Yelling at me will not make me do anything for you that I am already doing."

I find that this will often difuse the situation quickly and redirect the anger to someone other than I.

If they continue to yell, I remind them over and over again that I am not their enemy. And before long I generally I have a room full of people apologizing to me for their rude behavior.

Observation of the Day

The only docs I ever see hanging out in the doctor's lounge are surgeons. Is that because they have so much time more on their hands collecting 3-5X what I can collect seeing 1/3 as many patients?

Gosh Darn It, You Are Good Enough

From the comment file:

I've just found your blog courtesy of other great blogs. I read about nurses and NPs since I'm an NP. I went to a top ranked ivy league nursing school. You know what? I had to agree with your comments. My training as an NP was inadequate for me to practice safely independently, let alone in a supervised setting. I graduated near the top of my class, great grades etc. I realized as I went through the program that I was being spoon fed "medicine ultra lite." I have chosen to do this to myself, I continued to tell myself. Now I am 9 years out of my training. I wish there had been some kind of residency/internship for NPs. I wish there was a doctor who really was interested in supervising/training me. I wish a lot of things, but nothing can take back those years. I work very hard to educate myself so that I can be safe, to know what I do not know.

NP, it's nice to hear a breath of fresh air from someone who can admit to themselves that what they are being asked to do and what they were trained to do are are not congruent. The human body does not live in a bubble. You are being asked to perform tasks that you were not prepared for, even at the most prestigious of institutions.

Now you say

I wish there had been some kind of residency/internship for NPs

It's called medical school/medical level residency. But I admire your integrity for acknowledging the deficits in your training, despite a decade of experience. Especially when everyone was telling you that

Gosh darn it, you are good enough.

when you know your training tells you otherwise.

Straight From A Veteran's Mouth

I couldn't have said this any better myself.

I am a disabled veteran.  (And, no, the nature of my injuries is not open for discussion.) I served in Desert Storm. I spent the last three years of my enlistment undergoing physical therapy and taking drugs that would get me arrested if not prescribed by a Navy doctor.  I spent four years after being discharged under the care of the VA hospital in Birmingham, AL.  I never saw the same VA doc twice in a row.  It took months just to get a test scheduled, months more to get the results.  I actually lost a job once because I told my boss if I don’t go to B’ham next week it would take four months to get another appointment, and he told me I couldn’t have the day off.  During those four years, I was given experimental drugs by an intern who was doing a study and couldn’t get volunteers at a civilian hospital or a prison.  I was given a pain drug that was a THC derivative so powerful that I couldn’t function through the hallucinations.  The VA sent me powerful narcotics through the US mail that were stolen from my mailbox and not replaced.  The VA required me to use private insurance or cash to pay for some of my drugs, but thankfully none of my treatments.

And I never got any better.

Not until I went cold turkey on my meds (with the resulting psychotic episode) and saved enough to go to a private doctor and pay her cash instead.

The VA had no agenda here.  They weren’t deliberately trying to make my life miserable. They just didn’t care

They just didn't care.  Welcome to socialized medicine.  I lived "they just didn't care" medicine as a training resident at a VA hospital.  I was the shepherd and the patients were my sheep.   And everything had two speeds.  Slow and stop.  Because everywhere you turned road blocks are built into the system to make people not care.

How do you measure frustration?

Thanks to a reader for pointing this out.

What Do You Do If The Patient Refuses To Be Discharged?

A reader asked me the question:

I wonder if you could do a post on when a patient refuses to leave the hospital. I just ran into this and I wonder how others handle it.

Ah. One of my most prized situations. I love having this talk. It used to be dreadful. Now I thrive for the opportunity. With science on my side, money will trump attitude just about every single time.

With the consumer driven "I am boss" attitude of all that is health care these days we as physicians will come upon many a patient that simply refuses to leave. Patients, for whatever reason, who feel they are "too sick", "too weak", "too lazy" to take care of themselves, either at their home or even at a skilled nursing facility for which they refuse to go to.

If the patient has Medicare, the answer is simple. You give them "The Letter". This new policy, in the interest of patient safety (or whatever) was instituted a year or so ago. It says that if a Medicare beneficiary refuses to accept the recommendation of discharge from the hospital, they can appeal their decision to some sort of Medicare board (reportedly a protected anonymous physician, but I'm certain it's hired nursing hands, based on my experience). The board has 24 hours to respond with Yeah or Nay. If the board agrees with the physician and discharge is appropriate, the patient is notified that Medicare will stop paying for their care as of now.

I have never had a patient decide they didn't want to leave if they knew their insurance coverage ended immediately.

The same goes for private insurance coverage. Most patients, if told that their insurance will stop paying for their care will leave without force.

Now, what do you do about the uninsured drug seekers? Those who claim to have chronic pain. Those without insurance? I don't do anything. If my medical decision makes a determination that discharge to the community is safe and and in-patient hospitalization is not necessary, I have science on my side to make my decision. The patient can throw the biggest tantrum they have ever thrown, my decision still stands. I will simply write discharge orders and stop seeing the patient.

Now, if the hospital wants to call the cops to escort the patient out, so be it. I have performed my duty as a physician. I am not an enforcer. I am not a cop. I am not a social worker or a Priest. Once I discharge a patient, I am done.

Don't let the moochers get you down. Let the patient's wallet make your decision for you.

Now, if a patient refuses to leave even knowing that their insurance will stop coverage, in all likelihood, the hospital will demand payment upfront for continued service of medically unnecessary charges at full price.

Always Keep In Mind

One of the most important lessons to learn from data that doesn't make sense, is that it probably doesn't make sense because it's wrong. Most of science can be explained. There is a rational basis for making most medical decisions. Whether that rational basis is followed or not leads to the large variations in practice style.

With that said, I want to give you an example of an ICU patient of mine years ago. A critically ill gentleman in the ICU. I was less than a year into my now six year gig as a hospitalist. I got called by the ICU nurse, frantic that the patients O2 sats were critically low, despite all attempts to make them better.

• Ventilator was working. We checked. We adjusted PEEP. We increased volumes. We suctioned. We did everything we could. Nothing worked
• We checked the CXR. No different than the day before. Unchanged pneumonia with a touch of COPD.
  
• We checked the rest of the vitals. Stable as a rock. No signs of extremis.
  

I read through the chart. I went through everything with a fine tooth comb trying to figure out what else could be wrong with this patient. Just before the patient was going down for a CT scan of the chest to look for blood clots, I asked the nurse to change out the oximetry probe attached to the patients finger.

Viola.

Problem solved. O2 sats 100%. The problem with this patient was that there wasn't a problem. I spent 45 minutes trying everything to get this patients O2 sats up. I almost forgot about one cardinal rule of medicine. If it doesn't make sense, it's probably because of bad data.

Always keep in mind that the data may simply be wrong. And things like

• Making sure the O2 tubing is hooked to the wall
• Making sure things plugged in.
  

happen far more often than you think it will.

A Revolution In Food Labeling

An Ah Ha Moment. Why hasn't anyone thought of this before? So simple in concept. What is it? Traffic lights.

According to the study itself, traffic lights beat out the other systems tested in helping consumers choose healthier foods. I hear rumors that the Institute of Medicine is starting a study to evaluate consumers' understanding of the various kinds of ranking labels on food products.

What do you think. Would traffic lights help guide you for quick point of sale food choice?

My Solution To The Health Care Crises: It's Time To Pay In Smiley Faces

I blog constantly about lifestyle choices and their relationship to preventable disease. I talk about the rationing of health care based on lifestyle, not because I like to refuse care to those unable to provide for themselves (which I don't and wouldn't). But because, as a society, health care will be rationed to a far greater degree than it is today. Beyond any imagination you can think of in this country.

Pick your poison. Do you want rationing based on age, disease or lifestyle. You can't pick your age. Frequently you can't pick disease (unless it is lifestyle related). So I chose lifestyle due to a lack of other rationing techniques.

And I am mocked. A am verbally assaulted and insulted. I get slammed as heartless. As being an ass. As being a cold physician with no bedside manner, who doesn't care about the sick and dying patient in front of me who brought their illness upon themselves. And I am here to categorically state, in no other uncertain terms, that this opinion of me is just plain false. You have no idea how compassionate I am as a physician. I have an excellent bedside manner, excellent clinical skills. I also know my limitations and would go above and beyond the normal call of duty to practice good quality, communication driven care.

So I'm here to let you know, when I speak about rationing of health care resources, I am being brutally honest about what is coming. If you want America to pay for your health care get ready for the rationing of your access to life. The Medicare National Bank will not survive in its current FREE=MORE form. The greatest Ponzi scheme that ever lived. The biggest lie perpetrated on the American people since the denial of Roswell's existence.

I present to you British medicine, I beacon of care to which we are often ridiculed for not emulating. Even with time based rationing of resources in the Land of the Free (stuff) health care, it's still is not enough to sustain. I would like to thank a reader for finding my salvation and showing you that I am not alone in my quest to educate you on how screwed we really are.

I present to you the next phase of FREE=MORE known more aptly as socialized medicine, British style:

He added that society was facing a moral dilemma over lifestyle issues such as obesity, smoking and substance abuse. Such issues must be taken into consideration when a patient was in need of medical treatment, he said. “We've reached the stage where these difficult issues can no longer be ignored. Fast-forward five years and this problem is only going to get worse.

They go on to add that "Public expectations are relentless". That's FREE=MORE folks, socialized style. This is exactly where America is heading. All health care delivery systems world wide that promise everything are unsustainable. Centralized planning will determine your fate. This is the unavoidable truth of government run health care.

One more reason that I will blog till the cows come home that you need to get out and exercise, stop eating at McDonald's and stop smoking if you want any chance to finish strong in your life. The government will not be there to save you as long as you believe they are your crutch to health care salvation.

With that said, I am ready to hear your apology. You cannot separate morality from economics in the current reality we all live in. You'd better get used to an economic driven performance based health care platform and ditch your morality, or find another way to pay for health care.

Perhaps we could give away smiley faces. Economics be damned.

Outpatient Perspecitve

Stated passionately by Internist X from the front lines. I will let his/her comments speak for itself. Something has to change on the current state of outpatient internal medicine. How about another study, or perhaps another working group, or committee, or perhaps another demonstration project. Here's your demonstration project...

Internist X said...

Happy, you nailed it. And as a true general internist, AND a specialist in HIV medicine, I can see both perspectives.

Nurse K, your point has some merit, it does take a team, BUT you are also glorifying catastrophe medicine--a system in which the high-tech, procedure-based subspecialty medicine is fetishized and glorified and rewarded financially, while the low-tech, non-sexy preventive THINKING medicine is cut to within an inch of its life.

That cardiac cath you're asking for has been proven, now, to be no more effective than intelligent use of medications--but it is a fancy procedure that costs a lot of money and keeps hospital cardiac labs in business. My Canadian MD friend laughs cynically at how many of her "snowbird" patients come back from the USA wintering having had their unneeded and expensive cath procedures. You've been brainwashed by high tech medicine into thinking that expensive poking and prodding is needed. Often, it isn't.

It *is* a team effort--but increasingly, the reductionist subspecialists are behaving as if their job is to do a very expensive procedure, send me a note saying, "We didn't find anything," and send the patient back to me. Most of them don't appear to think about the case at all. That this is the case, despite the fact that they are paid 2-3 times what I am, and have 4 times as much time with the case, is infuriating to me. I have found most of them to be useless to me--aside from that poking and prodding you referenced, which is only critical in a minority of cases. And almost none of them spend any time discussing their assessment, treatment plan, or the patients' questions about their conditions with the patient--that falls to me. Even though they have a hell of lot more time to do this than I do. I have often said, if someone would freakin' pay me enough per case so that I didn't have to see 25 people a day to stay above water, I'd be able to do a hell of a lot more for my patients.

When you're a hammer, everything looks like a nail. That is my lived experience of many currently practicing specialists.

So: If the subspecialists refuse to do any thinking on the case, and refuse to spend any of their much-better paid time explaining the assessment, workup, or care plan to the patient, that leaves the only working medical brain left on the case to do that, as the primary internist.

Mid-levels are NOT that brain. They can carry out protocols, but their depth of analysis is not the same. I did not have this opinion when I came to practice 5 years ago; I developed it, reluctantly, after having mid-levels under my supervision miss cancers, miss iatrogenic renal failures (and nearly kill the patient), botch hyponatremia workups, and fail to act on HIV viral load breakthroughs.

In fact, the iatrogenesis case I mentioned above is a good example of what I'm talking about. The patient had seen 3 specialists in ID, cancer, and ortho for diffuse body pain over 12 months. The previously supervising MD was nowhere to be found. The PA gave me a garbled 20 minute rambling presentation of the case. I was struck that the patient had known kidney disease, and was demonstrating symptoms of rickets--a disease that anyone who's taken the internal medicine boards can recognize. I thought the PA was putting me on. "Did you check a Vitamin D level? He has rickets." And this had been missed by the 3 subspecialists (hammer/nail). The real problem was: I did not ask the PA *why* this patient was a kidney patient. It was because 18 months earlier he had been put on a nephrotoxic HIV medicine--and his slowly increasing creatinines were ignored. He nearly died of catastrophic kidney failure a month later.

Happy is right--"solving" the primary medicine crisis by unleashing a bunch of workers who cannot do primary medicine is not fixing the problem. It *is*, however, drastically changing the DEFINITION of what "primary medicine" actually means.

I've developed a hypothesis that the critical errors I've seen mid-levels make in the primary medicine setting is due to their lack of sufficient inpatient training in their all-too-brief instruction. When you've watched someone vomit out their life's blood into your lap, you have a somewhat greater sense of danger in dealing with truly sick patients. Yes, sometimes a headache is just a headache--but sometimes it's a brain tumor. Your primary better be able to tell the difference. Even the most experienced PA's in my building do not demonstrate that ability. And as the theoretical supervising MD, I don't want their clinical misjudgements jeopardizing my license.

The mid-level "solution" only works if you change the definition of what primary care is. My patients want intelligent problem-solving. Mid-levels can follow protocols; they do not, however, demonstrate the depth of analysis of an internist, period. I was willing to believe they could; they don't. And cases suffer for it.

If your primary is a non-doctor, and the subspecialist MDs are hyperfocused on their small part of the picture, what you wind up with is a "zombie team"--lots of running around and poking and prodding, but no hub to pull it together, synthesize the workup and treatment plans, and (duh) answer the patients' questions. In other words: A medical workup and treatment plan needs a leader. Without one, you wind up with a very frustrated and unhappy patient and family.

I've inherited patients from practices that use mid-levels as the bulk of their primary care providers. The patients transfer to me because they want an internist running their case, not just taking orders from subspecialists and (rarely) from their over-worked, barely-present theoretically supervising MD (whom the patient has never seen).

My HMO recently got in touch with me. A neighboring practice that uses mostly PAs to see patients has 3 times the hospitalization rate as does my practice; meanwhile, I have such a low admission rate the hospital asked if I was sending my patients to some other hospital! There is a reason. I spend very long days crossing the T's and dotting the I's on my cases, and the devil is in the details. I keep the patients out of the hospital. And therefore, I save the system TONS of healthcare dollars.

My reward? UHC cut my pay 50% 3 years ago. Medicare plans a 25% pay for me this year. I am doing superb medicine, and I am being punished for it financially.

The pay of primary internist needs an earthquake of reform.

Health economist Kevin Grumbach has observed that countries whose physician supply mostly consists of true primary internists have better care outcomes for much lower costs than does our country. That is not an accident. I've seen the truth of it in my own little hospital campus.

April 14, 2009 10:04 AM

What Would You Do?

"Mrs Smith, in room 702, admitted with COPD and pneumonia was caught smoking in the bathroom last night."

The goat rodeo of American medicine continues... The one greatest thing in the history of Happy's Hospital was to make it a non smoking campus. I haven't had a single argument with a patient, in over a year, about "allowing them" (as If I'm their father) to go out and smoke. The thing is, if you go out to smoke, you get discharged from my service. Especially now that hospital acquired fires/burn injuries are a never event. If you're healthy enough to smoke, you are healthy enough to go home.

My vote is for discharge. What would you do?

Doctors And Lawyers Are All Smoking Marijuana

Do you smoke pot?

I am a third-year law student at a top law school and I have never been around so much marijuana in my life, including my time as an undergraduate. The editor of the law review is going to become a prosecutor. He uses a vaporizer so that his neighbors cannot smell the smoke.

When I was a medical student some of my classmates where daily smokers of pot. Day after day after day. These are now your surgeons, your radiologists, your family practice docs. They are everywhere.

These are bright, intelligent folks who made it through the incredible rigors of Hell and back. And they turned out just fine. I believe that folks should be able to smoke what ever they want. The irrational criminalization of a weed that has been smoked for thousands of years does nothing but create criminals. If you want to make any mind altering drug illegal, perhaps we should criminalize excercise, an acitivity that gives a mind altering high on a regular basis. How about chocolate, which gives many depressed folks a food high.

The arbitrary criminalization of a drug has done nothing be drive a generation underground and behind bars needs to end. It's time to stop spending my tax dollars on creating criminals just so we can make them dependents of the state.  Marijuana is even being used to treat autism behaviors.

What would you think if your doctor smoked weed?

Lowest Calcium Level Ever, I Don't Know Why

CC: lightheadedness

A healthy 32 year old male lawyer with no chronic medical conditions presents to an urgent care center with acute onset of lightheadedness associated with transient nausea and vomiting. No other complaints. No nothing. No home meds. No illnesses. No surgeries. Review of systems otherwise negative. Physical exam negative.

Laboratories come back. He is transferred for direct admission.

Na 142
K 2.8
HCO3 20
CL 120
BUN 14
Cr 0.9
Ca 5.1
Alb 2.6
TP 5.1
LFTs otherwise normal
WBC normal, normal diff
Hgb 8.7
MCV 90
Plt 97K
UA negative
cardiac panel and CXR are negative

Impression: 1) What the hell is going on?  The Patient has the lowest calcium level I have ever seen.

Plan: Differential diagnosis anyone?

see my other records here

The Intact Humor Reflex

So I get asked to consult on a patient in the emergency room to admit for acute exacerbation of multiple chronic medical issues. Reading the nursing home transfer sheet clued me into exactly what the specifics were around the transfer.

92 year old female transferred for "confusion", "UTI", "3+leg swelling", "Neck and back pain" and "nausea and emesis".


That sounds like a sick lady. Especially at 92 years old. Something the FREE=MORE American medicine can certainly provide for. Fortunately for me, hospitalist medicine is continuity of care for a very large sub population of the chronically ill who present with an acute exacerbation of multiplemedicalproblemitis (my version of herchronicmedicalproblemology).

And this is a golden example of how hospitalist medicine brings value, not only to hospitals, but also to the Medicare National Bank. This sweet old lady just happened to be a bounce back of mine.

Perfect I thought, old lady, nursing home, multiple medical problems, sounds like the expected course of action. She'll need admitting for sure. Except she didn't. Because I knew her.

I knew

• The back pain was chronic
• The nausea and occasional emesis has been worked up since the Carter years, and has experienced the magic of American medicine first hand trying every test known to man.
  
• The edema was non existent. Fat legs do not equal edema. Especially when the rest of the body habitus confirms the diagnosis of adipose extremis.
• The UTI as well was a sham. I never believe urinalysis from anywhere, ever, unless it is collected by sterile cath technique. Urine from the ED? Crystal clear

Not to mention the chronic hypercapnic respiratory failure with a baseline CO2 of 70, a baseline creatitine of 1.8 and a pacemaker waiting to discharge its last electron from a sweetheart as big as gold.

The only thing left to address was her confusion.

Me: Why are you here in the ED today?

Her: I don't know, the nursing home sent me.

Me: I'm not sure I could do much for you in the hospital. Everything here in the ED appears to me like you have a 92 year old body.

Her: You're going to be 92 some day as well.

Final diagnosis: multiplemedicalproblemitis without exacerbation with intact humor reflex. ICD code 867.53.09

Disposition. Home. Intact humor reflex is always the best sign of intact cognition.

I saved the Medicare National Bank. an $8000 admission, of which Happy gets a piece of stale bread as a thank you. Imagine for just one moment had any other species of MD been called to admit.

Now go work out and stop eating McDonald's. I may be able to prevent the Medicare Ponzi scheme from collapsing on itself for a millisecond or two, but in the grand scheme of things, you had better find a way to avoid disease at all costs. Because the money will be long gone admitting 92 year olds without acute exacerbations of multiplemedicalproblemitis.

And trust me. I could admit her and create medical necessity out of any one of her multiple medical conditions, jut by knowing what to right and where, even if it is all factually accurate.
There is no incentive for me to send her home, and I do it anyways. I take all the risk of her getting worse out of the hospital. I get no benefit of billing her on multiple hospital days. Economically speaking, good medical decisions do not pay.

The system is just not set up to reward good medicine. It rewards volume. I may have saved the hospital a money losing internal medicine admission and Medicare thousands in DRG payments and opened the bed up for a more lucrative surgical or procedural based bed fill. So I guess, in one way, I have brought value to everyone involved. Including the patient, who didn't want to be admitted.

Try measuring that for a quality indicator.

Is It Time Internists Abandon The Ship?

In the last week I have received quite a response to my assertions that the practice of internal medicine is far more difficult to handle for anyone other than a board certified internist. I speak the truth when I say that real internal medicine cannot be safely practiced by any NP as a full service independent provider, whether they are in the inner city or the middle of BFE, as one commenter called it. Lack of access is simply not an excuse for sending an army of untrained worker bees out to colonize hives that are left empty by the bees that left them behind for greener pastures.

Every time I read a story about how extenders can replace primary care physicians I cringe. Not because NPs are dumb or ignorant. Not because they are incapable of practicing medicine. I cringe because I have come to the conclusion that somewhere along the line internists have been lumped into a category of care that values its service as one that is less than its true meaning. And in many cases, internists have failed their duties as board certified physicians, out of necessity to survive legally and economically.

Primary care has a connotation of simple medicine. A medicine that is first line and only first line. Who's job it is to divvy up disease to be managed by a potpourri of subspecialists waiting in line to get their $200 for passing go. In fact, internists are trained to treat the vast majority of all medical conditions that afflict the majority of adults in this country. Alone. Without any assistance.

Of all the top 10 killers in this country, most patients could be handled to their grave by skilled internists. This is what internists were trained to do. They were not trained to be the front line triage artists. They were trained to be the primary doctor. The doctor that takes care of everything. Not the doctor that decides who else will take care of everything.

Unfortunately, many outpatient internists have abandoned their training in favor of the role of glorified triage nurse extraordinaire. Some have given up their role as the primary physician for everything and instead have fallen victim to the economics of out patient volume medicine, out of economic necessity. Out of legal necessity in this goat rodeo medical complex we practice in. A medicine that only makes you money by seeing more patients, but will make you bankrupt should you fail to follow these rules.

The only way to remain economically viable taking care of sick patients is to send them to someone else in a never ending game of pin the tail on the subspecialist.

Perhaps internists, by choosing this course of action, have no one to blame but themselves for the devaluation of their role in patient care. From a position of economic viability, I don't blame them for a second. A devaluation that leads some to believe that those less qualified are capable of doing what they do. For internists who treat their role as glorified triage nurses, they are guilty of legalized institutional theft from the Medicare National Bank (MNB). They are no better than the rest of the legalized, codified Mafia robbing the unending money supply of the MNB.

For internists who still wish to practice a full scope of outpatient internal medicine. To be the primary doctor for the patient. Their only hope is a fundamental transformation in the way outpatient medicine is paid for. Until internists are paid to provide care, not paid to help others provide care, the goat rodeo will continue. Patients will continue to be poked, prodded, abused, and confused as they are herded from one trough to another where a part of them and their wallet, or America's wallet in the case of the MNB, is picked off in the process.

Those guilty of providing glorified triage nursing have damned centuries of training that few others can master. Those that struggle to maintain the integrity of our field realize, they too will fall without a fundamental restructuring of the outpatient payment model.

Outpatient internists are dying quickly. The way I see it, bundled care, which is essentially concierge medicine, whether funded by state institutions, or funded by private individuals is the only way out of this mess. It must be bundled with gain sharing commitments that give incentives to internists everywhere to do their job and to do it well. When you are paid to do your job, not paid to have others do your job, you will find a much larger satisfaction in your contribution to the equation. You will find your skills will shine. Until then, it may be time for internists to abandon the outpatient ship in favor of a model that pays them for the value they bring to medicine, and let the outpatient model struggle to find cost containment in the glorified triage model of care.

I have found that hospitalist medicine offers me just that.

This Is Not My Primary Care

According to Mayo, primary care is king.    Their idea of primary care  is not idea of primary care.  This is triage medicine they speak of.  You don't need a doctor to fill this role.  

Who's going to take care of the 78 year old (who I doubt is working at Mayo) with eight chronic medical conditions, some advanced, on 22 medications that who calls up and says "I'm weak", or "I'm dizzy".

That's primary care internal medicine.  Not seasonal allergies

After the overhaul, Hageman now prefers to go to her family doctor, Dr. Margaret Gill. Thanks to the flexibility of quick appointments she sees Gill instead of the visiting the ER . And Hageman is getting consistent care for chronic ailments such as seasonal allergies -- something she was missing in the emergency room.

For Deb Lange, a receptionist at the clinic, and her husband Dan, Gill not only coordinates Dan's treatment for colon cancer but sets up cancer screenings for other at-risk family members. Her relationship with the Lange family provides a sense of trust and ensures comprehensive care.

Pandology At Its Finest

He does it again. Makes you want to laugh while you're crying. I have played this game as well. Only it usually presents as a different version. VA patient presents to Happy's ED. Happy is asked to admit. Patient tells Happy he only has VA insurance and nothing else. Happy tells patient he has one of two choices. Admit to Happy's hospital and get nothing paid for or transfer to VA mecca 60 miles away and get everything paid for. Patient chooses the VA mecca. VA mecca is notified and promptly denies transfer due to lack of beds. Welcome to socialized medicine at it's finest.

Here is Panda's story, uncut:

The admitting physician adamantly refused to admit and suggested, not unreasonably, that I transfer her to The Big Academic Medical Center Sixty Miles Away as they were the last to lay hands on her and were most familiar with her condition. The Big Academic Medical Center Sixty Miles Away agreed, without hesitation, to accept her and I even spoke to the Leading Specialist in the Field of Herchronicmedicalproblemology who happened to be on call. Oh how the heavens sometimes align and, just when you think you are heading for a knock-down, drag out patient transfer brawl you see the triumphal field just ahead and prepare to eat the cheeses and hams of victory!

I never realized how much I missed you.

My Solution To The Perception Of Physician's Moral Obligation

A large population of our entitled country believes physicians are obligated to provide their medical expertise to others without consideration of one's ability to pay. That a physician has a moral obligation to help others independent of financial considerations.

Thinking about this rationale the other day got me thinking. If physicians have a moral obligation, an obligation based on religious rightousness to provide free care, does not society also have an obligation to provide physicians the same tax free status afforded to churches who establish these moral obligations?

I hereby recommend that all physicians who are required to see patients without any expectation of payment be afforded the same tax free status afforded to churches and hereby recommend all income declared untaxable by state and federal authorities.

I have just solved the problem of moral obligation, assuming you believe taxes are a moral obligation to begin with.

What do you think? If physicians should be expected to provide free care, should they gain tax free status like the churches that establish these beliefs?

My Third Arm

After having a stroke, a 64-year-old woman reports that she now has a "pale, milky-white and translucent third arm" that she can use to scratch itchy parts of her body. She also says the limb can't penetrate solid objects.

When asked to move her arm, MRI scans showed actual changes. That's just weird

via Boing Boing

Happy Easter

That's just good humor.

via Addicted to Medblogs

also, check out the insides of the Easter Bunny via Boing Boing





And one more, by request of little Marty with the Easter Bunny

Did You Know Dolphins Have Balls?

I found this interesting, considering I just finished swimming with dolphins (that's Iggy at Discovery Cove).  This explains why there were no balls to be seen.

The Land of the Screwed

Rationing always brings out the hottest heads. For example:

midwest woman said...

I can picture your health care world where the patients are huddled in a line frantically searching their minds for any indiscretions that might jeopardize their access...kinda of like Seinfeld's sponge worthy episode. Or perhaps a modern day Spanish inquisition...did you or did you not worship at the altar of the treadmill and raw vegetables? Albert Schweitzer, doctors without borders, I guess they're saps or enablers. To take your argument to the extreme. I guess you could just watch that COPDer suffocate to death and then sleep like a baby. No disagreement that medicare needs to be reworked and people should take more responsibility for their part of the health equation. But to sit as judge, jury and executioner, I don't think that was in the Hippocratic oath.

midwest women, you are angry at me when you should be angry at others. I am pointing out the inevitable. That rationing MUST occur on course we are heading. How we choose to ration care will be the debate of the century.

There used to be a time in the world were doctors were different. When doctors learned a special gift no others could. When doctors were respected for their sacrifices. When they were looked up to in communities for providing a gift no others could. That time is long gone. Not because doctors aren't still the sole providers of that gift for others. But because of the way doctors provide their gift.

Long before my time as a physician, there used to be a time where doctors charged patients, not insurance companies. A time when doctors figured out how much money they needed to live the lifestyle they desired and charged patients accordingly. It was up to the doctor to decide how much money he or she wanted to charge.

There was a time when patients felt obligated to pay that amount out of gratitude. And patients would pay it graciously. As a thank you for helping them. And those that couldn't pay were forgiven of their debts out of grace.

That ended long ago when patients and doctors left that equation. Replaced with a centralized bureaucracy filled with government administrators and private insurance companies. A bureaucracy solidified by the tax structures that codify third party medicine.

And the people bought it hook line and sinker. Because FREE=MORE. They saw third party medicine as their golden ticket to the Willy Wonka Factory of health care. And eventually, so did the medical community. The people, in their FREE=MORE mentality, now feel entitled to all the goods and services from the sweat of others. From the sweat of their physicians, a field once respected for providing a gift no others could (and still can't).

The people believe they are owed the services of others because they have pre paid for those services in the form of Medicare premiums and large $20,000 a year family deductibles. What the people fail to realize is that every penny spent on their insurances is less money in their pocket. There is no free money out there. You are paying for your premiums by way of lower salary and wages.

But the people don't care. They demand FREE=MORE because of their belief that they are OWED the services of others. This is the entitled mantra of socialism at its finest.

No longer does a physician feel the obligation to excuse those that cannot pay by allowing instead to have those that can subsidize those that can't.

The moment patients worked to get insurance coverage and the moment physicians worked to get insurance money is the moment the dynamics changed. The take it or leave it mentality of third parties has left the fee structure unacceptable for many physicians. In a sense, most physicians now view all third party money as charity care and feel no obligation to provide free care to those without insurance. Providing a gift became nothing more than a service with a defined value.

The real losers here are everyone. Everyone has become a slave to a system that codifies tax breaks for big business in order for them to decrease your take home wages to pay for your $20,000 health insurance premiums, or to a government that unilaterally takes money from all your income every month for your entire life to offer you FREE=MORE. This third party system has created a system of entitlement from patients who feel they are OWED medical care and physicians who are OWED insurance money.

I am not judger. I am not executioner. I am not jury. I am simply pointing out that the third party system is not sustainable because you, midwest women, feel entitled to everything health care as evidenced by your post, and physicians feel entitled to accept the stability of third party money to offer it back.

This is an unsustainable formula which cannot survive. I am pointing out the gut wrenching truth. That FREE=MORE will collapse. And no matter how you rearrange the deck on the Titanic, you will have to ration our modern day health care service because we simply cannot continue on the course for which we are heading.

Would I love to be a physician where physicians charged what they wanted, based on THEIR needs. Of course, as would you. As would everyone else in this word, who has a freedom to choose their price for their service. Would I love to write off the bills of those that cannot pay and allow those that can to subsidize MY needs and desires. Of course. I would love nothing more than to give away my service, when I felt my needs were met as well.

As it stands now, neither you nor physicians are willing to go down that route. Hospitals used to provide charity care for those less fortunate. Now they too rape the uninsured, charging them far higher rates than the fully insured. It's a backward system where those most in need are helped the least.

And you can blame it all on the third party system where patients and physicians alike are entitled. You want to blame someone for a system that throws away those without money? Blame the government with their Medicare. Blame your employer for their giant tax breaks to give you less in take home pay to pay for your insurance premiums. Blame yourself for feeling entitled to the services of others with no regards to the sweat and tears of their labor. Blame physicians for taking the plunge and becoming slaves of third parties instead taking care of patients.

There is so much more to the equation than you give credit to. You choose the physician as the easy target because you know no other way to express your dissatisfaction. Some may feel entiteld to free care because they feel physicians are too rich (financially). Who cares how rich they are? Everyone has a right to charge what they want. Freedom allows one to get rich without feeling guilty.

In my heart of hearts, I have no doubt in my mind that IF we flipped a switch overnight and abandoned ALL third party medicine so that contracts of care were created in an individual basis between physician and patient, physician and hospital, patient and hospital, that the cost of delivering care in this country would plummet. That those capable of providing for their own health care would subsidize those that couldn't. And EVERYONE would be covered for the right care, not the most expensive care. That the enormous waste being provided on the backs of the Medicare National Bank and your tax sheltered employer would disappear.

The concerns you express, midwest women, are the same concerns we all express. But you blame me for telling it like it is, instead of blaming the culprit that destroyed health care.

Insurance. An insurance that someday may have to line people up like the Spanish inquisition, as you call it, and ration care based on choices that nobody wants to make. As long as you accept insurance as your health care savior you will be at the whim of a centralized planning power that will make unpopular choices and could potentially cause you harm.

If you can get the other 250 million Americans in this country to abandon their FREE=MORE mentality and to pay their bills without feeling entitled to the sweat of others, you would see a remarkable change in the dynamics of health care delivery in this country. Until then, we are all on a steam ahead course to the Land of the Screwed.

It's A Whole Different Ball Game

I read this

It really pushed my last button when I told her that I was going to go and grab the patient's

dinner tray, then give his insulin and she said, no, give the insulin first. Really? Does it make that big of a difference? Like why can't I just do something my way if its not going to harm the patient?

and found myself thinking

Medical school is a whole different ball game. The 4:30 am surgical pre rounds lasting till 9 pm post surgery rounds. The all day OB rounds and middle of the night deliveries. From the all night calls. From the nights with no sleep to the days with no meals. From the daily morning reports, every day for 5 years straight. To the noon lectures, every day for five straight years. The morbidity and mortality rounds. The one on one sessions with my attendings, with my residents, with my interns. The intensity of cardiology rounds in the middle of a STEMI to the crashing septic shock patient in the ICU. To learning how to intubate during anesthesia. To placing central lines during CPR.

Nothing can prepare you to practice independent primary care like the medical school/residency experience.

I find myself wondering how on earth can a degree in nursing plus a couple years of part time limited clinical experience as a masters level nursing degree possible equate to the independent practice of primary care. I think and think and think and yet I still come back to the same conclusion.

The NP agenda for the independent practice of primary care must be vastly different and far less in depth not only in scope but also in concept, clinical application of skills and comprehension of basic science skills than mine. The only conclusion I come to is that primary care in the eyes of an NP is vastly less intense in scope and breadth as the practice of primary care by board certified internists.

Why? While this nurse was deciding whether to grab the patient's food tray or administer insulin, two roles this nurse will rarely, if never do as a NP, I, as a medical student was trying to decide how to titrate their insulin drip or dose their lasix or stabilize their hypotension. I spent years learning how to take care of patients. This nurse is complaining about the order in which to do remedial tasks. Years that can't be made up without the medical school and residency experience.

No matter how you try to slice and dice it it's a whole different ballgame.

Spraying Lidocaine On Your Penis Does What?

Spraying lidocaine on your penis does what?  Apparently it's a treatment for premature ejaculation.

Of course it is.

via Blog Around the Clock

It's Time To Stop Using PPIs

First comes word that the cytochrome interaction of proton pump inhibitors (Prilosec, Protonix, Nexium etc...) with Plavix may render the Plavix far less effective and could potentially increase mortality for those dependent on their Plavix for their cardiac stent health.

Now The Hospitalist has a nice summary of the current data. It basically says to stop prophylaxing stable out of ICU medical patients for ulcer disease.

Outside of the ICU, there is no difference in de novo GI bleeding among general medical patients prescribed stress ulcer prophylaxis . The Society of Health System Pharmacists guidelines thus conclude there is no indication for stress ulcer prophylaxis in stable, general medical inpatients.

The article goes on to say the only two reasons to really prophylax in the hospital are critically ill patients with mechanical ventilation suspected to be longer than 48 hours and those with underlying coagulopathies.

It's a good read. I stopped prescribing PPIs on most of my patients months ago. I think it's time to stop using them on all of my stable medical patients.

The Nite Bot

The Hospitalist reports on a start up company trying to take the load off hospitalists everywhere by having robots take cross cover night calls.

"Is an NP also a Physician?

Interesting collection of comments.

Virginia Henderson (nursing theorist) promotes the idea of nurses being the primary care provider. I only know this because of nursing theory this semester and she was the only theorist with whom I could even remotely understand!

The reason I mention this is because it addresses the idea of nurses taking over (or one might argue back) the role of primary care provider.

Says one reader over at allnurses.com. As I've said before, the idea that nurses can "take over" primary care is all dependent on how you define primary care. I have no doubt in my mind that how the NP agenda defines primary care is far different than how I define it. Primary care, the way I practice it in a hospital setting can't be practiced by NPs independently. There are certain aspects of my job that a monkey could do. That a secretary could do. That a nurses aid could do. That a nurse could do. That a nurse practitioner could do. But none of them can do everything I do as an entire package. Just as I can practice cardiology form a hospitalist point of view, I would never claim to be a cardiologist in the same scope a cardiologist practices.

I know this because I have lived through the training necessary to practice hospitalist medicine independently. I have lived through the training required to practice outpatient comprehensive primary care independently. I have had NPs train through Happy's Hospital rotation. I speak with NPs (and PA's for that matter) at 3 am who transfer me patient after patient from rural America with terrible ED work ups, stabilization and management skills. Work ups that lack basic medicine skills.

And I can say categorically, without a doubt that primary care as practiced by myself is not the same as primary care practiced by those less trained.

So define primary care as you may. As a patient, many may never know how to differentiate the care they are receiving from the care they need. Many are happy not knowing otherwise. I can say only that knowing what I know about the training involved in both, I would take a newly minted graduate of internal medicine, one week out of residency to be my primary care doctor over a 30 year practicing nurse practitioner every single time. That's not because nurse practitioners are bad. It's just that my idea of primary care is far different than what the nursing profession has to offer.

And I can say that with a straight face, every single time.

What's Your Best Suited Specialty?

click image to enlarge

Reader Marco found it here. Thanks!

What's Your Poison?

A blogger asked the question on when it was OK not to take care of patients because of conscience. I suggested that patients are free to do as they please, but shouldn't expect others to pay for their poor choices.

In response, Nurse K left a comment:

Sunbathing and getting a sunburn, eating too much, drinking (even episodically and falling down and hurting yourself), smoking, riding a bicycle too fast, driving a car on an icy road to get to work to save sick people, going out in the Texas summer and not drinking enough water, forgetting to take your BP pill/insulin injection, etc, going to a bad n'hood and getting jumped, forgetting to tie your shoes, working somewhere that used asbestos....

Maybe we should take care of sick people no matter how they got that way? If all you're doing is judging, you're going to burn out real fast. Cigarettes aren't without benefit btw--they increase social contact in certain circles, quell anxiety, reduce weight...When I was a waitress, I was literally the only non-smoker and had to work much harder than the smokers who were always on break because I was expected to always cover for them...

The suggestion here is that America should pay to take care of everyone, no matter how they got where they are. "Maybe we should take care of sick people no matter how they got that way."

In a world of snow angels and sugar plums this would be the ultimate social utopia. I would want nothing more than to know that if I became ill, that I would have an unlimited supply of FREE=MORE health care for which to feel secure. I am no different than anyone else. I love free samples at Sam's Club. I love 99 cent gas give aways. I love getting free movie coupons from Blockbuster.

But, I also know that this social utopia is not achievable. The grand experiment called The Medicare National Bank (MNB)has proven it. The MNB promises its depositors everything (minus a denied lab draw or a port -a-potty here and there). A key word here and there in the documentation road race and everything under sun is paid for. It is the sham known as "medical necessity". I could make a healthy 65 year old with no medical problems get any test in the world by playing the "medical necessity" documentation game. The game for which all of the MNB's payments are based on.

The MNB is a financial black hole who's unfunded mandates are more than 10 times the trillions of dollars our government is currently printing to prop up worthless assets associated with the likes of Lehman Brothers (the former), AIG, Citibank and B of A put together. The Medicare crisis is so much larger than the current financial collapse that comparisons are nearly unfathomable.

The promise of "we should take care of sick people no matter how they got that way" is not achievable going forward. Perhaps in a world where medical care for sick people was to diet and exercise and maybe one or two pills and to go home and die. That's not the current reality. The current FREE=MORE reality means that eventually, as the money spigot of the MNB runs out, FREE=MORE will become MORE=LESS. We will have no money to pay for care. End of story. The failure of the MNB will be the largest bank failure ever in the history of the world. it will take down 15% of America's GDP in one massive swoop.

This is the current reality.

Medicare's FREE=MORE party will have to end, and soon. If the unfunded mandates are ten's of trillions of dollars for only 50 million people in the current Medicare Utopia, the task of expanding "we should take care of sick people no matter how they got that way" to 300 million people would be like giving a million dollar subprime mortgage to every Tom Dick and Harry in this country and believing in your heart of hearts that they really will pay it off. We see what happened with that.

FREE=MORE for 300 million entitled Americans will never work.

The rapidly rising private premiums for both individuals and businesses and their inability to afford them is proof positive that the "we should take care of sick people no matter how they got that way" mantra is unsustainable. We have done it. It has failed. Soon, we will have money for no one.

There isn't a Ponzi scheme in the world that could sustain the FREE=MORE position And because it's not achievable, we will have to accept other limits on care in one way or another. Our current rationing system is not enough.

There are many ways we currently ration care.

1. Time. Prevent access by creating waiting lines.
   
2. Price. Witness the collapse of primary care. Prevent access by paying too little for the service. Also witness the explosion of procedural based, surgical based care.
   
3. Insurance. If you can't afford the care, you get no access. I think, however, that if the 85% of the population provided adequate payment based on price, the 15% would be absorbed by charity care. As it stands now, all care (non surgical/non procedural) is a form of charity care
   

In any of the above ration scenarios, we fail to "take care of sick people no matter how they got there". People die and get worse from all three scenarios. But it's still not enough.

There are other ways to ration care. I can assure you, that as the shit hits the fan, no stone will be left unturned. At some point, the Medicare National Bank will have to be recapitalized. Whether that means massive tax hikes on everyone or vastly decreasing services, or both, eventually the MNB will be called home on their fiscal irresponsibility. So how else can you ration care?

1. Disease. If you have certain stages of disease, you are denied care from the MNB. Metastatic cancer? End stage COPD? End stage CHF? Alzheimer's? Name your poison. There are many diseases that cheat death. At some point, the MNB will have to come to terms with the possibility of rationing care based on disease. Be prepared for this possibility.
   
2. Age. Too old for dialysis? Too old for an ICD? Too old for an ICU admission? It will have to be discussed. Decisions will be made. Rationing of resources will be made. Be prepared for this possibility.
3. Lifestyle. If you smoke, be prepared to be denied access. If you do crack, be prepared to be denied coverage. If you fail to join lifestyle modification classes or fail to show improvement in basic exercise tolerance tests, be prepared to be denied coverage or pay more for lifestyle associated disease process. Rationing of resources will be made. Be prepared for this possibility. We already deny liver transplants to those actively drinking. Scarcity of resources we say. Of course the MNB is a scarce resource already, we simply chose to look the other way. At some point we will have to look back and stare rationing down right between the eyes and deny coverage for poor lifestyle choices.

I don't live in a fantasy world. I know that "Maybe we should take care of sick people no matter how they got that way?" is not an answer to the problem, except when you're frolicking with fairy princesses. In a world where resource utilization will truly have to be rationed, we will have to pick one, two or all three of these future rationing tools. I pick personal responsibility. That's just me.

And that's also why I'm constantly saying that you have to start now to take the best care of yourself that you possibly can. Because in the not to distant future, there will be no money left to help you overcome things that you could have prevented. And the money that's left will be rationed. And you will get denied care for things you brought upon yourself. You think trying to get a liver transplant now is hard. Wait until the MNB collapses in a blaze of glory.

And you will have no one to blame but yourself for your failure to act now. Lifestyle rationing is my poison. What's yours?

My Keep It Simple Stupid Lesson For The Day

What do you think America? Should PAs change their name? This physician assistant thinks so.

There are many in our profession who think of the "assistant" title as denigrating, and demeaning. Count me among them. Patients and the public frequently misconstrue us as "medical assistants", and while I have nothing against medical assistants, that implication is insulting. Assistant implies that I have nothing to offer besides helping a physician with a specific task. It implies a lack of training.

I think the word physician should be taken out completely. Considering nurse practitioners practice independently in many parts of this country, perhaps physician assistants could work under the supervision of NPs. Then PAs would have to change their name to nurse practitioner assisstant, or NPA for short. It makes sense to me. If NPs are considered equals as physicians, equal enough in scope, education and capability to take over primary care's role, then PAs should have no concern about practicing under their supervision. Being called a PA wouldn't make sense.

It's all so confusing. Maybe PAs should change their name to CNP, for Clinician-Not Physician. Not to be confused with DNP, which in some circles stands for Doctor Nurse Practitioner. I think it stands more appropriately for Doctor-Not Physician. Maybe we should just create a single new training track called simply

Clinician

All prospective students wishing to take care of patients would begin their studies in the Clinician program. When they feel like they've spent enough time, effort and energy learning, they simply drop out and become certified as CNPs (clinician-not physician). At this point they are heralded out to rural America to care for the masses of patients who otherwise would have no access.

Those that wish to fully educate themselves on how to take care of patients could continue on to get their Clinician Physician or CP degree.

Problem solved.


That's my K.I.S.S. lesson for the day.

Observation CPT Billing Codes 99234, 99235, 99236, 99217, 99220 Explained

From the question gallery comes another question about billing observation status.

Dear Happy,

This is in regards to 99234-99236. There are 3 certified coders including myself who work in the physician building and then we have 1 certified coder who works in auditing.

Now: Supposedly the auditor is telling us per our Medicare Carrier that the only way the physicians can bill 99234-99236 is when then patient comes in the day of and seen the day of. Let me explain. Patient comes into the hospital 3/1/09 late night, but the doctor doesn't see the patient until 3/2/09 and then discharges them 3/2/09. The auditor said the only thing the doctors can bill is 99217 because the Dr did NOT get into the hospital on 3/1/09.

NOW...

I disagree.... I feel the date of observation starts when the Dr comes in to see the patient on 3/2/09. Therefor as long as the patient was in there longer than 8hours it is appropriate to bill the 99234-99236.

Now comes the sad part.... we can not find anything in the AMA that agrees with us...so the hospital is listening to the Auditor and making all the doctors bill discharge only. Until we can present proof from the AMA or different from our medicare carrier we have to start billing all these OPO as 99217.

Do you have anything in writing from the AMA regarding the codes 99234-99236?

From what I can tell from your website you agree with what we have to say with the 99234-99236.

I need your help!!!!!! Please email me if I have confused you... I am confused myself.

Dear Coding Specialist. I'm sorry to say, that you are wrong, and your auditor is right (but only part right). The ONLY time. Let me repeat that, the ONLY time physicians can bill using the observation/discharge codes 99234-99236 is when the patient is "admitted" and discharged in the same calendar day. This is not based on when the physician sees the patient, but rather when the hospital lists their "admitting" and discharge dates.

In your example above, because the patient was "admitted" on 3/1/09 and discharged on 3/2/09 they have crossed the elusive midnight hour and therefor they are considered to have been present for two calendar days. The only thing that matters is that the hospital has the patient listed as being admitted on 3/1/09 and discharged on 3/2/09. The fact that the physician did not see the patient until 3/2/09 changes nothing.

I deal with this scenario a lot when I'm admitting patients from the ED late at night. If I am in the ED and I first start my evaluation at 11:59 pm on 3/1/09 and decide after a 45 minute evaluation to admit the patient, it may be 00:45 am on 3/2/09 by the time I tell the ED charge nurse that I'm going to admit the patient observation status. But I tell them to make damn sure that the admit date is 3/1/09 because that's when I first started my evaluation. If the hospital lists 3/2/09 as the admit date and I submit a bill on 3/1/09, no matter what the charge is, my charge will get denied because the patient was not in the hospital on 3/1/09.

You can see much more here in my coding lectures or earn CME at E&M University

It makes no difference when the physician sees the patient. What matters is what calendar day the hospital lists as admission.

Therefor, a simple way to remember it is: If the hospital lists the admit date as a different calendar date as the discharge date, the physician CANNOT use the admit/discharge same day codes 99234-99236, even if the physician themselves saw and discharged the patient on the same date. If the patients admission and discharge calendar days are different then the physician must use the 99218-99220 for admission and 99217 for discharge.

The only thing I would disagree with from the auditor is that if a patient was admitted on 3/1/09 and discharged on 3/2/09, but the only date the physician saw the patient was 3/2/09, if the physician does an H&P, I would bill the H&P because it generally pays more than the discharge. If the physician does an H&P on 3/2/09, they should get paid for an H&P for 3/2/09, even though the admission date is 3/1/09. You get paid for the work you do. The physician can't bill both a 99218-99220 and a 99217 because Medicare will only accept one E&M code on a calendar day of service. So I say pick the one that pays more, which is more likely the 99218-99220, not the 99217.

I hope that helps. BTW. I'm not a professional coder, but this is my understanding of the rules as I interpret them.

As a side note, this only strengthens my assertion that E&M coding does nothing but add layers of complexity to the delivery of health care while adding nothing but inefficiency and cost to the bottom. We have professional coders who disagree. Happy's Hospital group does an in house audit several times a year. I am finding that I have to correct my own billing company's auditors when they claim I over or under bill. The Medicare auditors themselves have their own opinions and you'll get 10 different opinions from 10 different Medicare auditors. E&M coding is that loud sucking sound of money going right into a black hole. It is irrational, expensive and unnecessary to do my job. But it's here because some genius thought it was a brilliant idea. They have no idea how it bogs downs the delivery of health care into a giant inefficient and expensive failed grand experiement.

You can see much more here in my coding lectures or earn CME at E&M University

The Medical Village

There's the medical home concept. And then there's the Medical Village Concept.

As the name implies, a medical village expands on the concept of a patient’s medical home to include providers outside of the “home” practice (hospitals, specialists, etc.). The medical village will rely on several important concepts, including collaborative and coordinated care and shared responsibility: PCP-to-specialist, specialist-to-PCP and specialist-to-specialist.

What this implies is hospital care. Doctors who don't follow the patient on a routine basis. That includes hospitalists. That includes most subspecialists too. Most subspecialists don't round on their own hospitalized patients, unless they are on rotation at that hospital at that time.

What does the Medical Village mean economically? Well, as it stands now, none of the players of health care delivery are aligned. Physicians bill based on volume. Do more procedures, get more money. See the patient more often, bill more often. The goal of hospitals is to reduce length of stay. Since they collect based on DRG, the longer the patient stays in the hospital, the more resources they consume (bed space, rent, utilities, nursing staff, incidentals, pharmacy) for a fixed payment.

There in lies the problem. Hospitals want patients out as quick as possible. Physicians don't care. Except hospitalists. Whose incredible value has everything to do with reducing length of stay.

So how do you fix the problem and align the forces? You bundle the payments. One lump sum per patient. Primary Care. Hospitalists. Subspecialists. They all split the pot. That's the solution. And you add a sprinkle of gain sharing to top it off.

Physicians are worried that they will lose income. I say bull. Without physicians, hospitals can't operate. If physicians can't agree on bundled payment fees or some other contract negotiation, they walk. They walk until the contract is acceptable to them. Bundled payments are coming. It's only a matter of when.

Hospitalists. Correct that. Good hospitalists are in a great position to lead the way with decreased resource utilization. They are already aligned with hospitals in the delivery of efficient health care.

As I see it, one of the greatest benefits of bundled care is that the irrational Evaluation & Management rules go away. You would eliminate billion dollar cottage industries who serve no purpose but to prop up worthless rules and regulations created to determine complexity of care. I'm here to tell you, the whole E&M process is a sham. It's highly inefficient and adds no value to health care delivery.

Get rid of E&M and I could double or triple the number of patients I see on a daily basis with not change in quality.

What are some of the consequences of bundles payments?

1. More efficient physicians. If I could do the work of 2 physicians in one day, you don't need two physicians. Get rid of E&M and you open up a whole new world of medical based documentation, not economic and insurance based documentation.
   
2. You also don't need NPs and PAs who are used as data collectors to maximize billing, and to allow more physician time in the procedure labs. At Happy's hospital extenders are used frequently to data collect, dictate and screen nuisance calls. In a bundled system, you don't need to spend hours or pay others to spend hours collecting worthless information. Away goes the full dictated physical exam, the full 12 point review of systems.
3. You get less care. That's not a bad thing. Most of the stuff we do to patients in hospitals doesn't matter. It's expensive and doesn't change outcomes.
   
4. You get cooperation. No longer are hospitals and physicians frequently at odds. If you accept the contract for bundled payments, you accept the terms. You are now a team with all physicians, with administrators, with insurance. If you don't accept the terms, you walk. It's that simple. It's in the best interest of hospital and physicians to find a plan that works.
5. Efficient IT. Hospitals and patients now have every incentive in the world to create work flows and patient data bases that result in highly efficient care without duplication of services. When all the forces are aligned, you get less care, not worse care.

Are there any concerns for bundled care?

Shared Wisdom

The American Board of Internal Medicine (ABIM)  wants to hear about your health care experiences.  

We invite you to read the powerful stories that many health care professionals have offered, and to share your own. Through these stories, it is our aim to illuminate the realities of how physicians, patients and caregivers interact with each other and how the health care system affects the nature of those relationships. In short, we hope that you will become inspired to help make the quality of health care better for all the patients we serve.

Go spread your wisdom.

Another Primary Care Doctor Bites The Dust

In favor of hospitalist medicine.

This is the doctor that will come and ask you about 700 annoying questions while you lay, uncomfortably, in the overcrowded emergency room. And this person will, ideally, follow you for much, if not all, of your stay in the hospital.

Welcome to your new journey.  You are doing exactly what the economics of primary care force you to do.  And you are not alone.

found via The Hospitalist

Turn GPS Watch On. Hook Up Heart Rate Monitor. Ride Roller Coasters.

Watch this really neat flash  video of my ride on SheiKra (90 degree drop straight down), the infamous dive roller coaster at Busch Gardens. This is a flash video  of my ride  with my GPS watch turned on and my heart rate monitor hooked up.  It tracks the ride in real time with altitude, speed, heart rate and  Google Maps all at the same time.

  

I also rode Montu.

And Kumba (it made me dizzy)

How cool is that?

PFTs In A Nut Shell

Man, this brings back memories of physiology.  I haven't heard about nitrogen washout for years.  But I still remember the concept of dead space.  Amazing what the mind remembers after all these years.

Thanks to Mely for a great refresher on what it all means and how to order the dang thing.

Refusing To Care For Patients

Because Your Conscience Says So.

I would imagine one of the most common things we see, as hospitalists, are the COPD'er, who continues to smoke, returning to the emergency room with shortness of breath. We treat with bronchodilators, maybe throw in a touch of antibiotics, start a steroid taper. But if I'm morally against cigarettes, I can refuse to treat? What if I'm morally against stupid behavior, can I refuse to see the patient?

How do you decide when your conscience trumps patient care?

How Much Do Law Professors Make or Earn?

How much do law professors make or earn?  Apparently, Law professors make or earn more than  primary care docs. Just in case you were wondering.

via TaxProf Blog

Increase Your Chance Of Being Linked To

I've been doing this blogging thing for almost 1 1/2 years. 1 1/2 years ago I didn't even know what a blog was. I had no idea what RSS was. What Digg was or any of the other Web 2.0 platforms did.

Now I get a lot of requests. One of which is to be linked to.

ProBlogger gives you a list of things to consider when trying to get linked. I agree with them all. And #1 on the list is to write something worth linking to.

Sex With Mannequins Is Not Illegal

As long as you do it behind closed doors.

In a 5-0 ruling, the justices Thursday overturned the conviction of Michael James Plenty Horse [no, we are not making this up] for indecent exposure because he didn't attempt to arouse others when he tried to have sex with the mannequin in a dark, closed room at a YMCA in Sioux Falls, S.D.

What's going on in South Dakota? Where did all the women go?

via Overlawyered

How To Control Costs

Stop paying for it. This is why government cannot set the price. They will never ever ever ever ever get it right.

As a result of extreme reimbursement cuts in the State of Washington Medicaid program, Walgreens announced it will withdraw 44 of its pharmacies from the state's Medicaid program as of May 1. These 44 pharmacies represent more than 60 percent of the company's total Medicaid business in the state and are found in communities large and small. Walgreens operates 111 pharmacies throughout Washington.

If Walgreens, a national chain that has enormous economies of scale, can't survive at Medicaid prices, how do you think anyone else can?

When Nurses Attack

This nurse killed five patients by injecting them with bleach.

What kind of sick person does that? From a hospitalist standpoint, the thought of bleach toxicity wouldn't even enter my differential diagnosis if I suddenly had a bunch of dying patients on my service.


Here's a real honest to God case of bleach injection for purification, by a Schizophrenic, of course.

It's a crazy world we live in.

Ciagrettes Under FDA Control?

The House Just Made It Happen. Now it's up to the Senate. What I find strangely amusing is that Philip Morris (Altria) backs the bill.

Tobacco giant Philip Morris is also behind the bill. Altria Group Inc., Philip Morris' parent company, said in a statement that it supports "tough but reasonable federal regulation of tobacco products" and that the company would "monitor and engage on this legislation" as it makes its way through Congress.

Perhaps by submitting to regulation, big tobacco can shield themselves from further lawsuits and lift a vale of risk that clouds their stock price potential. I mean, if the government sanctions their product, by the FDA none the less, the same organization given the power to make our food and drugs safe; If the FDA sanctions the selling of cigarettes, how could anyone possible sue big tobacco without also suing the FDA?

The Medicare #2 Population

Medicare | Up to One-Fifth of Medicare Beneficiaries Are Readmitted to Hospitals Within 30 Days of Being Discharged, Study Finds

I know exactly why that is. They should be hospice, but aren't.

The study found that 19.6% of beneficiaries were readmitted within 30 days of their initial discharge, 34% within 90 days and 56.1% within 12 months

I'm surprised the numbers aren't higher. The Medicare population is divided into two very distinct populations.

1. The Healthy Habits. Those that take care of themselves, have few medical conditions and continue to stay active in their lives as productive members of society.
   
2. The Wounded Weaklings. Those that have multiple medical conditions who lead sedintary lifestyles (by choice or not) in their daily routines.
   

The population I see in the hospital is almost exclusively Medicare #2. The fact that 100% of them aren't admitted in the first 12 months is a miracle. Perhaps only 1/2 of them are readmitted in 12 months because the other 1/2 have already died. Take for example this data Canadian data regarding life expectancy after an index hospital stay for CHF

RESULTS: The average age of our HF cohort was 75.8 years and 50.4% of the patients were female. After a median follow-up of 6 years, hospitalized patients with HF had a 5-year mortality rate of 68.7% and a median survival of 2.4 years. Mortality varied substantially across risk groups such that median survival was only 8 months for patients in the high-risk group and only 3 months in the very high risk group. Similarly, among patients with depressed left ventricular ejection fraction, median survival was only 6 and 3 months in the high- and very high risk groups, respectively

And these are the Canadians, where everyone has access to care.

What I see over and over again are the end stage frequent flyers who are cheating death by the hair of the skinny chin chin. Whether they have bad heart failure, bad COPD, badly controlled diabetes, one leg, 12 compression fractures, alzheimers, arrythmias, skin infections. It doesn't matter. The #2 Medicare population are cheating death. If you are over 65 and sick enough to get admitted to the hospital, this, to me, is a very clear sign that your body is failing you.

I was taught as a resident that every admission to the hospital knocks five years off your life expectancy. Medicare#2 patients get readmitted frequently because the only ones who get admitted are the only ones who shouldn't be alive, were it not for the FREE=MORE magic of American Medicare health care. Try being a Medicare #2 patient in any other country. You'd be long gone.

Want To Fix Health Care Costs? Slash Subspecialist Fees 30%

At least that's what this PA suggests.

Essentially, If I were health care "czar", my first action would be an across the board cut of 30% in payments (CMS) to surgical specialists and interventional radiology, cards, etc.etc.etc. And then increase reimbursements by 15% for primary care and hospitalist care.

I have several problems with this approach:

1. There is no rational reason why all physicians should feed from the same fixed trough. The RVU system and SGR economics is irrational and dysfunctional. Taking money from one group to give to another based on any political whim is bound to fail. It does not matter who's taking from who and giving to who. The only solution to RVU/SGR/RUC is to disband it in favor of a politically neutral unbaised approach to pricing. The only way you can price a service in the market is to have an open bidding process. The open bidding process works because if forces the market to give the best value for the buck. There is no government committee in the world, RUC or otherwise, that can correctly value the price of goods and services from a top down approach. Only the market can determine the best price. Supply and demand. If you have too many cardiologists in a region, they will have to compete on price and the price of their goods and services must come down. It must, because that's what happens when supply outstrips demand. As it stands now, when more specialists come to town, you simple get more service. More expensive service. Even if the market is saturated.
   
2. I have previously suggested that Medicare and Medicaid should go to an open bidding process for providers to care for patients in a bundled system of care. That means every outpatient gets cared for on a yearly bundled fee, severity adjusted, of course. All non preventative care procedures should be bundled into the care of the patient. All subspecialty offices should determine how much money they need to operate, to do their procedures and to remain profitable as well. And then they should be required to compete with other like specialists in the region to determine the baseline price point for Medicare/Medicaid. If you are practicing cardiology in the middle of no where and you are the only cardiologist in town, your value is far greater than in a city with 200 cardiologists. You should command far greater fees in rural America. That's what would drive more cardiology supply into rural America. Competition. The higher the supply, the lower the price. The lower the supply, the higher the price.

If I am a surgeon in a town of 2000, my value may be 5X higher than what current Medicare/Medicaid pays. If I am a surgeon in a town saturated with surgeons, I may be worth 1/2 of what Medicare/Medicaid pays. You see, the value of the subspecialist is not in what Medicare/Medicaid is currently paying them. It's what Medicare/Medicaid should be paying them. And that can only be determined by the market.

I can assure you, when the supply of primary care doctors taking new Medicare/Medicaid patients disappears, the price point necessary to open up the clogged access is determined on a regional basis, by regional economics and regional dynamics. In almost every corner of this country primary care services are severely lacking in access. It's because of money. The solution to the problem of access. The solution to who's making too much and who's making too little is not a top down approach that is so popular in Washington, it is the market approach. A market approach that prices services based on local market dynamics.

Morbidly Obese People Are Sedintary

A new study published in the March issue of the journal Clinical Cardiology found that morbidly obese people — those with a body mass index of 40 or more — may be sedentary for more than 99% of the day, engaging in moderate exercise on average for only a brief time.

Inactive, on average for 23 hours and 52 minutes per day.  That's what you call sedentary.

Is the sedentary lifestyle genetic or is it a matter of choice?

The Case Against Breast Feeding

Perhaps it's all just propoganda.

An ideal study would randomly divide a group of mothers, tell one half to breast-feed and the other not to, and then measure the outcomes. But researchers cannot ethically tell mothers what to feed their babies. Instead they have to settle for “observational” studies. These simply look for differences in two populations, one breast-fed and one not. The problem is, breast-fed infants are typically brought up in very different families from those raised on the bottle.

What do you think? Breat feed or not?

FREE=MORE

Government Style.

THE CARD is a very expensive lesson on the FREE=MORE philosophy.

• Nine People
  
• Six Years
• 2,678 ED visits
• $3 million dollars
• That's $1,120 a visit
  

That's 50 ED visits per patient per year. That's one visit a week. Every Week. For six long painful years. All courtesy of your tax dollars. FREE=MORE at its finest

If we give the card to everyone, get ready for the most massive economically unsustainable system of health care delivery ever known to man. It may work in other countries. It won't work in America, where the standard of care is nothing less than perfection, FREE=MORE style.

A system where neither patient, nor hospital nor doctor have any skin in the game. A system funded only the elusive "rich folk" who pay taxes. A rich folk who will get crushed under the weight of an unsustainable FREE=MORE medical empire that will make the current unfunded entitlements look like pretty snow angles.

If we get FREE=MORE for all, we are screwed. I know this because I practice it every single day.



via MDOD

Rule#1: Leave At Least One Urinal between You And Another Person

There are rules most people take for granted.  But for those with autism, they may not come naturally.  So it's up to those around them to teach them the necessary social graces engrained in our society.  For example.  How is a young autistic boy to act in a public men's bathroom?

Rule #1:  Always leave at least one urinal between you and another person.

Rule #2: Do not look at others while using the urinal.

Rule #3: No touching.

I can't say I've ever thought about this.  But it sure is intriguing the things that society expects in public.  Things  all of us most of us take for granted.

I can think of one.  Don't clip your toenails at work.

What else would you teach your autistic child about the codified social graces?

When You Can't Even Trust The Hospital You Work At

When everyone lies and the only thing that saved you was the fact that your husband was a lawyer. I'm sure he knew of the lies and treachery that goes on behind the scenes with other lawyers.

This story is disgusting. When hospitals stab you in the back. When hospitals lie. When they won't admit their mistakes. It is the antithesis of transparency. And it backfired. They got exactly what they deserved. The following is the last several paragraphs of this remarkable story. Read the rest of it and be disgusted. I was.

If I had been angry about what happened to the patient, I was even angrier after learning of the deception. The hospital had deliberately lied to protect its staff members. They lied to cover up medical negligence, with the assumption that the doctors in question would continue to practice at the same hospital, free to make similar mistakes.
The hospital had been remarkably foolish. In a malpractice case, an attempt to alter the record is practically an admission of guilt. There was no limit to the millions of dollars that a jury would be willing to award in a case of avoidable death of a young mother where the hospital had attempted to hide the truth. The lawyers for the anesthesiologists and the hospital knew this, too.
My lawyer called me several days later.
“There isn’t going to be a trial,” he said. “The hospital offered the patient’s family an 8-figure settlement, and they have accepted.”

The Pope Should Watch 30 Rock

The Pope says condoms increase the spread of HIV

Conclusion 3 (and why the Pope should watch 30 Rock): He lives The Bubble--either hearing things he only wants to or being told by some Yes men that he's right. If that weren't the case, he (and the Church) probably would have realized that abstience-only policies are ineffective. At best, they delay sex a short time. At worst, they increase risky sexual behaviors, unwanted pregnancy, and the spread of STIs.

What do you think. Is the Pop wrong for preaching abstinence over condoms to prevent the spread of HIV. If I lived in a country ravished by famine and poverty and violence and sex was the only thing I had to look forward to on a regular basis, I'm fairly certain, on any given day, that sex would trump the Pope, everytime.

Can A Primary Care Doctor and a Hospitalist Bill On The Same Day?

A reader asks me the question. Can a hospitalist and the primary care doctor bill on the same day?

That's a great question. The answer is, anyone can bill. The question is can you collect? With that said, the answer is sometimes yes and sometimes no. Here is my understanding:

Generally speaking, two physicians from the same like specialty cannot both collect from the patient's insurer for similar services on the same calendar day, even if they are from different practices. In other words, most insurers, if they are paying attention, will not pay for two internal medicine doctors or two gastroenterologists or two infectious disease docs to round on the same patient on the same calendar day if they are providing like services within the same scope of practice.

If the hospitalist rounds on the patient and the primary care doc comes by and rounds on them as well and they both submit a hospital follow up charge 99231-99233, if the insurance company is paying attention (which they may not be), they will likely deny the charge submitted second as medically unnecessary.

There is one situation where billing by two physicians in the same specialty but different practices are allowed.

You can see much more here in my coding lectures or earn CME at E&M University

If a primary care doctor sees a patient in the office and admits the patient to the hospital, they can only bill one charge. Either the clinic visit (99211-99215) or the hospital admission code (99221-99223). Most insurance companies will not allow the same physician to submit both E&M codes in the same calendar day. But if the primary care doc sees the patient in their clinic and they have a hospitalist admit, then the primary care doc can submit a 99211-99215 clinic code and the hospitalist can submit a 99221-99223 hospital admission code and both will get paid. Because both docs are providing medically necessary care independent of the other.

As far as I know, if a hospitalist admits a patient after midnight and the primary care doc comes by later that morning and tries to bill either another H&P or a follow up code, it will likely get denied (depending on who submits the claim first) as medically unnecessary. Most insurance companies, that are paying attention, will not allow multiple claims from different docs in different groups but of the same specialty on the same calendar day.

Our group generally will only admit patients we see till the end. We don't admit over night for the convenience of the primary care doc so they can take over in the morning. We have established our program as one that does not do that. If you want us to take care of your patients, we will. But we won't do it just so you can sleep at night and work in the days.
You can learn more about coding here in my coding lectures or earn CME at E&M University

Florida Is A Calling

I'm off to a Florida Paradise with Mrs Happy, my sister-in-law and our nine year old niece.  A whirlwind trip through Discovery Cove to swim with dolphins, Busch Gardens to ride sheikra, watch a night show extravaganza with Shamu at SeaWorld,  take in the amazing Aquatica water park and entertain heading over to Disney's incredible Blizzard Beach.

I've left you some good posts for you all to ponder until I return.  See you next week. I may sneak a pic or two in for ya.

Bilateral Temporal Arteritis

It's times like this that I'm glad I did a medical residency. It's times like this that internists shine. Shine above and beyond all other specialties put together. It's times like that that separate a good internist from just another provider of medicine.

Some things you just never forget. Residency is a time of extensive patient experience. A time to master the common but also to become an expert in the somethin' ain't right here scenario.

Take for example the 79 year old female who showed up on my doorsteps as a direct admission from the eye doc's office with "blindness". Now, I don't know about you, but anytime an eye doctor wants an internist to admit a patient for blindness, you have to have some serious concerns about the patients condition.

After this lady had gone a week with stuttering episodes of blindness, had been seen by an ophthalmologist, not once, but twice, had made the circuit through the emergency room and got to know the radiology technologist/MRI tech quite well, I listened to the patient for 5 minutes and made a clinical diagnosis of not only temporal arteritis, but bilateral temporal arteritis.

I have never made the diagnosis as a hospitalist. Six years out of residency and this life altering, potentially permanent blinding condition was at the top of my differential diagnosis with only five minutes of history taking. I was 95% certain of this diagnosis doing nothing more than listening to the patient tell their story. Behind all the worthless information patients like to tell ( they don't know otherwise), the key nuggets came shining through with barely a nudging.

What was it that keyed me in?

• Stuttering blindness. Anyone over 50 with stuttering blindness has temporal arteritis until proven otherwise.
  
• Jaw claudication. Yes folks she actually had it, and she volunteered this information. You only read about that in a text book.
  
• Headache. It really wasn't that impressive to be honest, but it was there and it confirmed my suspicions.
  

The one thing going against my suspicion was the lower than expected sed rate of only 72. We are taught that temporal arteritis is part of the limited differential diagnosis of a sed rate greater than 100. In this regards, she fell out of the classic text book presentation.

But she didn't fall out of the disease process.

The gold standard diagnosis is made by getting a biopsy of the temporal artery. I was so concerned and convinced she had it that day that I started her on high dose steroids, which should be done even before the biopsy is obtained. I contacted a vascular surgeon to perform bilateral temporal artery biopsy (most vascular surgeons would balk at the notion of bilateral temporal arteritis) and to discuss the case with a rheumatologist.

And wouldn't you know, the pathology from both temporal arteries came back consistent with arteritis.

Sometimes, it takes an internist to see the big picture. And as a hospitalist based internist, I can tell you that these are the kinds of clinical presentations that should scare the crap out of people who don't know what they're doing, but also bring great pleasure for those that do.

Now, the radiologist probably got paid $500 to read the scans. The ophthalmologist probably got more to do their dilated eye exams. And I, the hospitalist, who spent 90 minutes gathering history, talking with family, reviewing the case with multiple specialists, will collect less than 1/3 of that.

For making the diagnosis.

Yes folks. Quality medicine does not pay in American Health Care. Doing stuff does.

Big Waste of Time

It's all about quality these days. You can't walk a foot through a health care experience without someone talking about this or that quality initiative. We have hospitals spending millions to meet government determined quality parameters. We have physicians submitting PQRI data in an ever more expensive and complicated bureaucratic medical practice.

So what is the public supposed to think? That they aren't getting quality health care unless some expert panel puts out a list and makes it simple for laymen and women to understand? It makes sense. Rank the hospitals. The higher the hospital rank, the higher the quality of the hospital.

One such reporting system is the Leap Frog Hospital Survey

The Leapfrog Hospital Survey allows hospitals to self-report the steps they have taken toward implementing the Safe Practices for Better Healthcare endorsed by the National Quality Forum. The Leapfrog Group currently ranks hospital performance on the safe practices initiative by quartiles and presents this information to the public on its Web site

So someone decided to study this data and determine if in fact there was a correlation between the quartile and mortality. Mortality seems to be the mighty determinant of quality in our really expensive health care system.

Guess what they found. It doesn't matter what quartile you're in . There is no correlation with mortality.

On the Internet, hospital performance on the Safe Practices Survey is ranked by quartiles, which may suggest to consumers that hospitals in higher quartiles are safer than hospitals in lower quartiles. In this first study of the relationship between survey scores and hospital outcomes, we studied a national sample of hospitals and found no relationship between quartiles of score and in-hospital mortality, regardless of whether we adjusted for expected mortality risk and certain hospital characteristics

Perhaps the survey itself is bad. Perhaps mortality is a bad measure of quality. Whatever the case, right now the public is being led to believe that the higher the quartile the greater the quality based on survey data used to rank hospitals based on quality, and endorsed by the National Quality Forum.

Big Words. Big Programs. Big Money. Big Waste of Time

Allow Me To Practice

The best way to learn medicine is to practice it. That's why it's called the practice of medicine. But how do we practice? Do we read a book and then just go do it for real? Of course not. No such book exists.

We have many books that describe diseases. We don't have any that describe how to practice medicine. The practice of medicine is learned through patient contacts. This is the way medical education has always been. Learning on real people with the direction of your attending staff.

Dr RB, a family medicine resident describes his recent lack of practice experience in The Shadow

Just once I'd love to see middle aged investment banker fiddling with his Blackberry say, "Sure, go ahead and practice your stuff on me, kid. Every one's got to learn."

When I work with residents now, I tell them they are the doctor. It is their obligation to formulate a plan. It is their obligation to order studies and be their doctor. That is the only way you learn. By thinking through the problem on a case by case basis.

It's unfortunate that attending physicians act otherwise. Where I trained, at an academic university setting, every patient admitted to the hospital waived their right to refuse evaluations by students and residents. It's in the fine print of your admitting paperwork. If you go to an academic hospital, expect to get practiced on by medical students, residents, fellows, nursing students, respiratory students, phlebotomy students. The mission of academic institutions includes the training of health care professionals.

And you have just agreed to be the guinea pig. Without your agreement to be practiced on, we would have nobody in the health care field capable of practicing independently.

So the next time you say no, remember, your doctor was ONLY able to help you now because someone before you allowed them to practice.

The same thing goes for employed and practicing health care providers. If you are a nurse and a medical student or resident is slowing down your ER or your clinic or your preop surgery clinic, tough. Find another job where students aren't practicing.

Philanthropist Donates 200 Kidneys

What  amazing generosity

Dr Nissen, My Only Question Is Why?

Over at EGMN:  Notes From the Road Blog, we have the polypill going head to head with lifestyle modification.

Over 16 weeks in a study with 49 people, this ( the DASH diet) lifestyle regimen led to an average drop in systolic blood pressure of about 12 mm Hg. As one cardiologist on the session’s panel noted, that’s about what can be produced by treatment with one or two antihypertensive drugs at usual dosages

VS

The polypill, which combined three antihypertensive drugs at low doses, a statin, and aspirin into a single capsule taken daily. In the first test of this approach’s safety and efficacy the polypill produced an average 7 mm Hg fall in systolic blood pressure during 12 weeks of treatment. The polypill also reduced serum lipid levels and other markers of cardiovascular risk.

Now, I'm willing to bet the farm that lifestyle modification would have a larger effect on "other markers" of cardiovascular risk than any pill would.

Cardiologist Dr Steve Nissen sums  up the debate

“Not everyone will follow diet and exercise. Reserve polypharmacy for the people you can’t get to respond to lifestyle measures,” said Dr. Steven E. Nissen of the Cleveland Clinic.

Why Dr Nissen?  People are creatures of free will.  If they choose not to respond to lifestyle measures, that's on their shoulders, not ours.  Why should we as tax payers and premium payers of private insurance  pay for someone who can't respond to the scientific evidence?  If you don't want to respond to science, that's up to you.  But don't make others pay for your unwillingness to make change.  

If exercise works better than pills, than the pills should not be paid for until a trial of successful lifestyle change has been proven to be unsuccessful.  If you chose not to pursue lifestyle modification, be prepared to pay for your own health care needs.

Find Your Peak Efficiency

It looks like everyone is different.  I find it amazing that some people can run a marathon at over a 10 mph clip for 26 miles.  It turns out that the efficiency of running varies with the speed and each person has their own optimal efficiency.  So quit trying to keep up with your spouse, or the guy on the treadmill next to you. 

The most efficient running speed determined in the study varied between individuals but averaged about 8.3 miles per hour for males and 6.5 miles per hour for females in a group of nine experienced amateur runners. Much of the gender difference may be due to variations in body size and leg length, which have been shown to affect running mechanics, Steudel says. In general, the larger and taller runners had faster optimum speeds.

Find your own optimal speed and go for it.

via Blog Around the Clock

How To Be An Effective Hospitalist

PookieMD gives us the list.

Some of my disagreements

• Tell patients when you will call their family? I don't generally call families. I think that's because our nurses do a great job of updating them. I will call if I am asked to, when I get a chance.
• Consider giving your pager number to families? Never. Not in a million years. I have been sideswiped too many times by family on the other end of a page.
• Use a check list? I wouldn't find that helpful

Some like to equate being a hospitalist with being an intern. Since I have been both, I can say that there is nothing similar about them. A hospitalist is no different than a cardiologist or a surgeon or an outpatient comprehensive care doctor, except in scope of practice.

The Response To The Financial Crises Explained

By Neurotransmitters? This is crazy stuff. But really cool. It is not the expected uncertainty, but rather the unexpected uncertainty that is driving the political destruction of our free market system.

According to this theory, the degree of expected uncertainty is signaled by the amount of one neurotransmitter (acetylcholine) that causes us to pay less attention to our models—our preconceptions—and more to what we are actually experiencing. The neurotransmitter that signals unexpected uncertainty (norepinephrine), on the other hand, has the additional effect of causing us to shift attention in order to search for new cues that might be predictive in the new context, thus helping us to form new models rather than just tune the old ones. Increased levels of norepinephrine are also associated with increased anxiety.

It is quite possible the treatment of the current financial crises is not more government, but rather nothing more than a little exercise and som prn Xanax.

via Marginal Revolution

That's Just Wrong

But funny


see more dog and puppy pictures

Status Hispanicus Defined: Ey Yei Yei!

Status hispanicus is what you get when a Hispanic patient comes in with pain.

The “Ey Yey Yey” (pronounced EYE YEI YEI) syndrome is one that ER docs dread. It refers to a usually middle aged Hispanic female who comes in with nonspecific compliants accompanied by a constant “Ey yey yey! Ey yey yey!” (incidentally, people of different cultures have their own versions of this). 9 times out of 10 is a bunch of nothing - some mild problem amplified by anxiety. It is also know as “Ey Tach” for the eyeyeyeyeyeyeyeyeyeyeyeye that can occur.

Status hispanicus.  This is just good humor. Go read the comments.

Overheard On Campus

“We learned about calories in physics and chemistry today. I figure since calories are really a heat thingy, frozen food doesn’t count!”--From Cranky Professor

This is why the road to medical school is a weed out process.

What The Hell Hospital Do You Work At?

Ferrari?

This Is How You Turn Healthy People Into Sick People

Two thirds of the 400,000 (sign up for account) elective heart catheterizations at 600 institutions between 2004-2008 showed no obstructive coronary artery disease. For an invasive test which is supposed to be performed after noninvasive testing gives it a relative likelihood of changing outcomes, I am once again, not surprised at the volume of invasive procedural testing that results in expensive medicine without changing the plan or outcomes.

These were 400K patients without a history of acute coronary syndrome and no history of revascularization. Just under 2/3 of the catheterizations failed to find a blockage greater than 50% stenosis of the left main or greater than 70% blockage of other major vessels.


What do you suppose this means? Here are my theories.

1. Get paid well to do procedures, get procedures.
2. Get sued to delay in diagnosis or missed diagnosis, get procedures.
3. Everything can be made medically necessary, get procedures
4. More specialists means more procedures, get procedures
5. Fewer primary care docs mean more specialist workups, get procedures
6. More patients demand invasive testing with the failed belief that more is better, get procedures

If none of these six factors are leading to so many unnecessary heart catheterizations, which should be the last step in the work up of elective heart catheterizations, one can only assume that we are training very poor cardiologists, incapable of making accurate clinical decisions, or the heart catheterization itself is a very poor test for diagnosing clinically significant coronary artery disease. It's got to be one of these two things, or one of the six things listed above.

I have no other explanation.

Also, with a complication rate of 1.6%, that means 6,400 experienced a complication of their heart catheterization.

This is how you turn healthy people into sick people.