Thoughts and Thoughts

So, I received an unsolicited mailing from a prestigious sounding “Consumers’ Research Council of America.”

“Congratulations on your prestigious recognition in the ‘Guide to America’s Top Emergency Medicine Physicians’ “

Too bad it looks like a sham.  It is pretty suspicious when they immediately want to sell me a $200 plaque.  It seems that they do this for various medical fields, but relatively recently they made the mistake of also trying to bilk financial planners… resulting in the following article from Forbes.com.

“Consumers’ Research appears to be trying to create the image of a quality, beholden-to-no-one research organization like, say, Consumers Union, the similarly sounding nonprofit publisher of highly reputable Consumer Reports. But Consumers’ Research looks more like a stalking horse for S L D Industries, which also sells a wide range of traditional trophies and corporate awards.”

In that respect, I have to admit the plaques look pretty nice, and it isn’t a bad way to make a practice look respectable.  I’m sure they get a decent amount of business from medical professionals.  Honestly, how is a patient supposed to be able to tell?

Scanned letters below the break:

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An essay column in the New York Times discusses a personal reflection on money aspect of practicing medicine by Dr Sandeep Jalhar:

To meet the expenses of my growing family, I recently started moonlighting at a private medical practice in Queens. On Saturday mornings, I drive past Chinese takeout places and storefronts advertising cheap divorces to a white-shingled office building in a middle-class neighborhood.

I often reflect on how different this job is from my regular one, at an academic medical center on Long Island. For it forces me, again and again, to think about how much money my practice is generating.

via Essay – A Doctor by Choice, a Businessman by Necessity – NYTimes.com.

I sympathize with the feeling that one may have entered medicine hoping to not worry about money. Unfortunately, those days are gone… the age where doctor’s are paid enough so that they can just practice and not worry about money have been gone for a couple decades now.

I do think that the current fee-for-service system is sick, and really needs to be fixed.  I know HMO’s got a bad name in the late 80s, early 90s, but I do feel that they are a much better financial structure than the system we have now.  Obviously, I’m a little biased.

I’m pretty sure doctors in general will be happier that way.  I know that there was a survey of Canadian doctors which showed surprisingly high satisfaction scores when compared to their salary.  I’ll need to dig up to reference, I’ll update this post when I find it.

Too often, EMS crews feel obliged to bring unresponsive patient to hospital, study finds

Quote and Link below

In the United States, paramedics treat almost 300,000 people with cardiac arrest each year. But despite what’s portrayed on TV, fewer than 8 percent survive, according to the American Heart Association.

The association’s guidelines include the recommendation that people who have not responded to cardiopulmonary resuscitation (CPR) and advanced cardiac life support in the field not be taken to a hospital. After paramedics have tried and failed to resuscitate a patient, they should stop, researchers say.

“Paramedics provide all the same lifesaving procedures that we can provide in the emergency department,” said the study’s lead researcher, Dr. Comilla Sasson, Robert Wood Johnson clinical scholar and clinical lecturer in emergency medicine at the University of Michigan Medical School.

“Once you have done 20 to 30 minutes of cardiac resuscitation, the best practice guidelines are to cease if a patient does not have a pulse,” she said. But the study, published online June 30 in Circulation: Cardiovascular Quality and Outcomes, found that several factors inhibit this from happening, including:

via HealthDay.

Most of the time when I get a patient like this, I find that the patient is ready to be declared dead within a couple minutes of arrival, but one is afraid the family will feel that no attempt was made if one stops that quickly.  The paperwork and burden of telling the family then falls on the ER doctor, who honestly knows very little about the case other than what the paramedics just told him.  I’m not sure what is the best option for this, but these cases can lead to significant crowding and disrupt the flow of the Emergency Department, and it would certainly be nice if they weren’t brought to the Department if it is not necessary.

One of the best articles I’ve read in a while:

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.

via Annals of Medicine: The Cost Conundrum: Reporting & Essays: The New Yorker.

Link to Story

Writing in the journal Academic Emergency Medicine, lead author Dr. Carlos A. Camargo of Massachusetts General Hospital estimates that it would take until 2019 to find enough fully-trained, board-certified emergency physicians to work in the 4,828 emergency departments that are open 24 hours a day. And that best-case projection assumes that no current doctors who meet those qualifications die or leave their jobs.

The Institute of Medicine said in 2006 that ERs should ideally be staffed by doctors who had spent their residency training in emergency medicine and had later passed tests to become certified in the specialty. But only about 55 percent of doctors working in ERs meet that standard, Camargo and his co-authors write.

Does any other field have such a low percentage of physicians that are not board certified in the field of practice?  I know some of this has to do with the recent certification process, but that is pushing nearly 20 years now, and grandfathering options were available for those who were practicing before that.  What makes this worse, these calculations were done under the rosiest of scenarios where the doctors do not burn out and leave the field… good luck with that.

I’m not sure there is an easy solution to this problem.  I don’t think anyone is (or shoud be) suggesting we lower the standard of being qualified as an emergency medicine specialist.  There are already over 1000 residents trained a year, and at some point you run out of quality facilities to train residents (getting the right amount of volume with broad, well-rounded training isn’t possible just anywhere).  Decreasing the meteoric rise in ER visits in the past decade will also help a whole lot.

A really great article by Atul Gawande (writer of “Complications” and “Better”) was published in the New Yorker. The ariticle follows the work on intensivist Dr Peter Pronovost, who made simple workflow interventions which made dramatic reductions on the rate of complications in the intensive care unit. The following quote, however, made him an instant hero to me:

“The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. It’s viewed as the art of medicine. That’s a mistake, a huge mistake. And from a taxpayer’s perspective it’s outrageous.”

A link to the article is here.

Thanks Phil Andrus at the Mount Sinai Emergency Medicine Critical Care Blog for bringing this to my attention.

One of the hardest things to try to explain to people when discussing various kinds of institutional or governmental policy is the law of unintended consequences. It basically says the policy can have effects that are very different than what one expects. History is full of examples, yet people continue to believe that the idea/policy is smart enough to prevent thousands or millions of people from figuring out a way to mess it up while imaginatively trying to better their lives. It shouldn’t scare someone from trying to change things, but steps need to be taken to measure the change in order to ensure that what was intended to happen is indeed happening.

Glen Whitman, an associate professor of economics at California State University, Northridge, wrote a very nice article on this topic, linked here. It is worth a read, as it explains an idea which can be difficult to explain in a nice, accessible way.

The article is also saved after the break for archival purposes.

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Adam Bosworth, VP of Google recently has posted a few items on their blog regarding health care and the poor information transfer withiin the field.  I can only imagine that Health Informatics must seem truly backwards when one comes from a place like Google.

His first post is here:

http://googleblog.blogspot.com/2006/11/health-care-information-matters.html

And there is a second post, including a link to a transcript of a keynote address regarding this very issue.

http://googleblog.blogspot.com/2006/12/thoughts-on-health-care-continued.html

There are a number of obstacles to overcome, and the technical limitations are only a part of them. The bigger problem is that people working in the field are so fearful of litigation from a privacy breach, especially when it gets released to the “net.”  Some of this is because people are afraid of increased insurance rates, and many of these concerns are legitimate because information is just SO easy to duplicate a million times over once it is digitized.

Another article from the New York Times.

A product sold by Neurometrix, called NC-stat, is the topic of an article today’s New York Times, in particular the way it shows the problems with how doctors are reimbursed for the care that they provide.

Also provided here, is a link from Medgadget, and their review of how the NC-stat device works.

The interest for me, however has less to do with the device itself, but the following paragraph near then end of the piece:

For physicians, who might be able to bill only $80 or so for a routine 30-minute office visit, Neurometrix’s promise of a profit as high as $250 for 15 minutes, is compelling. So was a customer-referral program in which physicians could receive hundreds of dollars in free products for steering other doctors to Neurometrix.

….

For some health policy analysts, the popularity of such procedures illustrates why primary care doctors should be paid more for basic office visits and less for money-making procedures. Earning $250 from a diagnostic test “is obviously out of line with what physicians can earn from office visits,” said Paul Ginsburg, the president of the Center for Studying Health System Change, a Washington research group.

The reality is that doctors are simply not paid very much for spending time with patients, particularly in comparison to doing some fancy procedure.  The Medicare payments system that prices things based on the amount of resources it uses encourages people to use resources.  It seems obvious, but if one creates an incentive, one shouldn’t be surprised if people take it.  In this case, one shouldn’t be surprised if the entire medical industry is geared toward using more resources.

In fact, the expert doctor who can accurately diagnose people quickly is actually paid less, because, well, they’re too fast.

Anyway, the complete article is below.

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Arthur L Kellermann is a role-model to many of us who have earned or aspire to MD-MPH degrees. Having met him, he speaks with uncommon insight and wisdom. He has written a valuable editorial in the New England Journal of Medicine this week regarding the rising problem of crowding in the Emergency Department, particularly regarding disaster capacity. The Journal has been good enough to offer the editorial for free on their website.

When crowding reaches dangerous levels, hospitals often divert inbound ambulances to other facilities. In 2003, diversions occurred more than half a million times — an average of once per minute.³ Diversion may provide a brief respite for a beleaguered staff, but it prolongs ambulance transport times and disrupts established patterns of care. It also creates ripple effects that can compromise access to care throughout a city. Because crowding is rarely limited to a single hospital, one facility’s decision to divert ambulances can prompt others to follow suit. When that happens, a city may experience the health care equivalent of a “rolling blackout.” Everyone’s access to care is affected — the insured and uninsured alike.⁴

The complete article can be found here.