Fricking Awesome

Spectacular footage from NASA -- ground, air, and SRB/ET video -- from the launch of Atlantis on STS-129.  Long, but totally engrossing.  Check it out here, oddly enough, on Facebook.

Words Absolutely Fail Me

Is it just me or is this the GREATEST COVER EVER?!?

The best political blog post I have read this week

TAPPED Archive | The American Prospect

Which Party Is Best Prepared to Save Us From the Robot Apocalypse?

Arthur C. Clarke famously said, “Any sufficiently advanced technology is indistinguishable from magic.” But if science fiction has taught us anything, it’s that any sufficiently advanced technology will inevitably rise up to enslave us. So if you want to get ready for the day when your Roomba declares that maybe it’s time for you to start crawling around on the floor sucking up dust, it might be a good idea to evaluate the Republican and Democratic approaches to this problem.

Best line: "Just as the GOP doesn’t really think there’s a health-care crisis, they don’t seem to be concerned about a robot uprising."

Yes, it's silly.  Still, go read it.

What if the Earth had rings?

Beautiful.

POTUS assigns some homework

According to TPM, President Obama and his henchman, Rahm Emanuel found this blog post by the Atlantic's Ron Brownstein a "good summary of cost containment" according to Harry Reid's health care reform bill.  Therefore, it became assigned reading for White House senior staffers.

And it actually is decent summary.  I haven't read the full bill myself (heck, I can barely find the time to read for the LLSA exam!) but the article explicates a few provisions which I had not heard about and sound pretty promising in their ability to "bend the cost curve."

While the whole piece is worth a read, I'll provide a summary of the summary, or at least the bits that I found interesting.  My observations and comments in italics:

"[MIT Healthcare economist] Gruber may be especially effusive. But the Senate blueprint ... also is winning praise from other leading health reformers like Mark McClellan, the former director of the Center for Medicare and Medicaid Services under George W. Bush."

Um, I guess this is good. McClellan is a wonk, not just a politico.  But I was not overly impressed with the direction he led CMS.  But some bipartisan support is nice, if ultimately only symbolically.

"[T]he Reid bill maintains virtually all of Baucus ideas' for shifting the medical payment system away from today's fee-for-service model toward an approach that more closely links compensation for providers to results for patients."

It's a baby step away from fee for service, just a baby step.  Will the results be dramatic, modest, or marginal?  That's the trillion-dollar question.

"The CBO projected that the bill would reduce the federal deficit by $130 billion over its first decade."

Not news but always worth repeating.

"[T]axing high-end insurance plans ... Economists argue that such a tax will help curtail the growth of private health insurance premiums by creating incentives to limit the costs of plans to a tax-free amount."

I'm astonished that this will be so effective (to the tune of $35 Billion per year) given that the tax is on plans costing more than $23K annually.  Who has a plan costing that much?  It does effectively put a hard cap on premium costs as they continue to inflate, or at least causes consumers to bear more of the cost for such plans.

"[C]hange the way providers are paid for delivering care to Medicare recipients; the hope was that once Medicare instituted these reforms, private insurers would also adopt many of them."

I think you can count on that.

"[T]o reward Medicare providers who deliver care more efficiently and penalize those that don't. ... hospitals under current law must report on their performance in treating patients for common conditions like heart problems and pneumonia; under the bill, their Medicare payments, for the first time, would be affected by their ranking on those reports. Hospitals would also be penalized if they readmit too many patients after surgery or allow too many to acquire infections while in the hospital itself. Another provision would begin the process of applying such "value-based purchasing" toward other providers like hospice providers and inpatient rehabilitation facilities."

We all knew this was coming when McClellan started P4P.  It's good (I think) to see it finally implemented, but it's hardly a novelty in the health reform world.

"The Finance Bill proposed automatic reimbursement reductions for doctors who order up the most care for Medicare recipients with similar medical and demographic characteristics. That was meant to respond to the research showing big disparities in spending on medical services for similarly-situated patients in different communities. ... the final bill takes a less direct route toward a similar end. It requires Medicare to begin studying the utilization patterns of doctors participating in the program. And then it establishes a "values based payment modifier" that would, in a budget-neutral manner, increase reimbursements for physicians found to deliver high-quality care at lower cost, and reduce them for physicians at the other end of that spectrum."

Wow.  I was unaware of this.  Would it be unfair to call this the "Gawande provision?"  That New Yorker article was highly influential.  As someone who works in a "high quality low cost" system, I like the idea of being paid for being more efficient -- we have been penalized for many years.  I like that it is budget neutral.  I worry that since it does not decouple payment from volume, that the low-efficiency area practices may respond by simply further increasing volume to make up for lost revenue.  When it's a revenue neutral game, there will always be someone at the bottom -- will this polarize practice patterns or reduce the disparities?  I don't know.

"[E]ncourages groups of providers to establish doctor-led "accountable care organizations" to more comprehensively manage patients' care by allowing them to share in any savings for Medicare they produce. It also establishes a voluntary national pilot of "bundled" payments that would encourage hospitals, doctors and other providers to work more closely together. Another pilot program would test coordinated home-based care for chronically ill seniors."

Pilot programs don't excite me too much.  Bundling worries me, that physicians will become highly subordinate to the hospitals, not in terms of practice style as much as the economics.  How do you work out revenue-sharing, especially when the physicians have little leverage?  Beyond that, these are intriguing but small cost-saving possibilities.

"[The] independent "Medicare Advisory Board" ... to offer cost-saving proposals when Medicare spending rises too fast; Congress could not reject its proposals without substituting equivalent savings. Since the board would be prohibited from offering changes that raise taxes or "ration care," and since the legislation initially exempts hospitals from its recommendations, it could choose to promote the sort of payment reforms the bill establishes. (More prosaically it might also clear away some of the expensive coverage mandates that Congress imposes on Medicare under pressure from different elements of the medical industry)"

This is pretty potent, and possibly a force for good.  It's a very big threat especially to the medical device industry, which for too long has been able to escape any rigorous cost-benefit analysis for new devices.  Which is not to say that the innovation is bad, but the costs have escalated dramatically and this may bring some rationality back to the system. 

"[A] second institution the legislation creates: a Center for Medicare and Medicaid Innovation in the Health and Human Services Department. Though this center has received much less attention than the Medicare Commission, it could have a comparable effect. It would receive $1 billion annually to test payment reforms; in a little known provision, the bill authorizes the HHS Secretary to implement nationwide, without any congressional action, any reform that department actuaries certify will reduce long-term spending."

Wow.  That really flew under my radar.  It sounds like it has pretty broad powers, and a broad scope.  This could be extremely effective at controlling costs, and de-politicizes the process of reforming payments, which is good.  I worry about the reforms that it might ultimately recommend.   Definitely a double-edged sword, from the perspective of a health care cost generator practicing physician.

"Another Republican cost-containment priority missing from the bill is meaningful medical malpractice reform. (The bill only encourages states to think about it.)"

Yes, this is a pity.  However, I blame this entirely on the Republicans.  We know that the Democrats have been four-square against tort reform for time out of mind.  There is no way they were going to put it in their bill on their own.   If Chuck Grassley had offered five solid GOP votes for the overall package in return for real malpractice reform, I am sure that Obama would have jumped at it.  Who wouldn't?  There would have been no last-minute drama over whether the bill was going to pass, the compromises would have been made in committee, and both the Democrats and GOP would have been able to claim to their constituencies that they had accomplished long-standing objectives.  Instead, the GOP chose immutable opposition as their strategy and as a result the bill reflects not one of their priorities.  Reap the whirlwind, boys.

Overall, it's promising -- as a start. I don't think this will be the end, not by a long shot.  A large number of critics claim that the health reform bills do "nothing" to control costs.  This is not nothing -- not by a long shot.  Whether it will work at all, or whether it will do enough are open questions.  I also find it interesting that the providers who have been most concerned about the escalation of health care costs (I'm looking at you, Kevin) have not weighed in on this element of reform.  As a provider, I have really mixed feelings about the potential for cost containment to (further) erode physician autonomy and to (further) reduce physician income.  However, no sane person can look at the rate of medical inflation and not see the burning need for cost containment.  I just worry that too much of it will fall on our shoulders, since reining in costs any other way is tricky and politically unpopular.

There, Mr President, I've done my homework.  Do I get extra credit?

H1N1 Impact

My daily email from ACEP tells me that the H1N1 influenza epidemic has finally peaked and is tailing off.  That is consistent with what we are seeing in our ER at the present time.  We got hit a little bit in April and more in May, but then seriously slaughtered in October, as you can see from the chart below, provided for all you data junkies:



From the beginning, 2009 was shaping up to be a banner year.  2008 had represented our high-water mark with 290 patients per day on average.  We were well ahead of that pace even before the emergence of the swine flu, with Feb-April all at record volumes.  You see the first true peak was in May when influenza (and the public fear of influenza) first became widespread. Things tapered off over the summer (if by "tapered off" you mean "remained at historically high levels).  Then we got the next peak in October: it was the first time we have ever seen 10,000 patients in a month.  We averaged 325 patients/day, 12% above our old baseline, and had peak days of about 390 patients, a full 33% above the old baseline.  The acuity remained reasonably low; at any given time, on average, we have had 12-15 inpatients with influenza.  Some of them, however, have been quite sick, and there have been a few young, healthy people who have been critically ill with influenza, which is very sobering.  Year-to-date, we are on pace for 112,000 patients, a 7% increase from 2008.

Operationally, I couldn't be prouder of our team.  They handled the historic influx of patients with aplomb.  Despite the fact that we felt that we were at maximum capacity before this all began, they took on the challenge and kept things running smoothly.  Our LWBS rate remained below 1%, and the door-to-bed time actually decreased from 9 minutes to 7 minutes.  It has been an amazing performance in trying circumstances.  Our processes that we have put in place held up beautifully, but it was without doubt the people behind the processes that made it possible for us to get through this epidemic successfully.

I'll be interested to see if there is a "third wave" of H1N1 in the late winter, when seasonal influenza usually peaks.  Perhaps it will just be predominantly the seasonal flu strains, or perhaps they will blend into one another.  I'm still anticipating a worse-than-usual flu season, but if the vaccine supplies ever do catch up, it may mitigate the outbreak somewhat.

On a slightly related note, there are now being reported outbreaks of Tamiflu-resistant H1N1:

CIDRAP >> Clusters of resistant H1N1 cases reported in UK, US

Nov 20, 2009 – Health officials in Wales today announced the identification of a cluster of patients in a Cardiff hospital who are infected with oseltamivir-resistant pandemic H1N1 influenza.

Also today, Duke University Medical Center in Durham, N.C., reported that oseltamivir-resistant H1N1 viruses were found in four very sick patients hospitalized there over the past 6 weeks. A Duke press release said all four patients had been in the same hospital unit, but it did not specify how many were there at the same time.

In Wales, the National Public Health Service (NPHS) said five patients in a unit at the University Hospital of Wales that treats people who have severe underlying health conditions have been diagnosed as having oseltamivir-resistant pandemic flu, and three of them appear to have been infected in the hospital.

Up to now, just one probable instance of person-to-person transmission of oseltamivir-resistant H1N1 flu has been reported. In September the US Centers for Disease Control and Prevention (CDC) reported oseltamivir-resistant pandemic H1N1 flu in two girls who stayed in the same cabin at a summer camp in western North Carolina.

Note to Dr Feelgood: this is why we don't hand out Tamiflu to every poor sucker with a fever and bodyaches.

I love me some graphs

Especially interactive graphs.

GE made a graph of the average annual cost of patients with eleven common chronic diseases.  Go check it out, marvel at the coolness as you grab the sliders and spin the wheel o' misfortune. 

Take home point: hypertension is the single biggest driver of medical cost in all patients age 33 and up.  Go figure.

Friday Night

Off to the ER.  Enjoy yourselves some classic Tull:

Awful and horrible and disgusting

Whatever you do, do NOT go read this post at Life in the Fast Lane.  Especially if you are prone to nightmares.  It's a post ostensibly singing the praises of bacon, a good and noble purpose which we all can respect.  But in reality it contains images so profoundly repellent that you may well claw your own eyes out in sympathetic horror.

The only thing I found surprising is that the nasty little creatures described do not hail from Australia.  I thought Oz had the market cornered on stinging, dangerous vermin.  I guess since these bugs aren't actually bearing lethal poison they're not up to Australia's standards: too tame.

So instead of scarring yourself for life by reading that terrible post, go over to Archie McPhee's and buy yourself some authentic Uncle Oinker's Gummy Bacon instead.  You know you want some.

Senate HCR Reax

As you are probably aware, Harry Reid released the Senate's version of the merged health care bill yesterday.  I don't think I can add much to what has been said elsewhere, so I'll spare you the painful rehashing of the details.  You're welcome.

As usual, Igor Volsky at the Wonk Room has the essential details.

There's a lot of comments that could be made about this bill.  It's nice to see that it's fiscally responsible.  It's not only deficit-neutral, but it actually pays down the deficit by $127 billion.  Not too shabby.  Of course it does that by deferring the best benefits of the bill to 2014.  That's not too great, especially because there is going to be an election between here and then.  If the health reform has been on the books for five years and has not done much to improve access to health care (which it will not have until the exchanges open in 2014) there's a very strong chance that the voters will punish the Democrats for broken promises.  I understand that this compromise was necessary to make the bill affordable and get it passed, but it may have been a very bad decision strategically for the Democrats.

The thing that I think is striking was that in the face of an explicit filibuster threat from Lieberman, and open waffling from the ConservaDems, Reid kept the opt-out Public Option in the bill.  I was quite expecting it to be thrown on the sacrificial altar, and it's so watered down and minimized that I was more or less resigned to it.  Moreover, Reid had a private chat with Nelson, Lincoln, and Landrieu in which he discussed, among other things, moving the bill to the floor using the non-filibusterable reconciliation process.  It wasn't couched as a threat, but the message was clear: block this and we will bypass you and make you irrelevant.  Does he have a secret plan to get health care through reconciliation intact?  I haven't got a lot of faith in Reid, and I won't be surprised if he buckles, but I like his positioning at this point.

How patients face Bad News

Dr Rob wrote yesterday about breaking Bad News to patients.  It's a great post and well worth a read.  I suspect that for Dr Rob, as for most primary care physicians, Bad News is a fairly uncommon part of their daily life.  For ER docs, it's perhaps not an every-day expectation, but in even a moderate-acuity ER it generally is a near-daily part of the job.

I had a shift recently where I was The Raven.  I went from room to room, it seemed, dispensing Bad News.  Not the most fun shift I have had.  "You know that numbness in your hand?  Brain tumor.  Sorry."  "Hey, that vaginal bleeding? Turns out your baby died a couple of weeks ago.  Bummer." "That chest pain you had yesterday went away because you completed your infarction.  You're probably going to need a new heart now.  Just sayin'." "Wow.  Your liver's big. Did you know you had mets?"

The thing that struck me during that shift, as it has so many times before, is how differently people experience and process Bad News.  It's almost like a case-control study, since I have a fairly standard method of dropping the hammer on the poor folks who receive The Badness.  How they respond seems more dependent on the patient-specific factors than on my delivery.  For example:

Option 1: Hysterics.  Common in the young, common with less serious bad news, and also common in certain distinct social/cultural groups.  More common in the families of the afflicted than in the patients themselves.  Can present with simple weeping, but can easily escalate to high drama.  Faux seizures and violence against walls are common elements.  The most distressing thing I have recently seen was a young man harshly mistreating his girlfriend/fiance who was having a miscarriage.  We were all kinda sorry he didn't cross any bright lines so we could have called the cops on him.  Challenging to manage in the short term, but tends to blow over quickly.

Option 2: Paralysis.  Perhaps the most common response.  As Dr. Rob says, "Saying words like “cancer” is like dropping a bomb; people won’t hear much else in the visit after you say that."  So true.  The unexpected "Hey, that's a tumor" on CT scan commonly results in this sort of emotional vapor lock.  It's much worse when there's no action item and when the patient doesn't feel that sick.  Typical physical findings include the fixed thousand-yard stare and monosyllabic responses to direct questions.  For me it's a non-management item, since I'm usually passing the baton to the inpatient team, but I feel bad for these folks.  I feel obligated to try to draw them out of the catalepsy, but in truth, these folks just usually need some time to process.

Option 3: Incomprehension.   A real challenge when it's genuine:

"So it'll just ... grow back again, will it?"  I've heard the equivalent of that many times.  "So they'll just cut out that liver mass then, will they?"  No, it's metastatic.  They can't cut it out.  "Right then, so after they cut it out, I'll be fine."  No, I just told you they can't cut it out.  To be fair, I suspect many cases of supposed incomprehension are just paralysis with a facade of incomprehension.  Denial, if you will.

Option 4: Fatalism.  Reminds me of an Onion story: "Faced with the prospect of a life-threatening disease, the 34-year-old husband and father of three drew a deep breath and made a firm resolution to himself: I am not going to fight this. I am a dead man. On Feb. 20, less than a month after he was first diagnosed, Kunkel died following a brief, cowardly battle with stomach cancer."  This actually seems more common with cardiac or stroke patients.  I tell someone that they are having a heart attack, and they just sort of check out and let events overwhelm them.  I recall one guy heading off the the cath lab, all of 45 years old, telling his wife, "I've had a good run."

Option 5: Stoicism.  Directly proportionate to the degree of familial hysteria, it also presents on its own.  I personally am quite comfortable with the stoics, because I think I identify with them.  A more long-term thinker might worry about their coping skills when the shit ultimately hits the fan and the stoicism runs out.  But in the short term it's a useful mechanism to defer the anxiety and grief than accompanies Bad News, and it's probably the easiest for me to manage.

Option 6: Creepy stoicism.  There are things so awful that the stoic response is glaringly maladaptive.  I remember a dad, informed of his young son's death, who calmly responded that the Good Lord giveth and taketh and are there papers for me to sign?  Wowie.  Sick sick sick.

Option 7: The mature response.  I don't know how to better describe this, but some people have the gift of a capacity to absorb the bad news, allow an appropriate shared emotional reaction, and turn back to me with an "OK, that sucks, what do we do now?" demeanor.  I'm not sure I'll handle it that well when it's my turn. I hate this because it's an article of faith in the ER that the nicest people always have the worst outcomes, and these are the folks that I tend to really like, personally.

I'm sure I've missed a few variations, and the possible combinations of the types are near-infinite.  As a student of human nature I am fascinated by the differences and commonalities in the responses.  I feel sympathetic grief for these folks, the few among the hordes of worried well congesting the ED who bear real life-changing illness.  Generally I don't get to do much to help them.  I'm the perennial bad guy -- I drop the bomb and then shuffle them off to someone else to get better -- which is a pity because I'd really like to have a positive contribution to their care.  I console myself that the bearing of the Bad News is an important job in itself, that well-done it can position patients to accept and move forward, whereas poorly-managed it can be highly traumatic.  So by being tactful, careful, and supportive in my presentation, the diagnosis can be the first step in the therapy. 

But it's still never fun.

it's a cartoon so it must be cute

LOL, as the kids tragically unhip thirty-somethings say.

via ERP

Back Doors

This post at The Central Line caught my eye:

Texas Recognizes ABPS Certification

The Texas Medical Board ruled on Oct. 20 that physicians certified by the American Board of Physician Specialties (ABPS) could advertise themselves as board certified to the public.

The ABPS is the certifying body of the American Association of Physician Specialties (AAPS). The ABPS sponsors 17 boards of certification, including the Board of Certification in Emergency Medicine (BCEM).

For a number of years, ABPS, in conjunction with AAPS, has been seeking recognition from various state medical boards, requesting that they allow physicians certified through an ABPS board to advertise themselves as board certified. The organizations were successful in Florida in 2002 but were recently rebuffed by the State of New York due to the lack of residency training as a qualification for ABPS board certification.

ACEP does not recognize BCEM as a certifying body in emergency medicine.

This is bad. I've mostly stayed out of the internecine squabbles in the house of medicine, for a variety of reasons. Mostly because 99% of the issues are incredibly petty and provincial; for that reason I have a hard time getting/staying interested in these issues. This is a little different.

For background, the certifying body for Emergency Physicians for the last 30 years has been the American Board of Emergency Medicine (ABEM), which itself is under the umbrella of the American Board of Medical Specialties (ABMS), which has been the standard board certification organization of all allopathic physicians for the last 75 years. There is a companion organization for osteopathic physicians. The ABPS is relatively new in the last three years, though it is an offshoot of an organization which has been around for about 25 years, and it also purports to provide Board Certification in various specialties.

As it relates to Emergency Medicine, the ABPS is problematic. Specifically, it allows physicians to seek certification in Emergency Medicine without completing a training program in Emergency Medicine. It accepts training in a Primary Care specialty or, oddly, Anesthesiology, as equivalent to an Emergency Medicine residency. As best as I can tell, Emergency Medicine is the only such specialty certification for which the ABPS does not require completion of an ACGME-certified specialty training program. Residency training is required for ABPS certification in Radiology, Ophthalmology, Family Practice, Anesthesiology, and Orthopedic Surgery, at least. Why is Emergency Medicine held to a different, lower, standard under ABPS?

Unlike the other specialties, there are thousands of doctors practicing Emergency Medicine who are not residency-trained. This is in part an anachronism due to the relative youth of Emergency Medicine as a specialty; there are many ER docs who have been working in the ER since well before the ABMS recognized Emergency Medicine as a distinct specialty. It is also true that there are more ER positions than there are residency-trained graduates of EM residencies, and this is likely to remain the case for the foreseeable future. Even as new training programs open, the rate of graduation of new residents barely makes up for the retirement of practicing ER docs, let alone makes up the gap in the number of untrained ER docs.

Even today, many young primary care docs tire of the drudgery of office practice and give it up for the easier lifestyle and higher compensation of the local Emergency Department. Many small ERs, especially those in rural areas, have trouble attracting good physicians and as a result are willing to credential almost any physician willing to staff their department. This is not an ideal circumstance, of course, but when your ED cannot find doctors any other way, it does become something of a buyer's market.

So it is necessary to recognize the existence of the thousands of moonlighters and other variously-competent doctors working in the nation's ERs; it's a reality that is not going to go away any time soon. It's actually a good thing that there is a certifying body that can guarantee some minimum level of competency for these practicing physicians. As long as we have the necessary but undesirable situation of untrained physicians working in the ED, I am not opposed to the existence of the AAPS program.

What I am opposed to is the dishonesty of these physicians and their organizations in presenting themselves to the public as "Board Certified." This is misleading in the extreme. Board Certification has always been held to mean a high standard of training and accomplishment. It is a standard across 24 specialties. For an alternate organization to set itself up and promote a lower standard is disturbing. More disturbing is the manner in which the ABPS/AAPS slipped this in through the Texas Medical Board apparently in the dead of night with no public discussion. If there is to be equivalency between ABPS/AAPS and the ABEM, it should be agreed upon after a full and open debate. For myself, I do not think that this equivalency is merited. The ABPS is like ACLS and ATLS -- a nice merit badge to show that you're not likely to hurt anybody while working in the ER, but not the same as a specialty training certificate. But if Texas (or any other state) medical board decides otherwise, then that decision should be the product of a public debate and consensus among the physician leaders in that state.

If the implication of the linked article is accurate, this decision was the result of a shameful bit of political sleight of hand. I hope that ACEP is successful in reversing this ruling.

Ultimately, this is a manpower situation that Emergency Medicine needs to come to grips with. While new residencies continue to open in drips and drabs, and existing residency programs expand a bit, the rate of increase is far too slow. Unfortunately, the funding from Medicare which underwrites the cost of graduate medical education is very hard to come by in this difficult budgetary environment. In an ideal world, the residencies would grow to the point that all Emergency Physician positions would be filled by, you know, trained Emergency Physicians. I don't know whether that will happen in my professional lifetime. The consequence is that many of the nation's Emergency Departments will continue to be staffed by untrained doctors of uncertain quality. That is a pity for the patients who come through the doors, who are after all a captive audience, unable to make a choice of their treating provider. They deserve better.