Why All Medical Students Should Go Into Nephrology

Because urine might just be our new fuel source.

-Wes

h/t: Instapundit.

Why Do People Get 48-Hour Holter Monitors?

Look, if an arrhythmia doesn't show up in the first 24 hours, it's not that much more likely to show up in the following 24 hours. Although it's probably happened, I've never seen a "48-hour" Holter detect an arrhythmia better than a 24-hour Holter and all it ever does is increase costs (and torment the Holter reader).

If a patient has infrequent symptoms, consider an 30-day event (loop) recorder instead.

There. I feel better now.

-Wes

Dr. Wes Goes to Washington

From Jessica, commenting on my "Are Doctors Sheeple?" post:

I for one want to hear what the physicians have to say and really, that's about the only group I want to hear from. It is beyond comprehension how people can condemn doctors/providers for health care costing too much. It makes me so mad - it is the best case of brainwashing I've ever seen and it would do us well to track that sentiment back to those who stand to gain the most from spreading such lies.

We are lucky to have the talented souls who go to work each and every day knowing the tape they have to work around and we need to stop now and listen to what they suggest. There is too many unnecessary layers between me and my providers, too much between me knowing how much something will cost so I can plan ahead, too many back room deals between unaffected players that help those who don't need it and hurt the ones that are dying for help.

While reading your post, I got this picture in my mind of like, all the great doctors in our country with their nose to the grindstone, doin' their thing, working their magic, not having the time to 'make deals' like power groups have time to - like you said, they are being the entrepreneurs, the innovators, the individuals who are healers and kind souls who set out on a mission to help people live their lives a little better than the day before. All the while, those who are not intrinsic to the provider/patient relationship are spending their time buying political capital. The individual-ness of doctors is what makes medicine in our country so great - your minds are free to work! No associations required, just more volume please!

Jessica, now's your chance to hear some doctors.

Dr. Wes will stop blogging briefly to participate in a press conference next week entitled "Putting Patients First", to be held at the National Press Club in Washington on 17 July 2009 from 9AM-12 noon EST.

Dr. Val Jones (of the blog "Better Health") has graciously invited me to participate along with other nurse, nurse practitioner and physician bloggers to discuss issues of health care reform that directly affect doctor/patient relationship from an "Outside the Beltway" perspective. The keynote speaker for the event will be Congressman Paul Ryan, (R-Wisconsin), ranking member, House Budget Committee and the moderator will be Rea Blakey, Emmy award-winning health reporter and news anchor, previously with ABC, CNN, and now with Discovery Health.

Participants will include:

Primary Care Panelists:

Kevin Pho, M.D., Internist and author of the popular KevinMD.com blog

Rob Lamberts, M.D., Med/Peds specialist and author of Musings of a Distractible Mind

Alan Dappen, M.D., Family Physician and Better Health contributor

Valerie Tinley, N.P., Nurse Practitioner and Better Health contributor

Specialty Care Panelists:

Kim McAllister, R.N., Emergency Medicine nurse and author of Emergiblog

Westby Fisher, M.D., Cardiac Electrophysiologist and author of Dr. Wes

Rich Fogoros, M.D., Cardiologist (and yes, another Cardiac Electrophysiologist) and author of The Covert Rationing Blog And Fixing American Healthcare

Jim Herndon, M.D., past president of the American Academy of Orthopaedic Surgeons and Better Health contributor

Better yet, you're also welcome to attend in-person. (Contact john.briley@getbetterhealth.com if they'd like to be in the audience. Seating is limited in the broadcast studio.) A video of highlights from the event will be created that I hope to embed in this blog or will link to after the event.

Got something you want said? Let me know.

- Wes

You Know Primary Care is Bad When

... you hear one of your more senior family practice physicians say:

"I now what I'll be doing soon: morphing into a practice manager supervising four or five nurse practitioners."

Thing is, he's probably right.

-Wes

Are Doctors Sheeple?

Imagine a couple caught up in arguing about who should take out the garbage while there's a fire on the stove. The garbage may be a real source of conflict, but bickering about who's turn it is risks the house being engulfed in flames.

Such it was this past week when Daniel Palestrant, MD, Founder & CEO of the physician online forum Sermo, Inc., took a step in the wrong direction by deciding to stand in opposition (subscription) to the AMA:

As physicians, our first step in the healthcare debate needs to be clearing the air about who speaks for us on what topics. Today, I am joining the increasing waves of physicians who believe that the AMA no longer speaks for us. As the founder and CEO of Sermo, this is a considerable change of heart, given the high hopes that I had when we first partnered with the AMA over two years ago. The sad fact is that the AMA membership has now shrunk to the point where the organization should no longer claim that it represents physicians in this country.

While some of his points might be perfectly valid, we wonder how further division amongst our ranks will affect our ability to lobby effectively for the doctors and patients in the current era of health care reform. Do we have the time for such pissing matches? I understand the inherent opportunity for Dr. Palestrant to mobilize the online physician community, but how do we mobilize the majority of physicians and break out of our specialty silos to develop points of consensus? Needless to say, the other partner, the AMA, was none too pleased and shot back:

The AMA has decided not to continue its business relationship with Sermo.

The AMA is always looking for effective ways to communicate with physicians. After an evaluation of the initial relationship with Sermo, we have decided that the value was not there to justify the investment of AMA members’ dues dollars. We continue to explore ways to communicate more effectively with all physicians.

Meanwhile, the politicians and lawyers smile.

This is not about "he said, she said." While Sermo boasts over 100,000 physician registrants, neither organization can say it represents the majority of doctors. Further, to suggest Sermo is any less conflicted than the AMA when it comes to revenue generation is misinformation. But all doctors are keenly aware of the bureaucracy, the middle men, the excess, cover-your-butt tactics needed to shelter them from litigation, their increasingly demanding work hours, frenetic patient visits and diminishing professional payments despite all of their work.

But now, all the politicos see is this: "Look Joe: Sermo guys ain't talking to the AMA and the AMA ain't talkin' to Sermo! Poor bastards. Guess we don't have to worry about them if they can't even agree with each other."

We are, after all, surrounded by professional organizations that have not permitted themselves to devolve into silos. The American Bar Association. The pharmaceutical lobby. The medical device industries. The American Hospital Association, etc. They have political clout. They have a powerful voice on the Hill. They know how to play the game. They have differences in political bents (trial lawyers typically democratic and corporate lawyers typically republican, for instance), but they know how to minimize their internal differences to maintain political bargaining power.

We, on the other hand, are fiercely independent, entrepreneurial, and schizoid: conveniently parsed into our narcissistic silos of primary care, hospitalists, nocturnists, specialists and subspecialists. Some are hospital-employed and others in private practice, some are academic and others fiercely clinical, some are deeply conservative and others even more liberal.

I have to admit I'm still miffed at the CMS proposal to cut cardiologists' fees and shift funds to primary care. I'm miffed at the AMA, too: where was their condemnation of the proposal?

But is this the big issue? To pretend that the cost of doctors' services are the reason for excessive health care costs is a chimera. Look on your latest hospital bill at the exact line items for a health care charge. Look at the "adjustments." Look at what the doctor ends up clearing for that bill. And that's all they can think of to cut?

Enough said.

On the other hand, as one commenter mentioned at the Happy Hospitalist blog in a post on why doctors' salaries are so high:

Take, for example, the Navy SEALS. As an elite unit, their work demands nothing but the absolute best of the best soldiers. In the midst of a shortage and recruiting crisis, the last thing the Navy should do is lower its standards in BUD/S to get more graduates to fill the demand. Lives are dependent upon the quality of the work that the SEALS do. In order to meet the growing demand for the SEAL ranks, the Navy has gone to ultra-marathons, 24 hour adventure races, and Ironman-type competitions to recruit the kinds of people who can hack it as a SEAL.

Medicine is no different. At a time when there are shortages across the board, why does it seem like the government and the industry have created less and less incentive for the best and the brightest to join our ranks? Arduous paperwork, debt, lawsuits, lack of emotional reward due to minimal patient contact, and the ever increasing leftist drone to decrease our income are some extremely powerful motivators to keep the best of the best looking somewhere else for satisfaction in life.

Getting doctors to argue about which among us should get the fee cuts buys into a myth that doctors' fees are the first and foremost reason health care costs are so high. Have doctors insisted on an intelligent discussion about true health care costs in Washington? Why not? Why are we being such sheep buying into the premise that doctors are the problem? Don't tell me that a doctor's pen is the single most expensive piece of medical equipment. Did my pen charge a patient a ridiculous $179,000 gross charge with a $43,000 "credit" seen on a recent 23-hour admission for a biventricular defibrillator implant?

No way. That's because the doctor's fee wasn't even included in the bill.

And what about the "Just To Be Sure" mentality that pervades medicine today? You know the one: "Mrs. Jones, I know you feel fine, but I think we should order another echo this year just to be sure your aortic insufficiency isn't any worse" or "Mr. Jones, we'd better check those liver function tests just to be sure your statin isn't somehow affecting your liver, even though we checked that test 6 months ago." Does the lack of liability reform and exorbitant malpractice awards force this line of reasoning? Dare we hold the politician's feet to the fire on this issue or do we just let the legal status quo with its ridiculous malpractice premiums continue?

I do not know what critical line was crossed that spurred Dr. Palestrant to sever his relationship with the AMA. Perhaps the damage is done. If so, God help us. But at this exact point in time, perhaps reevaluating and reconsidering the potential for reuniting the power of his forum with the established political standing of the AMA might be in the best interest to our profession, however staid the AMA might seem to him. With vigorous effort and collaboration, doctors might then have the ability to collectively voice their concerns to our political establishment and force policies beneficial to all physicians and their patients, rather than splintering our collective voice into impotent fractals of discontent.

Can physicians move out of their silos and develop consensus points we all agree upon?

The house is burning.

-Wes

Insuring the Sudden Death Survivor

I had to stop and ask again:

"What is your annual insurance premium?"

His answer: "$24,000.00 per year."

His wife chimed in, "And that doesn't include about $20,000 of denied payments we have to pay annually as well."

No wonder he needs a defibrillator.

-Wes

Spending More, Paying More and Getting Less

As spending accelerates to "stimulate" health care reform, hospitals are taking steps to cut back to promote "efficiency" while limiting patient access. Meanwhile, the "bluest" of Democratic states look like they'll be funding more of the health care tab through higher-than average tax increases.

Illinois ranks among the top 10 states with residents most likely to pay more in taxes if deductions were limited, with 1.7 percent of taxpayers possibly vulnerable to higher taxes, Citizens for Tax Justice data show.

The state also ranks above the national average in the cost of its employer-provided health care plans. Nearly 47 percent of people with family plans would face taxes under an Economic Policy Institute study, compared to 41 percent in the nation overall.

So Illinois residents as a whole might be expected to pay more in taxes under a Democratic health-care plan. About 13.7 percent of Illinois residents lack health insurance, compared to 15.3 percent nationally, according to data compiled by the Henry J. Kaiser Family Foundation, which studies health insurance trends.

Me thinks the divide in the Democratic Congress is about to grow more contentious.

-Wes

Happy Fourth of July

Yep, the kids are alright:



... and apparently enjoying a nice glass of wine.

More from AwkwardFamilyPhotos.com.

Happy Fourth!

-Wes

The Medicare Hatchet Begins

How's an 11% cut in a single year for cardiovascular services grab ya?

From CMS:

CMS is also proposing to stop making payment for consultation codes, which are typically billed by specialists and are paid at a higher rate than equivalent evaluation and management (E/M) services. Practitioners will use existing E/M service codes when providing these services instead. Resulting savings would be redistributed to increase payments for the existing E/M services.

And that's just the start.

-Wes

Reference: CMS Press Release.

More from BNET Healthcare.

President Obama Talks About Pacemakers

I was one of those who missed the "town hall" meeting aired by ABC on the 24th of June, but was nicely pointed to this video where President Obama speaks about placing pacemakers in 100-year olds by a loyal follower:



The video is remarkable on several fronts.

First, I was impressed with the remarkable footage that suddenly appears of the caretaker with her mother, demonstrating the staged nature of this "spontaneous" town-hall interview. No doubt, this question was asked to reassure our seniors about the choices that will soon be made by Washington.

Second, the number of times the elder woman presented to the Emergency Room for care. We are left wondering, did she have a primary care doctor? What were the other discussions that took place before?

Third, the issue of placing pacers in 100-year olds and the new, proposed reliance on bureaucratic "experts" in Washington that will tell the local doctors what the best course of therapy should be based on "research" (a reference to the 1 billion dollar research boondoggle that is comparative effectiveness research). To think that any research will occur on patients of this age is ridiculous. (I'll let others decide what this means for our elderly).

But this is not to say that we should not make choices in this instance. The issue of "cognitive ability" of the elderly, however, was conveniently dodged, and there ever discussion about the centurion woman paying for her own pacemaker (seems in this case it would be less than a new car).

But whatever you think, these are choices doctors and patients will have to make head-on in the days of increased pressure on Washington to cut costs. The thought of unknown and poorly-defined "experts" (MedPAC?) making these decisions based on non-existent data, rather than the frank discussions between the doctor and their patients and their families, is what really concerns me.

-Wes

Goodbye Northwestern. Hello University of Chicago

Today's the day I magically lose my appointment at Northwestern University and transition to the University of Chicago's Pritzker School of Medicine. As of 1 July 2009, NorthShore University HealthSystem changes it's medical school affiliation, so I changed the "About Me" section on my sidebar.

For patients and collegues alike, I really don't expect much change, except for the logos worn by the medical students and residents.

But as we change affiliations, I'd like to thank all the residents from Northwestern with whom I have had the pleasure to work with and learn from over the years. I wish you all the best as you transition to the real world.

Now, Univeristy of Chicago, it's your turn.... (heh, heh).

-Wes

On Health Care Rationing

From Michael Kinsey at the Washington Post:

I suspect that what a billion-plus dollars' worth of (comparative effectiveness) research will find is that perhaps 30 percent of what we spend on health care is almost entirely worthless, or just barely better than a much cheaper alternative. Or it might be better and no one knows for sure. Denying someone these treatments or tests is rationing.

Similarly, when fear of malpractice lawsuits leads doctors to practice "defensive medicine" -- a legitimate complaint about current arrangements -- it doesn't mean that they order worthless tests. It means they order tests with only a very long-shot chance of finding something wrong.

Here is a handy-dandy way to determine whether the failure to order some exam or treatment constitutes rationing: If the patient were the president, would he get it? If he'd get it and you wouldn't, it's rationing.

I think he gets it.

-Wes

Is Scientific Publishing About to Be Disrupted?

A remarkable and thought-provoking essay by Michael Nielson. Read the whole thing.

-Wes

Grand Rounds: Advice to Residents

And it's a good one over at Edwin Leap on advice to residents:

1) It’s going to be hard. Deal with it. The less you whine, the more you will be loved and trusted. Learn to be strong, learn to power through your fatigue. And remember that it often takes more energy to avoid work than to just do it.

2) Do the right thing. Ethically, professionally, morally. Be the one everyone can count on to do the right thing; however hard it may be.

3) Humans, to paraphrase Blaise Pascal, are glorious and wretched. Capable of nearly angelic goodness and demonic evil, they will both thrill and disappoint you. Be neither too judgmental nor too naive. And remember that you, dear ones, are human as well.

Nice.

-Wes

Virtual Consultations

"I'll be damned."

They were the first words I heard after I was called to the Emergency Room to see this older woman in complete heart block with a wide-complex escape rhythm at 33 beats per minute.

"Could this be why I've been so exhausted any time I try to do anything?"

Her disbelief continued.

I turned to the medical record to document my findings, notify the personnel to stick around for another pacemaker, only to find that another cardiologist had been notified of the patient's admission, written a note, and made an assessment - all electronically.

No detailed history. No exam. No review of labs.

Just this praphrased note on the chart from a doctor at another facility:

"3 weeks of fatigue. EKG demonstrates complete heart block. Pacer to be placed in AM by Doctor Frigamafratz."

A virtual consultation from another hospital, courtesy of the Electronic Medical Record.

"I'll be damned," I echoed.

-Wes