The Last Reprogramming

He had called the other day to update me up on his condition.  He did not sound upset, but resolute.  "They offered me peritoneal dialysis," he said, "but I decided against it and figured I'd just let nature take its course.  The hospice people are so wonderful - I've got things all set here at home, but I have two questions.  What should I do about my warfarin?  You know, I just don't want to have a stroke.   And what I do about my defibrillator?"

We were colleagues once and grew to be friends later when life's circumstances brought us together. He, a revered senior neurologist and me, a relatively new doctor in town. I could remember overhearing his heated discussions about administrative snafus with colleagues in the hall, or watching a horde of residents and medical students following him into a patient's room to teach at the bedside.

"Of course he didn't want a stroke," I thought.

So we decided to keep the coumadin and let him continue his daily INR checks at home and to turn off just the tachyarrhythmia detections on his biventricular defibrillator.

"I'll come over tomorrow and we'll turn it off," I said.

There was a brief silence, perhaps because of momentary disbelief that I'd do such a thing.  Then he proceeded to give me detailed directions and landmarks to watch for on my way over.  "I'm sure I can find it," I said thanking him.

So the next afternoon after most of the day's events had finished, I grabbed the programmer and drove to his home.  It was an unusually beautiful day - mid 70's, sunny - as if Someone had wanted it that way. There in the yard, was his wife, wearing a large-brimmed hat and holding a hose while pretending to water the shrubs.  She came over to greet me: "Thanks so much for coming over," she said, "I know this means so much to him." Then she realized she was still holding the hose. "Oh, I'm so sorry, it's just that someone has to try to keep the place up," she said, voice cracking.

The "place," of course, was beautiful.  A majestic grande dame of a house - one I would later learn they had occupied for the past 44 years and bought when they were "just kids on the block."  It was meticulousy kept, stately.  I entered with his wife and noticed a shadowy figure two rooms away sitting at the edge of a mechanized hospital bed.  The bed was placed in what must have been his study with a large bay window with a couch next to it.  A reading lamp was over the head of the bed and the walls held books from the floor to ceiling with icons and statues, likely from other, more active time.

"Thanks for coming, Wes," he said, looking up.

"How are you feeling?" I asked, somewhat stupidly.

"Pretty good, considering everything.  See?  My legs aren't quite so swollen and my abrasions all have eschars on them," he noted as only a doctor could.

"Is there a plug nearby?" and he proceeded to point me the way so I could plug in the programmer to do my job while he explained the device to his wife.  The process was quick and I interrogated his defibrillator, then turned off the tachyarrhythmia detections, therapies and now needless alarms. "There, that didn't take long.  All done," I said.

There was a moment of silence as I sat with this man whom I known for so long.  Like a wise sage and hospitable host, it was clear he wanted to talk for a bit, so I slowed my exit.

"You know, I've always appreciated your frankness about my condition," he said. "You're a lot like me in many ways, I think.  You never overstepped, let me have control, to manage things like I wanted to, and I've always appreciated that," he said.

Embarassed by his frankness, I wondered what to say.  At a loss for words, I told him how much I enjoyed meeting his family, wife, daughters, and grand-daughters recently in the hospital.  He looked puzzled, forgetting. "You know, that day I brought my daughter in your room with them?"  His eyes brightened and his smile widened as he remembered. 

"Oh, yes! That was wonderful!  How fast times flies, doesn't it?" he said.

"You know, I wrote about that day in my blog," I mentioned, ".. and included some pictures of my daughter from 10 years ago - about what she thought about medicine - can I show you?"

"Of course!"

So I showed him the picture and we shared our thoughts about family.  Then, to make reading from my iPhone easier, I read him the post I'd written about that day.  We talked about family and what they meant to each of us.  And then he shared with me another nugget, that he grew to become a writer, too.

"You know, I spent some time and wrote an autobiography for my kids not too long ago - over a hundred pages - about everything I could remember - from my earliest years as a child, about my immigrant father and  American mother.  My father made it as a successful lawyer - came over from eastern Europe - I even know the ship - I remember the picture of him standing there with his hat..., and I wrote about my family, influential teachers in grade school, fellow professors, and people that I knew throughout the years - everything.  You should do that, too, you know.  I'm so glad I did.  I gave them to my kids and even made some some extra copies - maybe for the grandkids, in case they want it someday..."  He looked away to see his wife leave the room, trying not to be noticed as tears filled her eyes once more.   She didn't want to him to see her this way.

He stared down at the floor beneath his swollen feet, then continued.

"You know, it was therapeutic for me to write that autobiography.  After all, what we do is terribly isolating for the most part.  No one understands that.  Like you do your procedural stuff and I do my diagnosing.  We do most of it all alone, with no one else there.  Just the patient and the doctor.  Wonderful, to be sure, but isolating.  So many memories.  I guess it helped me to put some of those feelings and the thoughts I had about those I loved into words.  It's hard to capture it all..."

He looked up from the floor and stared in my eyes.  "Thank you," he said extending his hand.

I sat motionless for a bit digesting the gravity of his words, lost in them before I saw his hand.  Once I noticed, I lept up to shake it and gave him a long hug to his increasingly skeletal frame.  It was a brief moment to share together once more and one I now realized I had done too infrequently with other patients in a similar circumstance.  Here he was, an incredible man who'd given so much to his family, fellow colleagues and patients, now teaching me once more so much about life as a doctor, about grace, and about real love.  Just the two of us, isolated again, but as friends. 

With great reluctance I packed things up and found his wife on my way out.  "Thank you," she whispered with swollen eyes, "I just don't want him to be in pain." 

"He's going to be fine," I told her, "... perfectly fine, especially now. He's such a wonderful guy." She smiled and opened the door.

As I drove away I realized we probably won't see each other again - his remaining time here will be saved for others now. There were so many thoughts, so much to remember, so much still to learn. Perhaps because I'd been through something like this before I was more prepared - it's never easy - but I still felt okay about it all - not sad - confident that we did the right thing... 

... together.

-Wes

Breaking: Senior Vice President of Doctoring

It's a job description for "Senior Vice President of Doctoring", being advertised by the American Board of Internal Medicine.  Remarkably, the position requires no patient care whatsoever. 

It's interesting how history repeats.

If you wonder why your health care costs are so high, consider what's happening in our new era of highly-paid Physician Inquisitors.

-Wes

Talking Heads

February, in case you haven't noticed, is "Heart Month" full of associations with Valentine's Day, love, peace and tranquility.  It's also a month to sell cardiovascular health care.

Everywhere you look these days are advertisements for the latest and greatest heart care, finest heart care facilities, touching stories of the latest cardiovascular intervention saving a life at this medical center or that.  Go ahead.  Type in "heart" as your Google alert phrase to see what I mean. 

Heart month, you see, is business month for most medical centers since the cardiovascular disease product line is sold more often than any other in medicine.  But what is good for the business of medicine is not always good for the reputation of physicians.  As one surgeon has wisely pointed out, physicians are devalued when breathless claims of magical health care delivery promised on TV can't be delivered. 

Most doctors say little about the problems inherent to this advertising trend.  We see no problem with advertisements for the latest drug or procedure on TV or the radio.  That's because doctors are becoming comfortable with their new subliminal marketing role for their new employers and as figureheads to quality.  

I worry that we doctors, overburdened with our new reality of declining pay, seemingly bottomless administrative meetings, data entry, coding requirements, and the million other regulatory changes that are detracting from direct patient care, are becoming comfortable (and worse, complacent) in our new role as talking heads.   We pretend that really there's no problem with "innovations" to care, when deep in our souls we know otherwise.    I get that we're all in survival mode right now, and perhaps this is why I'm concerned.

Recently the Wall Street Journal discussed the business case for using lower level providers in lieu of physicians.  The article discussed the "clash on proposed oversight" that exists when a less costly nurse anesthetist is substituted for a fully-trained anesthesiologist.  These capable nurse anesthetists don't want oversight.  They feel they can do their job just fine, thank you.  After all, they're the one's at the patient's side most of the time as the anesthesiologist flits in an out of several operating rooms instead of sitting in just one.  Is this the best quality for the individual patient to have a person with only two years' experience working independently?  Probably not.  Is it fiscally innovative for both doctors and hospitals to do anesthesia this way?  Absolutely.   Consequently, I wonder if tomorrow's "Top Doctor" will be a much-heralded clipboard-carrying oversight manager of an army of lesser-trained health care providers.

Perhaps these changes are inevitable given the realities of American health care delivery today.  In our rush to get more work done faster than ever, we use physician extenders to see patients first, then make cameo appearances at the patients bedside, more for PR (and billing purposes) than real clinical discovery.  Is this quality?  It seems that in our new world of upcoming Press Ganey patient satisfaction surveys linked to hospital payments, inpatient medicine is evolving to PR.  During the brief patient interactions, doctors had better smile, look good, and wash their face and hands lest the facade of quality fade.  After all, good doctor, big screen TVs, marble foyers, and extensive menu selections at the bedside can only get your hospital so far.  Yet if this trend is allowed to go to its next iteration, will image consultants be the next recertification requirement for physicians?

I wonder….

Sadly, conflicts such as these are only the tip of the iceberg.   For instance, instead of insisting that information technology giants and bureaucrats correct he horrible data entry requirements imposed by today's electronic medical records, many of us have succumbed to hiring costly scribes.  We justify the benefits of these scribes because they allow us to see and touch more patients, while not admitting that we have thrown up our hands to the root problem that created this mess in the first place.  Likewise, when physicians allow their administrators to purchase cheaper, inferior equipment or allow maintenance contracts to lapse in the name of "alignment" of doctors' and hospitals' financial interests, who are we serving?  Or as personnel ranks are slashed from hospital payrolls and patient wards consolidated, are our patients being served best? Can a nurse used to caring for post-surgical patients really manage a cardiac patient as well?

The list goes on and on.  While employee-physicians are losing our autonomy and ability to provide direct one-on-one patient care in all cases, there's a growing need to educate those who don't have a clue about patient care in hopes of improving that care without compromising its quality (if that is possible).  Perhaps more than ever, doctors are needed to fulfill a leadership role in the education of all factions involved in patient care - from administrators to ancillary care providers - about what is needed for their patients and when.  Doctors need to push to dismantle what is broken and organize those systems that work.  Being railroaded by a system that has changed way too soon and way too fast thanks to forces outside our control won't help anyone.

But before we embark on this seemingly impossible task, physicians will first need to ask themselves a very important question, one that strikes to the very core of being a doctor: will we dare to speak up as advocates for our patients and as advocates for each other as doctors, or will we just become a talking head?

Given what's transpired to our health care system so far, I'm not sure I really know the answer.

-Wes

Fixing the Wholesale Destruction of the "MD" Designator

Thanks to the unrelenting march of regulatory affairs in medicine, the MD designator (Latin: Medicinae Doctor) has been completely devalued for patients.  No longer does "MD" mean you care for patients.  Instead, "MD" could mean many things: like you work for an insurance company.  Or it might mean you sit in a fancy building lined with marble floors in Washington DC writing legal briefs and laws to torment other doctors.  Or it might mean you kill rats for a living. 

What patients need, and want, is a way to determine who is a "real doctor" that cares for and makes the majority of his income from actually seeing, touching, and treating real live patients.

For this, what is needed, like the Good Housekeeping Seal of Approval, is a "Real Medicine" seal of approval.  It could be appended to every clinical MD's signature.

The seal would mean an MD (or DO) spends over half his or her time, and earns the most of his or her income, directly caring for patients.  It also means that the doctor who uses this designator attached to his MD also is willing to work outside the normal 8am - 5pm business day and even takes call for clinical patient care (available 24-hours/day) on a regular basis annually.

So I have made a "Real Medicine Seal of Approval" for real doctors (as defined above) to use, free of charge:

So patients, the next time you need a "Real Doctor,"  look for the Real Medicine Seal of Approval:*

-Wes

* Non-clinical doctors who use this logo will be summarily humiliated publically by any means real doctors worldwide choose.  Doctors are advised to use this logo with the utmost caution and respect for the real profession of clinical medicine.

Health Care Reform Three Years Later - An Insider's Assessment

It’s been three years since the Patient Protection and Accountable Care Act (PPACA) became law.  There have been widely divergent opinions published by journalists on the impact of the law for Americans: from a rose-colored account from the New York Times, to a not-so-peachy account published at Reason.com.  Few doctors have ventured into this discussion.

The Need for Health Care Cost Reform

I should start by saying that I am biased.  I grew up in the days of an idealized image of the physician –where doctors were still held in relatively high esteem by our society.  I had to think this way for I was joining the system.  Back then, like now for the younger doctors, medicine was a still considered a calling, not just a job.  The unspoken code was that it was the patient above all else: screw the establishment, screw hospital loyalty, screw the drug company – if they couldn’t help your patient, you’d take them elsewhere.  So hospitals courted doctors.  Drug companies courted doctors.  Insurance companies courted doctors.  But the truth be known, doctors weren’t the apple in everyone’s eye, patients were.  And doctors enjoyed the limelight – so much so, that a few in our ranks succumbed to the greed, too.  After all, like now, patients paid everyone’s bills.

But health care costs for patients became increasingly hard to cloak.  Insurance companies, in the business of making the expensive seem cheap, needed an exit strategy.  The new hospital buildings, multi-million dollar corporate earnings, drug innovations costing tens of thousands of dollars, and the aging population that was growing too quickly weighed heavily on the entire system’s sustainability.  Something had to be done.

The First Steps

So without belaboring the obvious: we created Health Care Reform as we know it.  Health Care Reform wasn’t just the PPACA, though, but rather a carefully orchestrated series of legislative achievements that laid the groundwork for payers to offload the costs of health care on to the only other entity that could pay these high costs: our government. 

The process (as we have seen) first involved an expensive, multibillion computer roll-out that was part of the American Recovery and Reinvestment Act.  These computer systems promised “cost savings” by “improving efficiencies” of care.  Information systems were sold as our salvation from cost excesses like $15 Tylenols.  Corporate America (and their political lobbyists) bought it and so did the government.  To keep doctors quiet, doctors were promised $44,000 a piece to install computers in their offices.  Little did they realize their payments from government to private offices were to be slashed forty percent in the same legislation and computers would be required to bill the government.  So, the $44,000 actually went to doctors’ new employers.  Doctors were thanked for their services with a new $700-dollar iPad and a treasure trove of Meaningful use regulatory benchmarks that slowed patient care rather than sped it.

Our New "Reform"

Next came the PPACA, our signature health care law.  The law was spun as a way to save health care costs while adding 34 million more uninsured patients to the system.  Pulling heart strings was much more palatable politically than the much needed reality of fiscal restraint.

But we should admit that our health care system has flaws when it comes to the uninsured.  To prove the health care reform’s benefits, the easy-to-sell low-risk coverage for young adults was given as a loss leader to the new health care law's Health Care Happy Meal.  This benefit was universally welcomed by all because it was needed.  Yeah, it cost a bit more to provide this insurance, but in the scheme of things, the cost of this health care was relatively cheap to provide.  It was (and remains) a win-win. But our attachment to this part of the law may be a clever way to buy us off.

Preventative services, provided for free, were also included in the PPACA.  But this is a problem because nothing is free in health care.  Proving preventative services for free perpetuates an expectation that everything will be free in health care and have no consequences.  After all, preventative services take time and time for care providers overloaded with more and more patients entering the system is our most precious commodity.   Others argue that catching problems early will save money but the proof that this makes a difference to health care costs is really just a delightful narrative.  In fact, even the annual physical’s benefit to our health care has been called into question – especially when we recognize its value to the system compared to the benefits derived for the patient.

And people have argued that the PPACA has already reduced costs.  While I am not an economist, I really can’t speak to this.  I am just a worker and observer.  These days I see four or five administrators where, just a few short years ago, we had one.  I see fewer nurses with less experience caring for more patients now.  I see bigger buildings but fewer patient beds as wards are consolidated.  I see hospital-system employers with hiring freezes that are laying off workers in anticipation of upcoming costs imposed by the new law. 

How's the Quality?

And then there’s the overall quality of care.  I can’t say I really see a difference from five years ago.  Sure, I see things being done faster by fewer.  I see computers moving information around like never before.  But is the care to our patients really better?  I see reams and reams of documentation made not for the patient’s benefit, but for bureaucrats and bean-counters more interested in our use of computers than our patients.  I see better communication between doctors improved with the EMR, but has this translated to better care delivery? Not always. And when it comes to quality, the New York Times editors cited the example that health care in America is cheaper because Medicare patients have fewer re-admissions since the PPACA was enacted.  But they also failed to note that hospitals receive financial incentives to reward this behavior.  They claim this is “better coordination of care” while ignoring the fact that patients are labeled with scarlet A’s and shunted to health care facilities that don’t "count" as re-admissions.  They also failed to mention the effects of the higher costs that patients see from their higher insurance premiums.  Cha-ching.

What's Ahead

In the end, health care reform is still about the money for the system rather than the real needs of most patients.  We are cutting costs to corporations by inflating our Health Care Hindenburg with cheaper hydrogen.  We have spun a narrative of providing more care for more people with less cost while ignoring the shear forces and telltale weather patterns of cost concerns that blow our way and threaten our ship's buoyancy.  

Some doctors have leapt from the ship.  More will certainly follow.  Others remain silent yet quietly discontented; they do their job as just job now, marking time with little incentive for doing more.  They have become the common workforce drone  increasingly asked to do more by those who go home at 5pm and have no liability for the care they provide.  More risk with less reward has been the mantra for care providers in health care reform.  The stress is growing for everyone.   Unfortunately, the doctors that leave will soon be back-filled by well-meaning young physicians with fewer hands-on hours of training that have been sculpted by an educational system dependent on tenured med-school professors complicit with our new progressive mindset. 

Health care reform is here, alright, doing what it's always done: spinning reform without real reform for three years (so far) and counting.

-Wes

Physician Burnout: Meet Patient Safety

The majority of doctors in America today care deeply about their patients.  After all, they're the ones that have personal relationships with them.  They're the ones who sit with them, speak with them eye to eye, feel their pain, and witness first-hand the scourge of disease on the human body and psyche.

But you'd never know this from the Patient Safety Movement.  From day one when the Institute of Medicine report entitled "To Err is Human" was published in 1999,  the nebulous "98,000 preventable deaths" number was circulated far and wide by media outlets.  Strangely, this important publication was never made available free to physicians for review.   But instantly, the media took notice of this sound bite.  Breathless outrage ensued.  Hospitals took notice.  Even doctors and doctors' associations noticed.  Worse yet, we were still told by the media and their self-appointed safety enthusiasts that "medical errors kill enough people to fill four jumbo jets a week."  But to everyone's credit, we all did some real soul-searching.

So change came to our industry.  Overnight, enough bureaucrats to bury the number of doctors in America three-fold were hired as patient safety do-gooders.  Entire new organizations hell-bent on imposing their vision for the future of patient safety sprang up to guide large hospital organizations to their vision of patient safety nirvana.  None were as influential as the organization called the Institute for Hospital Improvement (IHI) run by the soon-to-be knighted-as-acting-CMS-directorship, Donald Berwick, MD who made a cozy sum from the safety scare.  This is the same "institute" that still provides mandated safety training to hospital systems across the US even today.

But a strange thing has happened.  Despite their best intentions, after ten years of trying with more administrative hires and scores of new imperatives thrust on doctors and nurses with hours of carefully-constructed safety courses, and scores of white papers and media stories, not much has changed.   To be fair, not all efforts have been worthless, but self-reflection on the negative consequences of this movement have been limited.

And in its place, physician burnout has exploded.

But this morning, I saw a glimmer of hope.  People might be starting to do some introspection.

Take a minute and read Bob Wachter's post.  It is a prescient view of the problems created by well-intentioned (but misguided) initiatives that ultimately fall on America's physicians and nurses to implement:

The lack of evidence that all our hard work is paying off is also contributing to burnout. Several influential papers (such as here and here), using the IHI’s Global Trigger Tool methodology, have documented continued high rates of harm; one study of 10 hospitals in North Carolina showed no evidence of improvement between 2002 and 2007. On top of that, a steady drumbeat of studies (beautifully chronicled by Brad Flansbaum) demonstrates that nearly every policy intervention that we thought would work (readmission penalties, “no pay for errors,” pay for performance, promotion of IT, resident duty-hour reductions) has either failed to work, or has led to negative unanticipated consequences. For people who have given their hearts and souls to making the system work better for patients, the result is more demoralization. 

My second major concern about patient safety stems from the Affordable Care Act (ACA), one of whose main goals, paradoxically, is to place a premium on value over volume. You’d think that the patient safety field would benefit from such a law (which also includes significant new spending on safety), and perhaps it will… eventually. But in the short term, the ACA is yet another speed bump on the road to a safe system. 

Just as physicians are overwhelmed and distracted, so too are hospital CEOs and boards. As the healthcare system lurches from its dysfunctional model to a (God willing) better place, healthcare leaders are scrambling to be sure that their organizations have seats when the music stops. The C-suite and boardroom conversations that, a few years ago, were focused on how to make systems better and safer now center on whether to become Accountable Care Organizations, how to achieve alignment with the medical staff, what the insurance exchange will mean for our reimbursement, and the like. To the degree that people remain interested in improved value, here too the emphasis has shifted from the numerator of the value equation (quality, safety, patient experience) to the denominator: cutting costs.

Read the whole thing again and think about what he's saying and what's coming unless real change that improves the burden these safety initiatives have on doctors and nurses occurs.

"Don't it always seem to go, that you don't know what you've got 'til it's gone.  They paved paradise, and put up a parking lot." 

- from"Big Yellow Taxi" by Joni Mitchell

-Wes

The Costs of Not-so-Shared Decision Making

This week's New England Journal of Medicine contains a perspective piece by Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D. entitled "Shared Decision Making to Improve Care and Reduce Costs." The original paragraph of the piece sets the tone:

"A sleeper provision of the Affordable Care Act (ACA) encourages greater use of shared decision making in health care. For many health situations in which there's not one clearly superior course of treatment, shared decision making can ensure that medical care better aligns with patients' preferences and values. One way to implement this approach is by using patient decision aids — written materials, videos, or interactive electronic presentations designed to inform patients and their families about care options; each option's outcomes, including benefits and possible side effects; the health care team's skills; and costs. Shared decision making has the potential to provide numerous benefits for patients, clinicians, and the health care system, including increased patient knowledge, less anxiety over the care process, improved health outcomes, reductions in unwarranted variation in care and costs, and greater alignment of care with patients' values.

However, more than 2 years after enactment of the ACA, little has been done to promote shared decision making. We believe that the Centers for Medicare and Medicaid Services (CMS) should begin certifying and implementing patient decision aids, aiming to achieve three important goals: promote an ideal approach to clinician–patient decision making, improve the quality of medical decisions, and reduce costs."

What a nice, lovely, fuzzy bunny.  Who couldn't want such "shared" decisions in complex medical care?  Especially nice simple teaching aids for Medicare's top 20 procedures printed at the "8th grade level" that are "brief?"

Doctors, don't you know that this will become simply another box to check on your EMR for Medicare reimbursement? 

And yet the benefits of cost savings that these "shared" decision making tools' will have on health care are assumed, especially when deployed nationwide, despite what the authors claim.  Note that the 2011 Cochrane Collaborative review of the 86 studies they reference said nothing about cost savings.

Doctors know this and so do the authors.

Why else would the authors require a cudgel to impose their "shared" decision making benefit if other real life clinical doctors fail to follow along?

"Providers who did not document the shared-decision-making process could face a 10% reduction in Medicare payment for claims related to the procedure in year 1, with reductions gradually increasing to 20% over 10 years. This payment scheme is similar to that currently tied to hospital-readmissions metrics."

Ms. Lee and Dr. Emanuel, in their zeal to impose their Progressive mindset upon America's physicians have forgotten several important tenets of health care delivery:

• First, decisions made in medicine are each unique to a patient's constellation of medical problems, socioeconomic and cultural background, age, gender, religious beliefs, etc.  In other words: decisions are made in concert with an individual's situation, and not based on the government's desire (necessarily) for cost savings (even if it is couched in euphemisms such as "shared decision making").


• Second, actual cost information (both out-of-pocket and real health care system costs) for patients and doctors will remain shrouded  in secrecy since payers rely on obfuscation of actual cost information to extract their portion of fees before patients receive any value for their dollar.  Also, other similar pay-for-performance measures have already uniformly flopped at demonstrating cost savings.  Then imagine for a moment if the cudgel for shared decision making is imposed.  The potential for a 10-20% Medicare physician fee cut on top of a 30% Sustainable Growth Rate cut that is likely to reappear in 2014 will be untenable for US physicians. 


• Third and very importantly, the ACA legislation has created a whole new "institute" of salaried individuals within government called the Patient-Centered Outcomes Research Institute (PCORI) to develop the authors' soon-to-be-mandated decision aid materials while another branch of government already exists to produce such education aids called the Agency for Healthcare Research and Quality (AHRQ).  Wouldn't our health care system benefit far greater from cost savings by not duplicating services already performed by another government agency? How much, exactly, will the PCORI cost us?


• Fourth, the push to re-invigorate the mass-production of physicians via three-year medical school curricula while simultaneously failing to increase residency slots assures poorer trained, inexperienced doctor-patient discussions about complicated medical issues, not better ones. Shared does not mean better.


• Finally, liability risks remain for doctors caught in these unenviable mandates that fail to recognize the individual complexities of an individual patient's care.  Until doctors sense a modicum of effort for liability reform, they will continue to offer care that exposes both themselves and their patient's to the path of lowest legal risk, irrespective of what teaching aids they give to patients.

Doctors and the AMA should demand transparency in the cost of creating and funding the PCORI and its shared decision making materials, yet another layer in the runaway middleman health care behemoth emerging as the front lines of health care delivery are systematically decimated. 

If that doesn' t matter to all of us, then share away.

-Wes

The Encounter

They sat together, staring down at their feet not sure what to say.

One was a silent war hero from the French Resistance, the other his doctor.

It was a chance encounter.  He, supporting his wife as she checked in to the orthopedic clinic, the other, there himself for the first time as patient.  For each, as life, it was unexpected.

They sat smiling, reflecting on the irony of it all.

Their story together, while brief at first, was rich.  On a trip back to his homeland of France, he had brought down a 747 single-handedly as his defibrillator fired repeatedly.  The event both humbled and embarrassed his doctor whose hubris had assured him of the effectiveness of a prior ablation, only to awaken to the epiphany that arrhythmias, like life, are difficult to predict.  An AV junction ablation would be required to quell another unexpected arrhythmic onslaught.   Both realized they were doing the best they could at the time.  Neither were in control.  But both had prevailed together.  And through their long history together, more stories were told - secret, personal stories - as they developed a deep sense of admiration and appreciation for the other.  But the stories were always told on the doctors' turf.

Until now.

There they were again: younger doctor joining the war hero once more as equals. 

Fighting the fight on the same field now.  Quietly sitting. Staring. Smiling.

Together.


-Wes