31 October 2008

But numbers are so boring!

I was browsing the Federal Register yesterday (I know, I know, don't we all?) and couldn't help but note that the 2009 Medicare Professional Fee Schedule had been formally issued.

Um, it's 1,459 pages of spine-tingling excitement!

But it kinda does matter. The most significant change this year is that CMS has changed its methodology slightly from the last couple of years. The 2007 and 2008 fee schedules were subject to a negative 10% "budget neutrality factor" adjustment due to the increase in the value of the E/M codes for cognitive services. CMS applied the BNF to the work RVUs. This year pursuant to the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), CMS will apply the BNF to the conversion factor instead and leave the work RVUs intact. Also, remember that the MIPPA, passed so dramatically this summer, allows for a 1.1% increase in the CF come January.

So the MPFS CF for CY 2009 is (drum roll please!): $36.0666!

Some interesting numerology there, perhaps.

I you would like to know how your specialty will be impacted by this, scroll down to page 1045. I'll save you some time and effort: Emergency Medicine will see a net 4% increase in reimbursement. Internal medicine, family practice and pediatrics will see a 2% increase. Interestingly, surgery and thoracic surgery will see 3 and 2% increases, as well. Most everybody else is flat -- either not change or +/- 1%.

Emergency Medicine is particulary benefitted by this change because such a high percentage of the E/M RVUs are work RVUs, so our codes rise proportionately more than other specialties' do.

Here are the 2009 RVUs relevant to Emergency Medicine:

So only slightly changed from the prior values. If you're a wonk, there's lots more in there, including the history of the RVRBS and a detailed explanation of how codes are arrived at, how they are valued, and the recommendations from the RUC. I'll write more about this later, when I have had time to delve deeply into the document. Enjoy!

30 October 2008

A Tough Day for our Family

We have -- or had -- two Bernese Mountain Dogs. Shadow, on the left, is not yet seven. Finn, on the right. was almost eleven, which is quite old for the breed. About three months ago, we noticed him snuffling a lot, and the vet did a nasal scope and saw a hemangioma. A knowledgeable doggie-oncologist told us that it was almost certainly an angiosarcoma. Treatment options at this age and with this disease were minimal, and we reluctantly decided to let nature take its course.

Finn had a great last couple of months. He got lots of treats, as many walks as he could stand, and lots of love and attention. But his appetite waned and he started losing weight. He developed generalized lymphadenopathy. His breathing progressively became more labored. He had trouble getting up. I went away to the ACEP scientific assembly worrying whether the crisis woud come while I was gone, and it did. My wife called me and told me that Finn had fallen and was not able to get up. It wasn't clear whether it was a spinal cord thing or just overall weakness. We got the vet to get him some steroids, and he rallied enough for me to finish up some business and come home early from ACEP.

He was a sad sight today. Practically skeletal, and barely able to walk. But he wasn't in apparent pain, and he was glad to see me. He happily snarfed up some doggie treats and we coaxed him outside for one last walk (to the end of the driveway and back). The boys came home from school and we told them that the vet would be coming by after dinner, and what was going to happen. The three-year-old was fairly oblivious, but the six-year old was devastated. We had been preparing him for a while, but he wasn't ready for it to be today.

Neither was I. Who ever is?

Our wonderful vet came over and gently administered a whopping dose of propofol and something pink (I didn't ask what), while I sat with Finn's head on my lap, and first-born-son clinging to his neck, weeping. It was shockingly quick, and peaceful.

Now, the kids are in bed, and we're numb. My wife is broken-hearted. He was her first baby, and she doted on him. I just can't get used to sitting here typing without him stretching out on the floor next to my desk. There's a huge vacancy in our house; a member of our pack has gone missing.

It's too hard to explain how much I'll miss him, so I won't even try. Good-bye, buddy.

28 October 2008

What exactly is a placebo, anyway?

An alert reader recently sent me a link to this article in the New York Times, which reports that 60% of doctors have used or would use a placebo. Accompanying this report is the obligatory and entirely unsurprising whine from a bioethicist (I believe whining to be their native tongue) decrying the use of placebos as a violation of patient autonomy and informed consent.

To an extent, they are right. Patients should be informed regarding their diagnosis, and should be informed of the nature of their treatments. I don't think anybody would argue with that. There are circumstances, however, in which full disclosure is not therapeutic and may even be detrimental to the necessary alliance between physician and patient.

For the purpose of this discussion, I'd like to expand the concept of a "placebo" The denotation of the word is a medicine that does nothing. In this discussion, I'm not talking about the classic sugar pill or vitamins or other inert substances. Those are not widely used and I would say that an intervention with no conceivable medical benefit is indeed beyond the pale. In the current context, though, what I am really talking about is a real medicine which does something, perhaps something other than, in addition to, or less than what the patient thinks it does. It may be that a med has multiple mechanisms of action, or it may be that it is a real medicine which the patient did not truly need. Or there may be equipoise -- a med may be more of a nostrum that has never been proven to be effective, but has widespread acceptance as "doing something."

The central point here is to explore the limits of consent, and the degree to which it is acceptable for a physician to skirt or evade explicit consent for an intervention. Bear in mind that in most cases in the ER, there is a blanket consent obtained at registration, that things happen quickly even for non-critical patients, and it is common for interventions to be initiated before a working diagnosis is arrived at. We do not generally stop and have a prolonged discussion at each step of the process. Usually we do tell patients what we are doing, what meds we are giving, with an assumed consent. My practice is to have a fuller conversation at the conclusion of the encounter to summarize the diagnosis, the treatments in the ED, and the aftercare expectations. This assumes an uncomplicated and noncontroversial ED course, and I do modify it as needed for each individual patient.

One thing that I would like to exclude from the discussion. The linked article referred to doctors giving what I call "Go Away pills" -- antibiotics given for a viral illness, for example. I do not consider bad medicine to be a placebo. It is harmful, and not to be condoned.

Some real world examples may be illustrative of the dilemmas we encounter, and how placebos come into play in the ED:

The "worried well" patient. This patient is commonly triaged as "flu-like symptoms," in the patient's words. No fevers documented, of course. Just vague constitutional complaints, such as body aches and fatigue, perhaps an episode or two of emesis. Ultimately, there is no clear diagnosis. Now, in most cases, I am honest with these patients: I don't have a diagnosis, but I am reassured at the absence of serious signs and we can observe them without doing anything else. That goes over OK in many cases. But patients react poorly to a perceived "there's nothing wrong with you," they feel dismissed. Nonspecific diagnosis such as virus or dehydration may be well received; I may hold them out as possibilities. But often, if the ER is busy, the patent will have received a lab work-up and an IV from triage standing orders. In that case, I often will give the patient interventions such as IV fluids and/or an anti-nausea injection. This is universally perceived as therapeutic by patients. They feel very validated in their "illness" and at discharge I point to the empty IV bag as evidence that they are going to feel better now. Or maybe they are a little sleepy from the side effects of the anti-emetic and they interpret this as the medicine having been "really powerful." Now, understand that I knew they weren't dehydrated, absent reports of fluid loss, and even if they were, they could have been rehydrated orally. I probably would not have ordered an IV placed, but it was already there. I can rationalize these interventions as being potentially therapeutic, they are certainly harmless, and I know the patient will feel better. So it's totally a placebo, but is it wrong? Do I need to tell the patient in advance, "You are not dehydrated, but I think IV fluids will help you feel better"? How much honesty is necessary?

The Nostrums. Patients with chest pain can get a variety of medicines while we are doing the work-up to exclude serious causes of chest pain. One common treatment is the "GI cocktail," which is usually a mixture of maalox and viscous lidocaine. If the cause of the pain is acid reflux in the esophagus, it can be very effective in treating the pain. But it also works for pain from anxiety, pleurisy, and ischemic heart pain (beware using it as a diagnostic tool!). It tastes so nasty and creates such a strange sensation in the chest that a lot of folks are convinced that it had a potent effect and just "feel better" after its use. Sometimes we add donnatol or belladonna alkaloids, which can relax smooth muscle spasm -- that's quite useful for abdominal pain as well. Since these are effective as symptomatic relief, it's not clear that they should be described as a placebo. But since they really don't do anything to cure the underlying disease, and their mechanism of action is unrelated to the nature of the illness in some cases, it sure feels like a placebo to me. It's not supported by any strict evidence-based standards, but experience shows it to be helpful. I defend this intervention as being genuinely unclear and so I would not subject it to strict disclosure requirements.

Those are the easy examples. It gets a lot dicier when you are dealing with psychiatric complaints, or cases in which the patient's perception of the problems differs from the physician's.

An anxiety attack manifesting as chest pain. Understand that an experienced ER doc can spot this a mile away. We do work it up to exclude serious illness, but also need to treat the true diagnosis How about some ativan, a valium-like sedative? It will predictably make the patient feel better. Is it necessary to tell the patient up front that they're "just anxious," before treating their anxiety? Does the patient need to explicitly consent to an anxiolytic? How much disclosure is needed prior to treating the patient? An honest but excessively blunt diagnosis is likely to backfire, producing a hostile patient interaction and a refusal of care. Sometimes, with very careful diplomacy, in a patient with good insight and an open mind, I am able to broach this and get an explicit consent. That's optimal. But most of these folks are convinced that they are dying, are unable to accept in their native state that their illness is psychogenic, and if you even hint at that up front it's game over. In this case I often have to be less than forthright initially. I put on my grave face, validate them and make them understand that I share their concern (even though I do not); I tell them that we will be doing tests to rule out life threatening illness (which we would do anyway), but I also need them to relax and so I am going to give you something to take the edge off their nerves. It's very paternalistic, and usually accepted gratefully. Only later, once they are treated, can I tell them that they were "just anxious." Even then, diplomacy is required. But it is also clear that at least initially, there is an abrogation of fully informed consent.

Another common clinical complaint that can be positively impacted with a placebo is a condition called cyclic vomiting syndrome. This is a poorly understood phenomenon. There will be a patient who comes into the ED with intractable retching maybe ten times in a month. Then we don't see him or her for a year, and then they come in again ten times. Sometimes they are really dehydrated, but as often, in my experience, they are euvolemic. Often they are never seen to actually bring anything up, and there is a strong affective overlay to their presentations. Standard antiemetics seem not to work, but patients will often tell me that "only" dilaudid works well for them. This makes no sense. Dilaudid is a pain reliever that is well known to induce vomiting, so it's entirely paradoxical to treat vomiting with it. Many of these patients are perceived as drug seekers, and some may well be. I have a hard time figuring out which are abusers, since they all seem to present in a highly dramatic and wretched state. Due to the typical co-existent complaint of pain, opiates almost always are required to relieve the symptoms, but I have found that ativan works as well or better. Is it because this is a psychogenically driven illness? I don't know. Ativan is an effective anti-emetic; just ask any oncologist. So how much do I have to tell the patient before giving them ativan for this illness. Most patients are, quite frankly, not interested in the names of the meds. I can tell them "I'm going to give you something to stop the vomiting," and they are happy to accept. If it worked, they may ask the names of the meds later. Others will ask questions, and I give answers which are general to begin with and become more detailed as the patient's questions become more specific. Again, it's not clear to me whether this is a placebo, but my perception of why this medicine works is somewhat different from the patient's. I pretty much never tell the patient the real reason I think they were vomiting, partially because it's speculation on my part, but also because I know that it would not be well received. Patients with CVS are often "veteran" patients with fixed ideas about their illness, and there's no value for me in picking a fight that is not going to help the patient.

Let us not forget the placebo value of the therapeutic x-ray. Radiation does not help patients, but a chest x-ray or ankle x-ray is so valuable at making patients happy and feel better (relief of anxiety yet again) that thousands of doctors ignore bullet-proof evidence to routinely order x-rays on patients who do not need them. Should we inform patients that the x-ray is not necessary but if they want it they can have it?

And the most powerful placebo I have found is the deep confident voice of a tall male physician with gray hair at the temples. I have gotten good at playing that guy. I review their symptoms, discuss a differential diagnosis and why the bad things are excluded, and why I am reassured that they will be well. It's theater, pure and simple. Of course it is good medicine to be a good communicator. But it has never failed to amaze me how often a patient will hear my explanation (even when I don't do any tests), let out a deep breath, and say "Oh, what a relief. I was just terrified I had 'x'. I feel so much better now." (This is also why it's often helpful to ask in advance what the patient's real concern may be.)

In the end, I don't really know what a placebo is. There's a no bright line that separates the "sham" treatments from the "real" ones, and consent is a variable which is inconstant in terms of patients' ability or need to explicitly understand and agree to the treatments.

As an amusing side note the AP version of the article notes that the referenced study was funded in part by the National Center for Complementary and Alternative Medicine. The irony just makes my head spin.

25 October 2008

Mental Health Breaks

A more civilized -- and funky -- way to choose a leader:

Unbelievable McCain Vs. Obama Dance-Off - Watch more free videos

And in the mold of School House Rock-meets-Dr Suess:


Eight years later

Funny. Kinda.

24 October 2008

See you later

I'm off to the ACEP Scientific Assembly through the middle part of the week. Posting may be light.



22 October 2008

The Undertaker

I had a patient die recently; it was someone with an obvious MI who came in in full arrest and despite much ado did not make it. He did not have a physician, and so a few days later, I was called by the funeral home to see if I would be willing to sign the death certificate. Now, in my training I was taught that as an ER doc, we should pretty much never sign death certificates: that was more properly for the patient's treating physician, who could more accurately reflect the cause of and contributing factors to the death. In most cases, all we know as the ER doc that is the patient came in dead and stayed dead, so it's not really appropriate for us to do it.

But this was an uncommon case, in that there was no PCP and that I did know the cause of death. I could have turfed it to the medical examiner, but that would have caused a lot of hassle and delay in the funeral. So I agreed. They said they would bring the papers by the ER on my next shift for me.

So the next day, I had forgotten about it until the triage nurse came and got me, obviously creeped out. "There's this guy, says he's here to see you about some papers, but he's kinda strange and I didn't know..."
"Oh yeah, the death cert. No problem, send him back."
"Are you sure? He's a little..." She trailed off, at a loss for words.
"Yeah, I was expecting him."
"Oookay. Your funeral," she slyly smiled as she went back to the front.

My eyes nearly fell out of my head when I saw the guy. It was amazing. If you asked Tim Burton to create a claymation caricature of what a mortician should look like, he would have made this person. He was tall and thin, and very very pale. The whiteness of his skin was set off by the black three-piece suit he was wearing (of course) underneath a full-length black trenchcoat (of course). On top of his head there was a black silk hat which looked like a cross between a fedora and a stovepipe hat. His hair was long and black, and he wore a very full black goatee underneath an elaborate waxed handlebar mustache. His manner was very grave (of course) and unfailingly polite. He could have stepped right out of the Victorian era, except that he was wearing a wristwatch.

"Boy, you've really got the look going on there, don't you?" I offered, as I filled out the forms.
He shrugged, "Goes with the job."
"Does it ever."

He politely filed the papers away in the black leather satchel (of course) he carried at his side, and quietly left. I can only assume the he climbed onto a waiting horse-drawn glass-sided hearse and rode away.

I love my job.

2008 or 1956?

This is a deeply disturbing scene. A line of african-americans, waiting to vote, being heckled and intimidated by an angry group of white protesters. In North Carolina.

This was reported in the conservative Washington Times, of all places. Meanwhile, GOP elected officials such as Reps Bachmann and Hayes describe Obama and liberals as "anti-americans" who "hate real americans who work hard and believe in God." GOP robo-calls and mailers decry Obama as a dangerous crypto-muslim terrorist. The candidate for Vice President apparently sees a distinction between areas of this country which are "pro-america" and which are not.

Demagoguery like this is dangerous and concerning. I never thought I would see a presidential campaign get so deep in the slime. It's kind of amazing to see that McCain is now running a campaign that makes George W Bush's look principled and honest, in comparison. At least Bush had the class (or wit) to keep his official campaign separate from the slime, letting the 527s do the dirty work (and then tepidly deploring it). In this campaign, some of the nastiest cmears are coming directly from the mouths of the candidates, and their surrogates, taking a cue from the principals, ratchet up the rhetoric yet more. It makes Nixon look good in comparison.

McCain is going to lose, and he deserves to lose after a campaign like this. And worse for him, has will have destroyed his reputation in the process.

Politics Funny

Courtesy Real Dan Lyons (formerly Fake Steve Jobs)

21 October 2008

Our New Hospital

Doesn't look like much just now; just a hole in the ground where the old parking garage used to be. It'll be a while before it's open, but wow is it going to be cool.


Cancer sucks. That's all I can say. It just sucks.

Henry and his family can use a little love right now. And if you are feeling like taking action, St Baldrick's Foundation is still accepting contributions towards a cure for children's cancer.

Deep Thought

No apple ever tastes as good as one you have picked straight from the tree. Except the one which you have picked from your grouchy neighbor's tree when he wasn't looking.

Works like magic

I saw a member of the medical staff the other day. It was one of our pediatricians, and the poor guy had a kidney stone. Being a typical doctor, he had self-diagnosed himself in the office and tried to treat himself at home. It didn't work, and he wound up going into his clinic's urgent care for pain control. He got the VIP treatment there: over 200 mg of Demerol! In an opiate-naive person! But to no avail: his pain continued to crescendo and was absolutely untouched by the medicines. We got the call that he would be coming over and that he would probably need to be admitted on and put on a PCA.

When I saw him, I had to feel bad for him. He was sprawled on the gurney, ashen and covered in sweat. He was completely exhausted, but he just couldn't stop writhing, to the point that he was halfway off the bed.

I reviewed his papers, and noted with a little surprise that he had not been given any toradol. I suggested that we give it a go, and the physician-patient readily agreed. I think he would have agreed had I suggested bloodletting, he was so desperate for relief. I put the order in, along with the other usual stuff, and went off to see the next victim.

Half an hour later, I stopped in to check on him. The transformation was amazing. He was sitting up in bed, pink and comfortable, hardly recognizable as the pathetic wretch I had seen before. He had a look of incredulity on his face. "I just didn't know toradol could do that," he marveled. "I knew it was a good pain releiver, but I always figured that Demerol was stronger, and when the Demerol didn't work, I figured nothing would." He rated his pain as a two.

It was a pretty satisfying encounter, and he went home singing our praises. For the life of me, I have no clue why the urgent care didn't give him toradol. It's the first-line drug for kidney stones, IMO. I don't know why it's so effective. I think it has something to do with its prostaglandin effect causing smooth muscle to relax, which eases the pain of ureteral obstruction (biliary obstruction, also). I've previously written about the efficacy of toradol in folks with intractable pain due to kidney stones, even in drug seekers, and for migraine headaches. So I apologize if I'm sounding like a broken record, but man, it's a great drug. And it's profoundly satisfying when it works as it should.

20 October 2008


Precocious Youngster Sells Cookies To Buy Attack Ad
It's so nice to see the kids of today getting involved.

I am a bully

Belly pain is one of those thing that is so common and so typically benign that it's easy to forget how bad it can be sometimes. I saw a fellow recently who gave me a little refresher in "The Bad Abdomen." He showed up in the patient tracking system without a lot of other information (the nurse had not yet completed the computer documentation). Ordinarily, I would not have sprinted right in, but I was not terribly busy and I'm a restless sort, so I went in right away. This guy was sick, one of those cases where you walk in the room and stop dead in the doorway at the sight of him. He had abdominal pain, a terrible pain which had come on suddenly a few hours ago, and he was trying to hold perfectly, still like a statue, despite the pain which contorted his face. His respirations were deep and fast, and the sawtooth lines on the heart monitor bespoke a heart rate twice what it should have been. His skin was gray and moist, and his blood pressure was in the mid double-digits.

Not a diagnostic dilemma. A classic acute abdomen due to a perforated viscus, with early septic shock. I was on the phone with the surgeon within ten minutes of the patient's arrival, and a well-practiced team of nurses had the patient stabilized shortly thereafter: IV fluid bolus, blood transfusion, antibiotics, pain medicine, vasopressors. His CT scan was impressive.

For the uninitiated, the black at the top is free air, which has escaped the gut and is in the abdominal cavity; there is a lot of fluid in the belly as well, probably intestinal contents, and the bowel wall looks boggy and has air in it, which is an ominous sign.

The surgeon arrived, ready to go to work, and went to see the patient. He came out of the room a few minutes later, bemused. "Get this," he said to me, "this guy is refusing surgery!"
"Are you kidding me? He's gonna die!"
"He's serious. I told him he would die without an operation, but he still says no. Put him in the ICU and let me know if he changes his mind." And with that the surgeon was gone.

Now this was strange. This fellow was young and otherwise healthy, and the odds were that he would make a complete recovery with a timely operation. Without the operation, death was certain. Why didn't he want surgery? I went in to talk with him.

As the surgeon had said, the patient was dead set against it. I asked why, and grimacing from the pain, he said, "Doc, I know my body, and I've just got to listen to my body. Can't you understand that? Just give me some time, let me get hydrated, give me some juice, and my body will heal itself. I don't need no surgery." I explained to him, clearly and carefully, that he was going to die without the operation, and I asked him to repeat that back to me so I could know he understood what I was telling him.

He did. He understood me just fine. He just didn't believe me. He elaborated, "Doc, I just know this, I've been through it before. You give me some juice and leave me to rest tonight, and I'm gonna be just fine in the morning." No explanation I gave him could convince him otherwise. I figured it might be inadequate pain control, so we gave him some more pain meds to try see if that would allow him to focus more clearly. No luck. I had a nurse who seemed to have rapport with him spend some time talking him about it. No luck. Deep down, this man just didn't believe that he was going to die. I got him a bed in the ICU, and figured I'd give it one last go before he went upstairs.

"Okay sir, before you go up I've just got some paperwork to complete. Do you have a next of kin?"
"Um, yeah, my sister."
"Great. What's her phone number? We'll be needing to call her later. Do you have a mortuary or funeral home selected, or should we just have your sister pick one?"
"Um, I don't think -"
"No problem, we'll just have her pick one. Now, in a few hours, you're not going to be able to breathe any more, and if we're going to keep you alive, we'll have to put you on life support. Do you want us to do that, or should we let you suffocate?"
"That sounds bad -- I don't want to suffocate."
"Right, then, the ventilator it is. But a few hours after that, your blood pressure is going to go really low and your heart will stop. Do you want us to pound on your chest and shock your heart to try to bring you back? It won't work, of course, but I just need to let the ICU doctor plan how to handle it when the time comes. So should we do CPR or not?"
He gave me a long look. "You really mean it, don't you?" I said nothing, but let the long silence linger. "You really think I need the surgery?" I nodded. He sighed, and slumped back, resigned,"Well, all right, if you really think I need it..."
"You do. It may save your life. I'll let the OR know."
"Does this mean I don't get my juice?"
"Not till tomorrow."

I've saved many lives (or at least prolonged them) through medical skills and diagnostic acumen. In this case, I was pleased and amused that I saved (or at least prolonged) his life through my skills at manipulation and blunt force persuasion. A useful job skill, one underappreciated in medical training: the ability to discern when to let the patient have their way, and when to bully them into making the right choice.

[Note: there are times when a patient may make a principled choice against surgery. They may have an incurable disease, or very high surgical mortality, or simply be old and ready to die. I respect those choices. This was different in that it was not a principled decision, but the patient's denial that had to be overcome.]

17 October 2008

This strikes me as not a good thing

Patriots QB Tom Brady had a second surgery on his injured knee to deal with an infection.   To me, this sounds like a wash-out, and I would think that an infection in a reconstructed knee is not a good thing.   Are there any ortho bloggers out there?

Full disclosure: I can't bring myself to care about the Patriots either way.  I don't love 'em or hate 'em.

Work Plan

One thing I don't like about having the government as our biggest single payer is that if they think we've broken the rules, they can send me to jail. Granted, that's pretty uncommon They usually settle for incredible punishing fines and driving you out of business. So it's pretty important to stay on the right side of the law, and one thing I like about working with the federal government is their boy-scout earnestness in their approach to enforcing the law.

For example, every year the HHS OIG (Office of the Investigator General) releases its work plan for the upcoming year. Basically, they tell the industry, in advance, what practices and violations they are going to be looking for in the upcoming year. It's remarkable! It's as if the state police announced that this week, they're going to be cracking down on lane changes, next week they'll be running speed traps, and the week after that will be enforcing DUI laws. I know when I'll be avoiding the bar on my way home from the ED.

I'm happy to furnish the full work plan to anybody who is interested (it's kinda dull), but here are the key points with some commentary:

Payments for Diagnostic X Rays in Hospital Emergency Departments
We will review a sample of Medicare Part B paid claims and medical records for diagnostic x-rays performed in hospital emergency departments to determine the appropriateness of payments. [...] concerns regarding the increasing cost of imaging services for Medicare beneficiaries and potential overuse of diagnostic imaging services.

My take: This sounds more like a "medical necessity" review more than anything else. So a sampling review will be conducted to see if the studies ER docs are ordering were actually justified. Sampling reviews are a little worrisome because they can open the door to more intrusive audits. Another possibility is that CMS may be looking to see who got paid, and did they actually provide the service. This is of concern to ER goups who bill for interpretive services. If you document CXR (-), and bill for it, you may be in trouble. Another common point of interest is whether radiologists who do not provide a contemporaneous read should be permitted to bill, but I do not see that practice as the biggest target of this measure.

Oversight of Hospitals’ Compliance With the Emergency Medical Treatment and Labor Act
We will review CMS’s oversight of hospitals’ compliance with the Emergency Medical Treatment and Labor Act of 1986 (EMTALA). A previous OIG review raised concerns about CMS’s EMTALA oversight, specifically regarding long delays to investigate complaints and inadequate feedback provided to hospitals on alleged violations. We will identify any variation among regions in the number of EMTALA complaints and cases referred to States, examine CMS’s methods for tracking complaints and cases, and determine whether required peer reviews have been conducted prior to CMS’s making a determination about whether to terminate noncompliant providers from the Medicare program.

My take: Note that this is an audit of CMS itself! I suppose it's nice to see that there is accountability within government. Clearly, the OIG wants to kick-start CMS back into actually enforcing EMTALA, and to improve the process and safeguards for practitioners. One might expect that we will see stepped-up investigations of EMTALA violations, though that is far from sure. As an ER doc, I'm kind of conflicted about this. I'm on record as being opposed to the unfunded mandate EMTALA levies on ER docs. There are, however, many private hospitals and private practitioners out there (in CA, especially, I understand) who flout the law with the tacit approval of their adminstrators. Make no mistake: patient dumping still goes on. So it is not entirely bad that EMTALA enforcement may come under scrutiny.

Patterns Related to High Utilization of Ultrasound Services
We will review services and billing patterns in geographic areas with high utilization of ultrasound services. In areas of high utilization of ultrasound services, we will examine service profiles, provider profiles, and beneficiary profiles.

My take: Pretty clearly a straight-up medical necessity review. I'm kind of surprised, since ultrasound doesn't seem to be the big problem. The costs of imaging have shot up, but I would say that for medicare patients I order ten or more CT scans for each ultrasound that I order.

Physician Reassignment of Benefits
We will review the extent to which Medicare physicians reassign their benefits to other entities. The Social Security Act, § 1842(b)(6), prohibits physicians who provide services to Medicare beneficiaries from reassigning their right to Medicare payments to other entities, unless a specific exception applies. For example, physicians are permitted to reassign benefits to other entities enrolled in Medicare when contractual arrangements that meet certain program integrity safeguards exist between the physicians and the entities or when payments are being made to the physicians’ employers. Investigations in South Florida have revealed schemes in which fraudulent providers obtain identifying information about legitimate physicians and request reassignments on their behalf. We will examine a national sample of Medicare physicians to determine the extent to which they reassign their benefits to other entities and the extent to which the physicians are aware of their reassignments.

My take: Wow. That sounds bad. I think it's good that they should investigate that sort of thing.

16 October 2008


I blogged about this last week after the second debate: that McCain blatantly misrepresented Obama's health care plan with regard to "fines." I was actually a little irked that Obama didn't refute it quite as directly as I would have liked.

Fortunately, McCain gave Obama another chance; a nice slow pitch down the center of the plate, and Obama hit it clean out of the park. Check out McCain's face in the reaction shot. Priceless.

(via Josh at TPM)

15 October 2008

I Respectfully Disagree with Mr. Cleese

This is the funniest Palin:

Though I cannot argue too terribly much with this.


Palin as President.

Juvenile, yes. But it made me laugh.

More Polling Porn

Pure horse-race stuff, via Nate at 538.com:
Yikes. There's a lot to like there. Early voting has started in a few states, and absent some historic event in tonight's debate, Obama can drop into the prevent defense for the next three weeks and sit on this lead. Of course, that's not what he's going to do; he'll push hard right to the end. The margin keeps growing, and McCain is running out of time to make it up.

But I continually remind myself that the Chicago Cubs were the best team in the National League this year. That didn't work out too well, did it?

Three more weeks.

Update: another cool thing about 538.com is that on the right side bar, down a bit, EVERY state poll from EVERY state is listed. (There are 45 from Ohio alone!) Nate weights them, pulls out party bias, trends and does a regression model to try to predict the current state of the state:

Here's his summary for Ohio:
I like the numbers, but as a politics nerd, I love the data!

14 October 2008

Never fails to amaze me

I've said it before and I'll say it again:

If I'm ever on coumadin, I am going to know why.

It just boggles my mind how often I have the following conversation:

Me:   I see you're on coumadin.  Why are you on coumadin?
Patient: It's a blood thinner.
Me:   I know it's a blood thinner.  Why are you taking a blood thinner?
Patient:   So my blood doesn't clot?
Me:   Do you know why your doctor was worried about blood clots?
Patient:   Well, they're dangerous, aren't they?
Me:   Yes, but have you ever had a blood clot, or an irregular heartbeat, or a stroke?
Patient:   I don't know.
Me:   (hits self in face with the chart)

13 October 2008

Screen 'em and Street 'em

The title of this post is a play on the old ER maxim, "Treat' em and street em." Rapid turnover in the ER is our friend, and we all want to get the minimally ill and worried well out ASAP so we can focus on the truly ill and the unknowns in the waiting room and hallway beds. So we do our best to churn and burn through the cases where we can to free up scarce resources.

My recent post about the odd little things you see in the ER produced a few interesting comments on this topic, the gist being the not-unheard-of solution of performing an EMTALA screen and immediately discharging those who are determined not to have an "Emergency Medical Condition." As a manager of a practice which is highly motivated to capitalize on every possible efficiency, I can tell you that we have considered this practice at various times over the years, and we have never pursued it. There are a number factors which we considered to be adverse or prohibitive:

  • EMTALA itself represents a major obstacle and potential liability. The statute requires a medical screening examination (MSE), but does not define exactly what an adequate screening exam consists of. Can a PA do it? How about an RN? What are the minimum acceptable components? The statute is silent on these topics, and case law is all over the map as to what constitutes a valid MSE. Each institution is left to set their own standards. If you choose to screen and street, and this practice ever comes under close scrutiny by a court or regulatory body, your procedures best be bullet-proof and followed to a "T" every single time, because this practice is generally viewed with extreme hostility. If you are found to be deficient in this practice, you may be in for the proverbial world of hurt. Most hospital adminstrators (nor practice administrators) will not have the intestinal fortitude to take this sort of risk.
  • EMTALA also represents a poorly-recognized malpractice liability. Though this is not authorized in the statute, and case law expressly argues against the practice, many Medicare Quality Improvement Organizations (QIOs) have come to use EMTALA as a proxy for medical malpractice. In short, if you treat someone, and they proceed to have a bad outcome, the QIOs have been known to step in and allege an improper MSE and levy fines as well as other penalties. These fines are not covered by your Med Mal policy. Worse, once the door is opened, the QIO has carte blanche to review large numbers of cases and practices and can be very unfriendly in their approach and the exercise of their broad powers. Don't ask me how I know this because I cannot tell you. You do have the option of fighting this to an administrative law judge, but your case had better be strong, and if you were screening and streeting, I would not want to defend you. Remember that although EMTALA was intended to prevent improper treatment of poor/uninsured patients, no improper financial motivation is required to show a violation occurred.
  • Then there's the simple Med Mal perspective. Never mind the Feds -- if you street someone, they will make a very sympathetic plaintiff (or, to be clear, you will make a very unsympathetic defendant).
  • To undertake such a practice, you will need the approval and cooperation of your hospital. There are some well-designed programs out there that generally involve screening non-urgent patients and redirecting them to a hospital-owned urgent care clinic or something of the sort. If your patients do have access to something of this sort, then this practice can indeed serve as an essential pressure relief valve to your ER. Absent some alternative avenue of care, it's hard to see a hospital administrator signing off on such a plan. Many hospitals have core values, whether religiously-derived or simply a committment to community service, that involves providing charitable care to those who cannot get it elsewhere. To me it seems like telling patients to "piss off" without providing some care plan would be a very tough sell to your CEO.
  • Most screening MSE programs would be of limited efficacy. In my experience, the most challenging cases, and the ones that are most consistent with "abuse" of the ER, are ones which you could not turn away from triage. I'm talking about the chronic recurrent abdominal pains, headaches, low back pains, febrile toddlers, etc. None of these can be dismissed as non-emergent without at least a physician performing an H&P on them -- there are potential life-threatening causes of each. So if the physican has to take the time to see and evaluate these folks, well, you've already provided the time-consuming portion of the service so you might as well finish off the job! Ditto for the uncommon/odd minor things. It's not clear to me that a policy could be crafted which would allow an RN to justifiably and defensibly turn them away from triage. It takes the judgement of a physician to know that there's no emergency, and that requires the doc to take the time to see them. Since these are the simple cases, it would probably take less time to reassure and discharge them (perhaps with a prescription) than it would to kick them out.
  • Even a well-designed and operated MSE program is likely to be a money-loser. Understand that you would have to be consistent in the application of the policy with all your patients, even the well-insured ones. There is no ER case which is more profitable than the insured minor orthopedic injury. Quick, easy, and lucrative. (Don't blame me if the rules don't make a bit of sense; I just work here.) If you send away all your minor sprains and nondisplaced fractures, you are sending away a significant fraction of your revenue, and the easiest money at that.
  • There's no way to generate more pissed-off patients and more complaints for your hospital than to block access to the ER. If you are in a competitive market: i.e., there are some insured patients, and they have treatment options, this will not go over well with your administration, less because of the cost than because of the negative publicity. The blowback may also have negative consequences for staff morale. Nobody likes feeling like a dick and blocking access to care.
Ultimately, the last point is really the deal-killer. Refusing someone's request for care -- or even just for an assessment -- is a crappy thing to do, socially, and a hard thing to justify morally. It just feels wrong, and for many of us who work in the ER, it seems to run counter to our mission. I take a lot of pride in the fact that we take all comers. Sure, it's frustrating when "all comers" includes those who didn't really need me. But some of those people surprise me, once you get the full story. Who doesn't have the story about the completely unexpected MI they once saw? And in this health care system, when people do not have funding for or access to a PCP, it's that much harder to justify the screen n' street. The practice seems counter to our fundamental role as society's ultimate safety net, which is why in the end, this practice has never really caught on in any large measure.

Conscience of a Liberal

A Nobel-Prize winning liberal, that is:

NY Times economist Paul Krugman wins Nobel Prize in Economics. He's been a favorite of mine for a while, from his prescience on Bush, to health care, to the financial meltdown; I had heard he was on the short list, but I didn't realize it was for real. Congratulations to him.

And if anybody out there is interested in a cogent and full-throated defense of liberalism, do check out his book, Conscience of a Liberal.

He'll probably want to update the title on that one.

12 October 2008

The ineffable beauty of blowing stuff up

Some amazing high-speed pics of stuff getting shot or smashed. Beautiful in their way. There is a whole series featuring a very brave red-fingernailed model holding the targets:

I guess it's not as dangerous as it looks -- that must be a high-precision setup to be able to capture the moment of impact, and it stands to reason that the aiming mechanism is precise as well. In addition to pics of vegetables getting shot, there are bottles, light bulbs, beautiful droplets of water, and bullets getting fired. Awesome. Check it out.

11 October 2008


A political maxim. If you have not seen these before, you do need to visit despair.com.

10 October 2008

The things you don't learn in school

Emergency Medicine is notable as much for its drama as for the pedestrian and mundane things that come through the door. Every time I meet someone new and tell them what I do for a living, I always get the "Is it as exciting as it is on TV?" question, or some variant.

Truth is, of course not. Headaches, abdominal pain, weak & dizzy, etc account for a substantial majority of our cases. In fact, the critical care stuff is generally less than 10% of what we do. Now sure, if I see 16 patients per shift, then yes, I do perform critical care daily. But it turns out that the simplest cases can be the most challenging.

You see, in residency, there's a lot of focus on critical care. I spent months working in the cardiac ICU, the medical ICU, the pediatric ICU, the surgical ICU, the burn ICU, the OR, anesthesia, and on the floors. I could line, intubate, and resuscitate in my sleep (and did, on a few notable occasions). I could recite the Killip classifications for MI and knew the DeBakey versus the Stanford classifications for aortic dissections. So I was well prepared and very comfortable with caring for severely ill and unstable patients, which is an important qualification for the job. Internal medicine also was highly emphasized: complex physiology, the key things not to miss in chest pain, electrolyte management, etc.

All this prepared me very poorly for some of the more mundane elements of my practice in "the real world." Stuff you might call "family medicine," though I don't know if that's the right phrase. For example, I remember the first time I saw a new mother bring in her week-old infant who was vomiting blood. Holy crap but I was scared. I knew all about GI bleeds -- in adults -- and vomiting blood was really bad. I didn't think kids even got GI bleeds. I was wracking my brain over it, wondering if the baby had some sort of vascular malformation in the stomach, and the nurse just stared at me when I told her to put in an IV and draw blood. "Why would you want to do that?" she asked, "It's just maternal blood."
"Huh?" I stammered, "How do you know that?"
"The mom is breastfeeding. Her nipples are cracked and they bleed when the baby feeds. Happens all the time."
"Oh." I went and examined the mom, and found that the nurse was right.

Or caring for the umbilical stumps of a newborn. (You'd be surprised how often new parents freak out and come in for this concern, that the stump is "infected" or bleeding.) Or the first time I saw scarlet fever. Elevating an ingrown toenail. Hand eczema. These and a thousand other quotidian maladies are the things that the textbooks cover briefly if at all, and that you will probably not see in residency at the high-powered trauma center. So you feel profoundly stupid when you go out to the community as the cocksure new guy from The Big Hospital and are stopped dead in your tracks by the simplest little thing.

If you're lucky, you may have a partner or an experienced nurse to point you in the right direction. Otherwise, you're left to figure it out on your own. The good thing is that knowledge learned that way is precious and you tend to retain it well. I've been doing this for a decade or so now, and I finally have enough experience under my belt that I now very rarely get that feeling of "Oh shit," when I see some minor but completely unfamiliar process. I won't say I've seen it all, because I have not, but I've seen the commoner stuff enough to be familiar with it. And now I get to be a resource for our new partners going through that same learning curve.

I love the variety and challenges this job presents. Still hasn't gotten old.

09 October 2008

The Big Lie

McCain seems to be sticking to the old saying that when you lie, you should lie big, and stick to it. He's doubling down on his most recent lie about Obama's health care plan:

On health care, Senator Obama has been [...] misleading about his own plans. He has said his goal is a single payer system where government is in charge of health care and bureaucrats stand between you and your doctor.

But John McCain is an honorable man.

Obama's not proposing single payer. Never has. He has allowed that were he "designing a system from scratch," he would consider a single payer system, but this was quite the hypothetical, and not what he has said he will do, and not what the political realities will allow, even under the best conceivable electoral outcomes next month. But McCain, that man of integrity, is losing and losing badly. He made a Faustian bargain with the smear merchants who beat him in 2000, and now they trot him out to lie, distort and shame himself . And for what? Let's face it, he's already lost. Sure, sure, the votes have yet to be cast, but let's just say it would be historically improbable for McCain to win from where he stands. You might think that in light of the circumstances, he would choose to rehabilitate his image and his honor by coasting to defeat with some dignity. It might even help him. But he's lashed himself to the mast of his sinking ship and is determined to scrabble and claw at Obama in a frantic effort to bring him down with him.

But John McCain is an honorable man.

Well, fine then

I surprise myself in becoming more of a health policy wonk as time goes on. I actually took the time to read both candidate's health plans (actually, four of them, including Hillay's and Wyden's). Ok, they were pretty dull, and thin on some details. But I have acquired a good working knowledge of the plans as the candidates have proposed.

One of the criticisms I had of Obama's as compared to Hillary's was that it was not truly universal. It did not contain any sort of mandate or requirement for enrollment. Many others, including the NYT's Paul Krugman said the same. Hillary's plan did have a mandate, though she was vague as to how it would have been enforced.

So I was jolted out of my chair last night when McCain asserted the "remarkable" fact that Obama was intending to "fine" Americans who did not have health insurance.

"If you’re a small businessperson and you don’t insure your employees, Senator Obama will fine you. He'll fine you. That's remarkable. If you're a parent and you're struggling to get health insurance for your children, Senator Obama will fine you."
He also snarkily repeated himself after Obama's rebuttal.

Yes, that is remarkable. Remarkable in that I had never ever heard that before. In fact, surfing over to Obama's web site, I noted that the full text of the plan made no mention of fines (or any type of enforcement) for failing to sign up. In fact, there was no obligation to sign up at all for adults, and while children are required to have coverage, tax credits, expansion of SCHIP and connector plans would prevent this from being prohibitively expensive.

I wasn't the only one to notice McCain's remarkable claim. (His running mate also made a similar distortion of Obama's plan last week.) Interestingly, most of the fact-checkers missed the larger point. Obama's plan, they note, exempts small businesses from the requirement to provide health insurance to employees. Nowhere is there specified a "fine" for business who do not -- simply a choice of providing health care or contributing to the national plan. It is a distortion at best to characterize this as a "fine." McCain's more ambitious claim, however, was that Obama will fine families directly. There's absolutely nothing outside of McCain's fevered imagination to support that contention.

I would say that McCain told a "lie" with this mischaracterization of Obama's intentions; that's what we used to call a deliberate statement of an untruth. But the word "lie" has been bandied about so much with him that it's lost all meaning. I'll simply leave it as remarkable; McCain's word is quite apt.

It is remarkable that a man whose career was built on the concepts of personal honor and integrity should choose to so disgrace himself in a desperate struggle for the Presidency. Remarkable, and sad.

07 October 2008

So I was wrong

Apparently healthcare is a right. Obama said so himself.

I consider myself corrected.

For the irony-impaired, yes, that is tongue-in-cheek. The question was framed terribly by Brokaw -- Right, Privilege, or Responsiblity? I'm not sure what that even means, and the options are not mutually exclusive. I'd have been happier with a more nuanced answer, but as an advocate of the moral obligation of universal health, I'll take it.

Debate Bingo

Here's your card, courtesy of Kevin Drum over at Mother Jones.

Man, looking at that thing, I'm going to get wasted.

I am so manly

My agenda for the day:

Cut up fallen trees with the chainsaw and pull out the generator and get it running.

Not bad for a city boy.

Linky Goodness

Toni Brayer over at EverythingHealth has an interesting post on some new research for prevention of SIDS. As the father of a nine-month-old, I find that to be valuable and timely advice.

Gruntdoc reports that they installed an EMR and four days later, everybody already finds it indispensable. I've never even heard of such a rapid adoption. When we were installing an EDIS, I was warned by a medical director who had already been through the installation, "Be prepared to be burnt in effigy by your staff for about six months," and that was pretty consistent with our experience. Four days is a remarkable transition time!

More on healthcare as a right

The inestimable Maggie Mahar over at Health Beat picked up on my earlier post, titled "Health care is not a right." She takes my humble post as a jumping-off point and expands on it quite a bit. Also, she flatters me terribly: Anyone who says that words are meaningful has captured my attention. I’m enthralled.

Enthralled! You hear that? I'm practically giddy.

It almost makes up for the attention she lavishes on that horrible shyster, JimII. But he didn't enthrall her, did he? I did.

Anyway, go read it. I can't recall ever seeing such a close examination of my writing without the use of the words "moronic," "half-witted," or "repellent," so I'm pretty happy just now. Her commentary makes me seem cleverer than I actually am, by way of her own insights refining some of my more clumsy points.



This is cool

For the political junkie in your family: 270 to Win, featuring electoral maps for every presidential election going back to the first one. (Spoiler alert: Washington won.)

06 October 2008

Touching the Third Rail

Well, I stretch the truth a bit. The third rail of politics has long been Social Security -- touch it and you're dead. But a close correlate might be Medicare. It's a closely related program, in that it serves basically the same constituency, which happens to be a highly politically active one, that it is very popular and very needed among its demographic. And if you touch it, you're probably dead, too. Maybe there's a"fourth rail?"

Because apparently McCain is planning on cutting Medicare to the tune of $1.3 Trillion, according to the Wall Street Journal.

Wow. Give them credit for honesty, if not for political sense. The details:

  • McCain's health care plan consists largely of providing a $5000 tax credit for families to buy their own individual health insurance.
  • Although there is a corresponding tax increase on employers, it does not offset and the plan results in a budgetary shortfall of $1.3 Trillion over ten years.
  • McCain has promised that his plan will be "budget neutral," meaning that the shortfall must be balanced by reductions in expenditures.
  • Douglas Holtz-Eakin, Sen. McCain's senior policy adviser, said Sunday that the campaign plans to fund the tax credits with savings from Medicare. Specific cuts were not identified.
Now, political calculations aside, I just don't see how this can be: it defies budgetary physics. We all know that Medicare is hurtling towards a cliff of insolvency, and significant structural changes will be required just to maintain the program as it is now. To propose that Medicare might be a cost center to derive savings from to fund another program seems insane.

Riding that train

Every so often I see a blog post that makes me want to shout out "Amen!" (Sometimes I do, which invariably startles the wife.) The oddly-eponymed "ERP" over at ER Stories put one such up the other day, on the topic of Demerol and migraines.

I too stopped using Demerol for migraines a few years back. That's not quite accurate: I never used Demerol for migraines. In my training, we avoided Demerol assiduously in favor of other, better analgesics. When I came to community practice, I was surprised to find Demerol as the "standard" med for pain, in particular for headaches. The frequent patients in our community were pretty habituated to this drug, and it caused no end of headaches for me when I started saying "no" to the Demerol request for patients with headaches. Fortunately, I was not alone, as a number of other new docs in our group had come out of training with a similar perspective, and we successfully lobbied to have Demerol removed from the ER formulary for exactly the same reasons that ERP cites.

There are a few main knocks against Demerol. One is the "toxic metabolite" argument, which, while true, is a pretty hypothetical concern. The big problem, in our eyes, was that Demerol is a powerful agonist (activator) of serotonin in a manner which is disproportionate to its analgesic (pain-relieving) properties. Serotonin is a neurotransmitter which is responsible for a variety of functions, among them a general sense of pleasure or well-being (very broadly put). Demerol also stimulates the dopamine and norepinephrine systems in a similar manner. The neuropharmacologic effects of Demerol are actually not dissimilar from those of cocaine. Conversely, Demerol has been shown to be no more effective for pain relief (actually, less effective) than other pain relievers such as morphine.

All of which is to say that Demerol may or may not relieve your pain, but it will reliably make you high. And if I give you a dose which does relieve your pain, it will make you much more high than a comparable dose of morphine would have.

Which is why it is an enticing but terrible drug for migraines. (I should say, for "migraines," since a large proportion of the "migraine" headaches that present to our ER are actually not migrainous, but the term "migraine" has entered the popular vernacular as meaning any severe, recurrent headache. So it's practically impossible to convince someone that their headaches are myofascial and not a migraine; I don't even really try any more. (But I digress.)) When someone comes in with a severe headache, and they receive Demerol, they often in short order report that they "feel great" and are ready to go home, happy and grateful. But the meds wear off, and glory be, here they are back in the ER 24 hours later with the same damn headache!

Worse, there is a powerful psychological association developed between the "rush" you get with IV Demerol and the pain relief. I've experimented with equianalgesic doses of oral and IV Demerol. IV hits the blood-brain barrier much faster and all at once with an almost-audible "rush" and the euphoria which results is dramatic and intense. However, orally, the med gets absorbed and distributed much more gradually. Absent the "rush," I've seen some patients on the threshold of respiratory arrest from narcotics insist they were still in terrible pain.

The problem is that they were not looking for pain relief, they were (perhaps subconsciously) looking for the rush. When I started in the community, there were legions of patients who insisted that "only Demerol" worked for them. Interestingly, when our ER and several other ERs in our area all started to move away of Demerol for headaches, there was a period of transition, when we often had to deal with angry or unhappy patients who insisted that they simply needed Demerol. Eventually, though, it seemed that the patients in our area had been weaned off of that drug, and now the frequency of patients with recurrent or intractable headaches seems far lower than it was before.

My interpretation of this is that the population of patients who had become addicted (iatrogenically addicted, I might add) to Demerol had been successfully detoxed, and thus were no longer (or more infrequently) presenting to the ER seeking their meds. This is an anecdotal impression: I wish I could compare the frequency of headache as chief complaint in our ER over the past decade, but I am not sure I can get that data.

I would like to point out that while it's easy to deride some of these people as "addicts" or "seekers," there were physicians on the other end of those needles which created the addictions in the first place. It is easy to "make them happy" and get them out of the ER, but I believe it is a great disservice to patients to create or perpetuate the addiction which drives them to the ER again and again. It's harder to say no, but in the long run, it can in some cases be better for everyone involved.

There's no standard template, but for headaches in my ER, my current practice is: a sumatriptan (such as imitrex) if the headache actually sounds like a true migraine, with toradol, reglan, IV fluids, and, if necessary, oral narcotics. Dilaudid works well, but is, IMHO, simply "Demerol-lite." If someone absolutely cannot take an oral med, Dilaudid is a tolerable alternative, but is not ideal and I avoid it if I can.

Seems to work OK. I don't get nearly as many complaints any more, which is a positive indicator, I think!

05 October 2008

The Financial Crisis, Explained

Um, vaguely NSFW language.

"Hot Steaming Pile of Assets." Heh.

Don't Cry For Me

Dodgers Sweep Cubs

I am a Cubs fan. As such, we expect things like this to happen. I am uniquely qualified to deal with soul-crushing disappointments of this type. Year after year after year.


Just wait till next year.

I've done this

Credit: SMBC

04 October 2008

Saturday Morning Funny

Presented without comment.

(h/t Crazy Andy)


I just knew, just knew that when I mentioned Medicare approvingly in the last post that it would bring the trolls out of the woodwork, and I'd wind up getting sucked into a "Medicare sucks" argument without end.


OK, here goes. I'm going to say for the record that I'm feeling grumpy that I have to argue that the earth is not flat and I find the prospect of an eternal flame war in the comments unappetizing. So I'm going to make my case for the intuitively obvious and then I'm going to leave it there.

Good things about Medicare:

  1. I wasn't alive in 1965, so I don't know about then, but now, medical care is really expensive. Especially if you're sick. Especially especially if you're old and sick. Because old people always die (100% of the time!) and they often get sick shortly before they die. If you are old and sick and not named Warren Buffett, you might have trouble paying for your health care out of pocket. So you would probably have to go get medical insurance to pay for your health care. But the problem is, you're old, and that means you probably don't work any more, so you can't go to your employer for health insurance. And so you would have to go to that nice Mr McGuire at UnitedHealth to see if he would like to sell you some insurance. Now Mr McGuire doesn't want to give away his shareholders' money by taking on a lot of clients whose claims are likely to exceed their premiums ('cause you're old and sick), so he's either going to decline to sell you insurance, or he's going to charge you an actuarially-derived premium that will cover the expenses you are likely to generate. Since you're old (and sick), this is probably going to be a lot of money -- statistically the same as paying out of pocket, because that's what actuaries do. Since we already established (see above) that you are not Warren Buffett, you probably can't afford that. So, you see, it is going to be hard to find a for-profit private company that can create an affordable business model that includes paying for health care for the people who are statistically most likely to cost money. It turns out that this is something that government does well, because they can collect premiums and taxes and they don't need to make a profit.
  2. Medicare is really, really efficient. I run a $16 million, 50-physician corporation. Medicare is our best payer. No, they don't pay us the most, more's the pity. But they pay us the fastest, and with the least hassle. The average claim lag is like two weeks, and they never ever reject a claim. If all my patients were on Medicare, I would collect somewhat less money, but the administrative savings would almost-but-not-quite make up the difference.
  3. Medicare is really, really efficient operationally. Their administrative overhead is about 3%, which is to say that of every dollar in their budget, 97% goes out in claims paid. Private insurance firms simply cannot be this efficient. The typical overhead for commercial insurance, depending on which data you think is most accurate, is between 8 and 20%. (This is also consistent with my experience administering a medical insurance plan for our employees.) Medicare has some inherent advantages in this game -- it's not a fair fight. they don't have to pay stockholders a profit, nor executive salaries, nor do they need to market their services much. Since they have no profit motive, neither do they need to spend a lot of money figuring out the best way to deny claims, nor do they need to engage in pesky maintenance of a network of physicians. (Consider this fact the next time you rail against inefficient government bureaucracy.)
  4. Patients love it. When I said medicare was one of the most popular government programs, I was not referring to its popularity within the medical community, but among its 43 million beneficiaries. As I said, I am grumpy and too irritated to pull up real data, but here is one study showing Medicare as the third-most popular government service. (Strangely enough, behind the National Park Service. Go Smokey!) Or you can sift through the 250,000 hits on this Google search yourself and the many media reports which refer to medicare as a wildly popular service.
Now, having thrown out the troll bait, I will immunize myself a bit against the inevitable backlash. Yes, there are bad things about medicare, some inherent, some remediable. Here are a few, but none in my opinion are so awful that they outweigh the massive benefits of having the program around in the first place.
  1. Medicare distorts the market. They set the price for medical services in two ways. First, their conversion factor, updated annually, determines how much docs get paid en masse: Medicare is the biggest payer, and many private insurers pattern their reimbursement on Medicare rates. Second, their adoption of the RVRBS and the procedure-based bias of the RUC prevents physicians from setting prices for individual services at the level that the market could bear. This is directly responsible for the declining reimbursement that is so threatening the future of primary care in this nation. (This is partially remediable -- the RVRBS can be fixed, but Medicare will always be the 800-lb gorilla setting prices.)
  2. Medicare may be my best payer, but it's also the only one that can send me to jail. If Blue Cross doesn't like my coding, they can demand a refund. If Medicare audits me, or if the RAC contractors start paying attention to physicians, I have no recourse.
  3. Medicare is intrusive. When you get a letter from your local QIO suggesting that you have an EMTALA violation and they want to review all of your transfers for the last three years, that's a bad day for your practice. They set half-thought-out P4P measures, force you to accept the burden of the Joint Commission and EMTALA, and bring out half-baked Quality Measures of the week.
  4. Medicare is fickle. The reimbursement is subject to the whims of Congress in the budgetary cycle, and the SGR is the sword of Damocles hanging over our heads. The reimbursement level is always shrinking, which is not sustainable over thee long haul.
  5. Medicare is expensive, and has more severe sustainability issues. This is not the fault of the program. The growth of Medicare is almost entirely driven by two factors: the rate of inflation of medical services to all comers has drastically exceeded the general rate of inflation over the past two decades; and the demographic "graying of America." Simply, Congress is going to need to face up to this fact and increase the FICA tax to support medicare, or it will go broke. It is possible that this necessity can be staved off for a while with means-testing or benefit reductions, but it's coming and is inevitable.
Enough. Also, it's off-topic but I'll say it again, before the inevitable comments spring up: I am not in favor of Single Payer. It's theoretically appealing, but fundamentally flawed. Medicare is not single payer, and my support for Medicare does not indicate that I am secretly in the tank for single payer. Medicare is special case where government provision of this service is better than private, and we should all be glad that Ronald Reagan and his right-wing apparatchiks were defeated when they sought to block its enactment. I can only hope that we can be similarly successful in transitioning to a universal health insurance system.

(Fun link: Krugman, discussing and linking to the history of the right's efforts to block Medicare.)

03 October 2008

Reagan and Medicare

I was struck by this line Palin used in the debate the yesterday:

Freedom is always just one generation away from extinction. We don’t pass it to our children in the bloodstream; we have to fight for it and protect it, and then hand it to them so that they shall do the same, or we’re going to find ourselves spending our sunset years telling our children and our children’s children about a time in America, back in the day, when men and women were free.
I did not realize at the time that she was quoting Ronald Reagan (She cited him, but I must have been typing and missed it), but the line jumped out at me as uncharacteristically eloquent for her. It didn't have a "youbetcha" attached to it, which was a dead giveaway that it was pre-scripted. So I was not terribly surprised in the postgame show to hear the origin of the quote; I could easily imagine President Reagan saying that in a State of the Union address.

Except that it wasn't President Reagan who said it. It was private citizen Reagan who said it in 1961, in a jeremiad against Medicare titled "Ronald Reagan speaks out against Socialized Medicine."

Listen to it. It's quite a blast from the past. I am always fascinated by reminders that Reagan had such a long history of political activism prior to becoming President (his election is the first one I clearly remember). Also interesting is that this was an LP commissioned and distributed by the AMA. I forget how regressive an organization it was back in the day.

It's also instructive to listen to it and see how profoundly wrong he was. He decries this "compulsory insurance" program as unwise and unnecessary, predicts that it will restrict the freedom of doctors to choose where they practice and the freedom of patients to choose their doctors. He is very clear in asserting that this is the "foot in the door" of socialism and that the inevitable consequence of enacting Medicare will be the downfall of capitalism.

Of course, it didn't quite turn out that way. Medicare isn't perfect, but forty years down the road, it's fair to say that it's the most successful government program ever. (Save perhaps Social Security.) It's wildly popular, and yes, even more efficient than private insurance. I'm not going to defend Medicare carte blanche -- it has many flaws, some inherent, some reparable, and the rate of medical inflation poses problems going forward. But in the long run, it is completely clear and inarguable that it has been a huge success and America, and American medicine, are much better off for having it. When you listen to Reagan's warnings, note how similar they are to the prophecies of doom uttered by the current opponents of universal health care. The plans on the table are considerably better than Medicare -- they are market-based and are not single-payer. So listen to Reagan, and remember that the opponents of government-adminstered health insurance were wrong in 1961, and they are wrong today.

(h/t Yglesias)

Something you don't see every day

We had a trauma patient recently who was in her third trimester of pregnancy.

It was a bad trauma: motorcycle-related with multisystem injuries and a frankly unstable patient. We knew she was pregnant but had an urgent need for definitive imaging, so the decision was made to obtain a CT scan. Here are the rather uncommon images:

This is a transverse image through the mid-uterus. Clearly visible is the bony skull, midface, hands forearms and legs of the fetus. I may be incorrect (any radiologists out there?) but I believe there is a small amount of fluid, probably blood, in the right paracolic gutter.

Our hospital has been doing gee-whiz coronal reconstructions routinely on scans, and this one is even more gripping. You can see the baby in near-perfect profile:
Again, fluid is visible in the right lower quadrant.

Trauma in pregnancy is complicated with regard to imaging. You need to try to minimize the amount of radiation while not compromising the care of the patient. Ultrasound is a good screening tool (especially for the well-being of the fetus), but does not provide great detail for the solid organs and viscera, nor for the retroperitoneum. Pelvic fractures (which this patient had, but are not visible on these images) and their concomitant injuries are essentially only visible on CT. But the radiation dose is somewhere around 500 mRem, or about 50 times the chest x-ray dose, with the radiation focused on the fetus. So there's a complex risk-benefit calculation you need to do before ordering the test. In this case, the fact that the baby was more than 20 weeks gave us a bit more latitude -- the risks of radiation are highest in the first twelve weeks, when the organs are being formed.

For stable patients, I have seen abdominal MRI utilized, which has the advantage of not irradiating the embryo, but the disadvantage of being time-consuming, difficult to obtain, and requiring the patient to be stable enough to sequester in the tube for the scan. I don't know whether there is any diagnostic advantage to CT or MR in trauma; almost all our experience is with CT, but I would imagine that the MR images are sensitive for most injuries, possibly moreso than CT for some.

I wish I could say there was a happy outcome to this case. Unfortunately, both mother and baby expired due to reasons unrelated to the findings on these images. As I said, it was a bad trauma and we knew from the moment the patient arrived that the odds were poor. A peri-mortem C-section was not an option, as the fetus expired first. I felt, however, that these scans were of sufficient educational interest to be worth posting, as they are quite unusual and they touch on an interesting management conundrum.

Thankfully, this is not a dilemma we ahve to wrestle with too often.

Deep Thought

Creeping through the house in the predawn darkness, the iPhone serves
as an excellent flashlight.

01 October 2008

I am voting for John McCain

It is with a heavy heart that I rescind my allegiance to Barack Obama for President, and announce that I will be supporting his rival, John McCain of Arizona. While I disagree with almost every policy and position he holds, and I find his ideology frightening and his character lacking, I learned today that Senator Obama bears a character flaw so deep, so shameful, so disgraceful that I can no longer support his candidacy.

I am referring, of course, to Senator Obama's stated support of the White Sox, and his mean-spirited, derisive, unpresidential comments about the Chicago Cubs.

I am sorry to subject you all to such disturbing images, but it needs to be out there. Can we trust a man willing to wear the black and white? Can America stand the moral stain of such a man in the Oval Office? I think not. We need a President who can bring honor and dignity back to the White House, and such a man clearly cannot.

I should have supported Hillary when I had the chance. She at least was on the right side -- the North Side. But wait, what's that you say? She was a traitoress, willing to wear black pinstripes when the political winds blew in their favor?

Ouch. That's even worse.

But McCain. He's a safe choice in these troubled times. The Diamondbacks aren't even in the playoffs. I'm not even sure they're still in the Major Leagues. And McCain isn't aware of them -- they're an expansion team, and I don't think he noticed in 1997 when they were created. For that matter, I don't think he noticed in 1969 when they started playing League Championship Series.

But he's not a White Sox Fan. So I can vote for him.

Go Cubs!