28 July 2008

Things that make me laugh

Ces Marciuliano, the writer for the comic strip Sally Forth, has a new online strip called Medium Large. Now Sally Forth, I am sorry to say, is a standard-issue bland, forgettable family-oriented strip suitable for the tastes of lobotomized newspaper features editors and the codgers who demand that the daily comics never change.

Medium Large, is, I am glad to say, rather different:

I'm adding this to my RSS feeds.

Telemedicine: the future is now

I was tending to a young man who had accidentally given himself a wrist and hand laceration. It was a classic mechanism -- he had jumped up to climb a fence, and the sharp, rigid wire at the top had pierced his wrist somewhat proximal to the wrist crease. The patient, surprised by the unexpected pain, dropped back down, and the wire tore upwards through the wrist and palm of the hand.

He was a tough kid. Never a whine or a complaint escaped his lips. I did a careful functional exam of the hand, and a careful irrigation and exploration of the wound. To my delight, he had no functional deficit, implying that he had not damaged any of the important nerves or tendons that run through that area, and the exploration showed no apparent damage to the tendons that I could see (they were clearly exposed). But the flexor retinaculum of the wrist, also known as the transverse carpal ligament, was clearly transected.


I had seen this before -- many times. As I mentioned previously, I had strongly considered going into plastic surgery, and still have an interest in complex hand injuries. This injury that he had given himself was basically the exact same thing that I had done (well, witnessed and assisted) quite a few times in the operating room, under the guise of an open carpal ligament release, for carpal tunnel syndrome. This laceration ran little more laterally, up onto the thenar eminence, with the muscle belly of the opponens pollicis clearly visible but uninjured, but otherwise might have been mistaken for a surgical incision for the above-referenced surgery. *

I was pretty sure that this was a clinically insignificant injury. He had basically replicated what a hand surgeon would do therapeutically: he didn't need a carpal release, but it wasn't going to hurt him. As a general practice I like to run it past a specialist whenever a tendon or ligament is violated. Unfortunately, I happened to be working this evening at one of our rural, outlying injuries and we did not have a hand surgeon on call.

I managed to get the hand surgeon from the regional center on the phone. I happened to know him from previous professional interactions, so, fortunately, he did not think I was Dr HuckFead. I was able to give a clear description of my functional exam, but he was having a little trouble visualizing the path of the incision and the nature of the ligamentous injury. Alert readers may recall my joy at my recent acquisition of an iPhone. One of the first things I had noticed was the high quality of images taken with its 2 MP onboard camera.

So I took a quick pic of the wound and emailed it to the surgeon. (After some consideration, I decided not to post it -- I still struggle with the ethics of blogging about patients, even with fictionalized details, but I think posting pics without consent is clearly a distinct issue.) After our discussion, and review of the images, the surgeon was quite comfortable with my management of the case, and with his blessing I went ahead and repaired the wound. The surgeon, though under no obligation to do so, graciously agreed to see this nice young man in follow-up, in case there was any need for surgical exploration or revision. (I so love helpful consultants.)

I have read extensively about the promise of telemedicine. It's always described as the "next big thing," in the same sort of way that the Segway will transform the way we plan our cities, and in the future we'll all have personal jet packs. Which is to say that while I love gadgets, I'm not exactly convinced that telemedicine will actually much change medical practice in the main. But for certain specific applications and in certain circumstances, it can be damn useful. I feel like I just got a little glimpse into the future of medicine. Kinda cool.


* Fun fact: traumatic injuries are often quite neat. I remember a guy who got stabbed in the femoral artery with a kitchen knife by a vengeful girlfriend, and required an emergency trip to the OR. The vascular surgeon later commented that the artery had been transected cleaner than he had ever been able to accomplish in the operating room with razor-sharp scalpels. And the many, many box cutter injuries I have seen have been remarkably clean. I don't know what it is about the rapidity and depth of these rapid, sharp injuries, but they can in many cases be perfectly clean. Similarly, in this case, the wound could have been surgical it was so perfectly incised. Weird.

27 July 2008

Obama: √úbermensch

An encounter at a gym in Germany:

He goes and picks up a pair of 16 kilo weights and starts curling them with his left and right arms, 30 repetitions on each side. Then, amazingly, he picks up the 32 kilo weights! Very slowly he lifts them, first 10 curls with his right, then 10 with his left.
Okay, the man can hit a three-point shot, and he can curl 70 pounds. Why are we even bothering holding the election at this point? By all objective criteria, Obama is clearly more qualified to be President.

Um, wait, what's McCain's clean and jerk?

How I spent my afternoon

So the boys were outside yesterday painting on the sidewalk and patio out front with some special paint they got, and today, around noon, I decided to go wash it off with the hose. As I was getting set up, I heard a buzzing sound and looked up to see the largest fucking wasp's nest I have ever personally seen, about two feet above my head. It was under the eave where the hose is, at the front corner of the garage.

I sprinted inside, hustling the kids ahead of me. Safe for the moment, I viewed the hive through my office window and took stock of the situation.

I am afraid of bees. Not pathologically so, but a healthy, substantial fear nonetheless. There were, I roughly estimated, a million of them swarming around the hive, which was slightly larger than an NCAA-regulation football. How long had that been there and how on earth did we never notice it? The mind boggles. What were my options? Sell the house and move was the first thing that came to mind. No, a tough sell in a down market. Maybe live inside forever and never venture out again - abandon the front patio to the bees? Hmm. Sooner or later, they'll come in after us, I figured, looking for tender man-flesh. No, I had to face the fact: the bees must be "dealt with."

As it happened, we had some "Wasp and Yellowjacket Poison-in-a-Can," with the thoughtful feature that the foamy stuff came out in a jet up to 22 feet long. Perfect. I hosed down the nest from a safe distance and hid inside from the *huge* angry swarm that erupted. The stuff worked wonders, though, and in half an hour, there was an apocalyptic scene of scattered bee carcasses strewn across the patio and a silent hive, which I pried off with a shovel and sealed in a plastic garbage bag.

Sobered by the carnage, I surveyed the house and found another six substantial-sized, active nests. Four of them were only accessible with our 24-foot ladder, being under the high peaks of the house. My brave wife held the ladder as I ascended, and stoically withstood the rain of dead bees that ensued. For the other two, I had to venture onto the roof. I was the Bee Terminator, armed with my laser cannon, dealing out foamy death. At one point a massive hornet landed on the wall right in front of me, its shiny wings glistening in the afternoon sunlight. Its complex eyes regarded me, and its mandibles opened to utter a prophecy of doom, instants before it was deluged with creamy white death. Sic semper tyrannus.

At this point I was covered in foam from blowback (and from hosing nests directly above my head), and the can clearly warned against contact with skin. My exploits being completed, I holstered my weapon and retired inside to wash the toxins off. The boys were completely in awe of their heroic father and showered me with deserved praise. And now I sit on my hymenoptera-free deck composing this narrative, sipping a Hop Devil Ale and basking in my utter manhood.

26 July 2008

Revisionist history

McCain now claims prescience and early insight into the situation in Iraq:
"I was the greatest critic of the initial four years, three and a half years."
"I strongly disagreed with the Bush administration's mismanagement of the war in Iraq."

He likes to have both sides of every issue, but his own words over the last six years show the record to be the exact opposite:




"On the transcendent issues of the day, I have been totally in agreement and support of President Bush, and I am talking particularly about the war on terror."

McCain's team whined bitterly this week about the hagiographical coverage Obama's Excellent Vacation got in the press, but you'd think he'd be glad nobody was paying attention to him as he emitted gaffe after gaffe after gaffe. He remarked about troubles at the (nonexistent) Iraq-Pakistan border, attributed the Anbar Awakening to the success of the surge (which occurred after the awakening) and he stated the Iraq was the first military conflict after 9/11 (forgetting Afghanistan). Are these minor slips of the tongue, or do they display a poor grip on the dynamics of the region? Don't know, but had Obama made similar mistakes, it's hard to imagine they would not have been characterized as due to Obama's inexperience and youth. Whether McCain's repeated errors are due to age, sloppy speaking, or sloppy thinking is not at all clear, but they are troubling. He also made the unprecedented and despicable explicit statement that Obama "would rather lose a war in order to win a political campaign." Even Bush had enough sense (or shame) to leave that sort of thing to surrogates. And all this in the context of the Iraqi Prime Minister explicitly endorsing Obama's timetable for a US withdrawal from Iraq, and Obama's truly transcendent speech in front of two hundred thousand people in Berlin.

Yeah, that's a bad week, even if you don't factor in the recently revealed fact that Obama hauled in more in a single day than McCain did in an entire month and will be an official sponsor of NBC's Summer Olympics coverage. Yeah, a really bad week.

25 July 2008

Finally!


I got to my local Apple store today half an hour before it opened -- and there were already 20 people in line ahead of me. They apparently had about 40 or 50 phones, fortunately, so I scored one for me and one for the wifey. Hooray!

(credit for hysterical Flickr set of lego dudes unboxing the iPhone: ntr23)

The Uninsured and the ER Overcrowding Crisis

The Annals of Emergency Medicine says that the uninsured do not seem to be to blame.

While this is maybe a little counterintuitive, it is consistent with my experience. Our ED has a poor payer mix, but our uninsured percentage is only about 18-20%, give or take. This number has been fairly steady over the eight years I have been at my current job, and the linked article in Annals implies that the national number has been steady to modestly declining. Given that the numbers of the uninsured have been increasing as a fraction of total population, a decline in the fraction of ED patients without insurance is indeed significant.

What does it mean? I think that it first supports the notion that those without funding for their health care are likely to defer care. Given the number of ED patients presenting with non-emergency conditions, this could be viewed as a feature, not a bug -- but I will reject that as overly cynical. Surely some fraction of the uninsured are in fact deferring needed emergency care due to their inability to pay. Not good.

More significantly, I think this ultimately is related to Kevin's passionate concern about the impending death of primary care in this country. The conclusion the authors drew, quite reasonably in my opinion, is that the increase in utilization of the ER stems from "disproportionate increases in use by nonpoor persons and by persons whose usual source of care is a physician's office." Why are they coming in to the ER? Because there are not enough primary care doctors, and because primary care is so fiscally tenuous that they need to schedule themselves to the hilt to maximize their revenue. If you have a doctor, and you get sick, there is an even likelihood that your doctor will not be able to care for you -- they do not have the time or the capacity to squeeze in their patients when they get acutely ill, especially if their care will involve a procedure, diagnostic studies, or IV therapy. So you get sent to the ER.

I've said it before, and I'll say it again: "Just go to the ER" is not a national health care policy. (despite what Our Dear Leader may think.)

But when you underfund primary care, create a system which reward procedures and skimps on cognitive services, freeze medicare reimbursements on top of it all, it is predictable and unsurprising that the more time- and resource-intensive acute illnesses get shunted to the ER. While it's good for my business, it is decidedly not good for patients, who deserve to be cared for when possible by their personal doctors in a setting where they can devote sufficient time to their care, and it is not good for the country, because ER care is incomplete, fragmented, and expensive.

Memo to Congress: fix primary care, and much of the ER crisis will be alleviated, too.

Now that's Presidential



Transcendent. There's really no choice this November, is there? What an event -- two hundred thousand people came to hear Obama speak. (Fun fact: they were mostly all German, but they all speak English well enough to understand him!) And did he ever deliver. This was transformative a foreign policy speech as his earlier one was on race. Obama is going to win, win big, and America will be a better place for it.

Know Hope.

24 July 2008

Orac reads the Tea Leaves

As a true Apple Evangelist, I watched the Stevenote (to the uninitiated, Steve Jobs keynote address at the WWDC conference) where Apple unveiled the 3G iPhone. Like very many others I was struck by how gaunt Steve looked, and like many others, I worried that his pancreatic cancer might have returned.

That seemed unlikely to me, since I vaguely recalled that he had had an atypical cell line tumor which was not associated with recurrence or mortality. But he still looked terrible, and it was noted by the analysts and other folks who provide market guidance for investors. One speculated that if Jobs were to die or become disabled that up to $20 Billion in Apple market capitalization would simply evaporate.

Today, Orac has a very insightful and detailed post with informed speculation regarding the possible nature of Steve's issues and the treatment he may have undergone. It rings true, and though there's no way to know if Orac is correct, I find this line of reasoning very reassuring.

I'm hoping Steve is well, and I'm still long on AAPL. I just got back from the local Apple retail store where I tried to buy a 3G iPhone, but the line was 2 hours long and I had two kids with me, so I bailed and will try again, sans kids, tomorrow morning.

The Future is Now


Amazing robotic exoskeleton for the disabled (via MedGadget). Wowie that's cool. It's the first device of this type that seems "ready for prime time," if I understand correctly. Check out the video.

Can super soldiers be far behind?

22 July 2008

Charming



I love Feist

Consent

The patient was a hispanic male in his early twenties. He spoke not a word of English, and my Espanol is, as they say, pocito. The triage note said he had abdominal pain, but he couldn't give me any other useful information. There were no spanish-speakers working in the department, and some phone problems temporarily precluded the language line interpreters.

Fortunately, the diagnosis wasn't challenging: we did the "dolor aqui? dolor aqui?" game, and his right lower quadrant rebound tenderness and fever made the decision to order a CT for appendicitis a no-brainer. I was not at all surprised when it came back positive, and finally we were able to get an interpreter on the phone so I could get the rest of the history and explain to the patient the diagnosis and treatment plan.

I hate using interpreters - especially the phone ones. It's a cumbersome process of handing a phone back and forth, a slow and asychronous communication process. They are a part of my life, though, especially with our large asian and russian populations. Although I hate it, I have great respect for the folks on the other end of the line. I am fairly detailed and complex in the instructions and explanations I give patients, and I do not stint the non-english-speakers. I have always been impressed by the professionalism the interpreters bring to their job.

So for this patient, I explained what appendicitis was, that he would need surgery, described the surgery and recovery, and briefly outlined the potential complications. Basically I went through the whole consent process for surgery; although getting the final consent and signature is the surgeon's responsibility, I like to 'prep' patients to make the surgeon's job easier. All with the interpreter flawlessly going back and forth in the background. Finally, the translator broke the "fourth wall" and said to me, "Doctor, I am sorry to say that I do not think your patient understands what I am telling him. I explained that he would need surgery, and his response was, 'I'll eat anything you give me.' So I tried to explain what an operation is, several times, and all he has to say is that he isn't hungry but if you tell him he has to eat, he will eat anything you say. I am very sorry, but I really don't think he understands."

We tried again, several times, in very simple and graphic terms, including my drawing a dotted line on his abdomen at McBurney's point, but still the patient was unable to verbalize an understanding of what we were trying to do. It was freaking weird. Maybe he was just very simple, or the language thing could have been the problem, as he apparently spoke a dialect of spanish that sounded funny to the interpreter. He sat there with stoic indifference and simply failed to get it. "Yes, doctor, but I'm not hungry," he kept saying.

Aieee! Finally, I gave up. I called the surgeon, presented the case, and warned him that though I tried, he might have to work a little harder than usual at the consent. Thank god it's not my problem, I thought. I did my best.

With this job, every day it's something new.

21 July 2008

Airplanes and Politics

Cool:

Airliners.net, home of obsessive planespotters worldwide, has a new pic of Obama's jet:


Note to McCain: it's a Boeing 757 (American made). McCain's plane? A french-made Airbus A320.

Update:

D'Oh! I forgot McCain got a new ride, too. He used to fly about in a chartered JetBlue A320, but recently switched to a renovated 737:

In case you're curious, it's called the "Lap Dog Express" because there's a VIP section up from where the "good" reporters can "earn" the right to sit with the candidate.

The old ride:

Hangman: it's not just a game

What's in a name? The Hangman's Fracture, over at MedPage Today.

Insurance Rules



Makes as much sense as any other explanation I've seen.

20 July 2008

19 July 2008

Failblog

Brilliant blog I have just become aware of. Perfect for late nights in an empty ER, not so great if you are supposed to be working, because you will give yourself away by repeatedly laughing out loud.

One of my favorite entries so far:

fail owned pwnd pictures
see more pwn and owned pictures

There are hundreds and hundreds of these. Hysterical. Another brilliant one:

Weird Shift

I had this strange patient sequence symmetry going on for my entire overnight shift.   I saw two headaches, then two seizures, then two abdominal pains, then two fevers, then three MVAs, then two flank pains, two psych patients, and two lower extremity injuries to close it off.  

Also, I went an entire shift, saw seventeen patients in eight hours -- a decent but unexceptional number -- and admitted none.  Not one.  In our ER we usually admit closer to 25% of the patients we see.  I didn't even page another physician for the entirely of what was a rather busy shift.   Well, not counting calling radiology to see where the hell my scan results were.

And now we just put the last patient up for discharge -- this whole ER is empty.  Empty.   I can't remember the last time that happened.

Full moon, I guess.

Weird.

17 July 2008

Futility

If you're going to pick a place to croak, the triage desk of a major ER is a good place to do it. That's what my patient the other afternoon decided to do. He walked in, told the nurse he was feeling short of breath, then promptly keeled over, stone cold dead.

Well, for a few minutes, anyway. We pulled him onto a gurney and rolled him back, bagging him and doing CPR. He was a skinny guy in his early forties, and I didn't know a damn thing about him, not even his name. We threw on the patches and the presenting rhythm was V-Fib; we promptly shocked him into this:

About this time I noticed the dialysis fistula in his arm. He was still pulseless, and as we were getting a line in him and intubating, his rhythm degenerated into this:


It didn't take a genius to figure out he was hyperkalemic. Another shock, speedballed with Calcium and Bicarb brought back a pulse and a nice tight complex ECG:


Someone had performed a wallet biopsy on him and gotten a name and some records; I got his nephrologist on the phone, stat:

-- Hi, Chris, I've got your patient Billy here in the ER.
-- Oh, yeah. I said hi to him about twenty minutes ago as I was walking through the waiting room. He looked fine then.
-- Nice timing! He coded about five minutes later.
-- I'm not surprised. He mentioned he hadn't been in to dialysis in a while. What's his potassium?
-- Just above ten.
-- Hmph. It was over eleven last time. Does he have a pulse?
-- Yeah, we've got him resuscitated and tubed.
-- Okay, well, I guess we'll have to take care of him again. This is probably the sixth time this year alone. Send him up to the ICU and I'll have them ready for him. You did give him calcium, I hope?
-- C'mon, man, who're you talking to? I'm no rookie.
-- All right, all right. But don't screw around too long down there -- just send him right upstairs, OK?

Later that night, as I was driving home, I reflected on the case. It's classic ER medicine: exciting to be sure, and fun, but demanding -- I had to figure out the potassium knowing nothing about the patient, quickly, and with no room for error or hesitation. This is what it's all about for an ER doc, and in the past I have taken great satisfaction in such cases.

But not today. Rather, this case felt incredibly hollow, that it had been another exercise in futility. This patient's persistent and severe self-destructive behavior was the sole cause of this and his many other critical presentations, and I felt like we were just enabling him by repeatedly rescuing him. Not that we had any choice in the matter. But there was a bitter taste left in my mouth. I happened to catch the nephrologist on my way out, and I asked him how Billy had done.

-- Oh, great, he says. We got his potassium right down and he's fine now, watching TV and eating dinner. Fantastic job -- you really saved his life.
-- Or at least delayed the inevitable for a bit longer, I responded.

Political Homage to xkcd

Hysterical, and for real. Check it out.

15 July 2008

It's Satire! Get it?

David Horsey responds to the New Yorker's controversial Obama cartoon:
Just for the record, I have no problem with the New Yorker's cover, except that it's poorly thought out. Simply repeating a smear/rumor/insult without adding any insight or fresh take on it is dumb.

As a secondary thought, how strangely meta is it for Horsey to have to include the image of the original cartoon in his cartoon to ensure that less-informed readers understand that he's critiquing the original cover, not making a comment on McCain?

As a General Rule...

IF:
You are entirely blind in your right eye,
AND you are sixty-six years old,
AND you pride yourself on your ability to hold your liquor,
AND you live in a rainy part of the country,
AND you are on coumadin,

THEN:
Riding a motorcycle may not be the best possible hobby for you.

Just sayin'.

11 July 2008

Unhooked

Family time coming up this weekend. Won't have access to email or computer. Behave yourselves in the comments, and I'll see you Monday...

Don't forget that today is iPhone Day! I hope to have mine by Monday! Woo hoo!

10 July 2008

The Next Step

After seven years, the man in the Oval Office still manages to surprise me. I tend to assume that most people have a limit to their stubbornness, but apparently still-president Bush, in his petulance, intends to veto the Medicare Bill. Most people would have seen the handwriting on the wall. Most people would have seen the reasonable compromise on a critical issue. Most people wouldn't want to waste the last of their political capital on something like this. Most people wouldn't risk the humiliation of an override as they prepare to cede the White House.

But Bush is not most people. He is full of bluster and bravado and a childish refusal to have it any way other than his way. And it has worked well for him, one must admit, to the detriment of the nation and the world. So there is no reason I should be surprised, no reason at this time that any rational person would expect Bush to behave like a normal member of society.

So what happens now? A lot will depend on timing. The new rates are scheduled to begin on Tuesday. It would have to be remarkably quick for Bush to issue his veto and Congress to vote on the override by then, but it can happen. The outcome of that vote will be critical.

What I worry about most is if the veto is over-ridden, and the cuts are rescinded, but it takes another week or so. In that case, Medicare will already have handled several million July claims at the lower payment rate. EOBs will have gone out to beneficiaries, secondary insurances will have been billed, co-pays will have been collected. All that will have to be re-done, and it will be a nightmare for the billing offices. They'll need to recalculate everything, issue revised statements, issue refunds, confuse seniors with multiple differing bills for the same service. "Nightmare" may not be a strong enough word for it. It will consume countless hours of biller productivity, and will certainly disrupt cash flows.

McCain, as I have mentioned, hasn't bothered to show up to his day job to vote for either of the Medicare bills (or anything else since April). He did eventually say that he would have voted against the bill as passed. Somebody needs to ask him between now and next week whether he will vote to sustain Bush's veto (or whether he will vote at all).

My best guess is this: enough republicans in the senate still are Kool-aid drinkers and will support the President, and the veto will stand. Reid will not allow the other compromise legislation to come to a vote, and the cuts will go into effect. The Democrats will continue to blame Bush and the republicans for the cuts, and the AMA will swallow the bait and campaign vigorously against vulnerable republicans in the fall.

Prove me wrong, guys. Please.

Fun "profile in courage" on the GOP side: Texas senator "Big John" Cornyn delivered a blistering speech against the medicare bill and voted against it. After it was clear that the bill had sixty votes, he switched his vote to "yea." Way to stand for your principles, Big John. I'd count on him to vote with Bush on the veto, by the way.

Clout


Kevin's Medicare Roundup includes the following from Joe Paduda (with whom I usually agree):

"It will also serve notice that the physician lobby and the AMA remains a very powerful force, a lesson that will be heeded when the health care reform process gets serious next year."
He couldn't be more wrong. The physician lobby is pathetically weak and not well regarded on Capitol Hill. Iconic Chicago newspaperman Mike Royko famously defined "Clout" as political influence, as evidenced by results (in Chicago, usually patronage). We don't got any clout.

There's an urge for all of us politically aware policy wonks to slap ourselves on the back and say "Boy we really muscled that one through! Boo-yah!" But no. Seriously, Medicare is the second most popular program in the history of the federal government, and everybody knows it was facing absolute implosion (again) and there was bipartisan, nearly unanimous consensus that a fix was needed to avert catastrophe (again), and all we were able to get was an eleventh-hour stay (again). And only barely.

That ain't clout.

Look at the other national legislative priorities the physician lobby has favored. How'd that "Patient's bill of rights" turn out? How about tort reform? (hint: the trial lawyers' lobby has clout.) Did we ever get EMTALA funded? Balance billing? For that matter, can you name a single major piece of legislation the physicians' lobby has gotten passed at all, let alone over major opposition? And I hasten to point out that Congress was for 12 years in the iron fist of our ostensible "allies" in the GOP. How'd we do?

Compare that to, say, the insurance or energy or farm lobbies. They write their own bills, and they almost always pass. Let's not delude ourselves into thinking that this "win" indicates a powerful lobby on our behalf. We'll have a seat at the table for health reform in 2009, but we'll have a lot of work to do to make our actual voices heard.

It's a win, so I'll take it. It's better than losing. But I have to (much as it pains me) agree with Catron: all we really won was another stay of execution.

09 July 2008

Inside Baseball

By now, most of you have heard that the Senate today passed HR 6331, the "Medicare Improvement for Patients and Providers Act of 2008" by a veto-proof 69-30 margin, with the great lion of health care, Teddy Kennedy, receiving a standing ovation from his colleagues on both sides of the aisle as he returned from his brain surgery to cast the decisive vote.   Now that both chambers have passed this bill by veto-proof majorities, it goes to still-president Bush's desk.   Will he sign it, or veto it and dare Congress to overrule his veto?    Hard to say -- he's never been the compromising sort, and I suspect he might veto it just out of spite.  But then, being over-ruled would be pretty humiliating, so he may allow it to become law to avoid that embarrassment. Either way, it looks like the iceberg has been staved off of the hull for another eighteen months.


Here are some things you may not know about HR 6331:
  • Of course, it freezes the 10.6% cut in Medicare payments to doctors for 2008, and provides a (paltry) 1.1% increase for 2009.
  • PQRI is extended another two years and the bonus for participation is increased to 2%.
  • Encourages the use of qualified e-prescribing systems through a variety of incentives.
  • Reapplies budget neutrality adjustment for the 2007 RVU changes to the conversion factor, rather than work RVUs, effective 2009. 
The last point is probably the most significant.   We all know that P4P is not going away, but is not ready for prime time, so it's no surprise that PQRI was extended.   It kicks the ball down the field to the next HHS administration to figure out how the hell to implement P4P for physicians.

But the RVU adjustment is more important.  As you may recall, in 2007 the value of the cognitive RVUs for physicians increased substantially, about 15% for ER physicians.  But the requirement that the changes be budget neutral pulled about 10% of that back, and CMS applied this to the value of the work RVUs.   Changing this to apply to the conversion factor helps because many of our commercially contracted payor rates are based on the RVU work value, and these RVUs will now increase as they were intended to.   I believe that Tricare and Medicaid rates should also increase proportionately, but I am not certain about this.  So that will provide a nice bonus to ER docs, and I suspect to other office-based physicians as well.

Oh, one other fun fact.   The only senator who did not bother to show up to vote on the Medicare bill?   John McCain.   He was even too mavericky to say whether he supported the bill or not.  As I mentioned, he hasn't cast a vote in the Senate since April, nor did he bother to vote on the FISA bill.   Why is he still in the Senate?   At least Bob Dole had the integrity to resign in 1996 when he decided that the demands of the campaign would interfere with his duties in the Senate.   I guess McCain figured that with all his straight-talking, nobody would notice he wasn't showing up at the day job any more.

08 July 2008

Running Scared

I sat down next to my partner -- during the day shifts we are in double- and triple-physician coverage, and we work side-by-side.  I couldn't help but notice that he was filling out a request form for a Head CT on a certain patient we all knew, who had been to the ER at least thirty times this year for chronic migraines.

"Hey," I said, "Are you scanning Andrea? What's up?"
"Oh, she's just here with another headache."
"So why are you scanning her?"
"Well, she says this is the worst headache of her life, so I need to scan her to rule out a head bleed."
"But she always says that it's the 'worst headache,' to get more drugs."
"Yeah, but what if this time she really did have a bleed?"

You notice things when you are working side-by-side with the same docs regularly. Practice styles. Who's direct and to the point. Who dithers endlessly before admitting patients. Who needs a consult for everything. Who gets frazzled when things fly out of control. Because we are usually working in parallel, in our own little worlds, there's not too much direct interaction, but you notice what people are up to.

I have noticed over the years that there seems to be a certain subset of ER docs who practice scared. They are terrified of missing something, so they work everything up to the hilt, above and beyond what is normal for an ER doc, or rationally required given the patient presentation.

Quick caveat: ER docs are by the nature of the beast, paranoid and cautious. The ER doc who has not been burned by the bizarre and unexpected is one who has not been in practice very long. So a certain modicum of over-testing and wariness is expected, necessary and praise-worthy, so long as it's guided by best practices and rational algorithms.  That's not the ER docs who I am describing here.

What I am describing are the ones who are afraid, and that fear informs their approach to patient care. The ones who go home at night and worry about the patients they sent home. The ones who obsess over extremely unlikely possibilities in situations where they are not really indicated.  The ones who over-test and over-treat all comers.   The ones who keep lists of all their patients and follow up on all of them, to make sure none died.

They are enslaved by that terrible question with no answer: What if?

I've seen this behavior in a number of ER physicians over the years. Some couldn't live with it and changed to a different specialty. Others, to my surprise, persevere despite exhibiting what seems to me to be a crippling level of professional anxiety. There is a learned skill of becoming comfortable with uncertainty that is an essential survival skill in this profession.   Some doctors never seem to develop that ability.

I trust my judgment, which is not to say that I think I am infallible (though I have been accused), but that I know what I know, I know the limits of what I know, and I know the limits of what is knowable. And I am comfortable with that.

I know that one day I will send home someone with an MI, and they will die. Hasn't happened yet, that I know of, but it's inevitable. I see about 700 patients with chest pain annually, give or take, and I've been doing this for ten years, so I've probably seen 5000 chest pain patients in my career. I can't admit them all, and to think that I can continue to do this without either making an error or getting blindsided by something unpredictable is not realistic. When it happens that I get the call from the medical director: "Hey, remember that patient you saw," I will be disappointed or worse.


But I'm not scared of it.

Part of this may come from the fact that I have made some mistakes, have already faced the consequences of my imperfections and have come to terms with it.   But that is not all of it, because I wasn't scared even when I was new, and many of our new hires are not scared either, at least not once they get over the jitters of their first "real job."

I don't know what separates the doctors who practice scared from the rest.   Maybe there's a difficulty in accepting the responsibility that comes from the life-and-death decisions we make.  Maybe there's a fear of or past trauma from the criticism that invariably follows a bad outcome.   Perhaps it's a simple fear of failure -- that the patient who does poorly is necessarily a reflection on you and your judgement, and your worth as a physician.   Curiously, most of the docs I've known like this have never been sued, but there is a constant genuflection to the altar of "I don't want to get sued."  I suspect that they use the bogeyman of malpractice as a proxy for their real fear -- the imagined consequences of making a mistake.

Some patient advocates might object that caution and diligence are good things in a physician, and if fear is the motivation, so be it.   But bear in mind that there are costs to excessive medical care, beyond the financial.   Would you want to take time off work and your personal life to be admitted to the hospital unnecessarily?   Would you want a needle stuck in your back if it was not to benefit you but to assuage the anxieties of the doctor?   CT scans use radiation which causes cancer.  And so on.   

I feel bad for these physicians.   I think they are missing out on much of the joy and satisfaction this job has to offer.  They don't seem happy.   As an employer, I worry about their career longevity, but as a partner and friend, I mostly just feel sad for them.   It's no way to live.

03 July 2008

Leaving it all on the field

The Boston Globe reports that Teddy Kennedy, recovering from his brain tumor surgery, is quietly laying the groundwork for universal healthcare legislation. Obviously, nothing can be done until the end of our long national nightmare (200 days and counting!), but it will be vitally important to have the basic framework laid out when President Obama (please please please) takes office.

This is encouraging on a number of levels:

  • HillaryCare failed in part because of a failure to adequately involve the legislative branch in crafting the necessary compromises, and in part because of a failure to move quickly enough, when the Clinton administration still had momentum and unspent political capital. It's nice to see that they have learned from that lesson.
  • The article reports that Kennedy's effort is "designed to identify areas of common ground between Democrats and Republicans, business and labor, providers and insurers." The SEIU, AARP and the powerful small business lobby have joined in an uncommon alliance to work together, and it's nice to see this collaboration extend into the legislative arena.
  • This coalition is much more likely to propose a workable plan like Wyden's, rather than a doomed single-payer system.
  • And, given that the 111th will likely, sadly, be the last Congress for Teddy, it's nice to see that he's working to go out championing the issue he has dedicated most of his public career towards.
I'll be fascinated to see how this plays out.

02 July 2008

It's just stuff

Washington congressional candidate Darcy Burner lost her house in a horrific fire yesterday morning. The former Microsoft exec was woken by her 5-year old son at 7AM, as he shouted "Mommy, there's a fire in my room!" She, her husband, son, and puppy all got out safe (the family cat did not). The house was consumed in minutes.I've been a fan of hers since she lost narrowly to Reichert in 2006. She's smart, sophisticated, and progressive, and also something of a Netroots hero. This may just be her year, though it's clearly not her day.

Obviously, she'll have to take some time off the campaign trail and off fundraising while they get their life back in order. If you're inclined, head over to ActBlue and show her some support.

Now, if you'll excuse me, I've got to go check the batteries in the fire detectors in my kids' rooms.

01 July 2008

Medicare Fall-out

Burnt Orange Report, um, reports that the Texas Medical Association has rescinded its endorsement of Senator John Cornyn over his vote to block the fix to Medicare reimbursements. The Border Health Caucus has similarly expressed opposition.

While I doubt this will have much effect -- Cornyn has a decent lead over his Democratic opponent, Lt Col Rick Noriega -- it's not the message that you want to have out there if you are a republican in a competitive election in this anti-republican environment. More to the point, it's a rare and dramatic expression of how pissed off the medical lobby is at republican obstruction.

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UPDATE:

According to MyDD, the AMA, traditionally a GOP ally, is now running ads against vulnerable GOP senators in Texas, Mississippi, and Hew Hampshire. See the ad here.

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I find this interesting from a political perspective. What we have here is a classic game of brinksmanship -- from both parties. The Democrats want to flex some political muscle, and they feel emboldened by the huge majority that the house bill passed by. The republicans, confident that the Dems will roll over, because, well, they always do, gambled that they could hold out for the Baucus-Grassley compromise. Who's to blame? It's equal shares, IMO. But just like when Gingrich and Clinton shut down the government in 1995, it's all about the posturing and public perception. I'd say that, this time, the Dems are looking better, and with the negative press and blowback from the medical lobby, I'd venture to guess that they'll peel off one or two more votes to pass the bill come July 7. Maybe Ted Kennedy will rise off his sickbed to cast the deciding vote -- great drama. Then we'll have to see if Bush is obstinate enough to veto it, as he has threatened.

As a matter of partisan politics, I of course want the democrats to win. But I would be remiss if I did not point out that there is also a substantive difference between the proposals that favors the bill that is currently on the table:

The cost of fixing the physician pay cut is estimated at about $6.8 billion. The house bill funds that by reducing the size of Medicare Advantage. The Baucus-Grassley compromise, I understand, funds that by reducing assistance given to low-income Medicare beneficiaries.*

Many Democrats view Medicare Advantage as, at best, an attempt to incrementally privatize Medicare, and at worst, a frank give-away to insurance companies. Conservatives contend that Medicare Advantage is a popular and successful experiment in market-based government-funded health care. Both may be correct. Still, I find it informative regarding the relative priorities of the parties that, while both factions want to curry favor with the doctors' lobby, the Democrats' first instinct is to preserve assistance for the poor, and the republicans' is to preserve free market reforms.


*There is also some difference involving medical supplies and competitive bidding that quite frankly, I don't understand.

Another Waiting Room Death

This one caught on video:


The staff apparently documented her up and around during the time that she lay dead on the floor. The report is a little unclear, but it sounds to me as if this took place in the ER's waiting room, involving a patient who had been committed for psychiatric reasons but was waiting for an inpatient bed.

While the angle the media will play on this is the indifference of the staff and other patients, the real story can be found here:

The psychiatric unit at Kings County Hospital had been a subject of complaints by advocates for the mentally ill.

A state agency, the New York State Mental Hygiene Legal Service, filed a lawsuit a year ago, calling the psychiatric center "a chamber of filth, decay, indifference and danger." [...]

The suit was especially critical of the hospital's emergency ward, saying it is so poorly staffed that patients are often marooned there for days while they wait to be evaluated. Sometimes, the unit runs out of chairs, according to the lawsuit, forcing people to wait on foam mats or on the waiting room floor.
ERs are overcrowded and underfunded. Psychiatric units are even worse off, and patients nationwide will languish in ERs for days waiting for psych beds, preventing more urgent patients from being seen. Nothing has changed since the Institute of Medicine published its report: Emergency Care at the Breaking Point. Expect to see more of these in the coming months and years. And expect to see the media gin up outrage at the callousness of the staff, missing entirely the larger public policy picture.

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UPDATE:

In defense of the staff -- many times I have seen patients dramatically and histrionically throw themselves to the floor, and moreover, if these patients were in truth supposed to sit in chairs for 24 hours while waiting for beds, I suspect that it may not have been uncommon for a patient to take a nap on the floor. So the presence of a patient supine on the ground may not have been as uncommon as you might think at first blush. Yes, I suspect that there was some inattention by the staff -- but I wonder whether it was negligent, or whether they were simply overworked and engaging in care for other patients? There's no way to know.

My point here is really that the problem is not bad care per se, but patients languishing in waiting room chairs for hours on end.