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Showing posts from August, 2012

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…

Getting the DNR--ethics and end of life decisions

During an internal medicine residency, newly hatched doctors are responsible for some of the sickest patients in their teaching hospitals. This is because those patients often don't have private doctors to attend them and are poor and sometimes self abusive, with the complex problems that go with smoking, drug and alcohol abuse and lack of regular medical care. These patients often present with their diseases late in game, when much must be done quickly. There is little or no time to discuss end of life issues and so the assumption is made that these folks want "everything done" which includes machines and potions to support organs and bodily functions as they cease to work right. A scenario might look like this: 48 year old heroin abuser comes in with fever of 104 and symptoms of a stroke. He is admitted to the intensive care unit with low blood pressure, becomes gradually delirious and his heart rate increases, he is sedated for trying to crawl out of bed and run off, …

More on Atul Gawande's Cheesecake Factory metaphor--how to not eat there all the time, but still improve medical care

Atul Gawande, a surgeon who writes for the New Yorker magazine, recently wrote an article about how the medical profession might learn from a large restaurant chain how to provide really good service inexpensively. I was intrigued, because I would very much like to see medical care get better and cheaper, and find it very frustrating that progress is so slow. But I was also a little horrified by the vision of my profession becoming another mindnumbingly reproducible chain restaurant.

One of the reasons that medical care has been expensive and not successfully focused on customer satisfaction is that physicians, at least good ones, are kind of scarce and have been trained in a culture that makes us consultants rather than service personnel. (Also, of course, the fact that we are usually paid by a deep pocketed third party without much consciousness of what the consumer really wants is a major issue.) If we, as physicians, are available to help solve a person's medical problems we n…

Why a person might or might not want their health care to resemble a meal at The Cheesecake Factory--a response to Atul Gawande

When I drive down a street and see only national chain restaurants and retail stores, I am sad. Can we do no better than this, to make everything the same, supporting certain foods, certain products at the expense of the tremendous variety of such things that exist?

Atul Gawande just wrote a very compelling article in which he explored the chain restaurant The Cheesecake Factory as a model or metaphor for good health care.  He not only ate there, but toured the facility and observed the processes that allow this huge place to provide food that is interesting, delicious and affordable. His main thesis is that an industry that standardizes excellent practices can provide high quality care, and that it is not unthinkable that medicine could be substantially improved by adopting such a model. He also looked at some excellent hospitals that have begun to standardize such things as patient care in the ICU and total knee replacements.

There are many things that, through scientific inquiry, a…

The Stanford Advanced Airway Management and Fiberoptics Course--learning to put tubes down peoples' throats to help them breathe

The actual secret to long life is continuing to breathe. The body has many amazing processes that go on all the time, little tiny molecular ones and microscopic cellular ones, organs that digest, produce hormones, pump blood, big juicy custard-like organs that think thoughts, stringy nerves and muscles that propel us, reproductive organs that beget poetry and children. It would be hard to judge any of them as being the most necessary, but the process of breathing would be a top contender.

People stop breathing for all kinds of reasons, most commonly because they have lived out their span of years and are done. When everything else ceases to work and the brain no longer gives adequate signal to the muscles of respiration to defy the elastic recoil of the diaphragm, chest wall and lungs, breathing stops. But sometimes breathing ceases or becomes ineffective because of a drug overdose, a lung inflammation or infection, morbid obesity, fluid overload, tumors, trauma, a reversible cardiac p…

Mentoring, collegiality, bedside procedures and the luxury of time

Hospitalists, the doctors who provide care to patients admitted to a hospital, sometimes see in excess of 20 patients in a day. I have seen that many a few times and it is awful. An average number of patient contacts for a hospitalist is 16, which just about breaks even financially for the hospitals who hire us, with quite a bit of variation based on how well those patients or their insurance companies pay. 16 is possible but busy. We theoretically have 12 hours to see these patients, make appropriate contacts with their doctors on the outside, their consultants on the inside, write a complete note, order appropriate tests and treatments, handle medical and social crises and occasionally eat a little food and go to the bathroom. We are also answering beepers and phones that go off at random and distressing times and cursing at computers.

In addition to getting the job done, ideally we are also doing it right, with knowledge, humor and compassion, and learning things along the way.

I h…

Learning things from patients

Traditionally the patient is supposed to come to the doctor to get some sort of help with a problem. That's what people pay us for, I guess. Patients bring us their various miseries, we help them figure out what they mean and what causes them and prescribe potions or recommend they do something that will help make them better, if there is such a thing. But in the normal give and take, in the moments when I'm not talking and the miseries have been adequately investigated, patients tell me stuff and I learn from them.

I've learned countless things from patients over the years, what works, what symptoms are associated with what eventual diagnosis, how to get the leaves separated from the berries after commercial huckleberry picking, recipes for baked fish. Some of these really stand out because they solve particularly pesky problems in creative ways or answer questions that have been bugging me for a long time.

They are also kind of random. But here goes:

One of my patients w…