tag:blogger.com,1999:blog-44202178594308699452024-03-13T03:26:22.290-07:00WeAreBrokenTheTrackerhttp://www.blogger.com/profile/10011829472333355911noreply@blogger.comBlogger17125tag:blogger.com,1999:blog-4420217859430869945.post-217511800099266762017-03-13T14:41:00.000-07:002017-03-13T14:41:08.069-07:00What's the ICD-10 for "Fucked-up healthcare system"?<div dir="ltr" style="text-align: left;" trbidi="on">
Details changed, it's all fiction, I'm really a 400 pound Ukrainian hacker, etc.:<br />
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<blockquote class="tr_bq">
<div class="MsoNormal" style="mso-layout-grid-align: none; text-autospace: none;">
<span style="font-family: Arial; font-size: 11.0pt;">Differential diagnosis includes [but
is not limited to] fracture, laceration, abrasion, contusion, hematoma,
ligamentous injury, vascular injury, nerve injury</span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: Arial; font-size: 11.0pt;">In
summary, this is a 29-year-old male who has done his utmost to follow the plan
laid down for him when this tibial plateau fracture was dx a week ago. He has followed up with
his primary. He elicited a list of possible surgeons directly from his
insurance company. He called ALL surgeons listed as accepting his insurance.
Five would take him, but have no appts in the next month. He then appropriately
returned to his primary, who then referred him back to our ED.</span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<span style="font-family: Arial; font-size: 11.0pt;">I spoke
at length regarding this case to Dr. It’s-2a. Not only would he not see or
treat the patient, he was emphatic that the consultation itself was
inappropriate and that it was a social work issue. Despite that his expertise
was of benefit in that he set the maximum time the surgery, ideally obtained
btw 7-10 days, could be delayed (two weeks from the injury, leaving four
business days for Mr XXX to overcome the hurdle of not having a orthopedic
doctor who would see him within a month, obtain a consult with them, and be
scheduled for and obtain surgery) and advising that Mr XXX's coldness/swelling,
in the setting of normal pulses and sensation, likely reflected a need to keep
the leg elevated more consistently to reduce edema. Appreciate his
consultation.</span></div>
<div class="MsoNormal" style="mso-layout-grid-align: none; mso-pagination: none; text-autospace: none;">
<br /></div>
<div class="MsoNormal">
<span style="font-family: Arial; font-size: 11.0pt;">As the
initial trauma was caused by a motorcycle accident, OSH YYY trauma service
agreed to accept Mr XXX in transfer and, in their words, "work something
out." Very grateful to them for their help with this extraordinarily frustrating
case of an insured patient who seemingly "did everything right" but
nevertheless was not able to obtain critical time-sensitive follow-up care.</span></div>
</blockquote>
</div>
TheTrackerhttp://www.blogger.com/profile/10011829472333355911noreply@blogger.com0tag:blogger.com,1999:blog-4420217859430869945.post-15785417605932005282016-09-28T23:12:00.000-07:002016-09-28T23:12:36.630-07:00Technology and the Old Masters<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="https://3.bp.blogspot.com/-GW9SuF4DbLU/V-ymGCZw2jI/AAAAAAAAAak/ca3rlJyyxrgwaZkMNmBMWPG6I_r2BdKXACLcB/s1600/Screen%2BShot%2B2016-09-28%2Bat%2B10.25.47%2BPM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="255" src="https://3.bp.blogspot.com/-GW9SuF4DbLU/V-ymGCZw2jI/AAAAAAAAAak/ca3rlJyyxrgwaZkMNmBMWPG6I_r2BdKXACLcB/s320/Screen%2BShot%2B2016-09-28%2Bat%2B10.25.47%2BPM.png" width="320" /></a></div>
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<div class="MsoNormal">
Boy, do I have feels about this. Feeling number one: it’s
complicated.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
While it’s great to have all the skills, technology will
inevitably cause the loss of some older ways of doing things. I’m sure the
first OB/Gyn residents to graduate without knowing their way around a foreceps
delivery faced some scorn from their colleagues. A few years after <span style="mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Laennec,
there undoubtedly was an old-timer who complained to another old-timer to the
effect of “Kids today, they don’t even know how to auscultate a chest without
their fancy amplifying wooden tubes.” Somewhere in the mists of history,
shortly after the introduction of practical glucose assays, there was somewhere
a great teacher who complained bitterly about young physicians who didn’t even
know the the taste of diabetic urine.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">On the other hand, it’s a good idea not
to let go of all the low(er) tech ways of doing things, as you made need them
when your high-tech gadgets fail you. And high tech or low, it is alays better to have more than one way to do something.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">But even so, we have to remember that
time and opportunities to practice are limited. “Learn both” is easy to say but
hard to practice. If we’re being intellectually honest, we should accept that
we already use the training time allotted to the making of a doctor, and if you
want to add something you should be prepared either to increase the hours of
training or cut something out. And the natural thing to suffer when you
introduce a new way of doing a task is the old way of doing a task: patients
will not likely suffer twice as much respiratory failure for your convenience in
learning and practicing the Glidescope and manual laryngoscopy both.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Which brings me to feeling number two:
it’s too early to say goodbye to landmark-only lines. Some rooms are too small,
some patients too critical for ultrasound. Machines number one or two in most
EDs; they may all be in use.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">What you come out of residency knowing how to do is in large part a reflection on your teachers. This physician, I'd wager, trained somewhere where it was ultrasound-guided IJs, all day every day. Tell someone at that program you wanted to put in a blind fem line to learn how to do it and they'd look at you like you just grew a second head.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">This is why once you have trained up your residents a bit it's important to put them out on their own, or close to it, in a place where hairy stuff can go down. Code teams. Night shift in the ICU. EMS months. Moonlighting. In those situations the need for hairy shit like a STAT femoral line arises organically.</span></div>
<div class="MsoNormal">
<span style="mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><br /></span></div>
<div class="MsoNormal">
<span style="mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">But this is contrary to the entire thrust of medical culture as it has developed in the last 30 years. In the name of safety, every learner must be supervised at all times. Consequential decisions are left to the higher ups. Uncontrolled and semi-controlled crises, which arise with sick patients all the time, make administrators' skin crawl and they strive to keep residents as far away from them as possible. When something bad occurs, the refrain goes up, "Only the attending should be entrusted with this" -- an attitude that does little for safety, by and large, but quite effectively stunts learning.</span></div>
<div class="MsoNormal">
<span style="mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><br /></span></div>
<div class="MsoNormal">
<span style="mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">What Samuel Shem wrote in the House of God is still true today: doctors learn "by taking risks in those hard times when you were alone with your patient." If you never leave a doc alone, because safety, well…this is where you end up, with physicians that function fine in routine situations but poorly when Death shows up and decides to eat their lunch.</span></div>
<div class="MsoNormal">
<span style="mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><br /></span></div>
<div class="MsoNormal">
<span style="mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Final feel: education aside, by five years out you should have a good idea where your holes are and be working to fill them. I can put in blind femorals by pulse or landmark (when there is no pulse) as well as under ultrasound; I can put in a blind subclavian with confidence, and my ultrasound guided IJs are respectable. Am I satisfied? Hell no! I want to learn how to use ultrasound at the subclavian and how to do a blind IJ. I've recently started to use Statlocks to secure the lines instead of sutures (fewer holes in the patient, less line infections.) Constant practice of what you know; constant reaching for new and better techniques and tools. The old ways will slowly pass out of knowledge, but a physician humble in their limited knowledge but restless and impatient for perfection will never go out of style.</span></div>
<div class="MsoNormal">
<br /></div>
<blockquote class="tr_bq">
<div style="padding-left: 1em; text-align: right; text-indent: -1em;">
For always roaming with a hungry heart </div>
<div style="padding-left: 1em; text-align: right; text-indent: -1em;">
Much have I seen and known; cities of men </div>
<div style="padding-left: 1em; text-align: right; text-indent: -1em;">
And manners, climates, councils, governments, </div>
<div style="padding-left: 1em; text-align: right; text-indent: -1em;">
Myself not least, but honour'd of them all; </div>
<div style="padding-left: 1em; text-align: right; text-indent: -1em;">
And drunk delight of battle with my peers, </div>
<div style="text-align: right;">
Far on the ringing plains of windy Troy. </div>
</blockquote>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><br /></span></div>
<div class="MsoNormal">
<span style="mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><br /></span></div>
</div>
TheTrackerhttp://www.blogger.com/profile/10011829472333355911noreply@blogger.com0tag:blogger.com,1999:blog-4420217859430869945.post-5540121735879877512016-09-05T21:01:00.000-07:002016-09-07T13:43:32.547-07:00Quit bitching and love your hospitalists<div dir="ltr" style="text-align: left;" trbidi="on">
The New England Journal of Medicine has <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1608289">some issues</a> with hospitalists:<br />
<blockquote class="tr_bq">
<blockquote class="tr_bq">
In fact, increasing reliance on hospitalists entails a number of
risks and costs for everyone involved in the health care system — most
critically, for the patients that system is meant to serve. As the
number of physicians caring for a patient increases, the depth of the
relationship between patient and physician tends to diminish — a
phenomenon of particular concern to those who regard the
patient–physician relationship as the core of good medical care.</blockquote>
<blockquote class="tr_bq">
Practically
speaking, increasing the number of physicians involved in a patient’s
care creates opportunities for miscommunication and discoordination,
particularly at admission and discharge. Gaps between community
physicians and hospitalists may result in failures to follow up on test
results and treatment recommendations.<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMp1608289#ref1" rel="#refLayer">1</a></span>
Moreover, the acute care focus of hospital medicine may not match the
need of many patients for effective disease prevention and health
promotion. </blockquote>
</blockquote>
Practically speaking, this is high-minded nonsense. Of course it would be ideal to have one physician caring for you from cradle to grave, with a light garnish of various specialists. This model, which was merely slow and inefficient 30 years ago, when it began its sharp decline, is now, in 2016, impractical and unsafe. But aside concerns of cost or time management: hospitalized patients in 2016 are too sick, too old, and too complex for the vast majority of primary care practitioners.<br />
<br />
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<div class="MsoNormal">
A hospitalist requires, in part, a thorough knowledge of the
diagnosis and acute management of heart attack, stroke, sepsis, hemorrhage,
DKA, HHS, DVT and PE, pancreatitis, cardiac arrest, COPD exacerbation, severe
asthma, cholecystitis, hepatitis, alcohol withdrawal, status epilepticus,
endocarditis, meningitis, myesthenia gravis, and I could go on and on (and on.)
On the floor in the dead of night with a patient who has developed hypotension,
or new neurological deficits, or severe chest pain, referral is impossible and
in most settings bringing a consultant to the bedside is almost as impractical
as referral.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Not only is extensive training and experience with many
acute conditions required (something most primary care doctors today have little, if
any, experience with), significant procedural experience is required and must come from somewhere. If an internist today does not know how to put in a central line, intubate a patient in respiratory distress, or place a chest tube, then someone must be on hand who can perform these tasks, typically an emergency physician or a ICU specialist. </div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://4.bp.blogspot.com/-jCkIZKm0-fI/V841FBj-vQI/AAAAAAAAAaI/rT_O1LwUs0we5_DuTRIygaZZVtgeVtz0gCLcB/s1600/Screen%2BShot%2B2016-09-05%2Bat%2B8.16.08%2BPM.png" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" height="86" src="https://4.bp.blogspot.com/-jCkIZKm0-fI/V841FBj-vQI/AAAAAAAAAaI/rT_O1LwUs0we5_DuTRIygaZZVtgeVtz0gCLcB/s400/Screen%2BShot%2B2016-09-05%2Bat%2B8.16.08%2BPM.png" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2855006/">Source</a>.</td></tr>
</tbody></table>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
But it is not desirable to pull either the emergency physician out of the department or the intensivist out of the ICU. In either case, you may be borrowing the only physician staffing some severely ill and potentially unstable patients. Yet only 11% of hospitalists in one large national survey performed are nine of the procedures identified as "core competencies." As underwhelming as this is, it compares to a mere 3% of non-hospitalist internists in the same study!</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As much as the NEJM may not want to hear this about their loyal subscribers, 21st century primary care physicians do not have either the cognitive tools or the physical skills to manage sick inpatients. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Today's primary care physician pushed into the hospitalist role would give us less coordinated care, rather than more. When you put any doctor in a position where the task at hand is beyond
their training and experience, they do one thing very reliably: they
call a consultant. They would consult EPs, critical care doctors, GI doctors, endocrinologists, cardiologists and so on, with great vigor (even more so than today's hospitalists, who have never been accused of being dilatory in this). The result would be even more doctors trying to drive the bus, even more opportunities for miscommunication and misunderstanding.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Look, I get it. Change is hard. Some people don't see quite where hospitalists fit in the grand tradition of the golden age (real or imagined) of American medicine:</div>
<blockquote class="tr_bq">
<div class="MsoNormal">
For most of medicine’s history, however, the boundaries of medical
fields have been based on factors such as patient age (pediatrics and
geriatrics), anatomical and physiological systems (ophthalmology and
gastroenterology), and the physician’s toolset (radiology and surgery).
Hospital medicine, by contrast, is defined by the location in which care
is delivered.…</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
The very term “hospitalist” seems problematic. If we call some
physicians hospitalists, should we call others “clinicists” or
“officists”?<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMp1608289#ref3" rel="#refLayer">3</a></span>
Similarly, the move toward shift work may open the door to “matinists”
and “nocturnists.” Using a misnomer such as “hospitalist” to mean acute
care medicine may seem harmless, but calling things by the wrong names
is often the first step toward becoming confused about them — a
particularly hazardous state of affairs for a profession facing an era
of great flux.</div>
</blockquote>
Guess what? A LOT of medical specialties are defined by where they work, by the type of patients that present there and the types of problems they have. A partial list would include emergency physicians, anesthesiologists, primary care physicians ("officists" indeed,) as well as hospitalists. Is that somehow less legitimate, less dignified than being defined by a toolset or a system?<br />
<br />
The hell it is. As medicine has become more and more specialized, more and more physicians specialize in saying no -- no, I'm not on call, the office is closed, no you need a specialist, or you need a subspecialist, or different insurance, or anything and everything -- but hospitalists, like emergency physicians, specialize in saying yes. When you come to the hospital, they roll up their sleeves and get to work. That is the true physician spirit, which the NEJM would denigrate in a misguided attempt to save it.</div>
TheTrackerhttp://www.blogger.com/profile/10011829472333355911noreply@blogger.com0tag:blogger.com,1999:blog-4420217859430869945.post-85767199999907546622014-12-05T08:02:00.001-08:002014-12-05T08:02:23.990-08:00How nostalgia killed Dr Singer's capacity for rational thought<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="http://scienceblogs.com/denialism/wp-content/blogs.dir/428/files/2012/04/i-880005398336c472547ab02e425e6cd0-commonwealthfigureII8.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="http://scienceblogs.com/denialism/wp-content/blogs.dir/428/files/2012/04/i-880005398336c472547ab02e425e6cd0-commonwealthfigureII8.jpg" height="290" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><a href="http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAMQjxw&url=http%3A%2F%2Fscienceblogs.com%2Fdenialism%2F2009%2F05%2F29%2Fwhat-is-health-care-like-in-th%2F&ei=19KBVJ7gAYezogTPsoLgAQ&bvm=bv.81177339,d.cGU&psig=AFQjCNFpBFQYvjcj_fQIdFAd9rnhWriVHw&ust=1417880658933730">Source</a></td></tr>
</tbody></table>
<br />
A Facebook friend recently has been sending around a <a href="http://www.cato.org/publications/commentary/how-government-killed-medical-profession">2013 article/toddler-grade tantrum</a> by Dr Jeffery Singer, general surgeon/old man sitting on a park bench. Let me tell you, it's a tear-jerker:<br />
<br />
<blockquote class="tr_bq">
These rules are being bred into the system. Young doctors and medical
students are being trained to follow protocol. To them, command and
control is normal. But to older physicians who have lived through the
decline of medical culture, this only contributes to our angst.<br />
<br />
One of my colleagues, a noted pulmonologist with over 30 years’
experience, fears that teaching young physicians to follow guidelines
and practice protocols discourages creative medical thinking and may
lead to a decrease in diagnostic and therapeutic excellence. He laments
that “ ‘evidence-based’ means you are not interested in listening to
anyone.” Another colleague, a North Phoenix orthopedist of many years,
decries the “cookie-cutter” approach mandated by protocols.</blockquote>
God forbid you should go to work and find rules "bred into the system" that restrict your ability to do whatever the hell you feel like doing. I'm sure no one but doctors ever feels that pain. <br />
<br />
This all seems very sad, but when a doctor opines that evidence-based medicine "means you are not interested in listening to
anyone" you have to understand that as code for "You aren't listening to me." Because until startlingly recently, that's how virtually all medicine worked; the leading lights of the profession laid down the law, and that was the standard of practice.<br />
<br />
There are now standardized grades of evidence, starting with multiple randomized controlled trials and extending downwards through observational studies and case reports and at the very bottom, "expert consensus" (i.e., this is what we believe but we have no proof of any kind.) This quality of evidence is known colloquially in the industry as GOB-SAAT. Good Old Boys -- Sitting Around A Table. Before evidence-based medicine, we had eminence-based medicine.<br />
<br />
Dr Singer's hatred of protocols -- things like washing your hands between patients, pausing before surgery to confirm you're doing the right surgery on the right patient, or observing low-risk head injuries in children rather than irradiating their brains -- is common in physicians, but in Dr Singer, it has been amplified by ideology:<br />
<blockquote class="tr_bq">
Ayn Rand’s philosophical novel <em>Atlas Shrugged</em> describes a
dystopian near-future America. One of its characters is Dr. Thomas
Hendricks, a prominent and innovative neurosurgeon who one day just
disappears. He could no longer be a part of a medical system that denied
him autonomy and dignity. Dr. Hendricks’ warning deserves repeating:<br />
<br />
“Let them discover the kind of doctors that their system will now
produce. Let them discover, in their operating rooms and hospital wards,
that it is not safe to place their lives in the hands of a man whose
life they have throttled. It is not safe, if he is the sort of man who
resents it—and still less safe, if he is the sort who doesn’t.”</blockquote>
What are we to think of a man with a responsible job and most of his career behind him who has the intellectual interests of a socially stunted 14-year-old? These are questions I cannot answer.<br />
<br />
To try and interest us in what is essentially an irrelevant paean to his own nostalgia, Singer's lards up his argument with predictions of disaster aplenty (All the doctors will quit! Except for the brain-dead younger generation weak enough to tolerate the intrusion of "so-called 'evidence-based medicine,'") some of which are really funny in their own right:<br />
<blockquote class="tr_bq">
In other words, we’re about to experience the two-tiered system that
already exists in most parts of the world that provide “universal
coverage.” Those who have the financial means will still be able to get
prompt, courteous, personalized, state-of-the-art health care from
providers who consider themselves professionals. But the majority can
expect long lines, mediocre and impersonal care from shift-working
providers, subtle but definite rationing, and slowly deteriorating
outcomes.</blockquote>
Yes, if nothing is done, we will soon experience the universal free healthcare that delivers better health outcomes at half the cost in the UK and Canada -- a model so wildly popular in those countries that right-wind politicians get nowhere near office without swearing to protect and defend it.<br />
<br />
But the real punchline here is his claim of "slowly deteriorating outcomes." The outcomes are better than ours, but in the confines of Dr Singer's Rand-poisoned mind, that simply means they are deteriorating too slowly for the terrible and inevitable decline to be evident to the causal observer.<br />
<br />
Back in the reality-based community, <a href="http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror">things look rather different</a>: <br />
<blockquote class="tr_bq">
<b>The United States health care system is the most expensive in the world,
but this report and prior editions consistently show the U.S.
underperforms relative to other countries on most dimensions of
performance.</b> Among the 11 nations studied in this report—Australia,
Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden,
Switzerland, the United Kingdom, and the United States—<b>the U.S. ranks
last, as it did in the 2010, 2007, 2006, and 2004 editions </b>of Mirror,
Mirror. Most troubling, the U.S. fails to achieve better health outcomes
than the other countries, and as shown in the earlier editions, <b>the
U.S. is last or near last on dimensions of access, efficiency, and
equity.</b> In this edition of <em>Mirror, Mirror</em>, <b>the United Kingdom ranks first</b>, followed closely by Switzerland (Exhibit ES-1). </blockquote>
Protocols have good and bad points. I deal with frustrating and clinically counterproductive protocols every day. If you are going to spend seven years training a doctor, you should probably leave room in the system for them to exercise their clinical judgement. But many protocols are proven to improve patient outcomes. So if they make our days as doctors a little less fun, so be it. And evidence-based medicine, like free speech, is best answered by more and better evidence, not nostalgia for the days when the stand of care was "I got a hunch." Fuck GOB-SAAT.<br />
</div>
TheTrackerhttp://www.blogger.com/profile/10011829472333355911noreply@blogger.com0tag:blogger.com,1999:blog-4420217859430869945.post-8617685409323338292014-10-20T22:02:00.000-07:002014-10-20T22:02:30.931-07:00Thoughts on Placebos<div dir="ltr" style="text-align: left;" trbidi="on">
CarbonKyle, scourge of alternative medicine and pseudoscience of all sorts, has some negative things to say about placebos in the comments <a href="http://carbon-comic.com/comic/143-family-tradition/">here</a>. As a frequent user of what one might term semi-placebos (things I hope will help a little, but are primarily recommended to give a non-harmful treatment whilst the body heals itself) I felt I had to speak up for the humble placebo: <br />
<br />
<blockquote class="tr_bq">
I recommend "<a href="http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0CCwQFjAB&url=http%3A%2F%2Fwww.amazon.com%2FThe-House-God-Samuel-Shem%2Fdp%2F0425238091&ei=FOhFVOS6K4b6yATc9IHoDA&usg=AFQjCNG4xkfM0YNk3mHGjz7VPukrVZ9f-w&sig2=EcxqKTESVYzOQOTve2dDYQ&bvm=bv.77880786,d.aWw">The House of God</a>" for a medical perspective on the value of, as Shem puts it "Doing as much nothing as possible."<br /><br />Allopathic medicine prescribes <a href="http://www.choosingwisely.org/">a lot of ineffective or unnecessary medicine</a> -- these are really placebos by another name. The difference is that while a good placebo is harmless, a bad placebo -- like an antibiotic for a viral pharyngitis or a muscle relaxant for back pain, or (a horror that takes place 250k times a year in the US) an unnecessary heart cath for stable angina -- may have some serious negative health consequences.<br /><br />Placebos are necessary because treatment is part of the ritual of healthcare. Listening, helping the patient make sense of the problem, and offering treatment all have a value in themselves, apart from the biomechanical efficacy of the treatment (or even whether the diagnosis is correct.)<br /><br />It's true that many people find the explicit use of placebos unethical, and it may be. But if you were to ask a hundred doctors "Have you ever prescribed a treatment you didn't believe would cure the patient, in order to give a patient something, knowing that the disease was going to get better in time regardless?" 90% of them would say yes (and the other 10% are lying.)<br /><br />The physician has a different role than the scientist. The purpose of the scientist is to seek empirical truth; the purpose of the physician is to seek healing. And to do that, our mandate is broad:<br /><br />"Life is short, and Art long; the crisis fleeting; experience perilous, and decision difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and external circumstances cooperate."</blockquote>
</div>
TheTrackerhttp://www.blogger.com/profile/10011829472333355911noreply@blogger.com0tag:blogger.com,1999:blog-4420217859430869945.post-79310796563932324082014-10-09T06:29:00.001-07:002014-10-09T06:29:29.643-07:00"Informed" "consent"<div dir="ltr" style="text-align: left;" trbidi="on">
Dr Orthochick over at Fizzy's place is talking <a href="http://doccartoon.blogspot.com/2014/09/dr-orthochick-consent.html">consents</a>.<br />
<br />
It's a tangent, but I find myself a huge skeptic/cynic of/about the whole concept of informed consent. This is of course supposed to be our antidote to the bad old paternalistic days when you would want some information about what was going to happen with your condition and your care and your wise old doctor would pat you on the head, take a long drag of his unfiltered Camel, and tell you not to worry your pretty head about it.<br />
<br />
But the concept of informed consent does not make very much sense, philosophically, nor is it particularly practical. Informed consent is supposed to include "PARQ," shorthand for "procedures, risks, alternatives, and questions." The big daddy here is risks; that's what we talk most about. The risks of doing a thing and the risks of not doing it. And then you get to chose. Sounds great! But how am I supposed to give you an accurate account of the possible risks of something I want/need to do for you? There are always dozens of things that can go wrong, some minor, some major.<br />
<br />
Obviously the significance of each particular risk depends on how likely it is to come to pass, which is a statistical question. But most people (including most physicians) are not good with statistics. We tend to overrate rare risks, underrate things we haven't seen personally, make big changes in response to one bad experience, etc.<br />
<br />
Practically speaking, in the best case I tell you and you understand whether a risk is rare or common. But if it's rare, you probably don't need to worry about it, and if it's common, it's probably minor. (Informed consent would be really useful if doctors commonly performed unnecessary procedures that killed or crippled half the people who had them, but for obvious reasons, we don't do that.)<br />
<br />
So what you're left with are rare serious risks, to which it will be difficult to assign significance to because they are rare, and common minor risks, which neither you or I care much about.<br />
<br />
Sometimes people have strong opinions about their care, and sometimes they have a much greater tolerance for one kind of risk (kidney failure from a coronary angiogram) versus another (a heart attack like the one that killed their father.) And sometime people are done with medical care, and they want to slow down or stop -- that's a really important discussion to have.<br />
<br />
Most of the time, though, people don't have the medical or statistical expertise to weigh all the risks and benefits of a particular course of action -- that's what they pay me for.<i> And they know that</i>. Most people are going to do whatever it is you recommend as their doctor (at least in the emergency setting, where I work). And that's really the only rational course, when you hire a professional to help you do something you don't know how to do yourself.<br />
<br />
It's not about the doctor thing. If I hire an IT person to fix my computer, and they tell me <a href="http://www.smbc-comics.com/index.php?db=comics&id=1768#comic">I have too many zeroes and I need to buy more ones</a>, then that's what I'm going to do.<br />
<br />
So at the end of the day, the real "informed consent" boils down to this: Do you trust me? Do you feel like I care about you? Do you think I am careful and competent?<br />
<br />
If you do, and I recommend something, you should do it. If you don't, then regardless of what I say, you probably shouldn't.<br />
<br />
You can't take the trust out of the doctor-patient relationship. Every patient (with decisional capacity) should have all their questions answered, know what's happening, and have veto over any and all things being done to their bodies. But on a daily basis we assault patients' ears and brains with a mountain of complications and terrible possibilities that they can't possibly weigh and measure, even well, and we badger them to make important decisions when they are hurt, scared, and sick, all in the name of a chimera called "informed consent."<br />
<br />
But the only decision they are really making, most times, is: Do you trust me?</div>
TheTrackerhttp://www.blogger.com/profile/10011829472333355911noreply@blogger.com0tag:blogger.com,1999:blog-4420217859430869945.post-51592150541052399882011-11-08T04:50:00.000-08:002011-11-08T04:50:29.772-08:00The roadwork<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="http://graphics8.nytimes.com/images/2011/11/08/sports/08frazier2_span/08frazier2_span-articleLarge.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="http://graphics8.nytimes.com/images/2011/11/08/sports/08frazier2_span/08frazier2_span-articleLarge.jpg" width="400" /></a></div>
<br />
<br />
Joe Frazier passed away last night. He died, at the age of 67, of liver cancer. Among many accomplishments, the great heavyweight champion uttered the best quote about medical education (or any other sort of preparation) I have ever heard:<br />
<br />
<blockquote>
<b>You can map out a fight plan or a life plan, but when the action starts, it may not go down the way you planned,
and you’re down to your reflexes – that means your training. That’s
where your roadwork shows. If you cheated on that in the dark of the
morning, well, you’re going to get found out now, under the bright
lights.
</b></blockquote>
<b>- Joe Frazier</b><br />
<br />
<br />
<br /></div>TheTrackerhttp://www.blogger.com/profile/10011829472333355911noreply@blogger.com0tag:blogger.com,1999:blog-4420217859430869945.post-2057651043210694392011-10-18T09:20:00.000-07:002011-10-18T09:20:20.620-07:00Keeping people healthy saves money. Duh.<div dir="ltr" style="text-align: left;" trbidi="on">
<div class="separator" style="clear: both; text-align: center;">
<a href="http://t0.gstatic.com/images?q=tbn:ANd9GcR9FmF8RXIUzXC17rhqSY84jPkwChVXbUY3Ce0F0aw4NrBypa5G" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="266" src="http://t0.gstatic.com/images?q=tbn:ANd9GcR9FmF8RXIUzXC17rhqSY84jPkwChVXbUY3Ce0F0aw4NrBypa5G" width="400" /></a></div>
<a href="http://www.theatlantic.com/magazine/archive/2011/11/the-quiet-health-care-revolution/8667/">Tell me something</a> I don't know:<br />
<br />
<br />
E<span style="text-transform: uppercase;">llen, an 82-year-old </span>widow,
lives in Anaheim, California. One Wednesday morning last year, she got
on her scale, as she does every morning. One hundred and forty-six
pounds—wasn’t that a little high? Ellen felt vaguely troubled as she
poured herself a bowl of oat bran. <br />
Half an hour later, the phone rang. It was Sandra at the clinic.
She too was concerned about Ellen’s weight, which had jumped three
pounds since the previous day. Sandra knew this because Ellen’s scale
had transmitted its reading to the clinic over a wireless connection. <br />
<blockquote>
Given that Ellen had a history of congestive heart failure, a
three-pound weight gain in 24 hours was a potentially dangerous
development, a sign of possible fluid buildup in the lungs and
increasing pressure on an already stressed heart. Sandra wanted her to
come in for an immediate visit: <b>the clinic would provide a car to pick
her up and bring her back home. Ellen’s treatment began that very
morning and continued for two weeks until she was out of danger. Had the
warning signs not been noticed and addressed so quickly, she might
easily have suffered a long, painful, and expensive hospitalization. </b><br />
Dan, a retired letter carrier, is a patient at a clinic in the same
system. At 87, he is decidedly frail, his once-sturdy legs now weak and
unsteady. He is a classic candidate for a fall of the kind that has
injured many of his friends, in some cases leading to weeks in the
hospital and months of rehab. The elderly are prone to falls for many
obvious reasons, including weak limbs, impaired vision, and medication
side effects. But Dan’s doctors knew that some less obvious causes
included shag carpets and long, untrimmed toenails. Because of this,
<b>they’d sent someone from the clinic to visit Dan’s apartment and make
sure that his daughter replaced the 1980s-vintage carpets with low-pile
rugs. Dan also visits the clinic regularly for light muscle-training
sessions and periodic toenail clipping. Due to these preventive
measures, Dan and his fellow clinic patients are one-fifth as likely as
comparable patients elsewhere to suffer falls.</b><br />
Joe, a 79-year-old diabetic, cut his foot when he banged it against
a door. When it didn’t heal after a couple of days, he limped into the
office of his family physician. After glancing at the cut, his doctor
immediately sent Joe to a clinic in the same system as those that
treated Ellen and Dan. For diabetics, even small cuts can be a serious
matter: untended, they can become infected and contribute to an
alarmingly high rate of amputation. <br />
At the clinic, a nurse practitioner cleaned and dressed the wound,
and told Joe she wanted to see him there in two days so she could
inspect and treat it again—and two days after that, and two days after
that, until it was fully healed. The clinic would arrange for
transportation if needed. <b>Thanks to the steady, regular care, Joe’s foot
healed without any infection or threat of amputation.</b> <br />
Ellen, Dan, and Joe are all real people, though their names have
been changed. The clinics that serve them are all affiliated with
CareMore, a company based in Cerritos, California, that operates 26 care
centers across the Southwest, serving more than 50,000 Medicare
Advantage patients. Those numbers are likely to grow, perhaps
dramatically, in the next few years: in August, CareMore was acquired by
the insurer and health-services provider WellPoint, which serves 70
million people nationwide directly or through subsidiaries, and has
plans to expand the CareMore model. <br />
CareMore, through its unique approach to caring for the elderly, is
routinely achieving patient outcomes that other providers can only
dream about: a hospitalization rate 24 percent below average; hospital
stays 38 percent shorter; an amputation rate among diabetics 60 percent
lower than average. Perhaps most remarkable of all, these improved
outcomes have come without increased total cost. Though they may seem
expensive, CareMore’s “upstream” interventions—the wireless scales, the
free rides to medical appointments, etc.—save money in the long run by
preventing vastly more costly “downstream” outcomes such as
hospitalizations and surgeries. As a result, <b>CareMore’s overall member
costs are actually 18 percent below the industry average. </b></blockquote>
<br />
Excuse my cynicism. But <i>we know these kinds of measures work</i>. And we know why they are not standard practice. Take it away, Dr. Berwick:<br />
<br />
<blockquote>
<b>The access we need to create is access to help and healing, and that does not always mean—in fact, I think it rarely means—reliance on face-to-face meetings between patients, doctors, and nurses. Tackled well, I believe that this new framework will gradually reveal that half or more of our encounters—maybe as many as 80 percent of them—are neither wanted by patients nor deeply believed in by professionals. </b>This is an example of a problem so big that we have trouble seeing it. The health care encounter as a face-to-face visit is a dinosaur. More exactly, it is a form of relationship of immense and irreplaceable value to a few of the people we seek to help, and these few have their access severely curtailed by the use of visits to meet the needs of many, whose needs could be better met through other kinds of encounters.<br />The alternatives to visits in the escape fire are many: self-care strongly supported and unequivocally encouraged; group visits of patients with like needs, with or without professionals involved; Internet use for access to scientific and popular information; e-mail care between patients and clinicians; and well-managed chat rooms, electronic and real, for patients and significant others who face common challenges.<br /><b>Payers should take careful note: Most of you still pay only for Pulaskis. The greatest potential for reducing costs while maintaining and improving the lot of patients is to replace visits with better, more flexible and fine-tuned forms of care. But almost all current payment mechanisms, whether enforced by the market or mapped into organizations by internal compensation systems, use impoverished definitions of productivity that actively discourage the search for and incorporation of non-visit care. </b></blockquote>
Every single country in the industrialized world spends less on healthcare than we do, and most have better outcomes. This is not an exaggeration, or a statistical trick. We have fallen behind and are going broke because we are pissing away money on poorly coordinated expensive interventions instead of cheap, proven approaches.<br />
<br />
The proximal cause of this is the reimbursement system, the madness of the RVU model. This system pays us for doing stuff, and it pays us a lot more for stuff that involves technology, cutting and sewing, labs, scans, and specialist care. This is exactly the reason we ended up with a system with a death of primary care and an abundance of technology, cutting and sewing, labs, scans, and specialist care. We designed the system that way. Practice has followed compensation.<br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="http://www.google.com/url?source=imglanding&ct=img&q=http://www.accu-tech.com/Portals/54495/images/VA%20Hospital%20Building%20lg.jpg&sa=X&ei=CaOdTunED-jg0QH4gPG1CQ&ved=0CA0Q8wc&usg=AFQjCNEv9ME0DZsRXXvAVXao45e9CjFrog" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="302" src="http://www.google.com/url?source=imglanding&ct=img&q=http://www.accu-tech.com/Portals/54495/images/VA%20Hospital%20Building%20lg.jpg&sa=X&ei=CaOdTunED-jg0QH4gPG1CQ&ved=0CA0Q8wc&usg=AFQjCNEv9ME0DZsRXXvAVXao45e9CjFrog" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">The VA saves money and improves outcomes the same way -- they are stuck with the person for life.</td></tr>
</tbody></table>
<br />
<br />
Technology has become a driver of costs, rather than a source of cost-savings, as a result of being yoked to this dysfunctional system of payments. You can check a patient's weight at home and intervene before their CHF exacerbation sends them to the ED? Say goodbye to the ED billing, the chest X-ray, the IV lasix and nitro paste, goodbye the bill for the hospital bed, the itemized charges, the bedside echo. Thousands of dollars saved by the healthcare system are thousands of doctors lost to the healthcare worker or the healthcare institution.<br />
<br />
<br />
CareMore can do this because they get a flat fee for each
patient, adjusted for their demographics and preexisting conditions. So
every dollar they save is a dollar they save, rather than a dollar they
lose. And the savings they are reporting are the tip of the iceberg, if
we learn to follow the simple principle that we pay once, for a person's
overall care -- their health -- and not piece by piece for every
intervention, which rewards disjointed care and rewards failure --
sickness.<br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="http://www.google.com/url?source=imglanding&ct=img&q=http://caasc.net/images/Sponsors_2007/Kaiser_Permanente_Logo.jpg&sa=X&ei=o6OdTre8PKPg0QHH4Y2OCQ&ved=0CAwQ8wc4FA&usg=AFQjCNEjWcqylhAdJ7E8iHpVusjtukjubQ" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="160" src="http://www.google.com/url?source=imglanding&ct=img&q=http://caasc.net/images/Sponsors_2007/Kaiser_Permanente_Logo.jpg&sa=X&ei=o6OdTre8PKPg0QHH4Y2OCQ&ved=0CAwQ8wc4FA&usg=AFQjCNEjWcqylhAdJ7E8iHpVusjtukjubQ" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Kaiser succeeds by making its money on the insurance side -- again, they get a lump sum per patient.</td></tr>
</tbody></table>
<br />
I'm glad CareMore was able to strike this deal with Medicare Advantage -- it's about time that big, fat, juicy piece of pork was used for good rather than evil. But at some point can we stop being surprised by this -- stop treating it as a bold outside-the-box experiment that might go either way? It's freakin' Capitalist Economics 101: if you pay doctors to do things, and pay the most for tests and procedures and scans, they will do more things, and especially more tests and procedures and scans. If you structure the compensation to align the incentives for the individual provider or hospital with those of the patient -- who wants to be well, not sick, and have few medical interventions, not many -- you get a system that is better for patients, for caregivers, and more society as a whole.<br />
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It's time to stop gawking at the pioneers and run our whole healthcare system on this basis.<br />
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</div>TheTrackerhttp://www.blogger.com/profile/10011829472333355911noreply@blogger.com0tag:blogger.com,1999:blog-4420217859430869945.post-9113365484200479902011-10-16T09:28:00.000-07:002011-10-16T09:28:23.229-07:00Abraham Verghese damns the physical exam with faint praise<div dir="ltr" style="text-align: left;" trbidi="on">
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Dr. Verghese, above, gives us a fun and seemingly unobjectionable TED talk calling for the revival of the physical exam -- one that unfortunately illustrates why the physical exam is dying of neglect.The TED audience seemed to like it, but I feel like I have heard this lecture with slight variations every year since the start of med school.<br />
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Doing medicine from behind a computer is condemned. Traditional rounds with extensive histories and physical exams are praised. The glorious history of the physical exam is recounted. Said history always includes allusions to Arthur Conan Doyle and <a href="http://www.the-hospitalist.org/details/article/255635/The_Birth_of_Percussion.html">Auenbrugger tapping wine barrels</a>, <a href="http://en.wikipedia.org/wiki/Ren%C3%A9_Laennec">Laennec watching children play</a>, and so on.<br />
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While they touch on the diagnoses missed and patients harmed by hasty or sloppy exams, the lion's share of the talk is always devoted to how the exam makes the patient <i>feel</i> -- how it helps or harms the patient's emotional connection with their doctor, how the exam reassures, how it conveys the unironically invoked "healing touch."<br />
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None of this is wrong, but it damns the exam with faint praise. It skirts past and implicitly concedes the question of what actual, reliable, actionable information can be obtained by the physical exam. How good is the physical exam at achieving its declared goal of giving us useful information about illness?<br />
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The problem of time is also intertwined with this, and also is ignored by Dr. Verghese, who speaks rapturously of splitting an exam off into its own half-hour appointment so that he can discuss the history uninterrupted during the first half-hour appointment. How does this anecdote help me in the emergency room, in the ICU, or on the wards? Fuck you very much, Dr. Verghese.<br />
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But it's not really his fault; he's just carrying on a proud tradition of unreality surrounding medicine at the bedside. How many prescribed work-ups open with this infamous phrase: "Do a complete history and physical exam." Anybody do that? Or anyone? Ever?<br />
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And that's the problem with those teaching rounds, too. So you want the hospitalist attending, with 20 people on their service, to interview and examine every patient, every day, with Q-and-A with the residents at bedside?<br />
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If you really want to promote the physical exam, the way to do so is exactly the opposite of Dr. Verghese's method. Enough about the exam's noble history. Bleeding has a noble history in medicine, too, but that didn't save it from the dustbin. The physical exam will rise or fall based on its clinical utility, which is determined by:<br />
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1. The sensitivity and specificity of particular maneuvers for particular conditions (see the <a href="http://www.google.com/url?sa=t&source=web&cd=1&ved=0CCYQFjAA&url=http%3A%2F%2Fjama.ama-assn.org%2Fcgi%2Fcollection%2Frational_clinical_exam&rct=j&q=Rational%20Clinical%20Exam&ei=XveaTpeAC_DI0AHkh9QH&usg=AFQjCNGi5ft-XHj6yaDCDhbsAp6bPdx6fQ&sig2=S3XDkgAXHb_S9_1gYlV4Dg&cad=rja">Rational Clinical Exam</a> series or <a href="http://www.amazon.com/Physical-Diagnosis-Secrets-STUDENT-CONSULT/dp/0323034675">Physical Diagnosis Secrets</a> for examples of this research). Stuff that is not sensitive or specific <i>needs to go</i> (bowel sounds, I'm looking at you). There are 1440 minutes in every day and God's not making any more time. <br />
2. To make this research applicable to the bedside, we need to agree on a standardized technique for performing a given maneuver. Students need to be taught a consistent method; students and residents need to be regularly supervised and evaluated in their performance of the exam.<br />
3. Students should learn how to do a comprehensive exam, but textbooks and instructors need to acknowledge the reality of limited time and state explicitly what parts of a comprehensive exam can be safely omitted in which patients. Do you need a heart and lung exam in a healthy 20-year-old with a sprained wrist and no other complaints? Obviously not, but common sense is often ignored in the teaching of the physical exam.<br />
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If I were to sum up my program here in a single sentence, I would say: <b>To restore the respect for the physical exam vis-a-via tests and scans, we must apply all the same principles that guide our use of tests and scans:</b><br />
<br />
1. What we do should be evidence-based.<br />
2. We shouldn't be indiscriminate or unfocused in our application of these tools. Our time is as precious a resource as the time of the MRI scanner.<br />
3. We should use sensitivity and specificity to guide our use of these tools in making a diagnosis. Some will rule in, some will rule out, some will be used in parallel, some in series.<br />
4. How we do a test/scan/exam may vary from place to place, but it should be, as far as possible, standardized around best practices, so we know the research we are using applies, and we can trust the results reported to us from elsewhere.<br />
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There is no question that the act of touching the patient deepens our relationship with them, and has an intangible value. That is a given. But it is also, if performed properly, a ruthlessly effective way to gather critical information about multiple systems simultaneously without exposure to radiation or expensive and time-consuming blood tests. The exam is fully capable of justifying itself within the paradigm of scientific medicine, and can be optimized for that task without losing any of its -- literal -- touchy-feely bona fides. What we must not do is strive to preserve an idealized and historically driven vision of the physical exam, which will lead to an impractical mess -- heartily praised and rarely performed -- that it is not subject to investigation and systematic improvement because it is justified in the first place as relationship-building, as emotional or spiritual comfort, a performance rather than an investigation. <br />
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The physical exam is not the ground on which to fight a battle over medicine as art versus medicine as science. The physical exam -- the act of looking, listening, feeling, and make decisions on the basis of the empirical evidence gathered -- belongs wholly to science. Appealing to art, like appealing to the notion of emotional and spiritual comfort, is not factually wrong, but is an act of self-defeating desperation.<br />
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The exam needs to be continually tested and improved by scientific investigation and critical judgement, or it will fall hopelessly behind blood tests and scans, where such continuous improvement is routine. Loving the physical exam, as I do, means not fearing for its fate at the hands of evidence-based medicine. It is a powerful and practical tool, and we can continue to prove that as we continue to improve it.<br />
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<br /></div>TheTrackerhttp://www.blogger.com/profile/10011829472333355911noreply@blogger.com3tag:blogger.com,1999:blog-4420217859430869945.post-23479121303667968032011-10-13T18:46:00.001-07:002011-10-13T18:46:39.716-07:00<div dir="ltr" style="text-align: left;" trbidi="on">
<blockquote>
<a href="http://www.nytimes.com/2011/10/14/us/more-places-change-course-on-fluoride-in-water.html?ref=health">Looking to Save Money, More Places Decide to Stop Fluoridating the Water</a> <br />
</blockquote>
<blockquote>
By <a class="meta-per" href="http://topics.nytimes.com/top/reference/timestopics/people/a/lizette_alvarez/index.html?inline=nyt-per" rel="author" title="More Articles by Lizette Alvarez">LIZETTE ALVAREZ</a>
<br />
</blockquote>
<div class="articleBody">
<blockquote>
MIAMI — A growing number of communities are choosing to stop adding
fluoride to their water systems, even though the federal government and
federal health officials maintain their full support for a measure they
say provides a 25 percent reduction in <a class="meta-classifier" href="http://health.nytimes.com/health/guides/disease/dental-cavities/overview.html?inline=nyt-classifier" title="In-depth reference and news articles about Dental cavities.">tooth decay</a> nationwide. </blockquote>
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</div>TheTrackerhttp://www.blogger.com/profile/10011829472333355911noreply@blogger.com0tag:blogger.com,1999:blog-4420217859430869945.post-65777362671769356232011-10-12T18:06:00.000-07:002011-10-12T18:08:57.332-07:00We're going to have to open another kit<a href="http://myobsaidwhat.com/">"My OB said WHAT?!?" </a> is a site which is basically devoted to hating on obstetrics, physicians and Western medicine in general. Along with a bunch of mildly insensitive comments and a few that are truly outrageous, a few of the stories are really funny caregiver wins:
<blockquote>OB: “Would you rather be cut or tear?”</blockquote>
<blockquote>
Mother: ‘Neither!”</blockquote>
<blockquote>OB: “Nurse, hand me my magic wand.” </blockquote>TheTrackerhttp://www.blogger.com/profile/10011829472333355911noreply@blogger.com2tag:blogger.com,1999:blog-4420217859430869945.post-12017127105450432152011-10-12T11:48:00.000-07:002011-10-12T14:00:33.677-07:00Should NPs call themselves doctors?<div dir="ltr" style="text-align: left;" trbidi="on">
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<br />
No. It's confusing. There, that was easy.<br />
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The NYTimes <a href="http://www.google.com/url?sa=t&source=web&cd=2&ved=0CCEQFjAB&url=http%3A%2F%2Fwww.nytimes.com%2F2011%2F10%2F02%2Fhealth%2Fpolicy%2F02docs.html%3Fpagewanted%3Dall&rct=j&q=nytimes%20nurse%20doctor&ei=99WVTq6hPIbn0QGj-YnnBw&usg=AFQjCNFpqlHLmtqWooGQgVhAxTePEO-wIA&sig2=eetkpygpdpXa8c87DKtuVw&cad=rja">opened this bag of worms</a> recently. The blogosphere <a href="http://emergency-room-nurse.blogspot.com/2011/10/is-there-doctor-in-house.html">took the cue</a>. For me the question itself fails to excite. Nurses are more trusted as a profession than doctors. Few of them are going to want to be confused with a doctor. Among those that do, most will have the common sense to realize that in the common usage, a medical doctor is a DO or an MD, and regardless of what brilliant etymological arguments one can bring to bear to illustrate that this should not be the case, it is so and a non-physician introducing themselves as the patient's doctor is going to destroy trust with that patient, who will feel deceived.<br />
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The story is more interesting for what it says about the state of healthcare today than the question getting all the attention. For instance, consider this fun fact:<br />
<blockquote>
For decades, a bachelor’s degree was all that was required to become a
pharmacist. That changed in 2004 when a doctorate replaced the
bachelor’s degree as the minimum needed to practice. Physical therapists
once needed only bachelor’s degrees, too, but the profession will
require doctorates of all students by 2015 — the same year that nursing
leaders intend to require doctorates of all those becoming nurse
practitioners. </blockquote>
Doctorates for all! And you're welcome to 'em. But might I ask, what for? As the article points out:<br />
<br />
<blockquote>
Nursing is filled with multiple specialties requiring varying levels of
education, from a high school equivalency degree for nursing assistants
to a master’s degree for nurse practitioners. Those wishing to become
nurse anesthetists will soon be required to earn doctorates, but
otherwise <b>there are presently no practical or clinical differences
between nurses who earn master’s degrees and those who get doctorates</b>.
</blockquote>
We have a huge labor shortage barreling down on us in healthcare, as the baby boomers move out of their healthcare jobs and into the stretcher in the hallway. Is this really the time to be raising barriers to those entering the profession?<br />
<br />
It would be one thing if those extra months and years were to be spent running codes in the sim lab, treating hundreds of standardized patients, or drilling deeply into pathophysiology or pharmacology. But that's not what they are doing:<br />
<blockquote>
<br />
While instruction at each school varies, Dr. McCarver <a href="http://www.nursing.vanderbilt.edu/dnp/courses.html#410" title="Vanderbilt’s course of study for a DNP degree">took classes</a>
in statistics, epidemiology and health care economics to earn her
doctor of nursing practice degree. These additional classes, at
Vanderbilt University, <b>did not delve into how to treat specific
illnesses</b>, but taught Dr. McCarver the scientific and economic
underpinnings of the care she was already providing and how they fit
into the nation’s health care system.</blockquote>
Nursing phD degrees focus on research skills, administration, public health. They don't go back to the basics and forge exceptional clinicians; they're not <i>for</i> that. It's hard to escape the gnawing sense that these are advanced degrees mostly for the sake of advanced degrees; mail-order MBAs for the ambitious and upwardly mobile healthcare worker.<br />
<br />
I think a lot of this is about credential inflation; the tendency to value and require more and more postsecondary education regardless of whether it actually effects the person's ability to do their job. And the artificial scarcity of physicians that creates and maintains a massive hunger for mid-levels; that's in there too. I mean, if you have bright people who want to study for eight years to go work in a primary care clinic and call themselves doctors, the $64,000 question is <i>why you don't just train them as doctors. </i><br />
<br />
But those are posts in themselves, so stay turned for part two: Credential inflation in healthcare.</div>TheTrackerhttp://www.blogger.com/profile/10011829472333355911noreply@blogger.com2tag:blogger.com,1999:blog-4420217859430869945.post-59646012940700118772011-09-01T03:49:00.000-07:002011-09-01T03:53:02.637-07:00The Hazards of Hospitals<a href="http://www.medicalbillingandcodingcertification.net/hazards-of-hospitals"><img src="http://images.medicalbillingandcodingcertification.net.s3.amazonaws.com/hospital-hazards.gif" alt="The Hazards of Hospitals" width="500" border="0" /></a><br />Created by: <a href="http://www.medicalbillingandcodingcertification.net">Medical Billing and Coding</a>
<br />
<br />I tell people this stuff in the emergency room, straight up, when they want admission to the hospital and it's not indicated. A hospital, I say, is a great place to be if you're critically ill, and a terrible place to be if you can be treated safely at home, keeping you within your family, familiar surroundings, and the flow of your life.
<br />
<br />There are no Dilaudid PCAs at home, though, so I lose that argument more often than not.TheTrackerhttp://www.blogger.com/profile/10011829472333355911noreply@blogger.com2tag:blogger.com,1999:blog-4420217859430869945.post-68279658804317762222011-04-30T16:22:00.000-07:002011-04-30T16:27:24.443-07:00The trouble with blockbusters: expensive, crappy sequels<a href="http://mystrongmedicine.com/2011/04/26/i-think-huey-lewis-and-the-news-hit-the-nail-on-the-head/#comment-5709">h/t My Strong Medicine:</a><br /><br /><blockquote> April 20, 2011 — The 10 most prescribed drugs in the U.S. aren’t the drugs on which we spend the most, according to a report from the IMS Institute for Healthcare Informatics.<br /><br /> …<br /><br /> Out of the $307 billion we spent on drugs in 2010, we spent most of our money on the following:<br /><br /> Lipitor, a cholesterol-lowering statin drug — $7.2 billion<br /> Nexium, an antacid drug — $6.3 billion<br /> Plavix, a blood thinner — $6.1 billion<br /> Advair Diskus, an asthma inhaler — $4.7 billion<br /> Abilify, an antipsychotic drug — $4.6 billion<br /> Seroquel, an antipsychotic drug — $4.4 billion<br /> Singulair, an oral asthma drug — $4.1 billion<br /> Crestor, a cholesterol-lowering statin drug — $3.8 billion<br /> Actos, a diabetes drug — $3.5 billion<br /> Epogen, an injectable anemia drug — $3.3 billion<br /></blockquote><br /><br /><br /><br />What struck me was that with the exception of Epogen and (for certain indications) Plavix, every single one of those drugs is a variant on an older, now generic drug, which works for all intents and purposes just as well.<br /><br />Crestor? Really? Nexium? Actos?<br /><br />If you wanted to shave a quick $20 billion off the government’s healthcare costs, you could just announce that the VA formulary are now the only drugs Medicare or Medicaid will pay for.<br /><br />When “Transformers 3″ comes out I will go see it, despite the fact that I’m shelling out money for a slight variation on a winning formula. But when the pharmaceutical industry is making its money off tired knock-offs, that’s more of a problem.TheTrackerhttp://www.blogger.com/profile/10011829472333355911noreply@blogger.com0tag:blogger.com,1999:blog-4420217859430869945.post-1297786855709635362011-04-24T07:29:00.000-07:002011-04-24T07:30:58.685-07:00Making healthcare cheaper<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="http://images-mediawiki-sites.thefullwiki.org/03/4/0/1/82572432845687379.gif"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 300px; height: 474px;" src="http://images-mediawiki-sites.thefullwiki.org/03/4/0/1/82572432845687379.gif" border="0" alt="" /></a><br />Making healthcare cheaper is not, actually, a particularly difficult problem. It requires political will, not theoretical innovation. It can be arrived at via many routes, provided they observe a simple principle:<br /><span style="font-weight:bold;"><br />We must pay for health, not for sickness. For outcomes, not for methods. For the totality of a life, and not a particular crisis.</span><br /><br />There are many ways in which this could be accomplished. A national health service, responsible for the health of the entire population, is one. A more market-driven approach would be to have a number of necessarily large healthcare organizations who would "bid" for patients, likely in lots, the contract for life-long health services going to the lowest bidder. <br /><br />If we prefer to nibble around the edges of the problem first, there are a number of small, commonsense reforms we could implement. We could cut reimbursement for diagnostic studies and all procedures by 20%. We could require all Medicare and Medicaid recipients to fill out an advanced directive (we aren't going to tell them what to put in their advanced directive, only require that they have one).<br /><br />Medicare could announce that it will automatically deny any claims by a physician who exceeds the census-adjusted rate of billing for a given code by more than 200%, excepting things like health maintenance or counseling. So if you, as an EM physician, order five times as many cervical spine CTs as your peers, Medicare will deny them all and require you to justify them one by one.<br /><br />Medicare and Medicaid could carefully chose a subset of the best-validated, evidence-supported practice guidelines, and automatically deny any claims not in accordance with those guidelines.<br /><br />Another money-saving and quality-improving device would be to rigorously limit the amount of documentation by health care professionals to the absolute minimum that can be shown to substantially improve safety and continuity of care. Fines for overcoding and fraud should be increased by orders of magnitude, forcing organizations to police themselves.<br /><br />It is almost too obvious to say Medicare should only cover treatments which are effective. That this is a matter of some controversy cannot help but raise the question of whether Americans are, as a nation, too stupid to survive. A NICE-style board, calculating cost per DAYL, is the best way to calculate effectiveness. I would go a step further, and have too sets of calculations; one for people over the age of 60 with two or more chronic health problems; one for everyone else. Because we need to stop pissing away hundreds of thousands of dollars a case to no purpose but to torture some poor benighted soul for three or four weeks in the ICU. If you want that (and no one but no one who has seen it at the bedside and knows what it is wants it) you can pay for it yourself.TheTrackerhttp://www.blogger.com/profile/10011829472333355911noreply@blogger.com0tag:blogger.com,1999:blog-4420217859430869945.post-16664250604303009982010-11-27T14:20:00.000-08:002010-11-27T14:34:29.867-08:00First principlesThe conversation here will, by necessity and design, be fluid, unsystematic, and hopefully transgressional. That said, it will not be so amorphous that it stands for nothing; should not be so casual it becomes merely an online version of that popular medical bloodsport, bitching about our jobs.<br /><br />These are the principles of what I am doing, whatever it is:<br /><br />1. We are all in this together. There is not physician crisis, or nursing crisis, or patient crisis, or taxpayer crisis. We will not exalt one perspective at the expense of the others, as if the solution were only better training for residents or more nurses or better support for outpatients.<br /><br />2. We are broken -- not in every way, not every time, but we are broken and we need to be whole. We will be whole when great healthcare is available to everyone at a reasonable cost, when compassion and good humor are ubiquitous, good communication a premise and errors as rare as your passenger jet falling out of the sky. <br /><br />3. There will be no sacred cows, not private insurance or physician salaries or the autonomy of clinical decisions. There is a goal -- great healthcare for everyone, every time, at a reasonable cost. Anything that might get us a step closer to that is on the table.TheTrackerhttp://www.blogger.com/profile/10011829472333355911noreply@blogger.com0tag:blogger.com,1999:blog-4420217859430869945.post-4198426569143112422010-10-01T17:06:00.000-07:002010-10-01T17:25:15.632-07:00A blog about medicine, American healthcare, healing and wellnessBy now it's no secret that American healthcare is in the weeds. Some of its problems have been well described -- the funding crisis, the moral and practical challenge of the uninsured, the increasing recognition of medical errors and poor communication with and support of patients and families by their caregivers.<br /><br />On the inside of the health system, where I and my colleagues are, all these problems are recognized, although some our obscured by the conditions in which we work (cost) and others by our work habits, our culture, and our self-protective rationalizations (few caregivers recognize how poor their communication with patients and families is, for example.) But also from the inside there are many more stress points that the public does not see. Care that sets out to be interdisciplinary and ends up fractured and confused. Reckless use of technology and medicine, often to patient's detriment, chasing the impossible dream of a work-up that takes no time, involves no exercise of judgment (which might leave it open to criticism), and misses nothing. The black hole of documentation which is swallowing giant swathes of time. And so on.<br /><br />The mission of this blog is simple: we will confront the ways in which we, the American medical community, are broken, the way in which the country itself is broken as regards public health, medicine and law, and what can and is being done about it.TheTrackerhttp://www.blogger.com/profile/10011829472333355911noreply@blogger.com0