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Showing posts from 2012

Transitioning from fee for service medicine and spending money where it does the most good

I just read in a recent issue of "Aequanimitas," the newsletter of Johns Hopkins Osler medical service, a brief interview with J. Mario Molina, the CEO of Molina Healthcare, an organization which coordinates managed care for recipients of Medicare and Medicaid for several states. It looks like he must have been one of my senior residents when I was an intern. It sounds like he practiced for a few years before taking on the leadership of his family business. He expressed his firm belief that medical care would soon be moving away from paying physicians for the individual services they perform and, instead, paying them for keeping patients healthy. Since it will be organizations, not doctors, who are paid for care, it will quickly become clear that paying for anything that prevents dire illness with its astronomical associated costs will benefit the whole. Medical institutions may find themselves in the business of making their communities healthy. This is not foreign to larg…

In the wake of marijuana legalization, what exactly are the health risks?

Colorado and Washington state have legalized the recreational use of marijuana. I thought this would take longer to legislate, especially with the recent backlash from the federal government about medical marijuana. Eighteen states (including California, Alaska, Vermont and Oregon) allow marijuana to be used for medical reasons, but have restrictions on which conditions can be treated with it, which don't necessarily correlate perfectly with the diseases for which it is effective. I have worked in a state which doesn't allow legal marijuana use for anything, but have seen patients from neighboring states who did use medical marijuana and have tried to stay abreast of the laws and issues surrounding use.

Marijuana is relatively nontoxic. Nobody has ever died of overdosing on marijuana, though it is theoretically possible. Combining marijuana with other drugs can lead to overdose death, and combining marijuana with driving or other activities which require fast reaction time has…

Evidence based medicine--but which evidence?

In the last year I've become more and more comfortable using online resources to determine the best treatments for the diseases I see. My favorite site is Up To Date, which has experts write articles which review the literature and share their experience to produce very readable background information and succinct recommendations. Up To Date is expensive, but most hospitals that have computer systems also have subscriptions to it, so it's easy to access when I am reviewing labs, tests or other data.  I've also been impressed with the American College of Physicians PIER (physicans information and education resource) which is available to me as a member of the ACP and has links to new articles and practical recommendations. It is less exhaustive than Up To Date, for instance there is no specific article dealing with Brucellosis (a cattle related infectious disease), but very easy to use and right up to the minute. For absolutely free I can use Medscape, as can anyone readin…

Multitasking and information toxicity--is that why I feel stupid?

Today I've been feeling stupid. My job absolutely requires critical, creative thinking and the ability to focus well, which was really hard today. But I don't think I'm actually stupid. I think it has something to do with the task at hand.

So this is how today went. I think it kind of explains the stupid feeling.

My morning shift started at 7:30 in a small but busy 45 bed hospital that serves a chunk of rural Alaska.  The night shift doc told me about the 13 patients who I needed to take care of that day. Seven of the patients were new to me, admitted the night before. For those patients, I needed to review their medical histories in the computerized medical record and get to know them, with a focused physical exam and an interview to determine what needed to be accomplished in the hospitalization. For all of the 13 patients, I needed to review all of the lab tests completed in the last day  and all of the radiological studies and check their vital signs and review the nu…

Mammogram screening--reconsidering the wisdom of saying "No."

Three days ago, on November 22, 2012, an article was published in the New England Journal of Medicine questioning the utility of mammogram screening for prevention of death from breast cancer. The authors were research professor Archie Bleyer MD at Oregon Health and Sciences University in Portland, an oncologist who was chief of pediatrics at MD Anderson Cancer Center and H. Gilbert Welch MD, MPH, a professor at Dartmouth Medical School.  The article examines the ability of mammograms to prevent late stage breast cancer by diagnosing and treating breast cancer early as a result of detection by mammograms. They found that mammograms do detect lots of breast cancer, but when we compare women during the years 2006-2008 when mammogram screening was widely practiced to women during the years 1976-1978, there was no difference in the incidence of the really nasty breast cancers, ones that had spread beyond the regional lymph nodes, and only a small decrease in the less nasty but still sign…

Creating dependency--is that what we do for a living?

Lately, it seems, I have been treating quite a lot of people who end up in the hospital as a result of prescription drug abuse. Most of them have chronic pain and have been generously prescribed long acting opiate medications such as methadone and morphine by doctors of various types, have taken excessive numbers of these medications or mixed them with other medications and have ended up being unable to breathe for themselves.

In the beginning of the last decade there was a well intentioned movement to recognize that pain was a real issue and should be treated. Pain is not visible, usually, and can often be ignored. Having lots of pain for a long while or intense pain for shorter periods is bad for us. It causes depression, anxiety, leads to post-traumatic stress disorder, and just generally hurts a lot. Humans view torture, deliberately causing another being to have pain, as vile and unacceptable. Conversely we regard the relief of pain as a great gift. In 1999 the Veterans Administ…

Hospitalists and the field of Hospital Medicine: why we are sometimes terrible and how we can be excellent

Internal Medicine is the branch of medicine that deals with diseases of the internal organs in adults. It also involves dermatology, minor surgical procedures, general psychiatry and preventive care of well people. It is an excellent field, full of opportunities to think and feel and connect with people, mysteries to be solved and an endless variety of stuff to be learned. Internal Medicine contains the subspecialties of nephrology (kidneys), cardiology, oncology and hematology (cancer and blood), infectious diseases, pulmonary and critical care medicine, endocrinology (glands), rheumatology (joints), gastroenterology (guts and livers), neurology and hospital medicine. The most recently invented of those subspecialties is hospital medicine. Unlike the rest of the subspecialties, hospital medicine is defined by the place it is performed, not the body system it aims to treat.

Hospitalists (the internists who practice hospital medicine) take care of patients who are admitted to hospital…

A sort of apology to hospitals, especially little ones struggling to make ends meet

In my previous post I said that an obvious reason why we over-diagnose serious conditions in patients who are not terribly sick is that this results in higher reimbursement to hospitals, "...and when a hospital does well they get remodels with big fish tanks and fountains and flat screen TVs which makes everybody happy."  This gives the impression that hospitals are evil and money grubbing, which is not true. Many small hospitals can barely make ends meet and are absolutely vital to the economic health of the communities they serve. Over-diagnosing and inflating severity are definitely the wrong way to go about making enough money to survive, but it is the strategy they are using now for lack of a better one. 

It is important to change payment structures so doctors and hospitals don't waste their time and energy doing the equivalent of clipping coupons in order to cover costs. Part of the costs that make it hard to survive are the administrative and documentation burdens …

What is health care like in India, why do Indian doctors come to the US and why are so many patients septic these days?

Lately I've been working in an unfamiliar state in a rural, but not small, hospital, and have been noticing all kinds of curious things. This is not the first time I've noticed these curious things so now I am sure that they mean something.

1. There are a lot of Indian doctors, especially in small towns in the US.

2. Small hospitals outside of major metropolitan areas often find it difficult to hire physicians, even though they pay lots of money.

3. There are many foreign doctors in the US who are not employed as physicians. They often work in hospitals but not as doctors.

4. In many hospitals patients are admitted to the hospital when they are not very sick and then proceed to have scads of tests and procedures done that are really expensive and not particularly helpful.

5. People who are not particularly ill get admitted to hospitals with the diagnosis of SIRS (systemic inflammatory response syndrome) which is a kind of synonym for "sepsis". (When I was training, s…

Balancing the budget: how exactly will we eventually pay for health care?

This week the American Medical News featured an article with the disturbing title, "Massive health job losses expected if Medicare sequester prevails." I wasn't entirely sure what a "sequester" was, since I thought it was a verb. Sequestration, I thought, was the noun. (I hear a loud knock. It must be the grammar police.) The story, as I understand it, is that when our government decided to pull together and raise the debt ceiling, they also passed the Budget Control Act, which was intended to reduce the deficit by $1.2 trillion by 2021. This was to be achieved by a bipartisan Joint Select Committee on Deficit Reduction, which would make well considered cuts in funding for various projects. They were unable to come up with a plan that they could agree upon (imagine that) and so automatic across the board spending cuts are mandated to go into effect in 2013, excluding only a few programs, such as childrens' health and disaster funding, and capping yearly cu…

The Ryan Plan and the Affordable Care Act--can market forces improve quality and cost in health care?

In today's New England Journal of Medicine an article by Republican health policy analyst, Gail Wilensky, brought up several excellent points. The article is entitled "The Shortcomings of Obamacare". She points out that the Affordable Care Act does not directly address the forces that have lead to high costs and less than optimal quality in American health care.  She points out that physicians are paid according to a relative value scale that creates perverse incentives to do more procedures regardless of whether they work, and that this has not been addressed by the ACA. She says that if we want to use market forces, putting consumers in a place where they can have an impact on cost and quality of the care they receive, we should look to Paul Ryan's health care proposal.

So I did.
I read the version called "Summary of the Legislation" in a .gov site dedicated to the "Roadmap Plan" that is part of a republican budget. It is much simpler than readi…

The changing nature of truth, answering questions for a chance to win a free MKSAP subscription and should we now stop using warfarin (mostly) for atrial fibrillation?

I am presently really excited about learning all over again what I thought I knew when I finished my medical education about 25 years ago. Since that time I have become wiser, learning how to do things and what works for patients by practicing medicine and reading literature. I also retain a body of knowledge that I absorbed from my grand old doctor professors at Johns Hopkins which is sacred and dear and not necessarily true.

Just recently in my e-mail I got an invitation from the makers of the MKSAP (the medical knowledge self assessment program which I used in studying for my internal medicine boards) to answer a set of not-ready-for-primetime questions in the various subspecialties, for which I will be rewarded with a chance to get the next MKSAP materials for free. I must answer these questions without using outside materials and the answers from all of the folks who do this will be used to standardize the test.

I took the endocrinology section first and had an answer for each o…

Back, but still a bit jet lagged: Health care in the Republic of Georgia

The Republic of Georgia is beautiful, welcoming, has great food, ancient and rich culture, is quite inexpensive, and I am now back. The language is fascinatingly complex, with an alphabet that does not resemble ours in any way, and the capital, Tbilisi, has the feeling of a thriving European city, but there is almost no crime and you can see snow capped mountains and farmed fields if you look up or out. I did no doctoring, but did sit down with a now unemployed pediatrician who told me a bit about their health system. I also talked to other Georgians about how they felt about their health care. Georgians are proud of their wine, their music, their architecture, their food and their loyalty, but they are not particularly proud of the quality of their medical care.

In the Soviet era, before independence, health care was entirely state funded and mainly based in hospitals. After the fall of communism, Georgia was torn apart by the sudden dissolution of their economic system and loss of …

Not dead, just on vacation

The joy of locum tenens work is that I can, actually, take a vacation. I have been working a lot, and so now I am going to be away from anything that begets blogs about medical care for most of a month. I will be singing polyphonic music in the Republic of Georgia and canoeing, briefly, in the Skagit River. I will miss the doctoring, but only a little bit. I will then return and jump right back in, with both feet.

I might write another blog while I am in foreign lands, but probably not, so I'm guessing I'll be checking in again sometime in early October.

Should physicians treat friends and family?

It is a very odd thing that most doctors, especially ones who really love what they do, provide advice and sometimes treatment to family members and good friends. It is also held to be true that this is a bad practice. How do we reconcile this?

In 1847 the AMA published its first "code of medical ethics" which covered many subjects and, though short, is dense and diatribe-like. It seemed to me, when I read through it, that it was mainly concerned with discouraging various forms of quackery, which was rampant in the relatively unregulated environment of the early 19th century in the United States. We physicians were enjoined to "unite tenderness with firmness and condescension with authority" and our patients were reminded that they needed to do what we told them and not fuss and argue with us. Physicians were required to be always available to sick patients, to get consultation when necessary, to treat those who could not afford to pay. In turn, patients were told …

On the RAC--the recovery audit contractor informational letter and me

In 2003 the Medicare Modernization Act established the Recovery Audit Contractor (the RAC) program to evaluate Medicare overpayment. It was extended to involve all 50 states in 2006 and will eventually involve Medicaid payments as well. The government hired 4 companies to audit payments to hospitals, durable medical equipment suppliers, physicians and other providers throughout the country. Health Data Insights is responsible for the largest geographical area, including my state, Idaho.

Since 2006 we have expected visits and inquiries from various individuals involved in the audits, and eventually we expect that we will all be presented with requests for repayment of money to Medicare in settlement of what the auditors believe are overpayments. This is definitely happening but, other than various highly publicized cases of fraud, I haven't heard that this process has been particularly odious or destabilizing. Nevertheless, in Medicare's report to Congress last year (http://www…