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Showing posts from 2011

How does Canada do it?

When I was at my marathon internal medicine update course at Harvard earlier this month, I sat next to a very bright physician from Tanzania who works as an internist in Canada. I am so glad I talked to her. I was really confused about the health care system in Canada, especially the meaning of "socialized medicine."

Canada has a publicly funded insurance program that pays for basic health services and covers about 99% of outpatient visits. Doctors, though, are not all on a salary through the government, which I thought they were. Most physicians receive fee for service, just like they do in the US.

What happens is that their "medicare" is much like ours, and pays doctors for seeing patients. I am not at all clear as to what a doctor can bill medicare for, whether Canada pays for things like management services not involving face to face contacts or that sort of thing, which would be really interesting to know. Some doctors are on salary through community health cl…

Being a hospitalist and watching our hospital get digital

Since quitting my primary care job 2 months ago I have been working at our local hospital as a "hospitalist". I take 24 hour shifts, several in a row, and during those shifts I am responsible for taking care of all of the patients admitted to the hospital whose doctors can't care for them in that setting. This ends up with me being a consultant for some patients who are particularly complex and time consuming and being the primary doctor for patients whose doctors don't have hospital privileges or are out of town or who don't have a doctor at all. I meet lots of interesting people and get to know them and do the diagnosing, communicating and treating that they need until I go off duty. For many of these people I miss being able to see the whole illness through, like I used to do. It is freeing, though, to know that my responsibility ends at a certain time.

My days vary from extremely busy, where I can't even answer a phone call from my family and have to keep…

Blog maintenance issues

This month the stats for this site showed that there have been over 10,000 views since its inception about 2 years ago. I was bragging about this to my 17 year old son, a computer whisperer, who has very little patience for my relative ignorance of the digital world. He gave me some advice, sort of the "queer eye for the straight guy" variety of advice. ( Reference: "Queer Eye" is a reality TV show where gay men give advice on fashion and lifestyle to clueless straight men.) Apparently it is amazing that anyone visits this site at all, for a number of reasons. The first is "TL;DR"--too long, didn't read. All anyone sees when they visit this site is a wall of words which is probably quite overwhelming unless the visitor is pretty darn determined.

The second is that there is hardly anything to grab the eye. I went with the packaged blogspot formatting and haven't changed it at all the whole time I've been writing. It is really quite attractive, …

How to lose weight, lower your blood pressure, have better cholesterol and live longer, all without me nagging about it

There are various things that appear to be good for people. These include maintaining a normal weight, or losing weight if a person is fat, drinking some alcohol, but not too much, quitting smoking and exercising. Doctors as a whole also believe that lowering cholesterol levels is good, and at my recent update in internal medicine course there was some good data that suggested that drinking coffee is a good thing! Controlling blood pressure is also very important.

Being obese is bad in a number on ways, increasing risk of getting cancer, increasing osteoarthritis of the knees, which in turn is responsible for quite a bit of suffering and death, and increasing blood pressure and heart disease. Diet changes can help, but unlike much of what I have believed, there is no particular diet that is better than other diets for everybody. One study looked at people attempting to lose weight using either a low fat or a low carbohydrate diet. The low carb diets are exemplified by the Atkins  and …

Harvard Medical School Internal Medicine Update--Deepak Chopra and more

Having now attended 4 of the 6.5 days of the Harvard Internal Medicine Update CME I am now more grateful for being here. The first day of talks was disappointing, with some of the presenters actually pretty much reading their notes word for word, which I could have done in the comfort of my own home. But many of the speakers since then have been more confident and have been speaking from their hearts and their experience and there has been more to think about.

Yesterday Deepak Chopra gave a special 2 hour lecture about the meaning of life which was quite moving. He is a physician turned writer, though reading his biography it looks like he was always destined to do things that didn't fit comfortably into the medical profession. He started as a medical student in India, went on to become an endocrinologist, was involved in Transcendental Meditation and was a follower of Maharishi Mahesh Yogi, learned Ayurvedic medicine and now is able to span the gap between alternative medicine, e…

Ranting about continuing medical education, evidence based medicine and cost ignorance

I am attending Harvard Medical School's yearly internal medicine update this week. In a little over 6 days we experience 62 hours of medical education, sitting for 12 hours each day in the conference room of a shiny glass and steel hotel in downtown Boston. We hear world authorities on diseases of all of the major organ systems tell us what they think we ought to know. I am two days into it and still pretty excited, but losing a bit of my enthusiasm.

Most of the presenters follow a set of power point slides, sometimes word for word, that are reproduced in our course syllabus in a size that is nearly entirely unreadable. The form of the talks is to present the scope of the problem, then the recommended testing and treatment, interspersed with the research that is the basis for the recommendations, with an occasional cartoon or anecdote. There are also brief question and answer sessions and cases presented with recommendations on management. There are audience response handsets so w…

how to become a hospitalist part 1

The field of "hospital medicine" has become increasingly popular in the last 10 years, especially for internal medicine physicians. When a person finishes medical school and enters residency, there are nearly boundless possibilities. Residency choices can include specialties such as radiology, surgery, dermatology, emergency medicine, neurology, psychiatry, family practice, pediatrics, obstetrics and gynecology, pathology and lab medicine and even internal medicine. I'm sure I'm missing something. If a person chooses internal medicine, she can still choose to become a cardiologist, rheumatologist, endocrinologist, oncologist or...again I'm sure I'm missing something. But after 4 years of medical school and then 3 years of internal medicine residency, which is a job, but with almost no time off and very little pay, some people are ready to start doctoring. I wanted to be able to be useful anywhere and be able to use the knowledge I'd spent so much time  pi…

Bedside ultrasound--what a great way to improve medical care and potentially reduce costs

I just completed a 2 day course in "point of care ultrasound" at Harvard Medical School.  It was great. I am completely sold, a convert, a true believer.

Ultrasound is by no means a new technology. Bats use it. Bugs use it. Whales use it. A very high frequency sound wave is produced and when it hits an object it bounces back and is sensed by the creature that produced it. Submarines have used it since the first world war to locate objects, since other detection methods based on light were not useful. Doctors have used rudimentary forms of ultrasound since the 1940s to detect abnormalities in the body. In the last 30 years the machines used in ultrasound imaging have become smaller and more accurate, and the number of conditions that can be detected by ultrasound has increased vastly.  

Medical imaging studies of all kinds have become better since I emerged from medical school, and the pictures of the body that they produce are beautiful.  We have x-rays, an old technology, w…

Advanced Trauma Life Support

My 2 year "sabbatical" started a week ago. It has not, so far, involved much sleeping late or eating bon bons, which is fine, I guess. I am working several 24 hour shifts this month for our local hospital, covering the "hospitalist" service. This involves care of hospitalized patients who have no primary doctor or whose primary doctor is unable to take care of them in the hospital. Some of these patients are critically ill, some have fallen through the cracks of our health care system and others have doctors who choose to do only outpatient or specialty practices.  In some communities, especially in big cities, doctors who have office practices are just too busy to be available to their patients at the odd times that hospital medicine requires and so nearly all of the patients in the hospital belong to designated hospitalists. In our community, most of the doctors do at least some hospital medicine, which is good for continuity of care.

After quitting my primary ca…

Should you get a flu shot? (plus comments on intranasal and intradermal vaccination)

Influenza is a nasty viral illness characterized by fever, headache, sore throat, runny nose and a cough. These words don't come close to conveying the actual misery of a real whomping case of the flu. Most of my patients with the flu feel too miserable to come in to the office, which is good, because influenza is very contagious. Not only is it contagious when it first occurs, it remains contagious for 1-2 weeks. But I stray from my description. The patients who do come in to see me with the flu are usually too miserable to adequately describe their symptoms, preferring to moan and answer my questions with short answers. I have had the flu several times, and what I most vividly remember is being nearly unable to move. Usually when I get the flu, I start the day out thinking that I might be getting a little cold, but that I can certainly work. Then the viruses start doubling and infecting my vulnerable cells and I realize that I need to get home. I have traditionally been able to …

The perfect electronic medical record

I have had a love hate relationship with our computerized medical record since we first started using it in 2007. Much like computers in all of American society, the idea that our computerized medical record is just a small facet of what we do, involved in the storage of information, is a gross simplification. In the US (also elsewhere, but I can't speak for Europe or Asia from much personal experience) the ubiquitous presence of computers has affected how we work, play, think, communicate. These interfaces with brains that we use so frequently have made us fatter, more connected to each others' thoughts, less connected to each others' bodies, has reduced our ability to use non-visual senses, has partially convinced us that 3 dimensions are optional, and I could go on for hours (at which time all hope of going out for a walk would be gone.) In my medical office, my near-umbilical connection to my laptop has touched all parts of what I do. The production of a document, whic…

Telemedicine: where could it lead?

I have only 6 more days in my present job as a primary care internist in my home town. The process of wrapping things up has been new and time consuming, but ultimately very rewarding. I get to see patients I've known for over a decade, in some instances, and review what has happened with their lives and their health and we work on future plans for maintaining what they have gained and getting a handle on problems still bothering them. We say goodbyes and good lucks and talk about the important, big stuff, like hopes and dreams and medication refills. Interspersed among these appointments and phone calls are multiple communications about my next job, whatever that will turn out to be.

I am signed up with 2 locums companies, and in contact with 4 recruiters who are my agents, as well as the recruiters that are associated with my possible new jobs. The phone calls are mostly really interesting, since I get to hear about new places and how they are doing what they do in health care. …

Meaningful use: the top heavy nit picky route to possibly better health care

As part of the 2009 American Recovery and Reinvestment act (the massive stimulus package enacted at the beginning of our economic slump) doctors were offered money to start using computerized medical records for their patients insured by Medicare and Medicaid.  It was felt to be evident at that time that use of a computers to document patients' medical encounters would make communication between providers better, reduce errors, reduce redundancy of testing and procedures and overall streamline documentation. Many physicians had already started on the road to making their records digital, but government support made others take the big step.  Our office bought a very expensive computer software package from GE along with all of the hardware to support it in 2007, and by the time the stimulus package passed, we had almost adjusted to the change. We figured we would probably be well set up to be rewarded for having made this momentous change before the majority of offices.

Adjusting …

Patient Centered Outcomes Research--a good start

The affordable care act, in its 2000 plus pages, provided for many projects with the potential to improve health care delivery in the US. The most actively debated part of the bill, the mandate to insure just about everyone, may not turn out to be the most important piece. The problems the affordable care act attempted to address are the fact that American health care spending is too high and buys too little, including poor outcomes for those who do get health care and the fact that too few people who need health care actually receive it. All of these issues are addressed in some way or another in the myriad provisions of the bill.

One rarely advertised provision of the bill is the Patient Centered Outcomes Research Institute (PCORI).  This is a private institute, publicly funded, which includes a huge diversity of players, from patients to providers and sundry others, who are charged with figuring out exactly what Patient Centered Outcomes Research is, and then making it happen and d…

Physician non-compete clauses--another way to gut rural health care

Lately I have been dealing with the painful process of separating from my medical group. I have been part of this group since its inception, about 12 years ago. It serves two small towns in adjacent states and has about 30 employees and 12 providers, mostly located in the larger of our two clinics, in which I do not work.  We originally came together from 3 primary care practices in order to share resources and reduce overhead. Cultures and values were somewhat different, but we did all care about delivering good quality medicine, letting our physicians have autonomy in decision making, and about making sure that each one of us could have lives that were humane, valuing family time or outside interests and covering each others' patient's needs so that care would not suffer.

When we came together we wrote a contract which was longer and more formal than any I had signed before and had various elements that made me somewhat uncomfortable. One was the "buy-in". This was…