Thursday, December 04, 2008

In Defense of Specialists

Bloom Stimulator
Click picture to enlarge

Not too many family practice docs and hospitalists can drive this baby now, can they?

For those unfamiliar, this is my favorite instrument in the EP lab: the Bloom Stimulator. With the flick of a few switches, we can start or stop most heart rhythms as fast as you can say "S1, S2, S3 or S4."




Jay said...

Good stuff, Wes.

Sorry to say that we stopped using the Bloom back in 2000 when we traded the Quinton for Y2K to an EP MedSystems Setup.

I still remember the finesse required to make a one handed quick switch from 300 to 290 without messing up. Loved those beeps, too.

Were you around when JB had a Bloom deliver continuous high output 60Hz pulses out all four channels. I think that unit ended up in the dog lab with you.

Are you guys still running paper too?


Marco said...

Just make sure the family docs and hospitalists don't get machines with lots of buttons (which don't connect to anything) just to impress the patients!


#1 Dinosaur said...

Nice "gotcha" there, Wes. But think about this: If you had to see 20 people a day with "chest pain" (for years), palpitations, shortness of breath when they exercise (which they only do two or three times a year) and all the other myriad patients who come in saying, "I want to see a cardiologist," how much time do you think you'd waste sorting out how many of them could actually benefit from your impressive machine, much less have any time left to use it on them?

No one is attacking specialists who take care of the patients with specialized needs. It's when some of your compatriots with too much time on their hands start putting up posters on buses advertising their fancy machines to the general public that we cry foul.

You have to admit that even more important than the skill to "drive that baby" is the years of training and experience required to figure out which patients will benefit from its use.

DrWes said...

You have to admit that even more important than the skill to "drive that baby" is the years of training and experience required to figure out which patients will benefit from its use.

#1 Dino-

I respectfully and vehemently disagree that one is "more important" than the other. My skills, like yours, are just as valuable to our health care system, but in a different way. Oh sure, we can bicker about the fact that you see 20 patients for every one I see. But you spend, what, 7 minutes on average with each one? I might spend hours with one. But those hours might be much more cost-effective in terms of time (and money) for our system. Often when I'm done, the patient might not have their problem ever again after years of ER visits and ineffective drugs. Now what am I worth to the system of overcrowded ER's and offices versus you?

You see, it depends on which perspective you're coming from. Maybe it has more to do with personality types: maybe you're more ADD and like seeing lots of patients, while I'm more OCD and like focusing on one - I don't know, but you elected to "get out there and get going" when you elected to finish training a start seeing patients. I elected to stay a bit longer with my education to focus, at significant cost to myself and my family over the years, on a relatively complicated subspecialty. Yes, I did it with a hope of making more income, but if there wasn't an expectation of making more money, I sure wouldn't have endured the time and cost just to operate a neat machine. There has to be some reason to pursue this field.

Right now, the emphasis in Washington is on giving everyone free (or nearly free) health care subsidized by a government that prints money so fast instead of insisting on accountability. As such, with our current policymakers, you (as a generalist) are in the policy driver's seat. You're also relatively cheap to the system, relative to me. Given the current state of the economy and current pressing social agenda, I can only wait for the axe to fall (and trust me, it will fall).

But as we move forward, will there still be an incentive for younger students to enter the field of medicine? Will enough incentive exist for young doctors to put with the extra time, energy and effort to specialize if their pay continues to dwindle and health care becomes a commodity profession? Last year, of 51 EP fellowship positions surveyed, 11 had at least one position left unfilled (personal communication). Are we, as a society, going to accept the loss of access to specialists in favor of making sure the uninsured are covered and delay or completely forego our curative procedures because Washington says so?

On paper, it sounds so simple this "universal health care" thing. In reality, the guys doing the grunt work are going to get hurt - you and me - since we'll be left holding the bag of "responsibility to patients" (with the personal and financial challenges that encompasses) while the policy makers look to negotiate their salary from the next multi-billion dollar government handout.

Anonymous said...

It has been my observation when around EP labs that a RT or RN are running these great machines. It seems also that many of them just have two years of education past High School. So dont feel to good about yourself Dr Wes . They are the true backbone to medicine with very little pay when compared to yours. Be greatful you have the skills to help people and quit gripping who is more important because of pay.

DrWes said...

Anony -

Sorry to sound like I'm gripping about pay - that's not my intent. And yes, while merely pushing buttons and flipping switches is a trainable skill (and we know there are some that are very gifted in this regard), those switches represent only a tiny fraction of the skills required to evaluate and properly fix an arrhythmia.

But any good patient care is only as good as the ones delivering it. None of us work in a vacuum. I need the techs as much as they need me.

Any policies moving forward must be careful not to underestimate the impact to specialites on the caliber of health care delivery we enjoy today going forward. It is so "PC" right now to shift dollars to primary care, but rather than JUST shifting, focus should be on expanding resourses, too.

Some of the finest individuals in my lab have only high school and college degrees yet contribute substantially to the care of our patients. Certainly, they make a lot less than I do, but we work as a team, each appreciating what the other brings to the health care table. We sure as heck don't run around sniping about who's "more important."


#1 Dinosaur said...

Wes, dude; apologies. You completely misread my comment.

My role is sorting through all the people who clearly don't need you, and steering those who might to you.

YOU are the one who ultimately decides who needs your skills. Furthermore, you're the one who knows which buttons to push and which switches to flip. That's what all your training and experience are all about.

What I meant was that even though you've got that wicked cool machine to play with, knowing what to do with it is at least as important as how to do it. The last paragraph of my comment was intended to give you credit not just for "driving that baby" but for your mastery of the road as well.

Anonymous said...


So where does this argument about lengthof training end? Are you suggesting that if monetary cmpensation is directly proportional to years of education, I can give you reems of examples where this does not apply. And what proportionally do you suggest specialists should be paid for their extra training? by my calculations, the return on investment of time for specialty training can actually double your salary for the remainder of your carrer. And what about the poor rhuematologist, endocrinologist, geriatrician, or other non procedural specialty involving extra training; why do they not make the same income as specialties of similar length training. Or on the other side of the coin, why to radiation oncologists make more money than God after spending four years training after medical school?

Lets face it; the payment of medicine based on procedures only encourages more of their use, often inappropriatly and there needs to be some balanced reasoning as to how physicians get compensated.

By the way, if you get paid on the basis of how fancy looking your machine is, why don't MRI techs get paid like EP cardiologists?

DrWes said...


Dude. No prob. Get the gist.


You make very valid points. There is no question that the political forces inherent to the RUC (Specialty Society Relative Value Scale Update Committee) have greatly distorted payments in favor of specialists, but the pendulum is about to swing the other way by another RUC-like committee. Like it or not, they were who Medicare turned to to decide the payments for procedures. They set the weights, and the market adapted accordingly. But it is not JUST the RUC that was a problem. It ALSO has a lot to do with how Medicare pays a TECHNICAL and PROFESSIONAL component for services. (We keep blaming it all on RUC, but when we look at reimbursements, TECHNICAL (non-doctor) revenues exceed professional ones by about 10 to one). Hospitals WANT more TECHNICAL revenue, because in the current system, it pays and pays handsomely. Specialties with lots of TECHNOLOGY make the bucks, rheumatologists with needles as their sole source of procedures, therefore, aren't worth as much to hospitals as guys like me who run fancy multi-gazillion dollar labs.

How we'll get to "balanced reasoning" that incorporates this technical AND professional components of Medicare payments is going to be one of the many great challenges of reform ahead and you can bet the hospital lobbyists will have plenty of pull in this debate.

By the way, if you get paid on the basis of how fancy looking your machine is, why don't MRI techs get paid like EP cardiologists?

Because their machine isn't as cool as mine and weighs too much.


Anonymous said...

That console looks so retro (at least to my uninitiated eyes). I'm having a radioablation done in a few weeks; hope I get a peek at the machine they'll be driving.


The Happy Hospitalist said...

Does that thing run on double AAs?

DavidA said...


I know that you were probably joking, but it quite literally does run on 9 volts batteries. The patient side of the isolated connection has a whole bank of 9 volt batteries. The clinical engineering folks are supposed to replace them every so often and if one bank of them runs down then you will lose the ability to capture when pacing on that channel.

I'm one of those button pushers that Wes mentioned, though not at his lab.