ACGME Turns Blind Eye Toward Issue of Physician Debt

"A new roadmap for improving residents’ professional skills was released Tuesday by the Accreditation Council for Graduate Medical Education (ACGME)" begins the press release.

As I dove into this announcement a bit further, I discovered the origins of this initiative outlined in this executive summary (pdf) published by the ACGME on the "CLER Program:"

The Accreditation Council for Graduate Medical Education (ACGME) recognizes the public’s need (emphasis mine) for a physician workforce capable of meeting the challenges of a rapidly evolving health care environment.

The ACGME has responded to this need by implementing the Clinical Learning Environment Review (CLER) program as a part of its Next Accreditation System. The CLER program is designed to provide US teaching hospitals, medical centers, health systems, and other clinical settings affiliated with ACGME-accredited institutions with periodic feedback that addresses the following six areas: patient safety; health care quality; care transitions; supervision; duty hours and fatigue management and mitigation; and professionalism.

The feedback provided by the CLER program is designed to improve how clinical sites engage resident and fellow physicians in learning to provide safe, high quality patient care.

While the "public" certainly wants responsible physicians with good clinical skills, shouldn't the ACGME be asking what their training physicians need to get achieve their goals?  To adopt a program that emphasizes the "public's needs" above those of training physicians,  political, academic and corporate agendas supersede those of the very people who need to learn.  It is missed on no one that hospital funding is now closely tied to "meaningful" completion of electronic data entry fields and "quality" and "performance" measures.  The ACGME, seemingly in concert with the American Hospital Association, appears to be focusing on creating a subservient and compliant physician workforce that will work lockstep in our new highly regulatory medical environment rather focusing on what is needed to create a better, sustainable physician workforce.

No where in the ACGME's new "CLER program" is medical educational debt, perhaps one of the biggest concerns of today's physicians, addressed.  Instead of focusing on this critical issue, the ACGME focuses on placating the many corporate entities involved in health care delivery.  After all, insurers, hospitals, and even the medical education complex needs submissive physicians that toe the line.

The ACGME has also systematically allowed medical education to devolve into nothing more than  recitation of the latest published guidelines for medical residents, thanks, in part, to the thousands of these published by various professional organizations and promoted by the US government.   Why do these pathways exist?  Well, in part to provide the best care possible in ideal circumstances, but also to assure that if these guidelines are followed, everyone in the health care complex makes money.  Critical outside-the-box clinical decision making, a skill sorely needed in tomorrow's evolving pre-canned medical world, is being sidelined.

If the ACGME is serious about having a viable, functional, and engaged physician workforce in the future, they'd better stop serving the public and start serving the real needs of tomorrow's physician workforce.  Giving lip-service to a program that ignores doctors in favor of the public isn't going to get patients where they'll need doctors to be in the years ahead.

-Wes

For Medical Students, It Seems Nothing's Changed

It was a very brief 15 minutes but I had arrived early.  There they were, sitting in our conference room, waiting to be interviewed for a residency position at our institution.  They had come from far and wide: California, New York, Michigan, for instance - all dressed in their nicest suits or business attire - a 50-50 split of bright women and men.  I was to give a lecture as part of my monthly series on EKG interpretation that fell at this time of year.  So these applicants could see how faculty interact with residents firsthand, I was asked to give my lecture to a crowded room of residents and the applicants together as part of their visit.

Since I had a few minutes, I introduced myself to the applicants and asked them how things were going.  They were very complimentary (of course) and seemed eager to want to talk about something besides why they wanted to come to our institution for residency training.  So being a bit subversive (of course) I asked what seemed like a little question: "How much does medical school cost these days?"

Heaven to Betsy, every one responded and shook their head.  "It's cost me $75,000 in loans so far this year!" one female residency applicant exclaimed in an embarrassed tone.  Most agreed that many of them were astonished at the costs, quoting some with debts of $300,000 to $400,000 for some of their classmates."  "How did you do it?" they asked.  And I mentioned by 26 years in the Navy and how I couldn't believe my roommate in medical school left with $65,000 debt at the time.  They all laughed that I thought that was a lot of money, realizing how much more most of them owed in the present day.  "I guess none of you are going into primary care, right?" I said.  They laughed nervously, yet didn't really answer.

Medical school costs and the costs of educating America's physicians is in its bubble stage, about to pop.  Our finest medical students are accruing huge debts and no one cares.  After all, these young doctors were the lucky ones, right?  Smart, social, good interpersonal skills, hard-working, driven, and most of all, disciplined.  Look how lucky they are!

But when these young doctors look at their first salaries, reality will hit hard.  They will realize the next mountain they will have to climb (as if medical school wasn't enough).  Tough choices will have to be made.  Needless to say, the picture for lower-paid specialties in medicine is particularly grim, yet the reality of fewer residency slots also exists.  Depression, already a problem, is likely to increase.

In the past five years, the world of medicine has forever changed for everyone, except medical schools it seems.  Their costs and expectations for revenue continues to exceed inflation by a large margin.  When will it stop?  For our newest trained doctors increasingly saddled with nearly insurmountable debt, the lure of medicine is waning. For those already in the pipeline,  the reality of what's coming when the loan bills come due is inevitably going to be turning our best new hope for medicine's future away unless the cost problem is fixed soon.

I am not proposing we make medical school free - that would make things worse in my view.  Different, more disruptive ideas that reign in costs will be needed - removing tenured professorial positions and limiting medical school building projects would be a good first step, but admittedly difficult with our entrenched old-school teaching model.  Unless we really work to change the cost of educating our next generation physicians I fear that medicine's best hope for the future will quickly dwindle away.

-Wes

If Only For a Second

Sometimes, the best ideas aren't so straightforward:


-Wes

Insurance Marketing Burn to be Passed to Patients

According to this morning's Wall Street Journal, Aetna, Inc. has noticed that "the evolution of the U.S. health-insurance market will soon push insurers to spend billions more on marketing to consumers" - as much as "fivefold" more.  "Advertising is the game," they said.

A game except that the "the consumers" will be paying for this marketing.

Which leads those of us in health care to contemplate what the marketing will look like.  No doubt there will be plenty of smiling faces doing vigorous activities or looking longingly at computer screens.

But if they look to the example set by "Covered California" (that one blogger quipped looks like "a laughable rip in the time/space continuum"), we should stand up and scream.  Here's how our tax dollars were recently spent as Richard Simmons tried to convince young "invincibles" to sign up for "Covered California:"



What a waste -

-Wes

MOC Goes Mainstream - But Should It?

How should patients determine the quality of their doctor? 

This is an interesting question that has now reached main stream media status as evidenced by the morning's Wall Street Journal "Health and Wellness" article by Laura Landro, a very accomplished veteran health care reporter. 

With the best and brightest going in to medicine, the requirement for more rigorous training than anywhere else in the world by (some might say) "exceptional, world class" medical educators and longstanding ongoing mandated continuing medical education to maintain competency and licensure, why is there suddenly such concern over the quality of doctors in America?  Most Americans have been very happy and trusting of the physician they knew and loved before - why the change?

Is it so that patients who must see new doctors in their new insurance plan can feel good that the new doctor (or nurse practitioner) is as good as the physician that has cared for them before? 

Perhaps.

Or perhaps it's because the huge Industrialized Certification Complex that foistied its Maintenance of Certification requirement every two years beginning 1 Jan 2014 upon America's physicians is finding unprecedented push-back from their member-physicians so a direct-to-consumer PR campaign was  undertaken in an attempt to quell the unrest. 

Perhaps.

Or perhaps it's because the American Board of Medical Specialties, along with its 24 subsidiary professional organizations, feels there is a need to justify the salaries of the multiple specialty board members that often exceeds that of their physician members and whose salaries are funded in large part by the fees from the MOC process. 

Perhaps.

Or perhaps there is a need to justify the difference and numbers of fees different types of doctors have to pay to maintain their certification.

Perhaps.

Or perhaps the PR was required to justify the expansion of this certification process to include not only testing doctors, but to making them also perform unproven data collection exercises called "Practice Improvement Modules" that have absolutely no bearing on a patient outcomes or a doctor's intellect and skill as a practicing physician, but typically take many months to complete. 

Perhaps.

Or perhaps the article was another effort to deflect attention from the fact that despite publishing a webpage of opinion pieces and articles claiming to substantiate the need for MOC, only 25% (at best) of board members of the various recertification bodies have bothered enough to maintain their own (sub)specialty certification.

Perhaps.

How do patients really benefit with the MOC process now being foisted on America's doctors every two years?  Do they get better access to their doctor?  No, for their doctors must take time away from their practices to study, take tests, and collect data for this.  Do they get to keep their doctor as long as they want if their doctor maintains their certification?  No, certification provides no guarantee that a patient can keep their doctor as patients are shunted to insurance company-controlled populations called "Care Organizations." Does maintaining certification guarantee that a doctor will practice better medicine?  No, at least not when the MOC process is compared head-to-head to the knowledge gained by years of close patient-care experience.

Ms. Landro seemed to be writing for the business interests in medicine in her role as a news reporter for the Wall Street Journal because she failed to mention these points and the impact the MOC process has had on hard-working, careful, and ethical clinical physicians in America.  While she does mention the suit filed against the American Board of Medical Specialties by an opposing organization called the American Association of Physicians and Surgeons, her article failed to mention the real reason this suit was filed: because a surgeon with over 30-years of patient care experience refused to "recertify" in his specialty and then had his privleges to practice medicine revoked by his hospital system as a result.

Years of experience and patient care - a measure most would agree is the most important determinant of a quality physician -  lost because a doctor refused to perform these unproven MOC exercises.

It's a classic David vs. Goliath story, really, since millions and millions of dollars annually are at stake for the certifying organizations.  And while the story continues to be played out in court, it is clear that the Davids are getting more upset - especially when Goliath's unproven tests and "Practice Improvement Modules" (and who knows what else in the future) have the potential to affect David's  ability to practice medicine in the future.  Is this really what patients want?

Should a series of tests ever trump clinical experience in determining physician quality?  Should a series of tests be able to void a doctor's lifelong commitment to patient care?

Not in my book.  And if patients think for one second this MOC process is just about having "quality physicians" at their disposal, they should think again.

-Wes

PS: I continue to wait for the Cardiovascular Subspecialty Maintenance of Certification test results I took 8 November 2013.  The test was entirely electronic, yet the results still have not been reported.   No doubt we'll soon have to pay to get our results in a timely fashion, too.

Reference: Buscemi D, Wang H, Phy M, Nugent K. "Maintenance of Certification in Internal Medicine: Participation Rates and Patient Outcomes." J Community Hosp Intern Med Perspect 2012; 2(4): 10.  Published online 7 January 2013.

The Importance of Demonizing Specialists

Most of us would agree that health care costs are too high in America.  They must be controlled or else we won’t have a sustainable health care system here.  And we should acknowledge that, on average, all doctors in America are paid higher than their overseas counterparts.  But we should also agree that expenses for doctors to earn a degree, maintain that degree and licensure, and pay their malpractice premiums is also much higher than the rest of the world.

So why has Elisabeth Rosenthal of the New York Times decided to bash specialists with her front page story entitled “Patients’ Costs Skyrocket;Specialists’ Incomes Soar”?  Perhaps the subtitle of the story explains part of the reason: “When a Doctor Becomes an Entrepreneur, Small Procedures Offer Big Returns.”

We should acknowledge that several moons have aligned that make such an article newsworthy. 

First, of course, is the remarkably unaffordable Affordable Care Act.  The new law is confusing for patients (to say the least).  Not only are terms like deductibles, co-pays, subsidies, and co-insurance confusing, there is absolute uncertainty about which doctors or health care system can provide once their insurance is purchased.  Is a doctor “in-network” or “out-of-network?”  What, really, do I get for Platinum, Gold, Silver, or Bronze coverage?  How many mental health visits can a patient have with their particular policy? Because every one of the hundreds of different policies has different “rules,” patients are left to fend for themselves like never before.  Patients are confused.  Doctors, having little clue about anything regarding such care limitations and cost structure, also have little understanding about the programs sold, so they become easy targets.

Second, is the current political pressure to develop physician payment reform.  It has long been known that health care was on an unsustainable cost path.  Numerous Congressional fiats have been used to control physician costs.  There was the Medicare Volume Performance Standard (MVPS), for instance, that was later replaced by the infamous and never-enforced Medicare Sustainable Growth Rate (SGR).  Why hasn’t Congress enforced their own law?  Simple: because doctors matter to seniors worried about health care and seniors vote.  Oh, and doctors take care of Congressmen, too.  But let's not mention this, Ms. Rosenthal - you see Americans might think their doctors are actually worth their salaries.

Third, was the Stimulus Package, formerly known as the American Recovery and Reinvestment Act of 2009 used to bolster the American Economy.  Within the confines of this bill were several features that laid the groundwork to the later Affordable Care Act.  These included the Health Information Technology for Economic and Clinical Health Act (HITECH Act), another 25.8 billion for information technology, $1 billion for “health and wellness”, $1.3 billion for “comparative effectiveness research” and (most important for specialists) a 40% cut to Medicare technical revenues to specialists who perform office-based procedures without a corresponding cut to similar fees paid to hospitals.  This final provision proved devastating to private specialist offices nationwide, forcing most of them to become employees of large health are systems.  The move was massive and has forever changed patients’ access to their physicians and elevated costs for them dramatically.  With such a move, doctors must now serve two masters: their employer and their patients.  All those pretty buildings, big screen TVs, administrator salaries, CEO salaries, and computer systems are very expensive.  Gee, who knew specialists’ bills would skyrocket as a result?  Yet according to Ms. Rosenthal, it's the specialists' fault.

But this is not the entire story.  While specialists' bills have skyrocketed, their incomes have not.  I should know, because unlike Ms. Rosenthal, I am a real live US specialist and I have the W-2’s to prove it.  Again this year, another $20K less.

Why?  I believe this year’s cut was due to how I am paid.  (Because I am sworn to secrecy about such issues by my employment contract, I can’t delve into all the details, but let’s acknowledge to points: (1) productivity is important to employers since they want to get the “most bang for their buck,” and (2)  most doctor’s work is “valued” based on a Medicare metric called “Relative Value Units.” )

 This post is already too long to delve into details about how procedures are “valued” by the system, but suffice it to say, they are.  Every procedure has an RVU value.  The more you do, the more you get credit for.  This really bothers policy wonks who feel this is the single reason costs are so high in medicine.  Never is mentioned the next fact: that Medicare has a habit or “bundling” several procedure codes into one to cut costs already.  What does this mean for the doctor?  It means they earn fewer RVUs for the same work.  So doctors are spurned to do more and more to make up the difference.

Until they can’t any more.  After all, there are only so many hours in the day.

Last year my specialty had a huge change in RVU values for our expensive specialty, and because I am well-established, I have lots and lots of patients in my clinic.  Adding new ones has become nearly impossible.  But new patients means new procedures.  And without procedures, I invariably have my pay drop thanks to these hidden changes to how I am paid.

Finally, there’s the problem of Ms. Rosenthal’s salary data.  She received it from an industry-standard company that makes money reporting physician salaries to hospital systems.  They claim their data is based on physician salary surveys, but I for one can attest that I have NEVER been asked to reveal my salary to this company.  Could they be getting their data from hospital systems instead?  Of course. 

I have had the opportunity to inquire about the MGMA’s data for my subspecialty of cardiac electrophysiology.  Their dataset supposedly represents only about 400 physician salaries (10%) of the entire nation’s 4000 or so electrophysiologists.  We have no idea where these data were collected.  Yet the salaries are stratisfied by RVU productivity into percentiles: 10%, 25%, 50%, 75% and 90% or better.  If you earn only a 10% RVU value, you are a dog in an employer’s eyes.  If you are 90% or better, you are worshiped. 

But for electrophysiology, several interesting tidbits exist: to achieve a 90% RVU value, the MGMA says that doctors must achieve over 19,000 RVUs per year as a specialist. Now I work my fanny off.  I am on call every third week.  I cover four hospitals and do plenty of procedures.  I have never made that kind of RVU productivity as shown in the 90^th percentile.  Not even close.  Might this be a unachievable carrot that is being dangled before specialists' eyes?

I was so amazed by that statistic touted by the MGMA that I asked our hospital administrative leadership to identify who the institution (or doctor) was that was producing like that.  After all, if I could learn how they are producing, I might be able to  improve my efficiencies, right?  Yet because the MGMA’s “benchmarks” are proprietary property, no one could identify the physician producing like that.

Which brings me back to the salary figures Ms. Rosenthal quotes in her inflammatory front-page story in the New York Times.  They are non-transparent.  They are skewed and cherry-picked to make her point.  And while some salaries might be representative for some areas of the country, I suspect most are not – especially for those in competitive health care markets.  Ms Rosenthal never mentions the regional differences in physician salaries that exist.

It seems there remains a real need to demonize physicians, especially specialists, as we proceed in health care reform.  In a system that has devalued primary care so dramatically, perhaps this is a way to gain favor for a shift in salaries to the primary care doctors.  Perhaps it’s a need to cut costs for large hospital systems that jury-rig their compensation structures on non-transparent benchmarks like the MGMA.  Whatever the reason, specialists’ salaries, jacked up my hospital systems eager to hire the most marketable talent, will remain easy targets.  After all, it’s much easier to point the finger at specialists that struggle to see all of the new patients, than to acknowledge the shortcomings of the very system that has gotten us where we are today.

Case in point: Most hospital-system CEO’s in Chicago salaries exceed many millions of dollars.  Salaries and benefits of pharmaceutical and insurance companies exceed ten times that of hospital system CEOs.

But better that Ms. Rosenthal doesn’t mention these salaries or the other infrastructure changes that have gotten us where we are today.   After all, it’s much easier take a cheap shot at specialists in the New York Times.

-Wes

Electronic Triage

Type a note.

Use a shortcut.

Cut and paste.

Order a test.

Review your tests.

Every result gets a note.

Release the result.

Ten new patient messages arrived.

See vacationing colleague’s results.

Did you see your patient’s been scheduled?

Verify you saw your patient was admitted.

Verify your order.

Sign your verbal order.

Telephone message.

E-mail message.

Operative note.

Code the note.

Bill the note.

Type instructions.

Order a procedure.

Print the summary

Update the problem list

Verify the medications – all of them – again

Update the medical history

Update the surgical history –right or left? When?

Family history?

Social history

Immunization history

Verify the allergies.

Make it meaningful.

Now repeat.

This is today’s electronic reality for doctors, and it’s getting worse every day.  Everything, it seems, must pass beneath a doctor's fingertips.

But there’s one thing skill that doctors have mastered when flooded that computer scientists and policy makers haven’t:

Triage.

And electronic triage is happening every day.

It has to.

After all, this is about life and death for everyone involved.

-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.

The AMA's Role in Maintenance of Certification

Andrew Schlafly, attorney for the Association of American Physicians and Surgeons and the group who sued the American Board of Medical Specialties over the Maintenance of Certification process, recently described (video - scroll ahead to 5min, 30 sec) the scene in court:

“When I sued the ABMS and six attorneys showed up on the other side to oppose the lawsuit, the lead attorney on the other side was an attorney that has represented the AMA for decades. He was on the other side defending this MOC and trying to stop our lawsuit and trying to stop the discovery. We’re going to get in and get discovery and find out what they have in mind for this and how they’ve been doing this, how they’ve been getting this into hospital medical staff requirements for so long.

And already I’ve traced that they paid this ABMS group (which is the umbrella group) something like $600,000 to a law firm in Newark, New Jersey. It popped up on their IRS Form 990, which discloses what their expenditures are, and I raised that with the court. 'They say they don’t practice in New Jersey, they don’t do business in New Jersey and here they are paying $600,000 plus to a Newark, New Jersey law firm. What’s that for?'  And by the way, what this Newark, New Jersey law firm does is it has a relationship with hospitals. And they came back and said 'Oh, no, what that money was for that was to help us set up MOC in Singapore.' They’re going worldwide with this!”

I was surprised the AMA (who is touts themselves as the political voice of US physicians) is defending the Maintenance of Certification (MOC) process and (more troubling if true) going to such efforts to expand this process to a country in which it has no jurisdiction.  Most physicians find the MOC process onerous, overly time-consuming and ridiculously expensive.  Why are US doctors paying dues to support AMA activities involving credentialing and licensure overseas?  A little digging shows that the AMA holds furvent support for the overall progression of the Maintenance of Certification process evolving to a Maintenance of Licensure (MOL).  From their own Council of Medical Education minutes (pdf):

“The AMA has robust policies related to medical licensure. A review of all AMA policies related to licensure was conducted to validate that the policies are consistent with the AMA Principles of MOL (Maintenance of Licensure).

AMA policy supports the underlying principles of MOL which are consistent with the direction that the practice of medicine is evolving. The recommendations of the Advisory Group contain options for doctors to meet MOL requirements that can also be used to meet other purposes and will provide an opportunity to monitor outcomes and produce useful data. The AMA will await the final document of the FSMB (ed note: Federation of State Medical Boards) with great interest and hopes that the MOL program will be carefully coordinated as much as possible between the states.

CME will predictably be a major component of the MOC/MOL model.

Physician members of the AMA might want to ask a few pointed questions to their leadership. After all, they're paying for this in more ways than one.

I just endured the maintenance of certification process for both cardiology and cardiac electrophysiology and can attest to the stressful nature of this process for working physicians. The thought that this unproven testing process could also be used to revoke my license to practice medicine in the future is unconscionable.

-Wes

Case Study: Mitral Annular Left Atrial Flutter

Sometimes what we do is just cool.

Cardiac electrophysiology has amazing technology at its disposal. One of these is three dimensional mapping. While three-dimensional mapping is not always required to perform catheter ablation, it can be invaluable when mapping and ablating forms of post-surgical atypical atrial flutter. The video below shows one such case we performed with the three-dimensional mapping system from Endocardial Solutions.

This system uses an X/Y/Z coordinate system created by referencing impedance changes that occur between paired electrodes placed on the patient's chest. Moving a single mapping catheter inside the left atrium during the patient's tachycardia permits localization of both the ablation catheter and the signal recorded.  An "activation map" from approximately 200 different points (the tiny white dots) that we collected in patient's left atrium is displayed below. The low amplitude signals (less than 0.5 mV) were colored grey. The map had the area of the mitral valve "cut away" using software so the endocardial surface could be better seen.

In this map, endocardial activation proceeds in a clockwise fashion and slows ever-so-slightly in the posterolateral mitral annulus near the blue dot. A single radiofrequency energy application at this location immediately terminated the patient's incessant left atrial flutter.



I love my job.

-Wes

When Push Comes to Shove: The Slow Death of the Medical Blog-o-sphere

Is the medical blog-o-sphere dying?

As I surf the internet these days, I wonder.

It seems to me that there are a few new blogs from time to time, and even some old, fun, stalwart ones, but the adoption of medical blogging by many has fallen on hard times, despite the best efforts of blogging enthusiasts.  The reality is this: the adoption of blogging by physicians has either become flat, or waned.  So some extent, there is a move toward micro-blogging services like Twitter, but even Twitter seems populated by most of the "same old-same" old group of voices, punctuated by a steady and ever-growing stream of marketers.

I believe it's because blogging takes time, passion, and commitment.   And with all of the changes these past years, most of us are finding less and less time for social media as new pressures mount to produce.  Oh sure, a few make real money at this endeavor, but most do not.  The reality is that "google ads" just won't offset what a doctor's day job produces.  And as doctors are pushed toward more production with more computer screen time than ever, something has to give.

Gone are the days of the annual "best" Medical Blog Awards.  Gone are the most of the exceptional story tellers.  Gone are many case studies as legal, HIPAA and corporate gag orders loom large over online medical content.  Sure, some stay because they have something to say, some just like the to and fro interaction,  and a few might have a mission or agenda, but the truth is, real clinical doctors with blogs are a dying breed.  After all. how many social media meetings can one attend each year without compromising patient care?  A dare say, very few.

I do not say this to tout my presence here, but rather to ponder my future.  I still like to write, though I find I do it much less now.  I feel the pressure to produce like never before - bogus MGMA benchmarks and dwindling RVUs have a way of doing that to you.  So it is harder to be a cheerleader for social media when I see the mounting challenges real care-taking doctors and nurses are asked to face. After all,  not only are we tasked with the responsibility of being care givers, we are also being tasked with negotiating minefields of codes, becoming typists, consulting as business efficiency experts, and serving as social psychologists, too. If we could just add another eight hours to every day...

So blogs go untended.  Writing shortens. Or withers away.

I suppose this blog, too, survives now on caffeine, frustration, and a strange sense of duty to report what I'm seeing as health care evolves.

But I wonder, now more than ever, when the plug will have to be pulled here, too.

-Wes

Medical Device Companies Begin Posting Physician Payments Online

As part of the Physician Payment Sunshine Act ("Sunshine Act"), some medical device companies started posting physician payments online. 

Here are the current links to the "big three" US medical device companies' reports I could find online at this time:

Boston Scientific Corporation
Medtronic, Inc.
St. Jude Medical  - to report payments beginning March 2014.

-Wes

American Board of Internal Medicine Changes Governance

Recently, the American Board of Internal Medicine (ABIM) announced "new policies to include non-internist and public members in ABIM governance."

Internists and subspecialists in medicine everywhere should wonder why.

The reason posited by the ABIM was the following:

"These historic governance changes recognize that although ABIM is of the medical profession, our primary responsibility is to the public, to our patients,"  said Dr. David H. Johnson, Chair of the ABIM Board of Directors (editor's note: very strange quote, if I might say). “ABIM's obligation is to ensure that our policies and programs are meaningful to both physicians and patients. Without the public voice, we don't have the full picture we need to meet that obligation and fulfill our mission.”

What could possibly go wrong?

Once again, we see the insidious creep of the ethic of caring for the collective superseding the ethic of caring for the individual.  Rather than physician organizations fighting tooth and nail for our patient's best interests in our new hostile environment hellbent on either cost savings or profiteering, the ABIM has acquiesced to a more "socially-conscious" ethic that places the needs of a certain collective (perhaps one that funds the organization?) before the needs of our individual patients and their doctors.  Is this just so they can remain politically relevant?

Perhaps this move is in preparation for the deployment of the mostly non-physician Independent Payment Advisory Board that will begin to make health care rationing decisions on the basis of "cost-effectiveness" in 2015. Perhaps it is so the doctors-members of the ABIM can feel better about their their abandonment of their physician membership in favor of appearing "inclusive" as they become a money-making CME-granting body.

Either way, doctors should understand whom the ABIM has officially abandoned with this governance change in spite of the spin: our patients.

And that, quite frankly, is a shame.

-Wes

Three Health Care Trends Patients Will Notice in the New Year

As we enter the New Year, I like to reflect on where we've been and where we're heading in medicine. By far and away, this is the most tumultuous time I have ever experienced in health care.  Doctors and nurses appear stressed and downtrodden, administrators are running scared, desperate to seem "value-added," and patients are scrambling to get seen in these last two days of 2013.

It's strange really.

I thought I'd try to make some realistic predictions of what patients should expect in the year ahead now that the "Patient Protection and Affordable Care Act" (PPACA) begins to sink it's tap root into the American medical system.

Triage

With the sudden expansion of the patient pool without a relative expansion of the physician pool, patients can expect a greater degree of triage to occur in medicine when they need to see a doctor. Triage will occur in many ways, but will fall along two lines: (1) treat the most urgent then (2) the most lucrative. Like it or not, these priorities will drive care for most medical facilities, especially our newly minted Accountable Care Organizations (aka, large hospital systems and care networks).  Specialists will become purely  proceduralists, internists and family practice doctors will see specialty follow-up and manage a team of nurse practitioners and "physician extenders," and these care extenders will become the front line care team for the more common ailments. In effect, follow-up specialty care will shift down the health care "food chain" to those less specialized in the name of improving "efficiencies" in health care. Some will argue this is cherry- picking lucrative patients and procedures, others will see this as a survival necessity for health care systems squeezed for revenue. Call it what you will, but realize it's another unintended consequence of the changes taking place in our health care market today.

Costs

There is no question that out-of-pocket costs (both direct and hidden) for health care will continue to rise for patients.  Given the recent holiday season, most Americans are strapped for cash at the beginning of the year.  But insurer's want their first installment for coverage as early as 10 January 2014.  Hidden in their premium will be a 2% tax added to the every insurance plan's premiums, plus a $2 fee that goes to the Patient Centered Outcomes Research Institute (PCORI) created by our new health care law.  As I've previously pointed out, the costly PCORI replicates functions already performed by the Agency for Health Care Quality and Research (AHRQ). The PCORI's budget is also scheduled to mushroom from $350 million to over $500 million annually in the years 2014-2019 with patients paying directly for this government agency thanks to this added fee.  And what do they get in return from the PCORI?  A wealth redistribution scheme to pay for even more "patient-centered" research redundancy.

Patient's take-home pay will also be reduced for middle-class individual tax filers earning more than $200,000 and families earning more than $250,000.  This is because they will pay an added 0.9 percent Medicare surtax on top of the existing 1.45 percent Medicare payroll tax. They’ll also pay an extra 3.8 percent Medicare tax on unearned income, such as investment dividends, rental income and capital gains.

Finally, patients will quickly begin to understand what the terms "deducitible," "co-pay," and "co-insurance" mean when it hits their pocketbooks.  My bet: they won't be happy about it.

Finally there's the issue of health insurance subsidies actually being tax credits.  As reported in the Wall Street Journal:

The federal subsidies that will help many people pay for their coverage are actually tax credits tied to their income. They will go to people making as much as 400% of the federal poverty rate—in most states, $94,200 for a family of four in 2013. The more you make, the smaller your subsidy. The subsidy process "will all be part of the tax computation," says Judy Solomon, of the Center on Budget and Policy Priorities.

People can choose to receive these credits as monthly payments that flow to their insurers over the course of the year. But if they do this, and the subsidies turn out to be too large—if the consumer's income was higher than expected and she should have received a smaller subsidy than was dispersed—the recipient may need to repay at least part of the overshoot.

To avoid this situation, people should report major changes in income to their exchange website when they occur. Consumers who know in advance that their income may fluctuate can also take "less financial support," meaning a smaller subsidy upfront, or opt for a lump sum at year's end, says Cheryl Fish-Parcham, of the consumer group Families USA. 

The government giveth and the government taketh away.   Hey, someone has to pay for all of this bureaucracy.

Confusion

The difficulties experienced with the government's HealthCare.gov website will have their trickle-down effects felt in 2014.  Given the number of vendors involved in development of the site, and their unwillingness to claim responsibility for the site's shortcomings, patients who registered on the site are likely to have little recourse for their difficulties readily apparent.  Social workers will be saddled with helping these patients, along with their other duties.  As if they don't have enough to do already.

Doctors will be introduced (perhaps "force-fed" is a better verb) to the "new and improved" ICD-10 coding scheme in 2014.  With bureaucracy run amok in medicine, this is another hassle foisted upon physicians and care-givers.  Compliance with the scheme is now a pre-requisite for physicians to be paid properly.  Expect more screen time, cursing,  and less patient-care time from your doctor as a result.

Insurers will be even more aggressive with denials based on insurance industry-developed "coverage decisions."  Doctors and patients alike will continue to find this frustrating as insurers must assure their profit margins.

So as we begin the New Year, strap in, and get ready for Health Care 2014.

We're all going to be taken for quite a ride by the changes ahead.  Rest assured, though, that there are still many doctors and nurses out there who will try to help ease their patients' burdens in such a stressful time for everyone.

-Wes



  

Mission Impossible V: The MOC Exam

"Place the palm of your hand on the palm scanner," she said.

 He complied and watched the computer screen in front of her read "Verified" in bold green letters.

With that, she looked up at him, shrugging her shoulders.  "In my time here at the testing center, I'm still waiting for someone's identity to change between where you scanned your hand around the corner to here, just 10 yards away!" He smiled and she chuckled to herself.  "Now pull out those pockets and let's seem 'em."

He complied.

"And the back pockets."

He turned. "Nothing.  See?" he said.

"Now roll up your sleeves..."

Secretly at this moment, he was hoping a rabbit would appear, but complied again.

She handed him back his driver's license, rose from her computer, and said, "Follow me."

She led the way through a high security door toward a testing cubicle and quietly sat him at a screen that contained an image of his face shot earlier during his check-in process.  She logged him in and there before him was a computer screen with a large American Board of Internal Medicine logo on it.  She pointed out the silver headphones for to the left of the screen.

"Those are for audio, in case there's any of that on your test.  And these to the right are noise-cancelling headphones if you prefer to wear them.  Here's a white board for your use.  Remember we are audio and videotaping everything.  Whatever you do, don't raise your hand at any time unless you need us.  Got that?  We will come get you.  Don't raise your hand otherwise.   Any questions?  Good luck..."

With that the escort left the room.  He sat before the screen and placed the noise headphones on his head.  The screen asked if he wanted to take a tour to familiarize himself with the features available on the software before starting his test.  He clicked the "Yes, tour" button.

With that, the screen flickered and went black. He could hear the noise cancelling headphone suddenly begin to make sounds.

"Good morning, Dr. Phleps."

A picture appeared on the screen as the mysterious voice continued: "This is Dr. Richard J. Baron, the mastermind and ring-leader of the American Board of Internal Medicine that supports the security and secrecy procedures that you have just endured.  He and his many well-paid collaborators have conspired to create a series of time-consuming and anxiety-producing tests and questionnaires designed to frustrate and instill fear in their professional membership. It has become clear that their processes are being promoted as a measure of physician excellence, when in fact, it sets a floor of performance standards for physicians while assuring the continuation of their administrative positions. Your mission, should you decide to accept it, is to pass your test so you can continue to demand accountability for the high salaries of these physician admistrators and the expense of this process that are soon to be imposed on physicians every two years. ... But remember, if you fail to pass, the Secretary will disavow and knowledge of your actions and perhaps your ability to practice medicine...  Good luck.  (This program will self-destruct in five seconds)..... * bbbbzzzzaaaaaaaappppppp *"

And with that, a small puff of smoke arose from computer and the screen went black briefly before it returned to the ABIM logo screen. The menu there again asked if he wanted to start the test.  He clicked the "Yes, start the test" button on the screen. A contract screen appeared reminding him that he'd only be able to take the test if he agreed to be disavowed and reported to credentialling agencies if he divulged any test content or materials to anyone at anytime.

Realizing his wife would kill him for wasting thousands of dollars if he refused, he clicked "I Agree."

The first question appaered while the clock in the upper right corner of the screen began counting down. (A familiar theme song began playing in the background)

-Wes

(Epilogue: Yes, dear reader, Dr. Phelps recently learned that he accomplished the impossible.)

You Are Christmas

To all of the first responders
Laboring in the icy night in an hour of unexpected need
While their children get tucked into bed
In the blanket sleepers...

You are Christmas.

To all the caregivers
Who make Christmas happen
Even when their hearts are heavy and
Moments of rest too few…

You are Christmas.

To all the suffering
Who rise to the occasion
With a smile or a simple gift
Or permission for others 
To celebrate without them…

You are Christmas.

To all the doctors, nurses and hospice workers
Whose own trees go undecorated and gifts go unsent
Because it seems every year
The hospitals are full at holiday time...

You are Christmas.

To all the parents
Who recapture the innocence of the season
For the sake of their children
With a song, a story, a silly ritual…

You are Christmas.

After all, it was never about the strong, the powerful, the rich,
The proud,
It was always about the humble, the faithful, the courageous,
The quiet, hopeful ones.
The scared young family standing in wonder at the manger,
Trusting, holding faith, believing in good,

Believing in love.

From both of us – Merry Christmas,

Diane and Wes Fisher

This Christmas, Look Up

I sit before the computer screen this morning, wondering "What should I write?"  Yet as I thought about this, I realized I should really write about why I'm thinking about this.

My journey in this space of social media has been a bumpy one, full of ups and downs, ins and outs, obsession and indifference, all rolled up into one.   Yeah, this sums up health care social media now, at least for me.

I began writing here in November 2005, not really knowing what I was doing.  I thought of this space as a marketing space, then an information-to-patient space, then a social space ("gee, so many interesting people here!) and even an "inside view of medicine" space.  In reflection, I really didn't know what the hell this space should be.

But then came 2006 and 2007, my father became gravely ill, and social media was a wonderful outlet for me to reflect on all of the emotions, memories, and experiences that such an event invokes.  I found I loved writing.  To this day, I use this space as a diary of that time in my life, and even found my eyes blurring a bit this morning as I re-read my earlier Christmas reflection of the events that occurred that year.  Blogs, I've found, are really a good space for remembering certain events, certain times.

Later, I'm not sure where I went with social media.  I signed up for Twitter during the Twitter-craze and learned about "tweets" and "hashtags" and all that stuff.  I was amazed at how "up-to-date" I could be with the latest rage, outrage, sound bite and scandal in medicine.  Heck, it my cell phone would come alive!  Medicine is so, *ping* , i-n-t-e-r-e-s-t-i-n-g again!  *ping* *ping*

As if the latest cell phone vibration, chirp, and flash was really what mattered and dull ol' medical care was just, well, glacially stimulating by comparison.  What's not to like, right?  You could be a teacher, provocateur, and health care social media detective!  You, dear doctor, could make a difference!

But in reflection, reality's been very different than that.

I realize now that I am just one voice, one small individual in a the overcrowded mess that is the internet.  Everyone is trying so hard to be heard.  Entire social media companies are developed just to make sure you pay attention to your cell phone - just look at SnapChat, where if you don't immediately attend to your cell phone, the image, message or 10-second video is gone, never to be seen again.  Pay ATTENTION, people!

This is not to say people's voices aren't important.  In fact, many in this space say incredibly powerful things here.  But I am seeing something very interesting on social media now, especially as it pertains to doctors' participation in this space: propaganda.

There are very savvy, well-organized forces on social media now.  Everyone knows this is where the battleground of public opinion rests.  So forces are marshaled, teams assembled to make sure the party line is towed.

I ask you, dear doctor, who much time do you have?  So it is with social media in health care.

But recently in my evolution in this space, I realize I have matured.  I don't come into health care social media starry-eyed any longer.  It has a purpose.  You can meet some remarkably thoughtful and insightful individuals here.  You can make some pretty amazing friends.  And you can get lost.

But I realize there's a purpose, too.  People can tell a single, quiet, story  here - a small, transcendent one, too.

Nowhere was this more visible than in the recent quiet, painful reflections of a young boy suffering with leukemia and the wonderful stories he and his parents shared in their blogs.  These are not people providing propaganda, these were people with a purpose.  These were people who realized what mattered.  These were people who were an inspiration to us all.

As I reflect on all of this at Christmas time, I find it's more important to spend these short, dwindling, yet cherished moments with real life, not one manufactured by the media companies.

Time is precious.  Family is paramount.  And social media is, well, social media.

This holiday season I hope all of us will take time to pull our heads from our cell phones and computer screens.  There some amazing things going on around us, some amazing stories of hope and courage, and things we really need to appreciate.  Most of those things aren't represented by bits and bytes on an iridescent screen, but rather what we take for granted every day, if we dare to look up.

Merry Christmas.

-Wes

The Matrix

"As a third year medical student, I would also argue that this is creating a generation of dumb doctors. My school (average US MD school in the Midwest) has almost abandoned teaching physiology and understanding. We have the virtues of guidelines shoved down our throats instead. Recognize a pattern, apply the appropriate guideline. That's medical school these days...."
-Anonymous commenter
Dr. Wes blog

Dear current medical students,

Welcome to The Matrix.

-Wes

When Physicians Drown in Noise

The infrequent side effects of Paxil
(Click to enlarge)

I was just trying to look up the side effects of Paxil and was greeted to this incredible and quite ridiculous array of potential side effects.

I had to ask myself: how helpful is such a list? Why do we have this noise available to us?

The answer, of course, is obvious to anyone who understands our legal system in America.

But we should ask ourselves another question: in our effort to assure patient safety, might we be losing important signals to care-givers amongst the recesses of all of this incredible noise?

-Wes

If The Hunger Games Came to Medicine

““A totalitarian state is in effect a theocracy, and its ruling caste, in order to keep its position, has to be thought of as infallible. But since, in practice, no one is infallible, it is frequently necessary to rearrange past events in order to show that this or that mistake was not made, or that this or that imaginary triumph actually happened.”
                                               - George Orwell

* * *

The brushed, steel belly of the scalpel blade pressed down on the orange antibacterial film and released the subcutaneous yellow fat globules surrounded by small beads of red blood.  The movement of his hand was fluid, purposeful, and without hesitation.  The electrocautery pen carefully seared the points where blood appeared.  A retractor was installed to spread the tissues farther apart as he worked quickly to gain access to the tissue plane just above the muscle.  His movements were deft for he knew they were watching.

The Capitol's campaign to ensure perfect outcomes was well underway. They had installed cameras throughout the hospital just four short years before: in the halls, the changing rooms, at the scrub sinks, and in the operating rooms.  The Capitol had discovered that the operating room was like yesterday's boxing ring, or even farther back in the mists, the Coliseum.  In the New World unpredictable events and venues that stirred primitive passions were few - and yet they were longed for as they were feared.  This context explained the popularity of the annual Hunger Games, created as punishment for the destruction of District 13 by a failed patient uprising after the health care financial apocalypse.  Each year, one male and one female physician "tribute" from each of the surrounding twelve Districts were selected by lottery and performance metrics to fight each other to the death. Providing spectators with a window into the drama, and ensuring that drama by creating just the right conditions, gave spectators a sense of aliveness that they barely remembered, and just enough to stimulate fear.  The Games also served as the perfect venue to deflect blame from the Capitol's expedience in sacrificing people for their own avarice.   

The call had come after a full, exhausting day.  The patient had presented to the Emergency Room only two weeks after open heart surgery for coronary disease and to replace his critically-narrowed aortic valve.  The surgeon-tribute wasn’t sure why his conduction system should fail this late after surgery but it didn’t matter; his heart rate had slowed to a dangerous 19 beats per minute. His blood pressure, while low, remained stable.  A quick review of this medication list disclosed the mandatory heart medications that included an anticoagulant for the heart valve and antiplatelet agents for his coronary disease.  No heart rate slowing medication was being used so the Capitol's appropriateness indication to proceed with the procedure was indisputable.  It was also fortunate that the anticoagulant the patient was taking hadn’t thinned his blood too far.   He decided to take him to the operating room directly.  It was 3 am.

Meanwhile, back at the TV studio:  “I tell you, Frank, every year the footage gets better and better!  How did your team know that these untenable circumstances would result in such great late night viewing?  This is so exciting!” 

The call team had been called, but was short-staffed.  Efficiency meant lower cost, fewer people, and longer work hours.  The designated scrub tech had car trouble and would be delayed.  So the other technician and nurse worked feverishly to ready the room.  The call had already been made to the device representative who brought the new pacemaker hardware, but he was barred from entering the operative suite for he was not part of the medical team.  Rules were rules.   The patient, of course, was agitated, gasping for breath.  The doctor worked as fast as possible to establish pacing – the air was tense.

“Are you kidding?  I love seeing this, don’t you?  The nervousness of his voice!  The anxiety!  The skeleton crew at night!  Beautiful!  I’m not sure it gets much better!”

John had no idea why his car wouldn’t start that night (but the spectators did).  He turned the key again and again, only to hear the engine spit in return.  He slammed his hand against the steering wheel, frustrated that he was unable to keep his car tuned for poor weather.  But such concerns were luxuries now that hospital budgets were tight thanks to the Capitol’s Bundled Payments for Care Improvement campaign.  Finding a ride to work became the imperative.  He raced back into the house to wake his wife in a panic, asking her whom he might call to give him a ride – they each knew the consequences of failure.  They called their neighbor and woke him from a sound sleep.  The pressured nature of their voices convinced him to loan them his car and five precious minutes later, he was off to work calling ahead to notify them of the delay.

At the hospital, Chloe answered John's call as she sat behind the monitoring console.  She was one of the best young technicians to graduate from her training school.  Still, her hospital’s equipment was not up to date because maintenance contracts were left to expire in these cost-saving times.  Still, although the software it ran was now several versions old, it still reliably fed data to the Capitol's chargemaster.  She looked down at the dust on the keyboard.  Seeing this, it was clear she couldn’t enter the room to assist because the risk of surgical contamination was too great.

The surgeon-tribute was glad he’d placed two venous sheaths to gain vascular access, rather than just one.   He had successfully placed both pacing wires through the sheaths to the patient’s right atrium, ready to be secured to their appropriate chamber.  But he needed a softer shaping wire – the stylette – to insert into the inner lumen of the pacing wire.  Without the stylette, the pacing wire had the consistency of a well-cooked spaghetti noodle.  With it, he could place the pacing wire to its appropriate chamber.    As he turned, his eyes left the surgical field for just a moment.  He scanned the table crammed with scattered instruments and hesitated briefly as he located the proper stylette. 

A hush fell over the audience as they saw the opening.  They leaned forward in anticipation, reveling in their luck to see such a careless mistake.

John leaned his head in the room to notify them he’d finally arrived and would assist as soon as he could change.  The surgeon smiled, acknowledging his dogged efforts to arrive as quickly as humanly possible.  He turned to the field and shaped  the stylette to the perfect curvature that would allow him to affix the pacing wire to the lower, primary pumping chamber of the patient’s heart.  He focused his blurring vision to place the tiny stylette in the endhole of the pacing lead.   Chloe broke the silence of the moment: “Hey guys, did an electrode fall off?”

The doctor looked up briefly to see atrial P waves dancing across the monitor screen without any corresponding ventricular electrical activity. With that, his worst nightmare was realized.  The patient began posturing on the table, his head thrown back beneath the drapes, his arms slowly but powerfully raising.  The surgeon leaned forward to grab the patient while trying to control the leads, stylette, and surgical wound sterility.  The patient began violently thrashing beneath the drapes, his face turning blue and lips crimson as saliva and exhaled gases mixed into a frothy spraying mess.  He was seizing uncontrollably.  His once steady escape rhythm had chosen this unfortunate moment to stop. 

If the surgeon was expecting help from a sponsor it was unlikely to be forthcoming.  Just yesterday, the tribute's most likely supporter/sponsor, Sylvia, a well-to-do matriarch from the Central District, had noticed an incipient sign of aging on her neck – subtle crepe-like thinning of her skin, this despite her  rigorous adherence to all of the Wellness Initiatives the Capitol had advertised.  She had reason to hate, didn't she? She'd  been failed one too many times.   She remembered sitting with her 65 year old mother gasping for air in one of those infernal assembly-line clinics with the young doctor glancing at the red, flashing "Do Not Admit" guideline on the computer screen as he sent them home with morphine with that flat, dead, passive expression on his face!  He didn't care then and so she wouldn't care now!

Seconds felt like hours as the patient's body slowly twisted sideways.  The nurse did all she could to support his weight and keep him from falling.  The surgeon, too, felt helpless as the powerful frame shook uncontrollably beneath the drape.  The restraints tethered his arms but his involuntary leg movement forced him further sideways.  John felt powerless as he watched from the door.  Finally, he could watch no longer and ran into the room just as the patient fell to the floor.

Four cannon blasts were heard in the distance.  The spectators roared.
 

-Wes