31 October 2009

Happy Halloween

Credit: Ces

29 October 2009

House Health Care Reform Bill released

You know you're deeply over the line into nerdy obsession when, upon the posting of a 1900-page reform bill, you immediately download it and start skimming the headings.  Fortunately, I didn't have anything else going on today.

The bullet point summary:
  • As widely reported, the "Robust" public option is dead; long live the "Weak" public option!  Enough House moderates - citing fiscal conservatism - rejected the cheaper option which would have paid providers at Medicare + 5%, and the bill as released would require the public option to negotiate fee schedules with providers like any other insurance company. IMHO, this is better policy even though it costs more, but hypocritical Blue Dogs get under my skin.
  • 96% of legal American residents covered.
  • The bill is Deficit Neutral and actually reduces the deficit by $100 Billion over ten years.
  • Total expenditures are in the region of $900 Billion.
  • Slows the rate of growth of Medicare from 6.6% to 5.3% annually.
  • Expands Medicaid to 150% of federal poverty level (and I didn't find the citation but I read the Feds were going to pay 75% of the costs of the expansion).
  • Financed though savings in Medicare Advantage, taxes on families earning >$1 million, individuals earning more than $500,000, taxes on the insurance industry and medical device makers.
  • The Insurance industry's anti-trust exemption is revoked.
  • Curiously, it allows states to make "insurance compacts" which will allow insurers to market policies across state lines -- a long-time conservative goal.
  • Closes Medicare Part D donut hole
  • All the typical insurance regulations, Insurance Exchanges, etc, with a strong employer mandate (8% of payroll for large companies).

Things of particular interest to me:

  • Sec 1123 states that regions of the country (by county) which are in the top 5% most efficient in delivering care (on a cost per capita basis) will receive a 5% bonus on their medicare payments.   (I'm in one of those areas!  Woo Hoo!)
  • Primary care docs will receive a 5% bonus as well, and a 10% bonus if they are in a primacy care shortage area.
  • Primary care docs providing services to Medicaid patients will be paid at Medicare rates.  This is a huge boost to the primary care infrastructure as regarding access for the poor. 
  • The SGR fix, which drove up the cost of the bill by $240 Billion, has been dropped.  Wonder if the AMA will drop their support.  Pelosi says the SGR will be addressed in a separate vehicle.
  • Death Panels are back!  Sec 1233 authorizes Medicare to pay for a VOLUNTARY consultation on advanced care planning once every five years.  Calling Betsy McCaughey!
  • Sec 1152 includes a "Bundling Pilot Program" in which a single payment would be made to all providers in an acute hospitalization and the post-acute care.  How that gets divided between the docs and hospital will be a feeding frenzy.
  • "Sunshine policy" requiring drug & device manufacturers to disclose all payments to physicians, and hospitals to disclose ownership by physicians.
  • CMS will be granted the authority to revalue codes or families of codes which it finds to be misvalued. I'm not sure what exactly this is targets at but the verbiage implies that there are codes which Medicare feels are being abused by docs and they intend to stop paying them or dramatically reduce the amount they will pay for them.

After I'd already spent an hour combing through the full bill, I found this nice, easily readable 10-page PDF summary on the House Education & Labor Committee web site.

Overall it looks surprisingly good.  Igor over at the Wonk Room has a great summary why conservatives should support this health reform bill, at least if this were a sane political environment.  I agree with it entirely with the exception of the medical malpractice reform provision, which is window dressing only.

Lots of eyes

Amazing Macro images of spiders:

Rabid Wolf Spider

Be sure to check out more of these amazing pics at Thomas Strahan's photostream.

Ultrasound in the ED

What Shari Welch Said.

Ultrasound is a neat toy, and I'm all about toys.  I found two opportunities to play with enhance patient care with our ultrasound today on my shift.  But it doesn't have the bang for the buck that the enthusiasts think it does.   It has very narrow, but real, utility, and does nothing to generate revenue.  It does in some cases enhance patient turnaround, and it certainly enhances patient satisfaction (they love cool toys as much as we do -- and extra face time with the doctor to boot!).  But that's a small return on a machine costing tens of thousands of dollars.

But what Dr Welch is griping about is not just the cost of the machine (after all, the hospital pays for that), but about the hassle and time required to generate a professional bill for ED ultrasounds.  The rules are fairly clear -- you need to archive the images, you need to generate a report comparable to that which a radiologist would have done (which is not to say that you need to perform a complete exam; the "limited" disclaimer will exempt you from the requirements for a complete exam, though you will bill out at a lower code as a result), and you need to perform regular Quality Assurance.  It's a big commitment, and if you are really going to comply with these rules it will take a lot of administrative time, and will certainly slow down a busy ER doc trying to, um, move the meat.  As an entrepreneur, I'm all about trying to maximize the income stream.   Is there potential revenue in ultrsound?  Yeah, sure, some.  Not a lot, and definitely less than the opportunity lost in the time required to realize that revenue.

I kinda hate to be a wet blanket on this point.  I mean, it's a gadget!  How can I *not* be insanely enthusiastic about it?  Turns out it's kinda like my old Palm Pilot (yes, I am old enough to remember when it was called the Pilot).  I was the early adopter, got one as soon as they hit the market.  Showed everyone how cool it was and evangelized about how it was going to change the way doctors interacted with patient data.  Slowly it started to get used less and less till it ended up in my desk drawer.  The ultrasound's not relegated to that ignominious fate and I doubt it will be.  But neither will it ever be one of those "I don't know how I ever got by without it" things.

28 October 2009

Parody and reality are converging

This is sadly plausible:

Obama's Declaration Of Swine Flu Emergency Prompts Pro-Swine-Flu Republican Response

October 28, 2009 

WASHINGTON—Claiming that the president was preying on the public's fear of contracting a fatal disease last week when he declared the H1N1 virus a national emergency, Republican leaders announced Wednesday that they were officially endorsing the swine flu. "Thousands of Americans—hardworking ordinary Americans like you and me—already have H1N1," Republican National Committee chairman Michael Steele said during a press conference. "Now Obama wants to take that away from us. Ask yourself: Do you want the federal government making these kinds of health care decisions for you and your family?" Other prominent Republicans opposing Obama's declaration of emergency include Louisiana governor Bobby Jindal, who urged residents of his state to continue not washing their hands, and radio host Rush Limbaugh, who made a point of dying of the virus during his show on Wednesday.

Perhaps it's not true, but I stand by the fabricated quote because we know they think it anyway.

Another flow chart

This one's just for the Padre:

Equally opportunity offense!

27 October 2009

OK, just one quick off-topic post

I so love flowcharts

Via Pharyngula

Light Blogging

Apparently my employer expects me to prioritize work over blogging. These people are entirely unreasonable.

24 October 2009

Well this is just beautiful

Never liked that song until now.  Eerie and beautiful.


23 October 2009


Per Sully:

A recent Pew Poll showed the following:
57 % of Americans believe in man-made global warming
79 % know that the earth goes around the sun
80 % believe that prayer accelerates healing
75 % believe in Angels
39 % believe in evolution
Hoo-boy.  We're screwed.

22 October 2009

Aminating XKCD

I Love xkcd from NoamR on Vimeo.

Charming. There's no limit to what geeks will do with too much time on their hands.

Original here.

There's a blog for that

All-time iconic photos, explicated daily? Check.

One of my favorites.

SGR Still Broken

It wasn't terribly surprising, since the signals had been plain for a couple of days, but the proposed fix for the Sustainable Growth Rate was defeated in the Senate yesterday.  All republicans plus about a dozen democrats voted against the repeal, so it wasn't even close.

Igor over at the Wonk Room points out that Mitch McConnell opportunistically and hypocritically criticized the dems for trying to deficit finance the SGR repeal, despite the fact that McConnell has repeatedly voted for deficit-financed single-year SGR patches.  McConnell also voted for the $1.1 Trillion deficit-financed Medicare Part D (the drug benefit).  Having said that, it is entirely right that it was a weak and irresponsible maneuver on the Democrats' part to try to repeal the SGR without finding an offset.  Just because their predecessors were criminally reckless with the nation's fiscal future should not give the Dems license to follow in their footsteps.  That's part of the reason that the GOP got thrown out -- people wanted responsible governance.  Obama has taken some positive steps in getting rid of Bush's accounting gimmicks.  For example, his budget outlooks have included the presumption that the SGR-mandated reduction in physician compensation would not actually happen, thus admitting that the deficit projections are worse than they actually were under Bush's projections, which assumed that Congress would allow the cuts to go forward.

However, Jon Chait at TNR is quite right that it's dishonest to attack this as a failing of "Obamacare."  It's a problem which predates Obama's administration by a decade, and even without the greater health reform effort, Congress was going to have to grapple with this sooner or later. 

It's to the credit of the Democrats' efforts that the House Bill, the much-maligned 1,000-page HR 3200 does include a repeal of the SGR, which to my understanding was fully paid for and not deficit financed.  Hopefully, when (if) the process advances to the point that there are House and Senate bills to reconcile, that component of the House bill will be adopted in the final legislation, or we will just go back to the high-drama, high-stakes annual game of "stop the SGR cuts."

Rape is a pre-existing condition

Charming, if true. I'm so glad we have Ben Nelson and Blanche Lincoln working tirelessly on the Hill to protect and preserve the insurance companies and their profits.

Christina Turner feared that she might have been sexually assaulted after two men slipped her a knockout drug. She thought she was taking proper precautions when her doctor prescribed a month's worth of anti-AIDS medicine.

Only later did she learn that she had made herself all but uninsurable.

Turner had let the men buy her drinks at a bar in Fort Lauderdale. The next thing she knew, she said, she was lying on a roadside with cuts and bruises that indicated she had been raped. She never developed an HIV infection. But months later, when she lost her health insurance and sought new coverage, she ran into a problem.

Turner, 45, who used to be a health insurance underwriter herself, said the insurance companies examined her health records. Even after she explained the assault, the insurers would not sell her a policy because the HIV medication raised too many health questions. They told her they might reconsider in three or more years if she could prove that she was still AIDS-free.

I will say that I have some concerns whether this is true, the source being the Huffington Post and all.  On the other hand, it's certainly within the realm of possibility and fits the pattern of behavior long exhibited by the insurance companies, so I'm inclined to grant it some credibility unless or until it is debunked.

As health insurance reform nears passage, it's stories like this that remind us why we need to hold fast and get the job done.  These bastards have brought it upon themselves with their despicable practices.

21 October 2009

What I'm eating

Apple Cobbler

Home made Apple Cobbler, made from apples picked in our front yard.

Yeah, you should be envying me right now.

Auto-tuning science

I'm only modestly interested in the whole auto-tuning phenomenon, but I have to admit that I really enjoyed this: Carl Sagan, Bill Nye (The Science Guy), Neil deGrasse Tyson, and Feynman:
I've watched it several times over and I still can't help smiling.

Courtesy of Symphony of Science

19 October 2009

'Cos I can't get enough of Dara O'Briain

You know you want to watch it:

18 October 2009

Like Peanut Butter and Chocolate

Two great things that go great together:

Mythbusters and the Blue Angels.

Those guys have the best jobs on earth. And that applies to both the Mythbusters and the Angels.

I'm so happy I had Influenza

Because of my 21 patients tonight, no fewer than eleven had an influenza-like illness.  We're not even bothering to test for it any more.   The sensitivity of the test is about 70%, which is not much better than flipping a coin), and the CDC isn't recommending Tamiflu for healthy people, so why bother? 

But I felt like a commando going right in while everybody else hovered about in their (useless) N95 masks.  I was totally unafraid because I've already had influenza!  You can't make me sick!

At least I hope not.

Funny side-note:  We spent a whole bunch of time/money getting everybody in the ER fitted for N95 masks and developing the respiratory isolation protocols, and where do the patients with influenza get placed?  In gurneys lining the hallways.  Of course.

16 October 2009

There's a Rep for That

Clever parody of an iPhone commercial

Oh please don't ask me that

I was camping not too long ago when my oldest son and I were lucky enough to see the most amazing shooting star I have ever seen in my life.  Not the one pictured above -- I didn't have a camera handy -- but it looked about the same.  (See the Bad Astronomer for the awesome backstory on the above picture.)  It was the coolest thing I have ever personally seen.  It lit up half the sky as it streaked across with the most incredible speed; it was brighter than any firework I have ever seen.  And in an instant, it was gone.  We continued to hang out by the campfire for a while, every so often reflexively looking back at the sector of the sky where the fireball had been, as if it might be there again.  It was certainly the most remarkable event of an eventful day.  As we walked back to the cabin, my son asked me a question that kids must have been asking their parents for millennia: "Dad, that shooting star was cool, but what did it mean?"

I explained that it didn't mean anything.  It was just a hunk of rock becoming superheated as it slammed into our atmosphere at thousands of miles per hour.  Ultra cool science-y explanation, but it clearly left him unsatisfied.  He was hoping for something more.  I could imagine in ages past how a father might make up a satisfying explanation regarding the anger of the gods, or an omen of good fortune, and how readily a prescientific community would accept such an explanation.  It was the most amazing event -- it just had to mean something.

I've noticed that this is just the way people are.  We have a deep seated need to look for patterns, to find the deeper meaning in things.  It's how we make our living, evolutionarily speaking.  We figure out how things work, find the causation, and exploit it to our advantage.  It's natural and a highly adaptive trait.

But it also is one that drives me nuts, in my professional life.  That terrible question -- "What does it mean?" -- is one that one that stops me in my tracks, raises my hackles and induces an involuntary inward cringe.

I see a lot of people who come to the ER after experiencing an unusual physiologic phenomenon.  Whether it's a fainting spell, or sudden loss of vision, or an intense bout of dizziness, they are often really freaked out.  I don't blame them.  I've experienced vertigo -- it's a shocking thing to go through.  Nothing in your experience prepares you for the feeling that the world is whipping around at 33-1/3 rpm.   I do my thing -- check them out, make them feel better, and explain the cause in as much detail as seems appropriate.   Generally, patients are grateful and receptive, especially once I've reassured them that what they are experiencing is not dangerous.   It never seems to fail, though, that as I put my hand on the proverbial doorknob to step out, I get that awful question, "But doctor, what does it mean?"  Just like the fiery streak across the sky, when it happens to you it's such a remarkable thing that it simply has to have some deeper meaning.

This question is an absolute rhetorical haymaker because, just as with my son and the technical explanation of a meteor, the technical explanation of vertigo (or syncope, a TIA, etc) is completely unsatisfactory to the patient.  Unlike a seven year-old child, however, the patients are adults, infinitely more concerned, and I have something of an obligation to answer their concerns.  And it just can't be done.  99% of the time the answer to "what does it mean?" boils down to either "I really have no clue what actually happened" or "it's just one of those things."  You can guess how well that goes over.  You offer up such weak tea to an anxious patient and you are either guaranteed an irritated and unsatisfied patient, or a thirty-minute question-and-answer session till they're finally content.

I've learned that the best response is a redirect: "You know, the ER's not really the best place for philosophy..." and then to bring it right back to the pragmatic concerns: "What it doesn't mean is that you are at increased risk for having a stroke..." or whatever seems to be the real underlying fear the patient may have been harboring.  That seems to work as well as any other response I've tried.

Every time I hear that question, I swear it takes years off of my life.

Once Again Medium Large makes me spew my coffee

Oh man this is funny:

Link here

15 October 2009

Um, is there something I should know?

I walked out the back of the ER tonight to see this in the ambulance bay:
Uploaded with plasq's Skitch!

And this inside:
Uploaded with plasq's Skitch!

OK, it looked pretty cool.  Surprisingly big inside, too.  But what the hell was it doing there?  Sure, we're seeing a lot of pandemic influenza just now, but the ER is handling it well, at least as well as we usually do, bulging at the seams as we are.  Maybe the hospital or EMS are just running some drills.  But it makes me worry that someone out there has inside information that things are about to get a lot worse...

14 October 2009


Seriously.  And get the damn shot.

In our community, there was a six-year old with H1N1 who developed pneumonia and staph sepsis (MRSA, of course).  Resulted in septic emboli and necrotizing fasciitis. Very grim prognosis.

Get the shot.

13 October 2009

That's why they call them "Donorcycles"

Creepy Analysis of Motorcycle Helmet Laws [PDF]:
Our estimates imply that every death of a helmetless motorcyclist prevents or delays as many as 0.33 deaths among individuals on organ transplant waiting lists.
That's awesome.  No, not awesome: terrible.  Maybe both.  I don't know what to say, except it's somewhere on the fine line between fricking awesome and completely awful that someone went through and did the math on this one.

(via Crazy Andy)

What I hear when I close my eyes to sleep

If you have kids you will understand.  Laurie Berkner is actually pretty nice, catchy and inoffensive.  Almost enjoyable.  The first thirty thousand times you hear her, anyway...

I get to be part of the (Pandemic) club

It's been sort of weird the last few weeks. There has been so much noise in the media about the H1N1 influenza outbreak. I've been reading about overwhelmed ERs, triage in the parking garages, twenty-year olds on ventilators. It's scary stuff. One ER friend tells me his department volume is up 40% due to H1N1. We've dusted off the disaster plans and have been ready to go for a while now.

But instead: nothing. We sat in our near-empty department and stared at one another wondering when the tidal wave was going to hit. It's been a little like working New Years Eve, or during the Super Bowl. You know you're going to get crushed but you don't know exactly when or how bad it's going to be. Frankly, I was starting to feel a little left out, as everybody else got into the game and we were left on the sidelines.

No more. The other shoe has now hit the floor. We are off the tenterhooks. The suspense has ended and the pandemic has officially hit our corner of the Northwest. Surprisingly, it hit abruptly. One day I saw zero influenza-like illnesses. The next day they represented 50% of my cases. Strangely, I feel relief. It's game time.

On another note, I came into my shift today and the nursing station was consumed by a vigorous debate over whether we should "take" the H1N1 vaccine. There's no obligation to do so at our hospital, but the infection control people are being quite diligent in trying to get through to everybody. And this just freaking blows my mind. We are health care providers. We are supposed to be smarter than this. When you have thought leaders in the field of health care writing op-eds in the New York Times practically begging caregivers to get the vaccine, and still there is widespread uncertainly whether it would be a good idea or not, then we've lost. It's official, folks: Jenny McCarthy and Oprah have won. Vaccines are the agents of the devil; science and evidence-based medicine have been once and for all repudiated. When the debaters asked me whether I thought we should get vaccinated, I perhaps a bit too caustically opined that it was either embrace the vaccines or give up the ghost and go back to bloodletting and purging evil humours.

Maybe we'd be better off with homeopathic vaccines. They're injections of water, but they were once near someone who had had the flu.

Seriously folks, get the fricking vaccine. It's safe -- much safer than the influenza, and far far less miserable. I had the misfortune to get H1N1 in May, and it was the sickest I have ever been in my adult life. I was prostrate for five days, and there are long spans of time that I just don't remember. Especially if you or a loved one are high-risk: very young, very old, or pregnant. Get the damn shot.

Frankly, though, I have no sympathy for any health care provider who chooses not to get immunized. I hope they do get influenza. They will deserve it. Hopefully they won't get too many of their co-workers and patients sick along with them.

Health Care and Cost-shifting

Ezra has blogged skeptically about this more than once, and he's not the only one.  To explain, health care providers have been arguing for years that Medicare is underfunded -- that the reimbursements from Medicare do not cover the cost of providing the services.  Medicaid reimbursement is even worse.  Providers claim that this has forced us to charge privately insured patients more to offset the low reimbursement from the public programs.  Understand that "providers" include both physicians as well as hospitals.

There's some logic to the skepticism: Keith Hennessy summarized it nicely:
If you believe that a hospital will raise the prices it charges privately insured patients in reaction to cuts in reimbursement rates from government programs, you must believe (1) the hospital has pricing power and (2) it has until now charged less than it could. (1) is quite plausible in some circumstances. I find (2) incredible. If someone has pricing power, I generally believe they will exert it. Are we to believe that providers of medical care were charging privately insured patients less than they could have before the cuts in government payment rates?
From a theoretical economic point of view, this is accurate.  If health care providers were perfectly rational actors operating in a vacuum where their only goal was to maximize revenue, it would make sense.  You take what you can get.

But I would argue that the cost of providing health care -- especially for a hospital -- is relatively inelastic on a year-to-year basis.  The number of nurses, the payroll costs, the capital expenditures.  All of these are not quite fixed costs, but there is very limited ability to make drastic changes in them.  Yes, you can decide not to build the $300 million cancer center, or to build a less-opulent version of the cancer center for only $200 million -- there is long-range elasticity in the cost of providing care.  But once the buildings are in place, the scanners and equipment are purchased, and the staff is hired, the need to meet this year's operating budget becomes imperative. 

Government-funded revenue is completely fixed.  It's inelastic. There's no negotiation possible -- the rates are set and providers can take them or leave them.  But prices with private payers are negotiable.  When you are looking at a budget shortfall, or in the case of physicians, declining physician compensation, and you need more money, there's only one place to go -- to the insurers.  It's the only variable source of funding.

It's true that the "rational" thing to do would be to maximize the revenue from the private insurers every single year.  But in the real world it turns out that it's not so easy.  Providers have limited leverage, and it is a bilateral negotiation with a very powerful opponent.  You can't fight a scorched-earth battle every year, and with every insurer.  The only real threat we have is to drop out of an insurer's network -- which is the "nuclear option" in the health care contracting world.  You make that threat every year, and soon enough the insurers stop believing it.  You follow through on the threat, and it is a massive war, with media attention and angry patients and the risk of losing money if patients leave and don't come back.  Worse, you could go to war and lose -- you bear the cost of the war in PR and lost revenue and wind up with lower reimbursement anyway.  There are real risks and costs of taking the hardest possible line in negotiating reimbursement rates with the private insurers. The analogy I use is that most insurers and providers live in a state of perpetual d├ętente.  We edge to the brink and back, over and over again.

(I should also point out that when we are at the negotiation table, there are human beings on the other side of it.  They may be "the enemy" and they may be motivated to minimize their costs, but they are also emotional and irrational at times.  As an ER doc, I am shameless about playing the "uninsured and Medicaid" card in negotiating.  This does evoke a sympathetic reaction.  It's not huge -- we don't all break out into tears and hug one another.  They know the realities of the situation, and they hate it, but it has an effect on the interpersonal dynamics.  Economists can argue the whether there is a causal relationship of cost-shifting, but there is a clear tactical relationship between the under-insured and increased private insurance compensation.)

So when do we go to the mat?  When do we pull the trigger?  When the budget crisis hits.  That can be caused by a drop in government funding, or the inciting factor could be anything else -- a change in the number of the uninsured, wage escalation, etc.   And I agree with the assertion that the pass-though is not 100%.   If nothing else, the insurers are not willing to give you 100% of your goal in every negotiation.  But the idea that there is no causal relationship is absurd.

So, yes, I would say to Dr Hennessy, there are times that health care providers do leave their leverage un-utilized.  I think of it as "keeping the powder dry," or "picking your battles carefully." 

There is, as the skeptics would note, an alternative to cost-shifting.  It's to accept the loss of revenue.  It's to cut back on services (or amenities), to cut back on staffing, to accept lower physician reimbursement.  That happens, too.  In fact, that is one of the big reasons for the problems in primary care -- physician income has been flat-to-negative and doctors don't want to do it anymore.   For many reformers, this is not a bug but a feature of the public option -- that it places pressure on hospitals and physicians to make less money, on the theory that we'll find ways to deliver the same care for cheaper.   I'm apprehensive about this, because it's such a blunt instrument.   This is why I'm not a single payer fan.  The strategy of just turning the screws on healthcare providers and leaving it to them to figure out how to eliminate excess costs seems simplistic and unlikely to succeed. 

10 October 2009

Managing the Inappropriate Plastics Consult

In the comments, a question was posed from reader "Seattle Plastic Surgery on Lake Union" (an online handle that is as unwieldy as it is descriptive).  He asks:
I would like to hear your opinion on a topic that is rapidly growing near and dear to my heart...the scenario is thus:

I'm on call, the local plastic surgeon, for the local ER. You are seeing a nice family with a child that has sustained a simple facial laceration. No fractures, no missing tissue, just a simple, linear, forhead laceration.

The Mom asks that a plastic surgeon be called to come in from home and close the wound. You reply that you are able to do the closure, the child is medically stable, and that a you are qualified to close the wound. The family presses you: call the plastic surgeon.

Can you tell me, from an ER doc's standpoint- what is the most appropriate response from the on call plastic surgeon?

In your experience, are families aware that they may be sent a second bill for the ER laceration closure by the on-call plastic surgeon? Are they made aware of this possibility?

Without question, if an ER doc tells me that they need me to close a laceration, due to its location, complexity etc...I come in to close it. But these 'parent requests' plastic surgeon call are becoming more frequent.

This is a pretty easy one, in my mind.  As posed, it's a wound that could even be treated with dermabond -- utterly ridiculous to consider calling in plastics.  There are times when it's OK to say no.  In fact, as the ER doctor, I would not even call the plastic surgeon in such a case.  I'd say no to the family straight off, and not make the surgeon be the bad guy.

But all life is a negotiation, and there are so very many shades of gray.

Consider a slightly more complex situation, where it's not a toddler with a simple forehead lac, but a fifteen-year-old girl with a stellate laceration of the forehead right between the eyebrows. This is a case where cosmesis is legitimately going to be very important to the patient/family.  But let's be honest: there's going to be a scar, and I'm quite doubtful that the cosmetic outcome is going to differ much whether the ER doc or the plastic surgeon does the repair.  In this example, the family's request for a plastic surgeon is more reasonable, but it's still probably not necessary.  How best might we handle this situation?

It should go without saying, but I'll say it anyway; the ER doc's first tactic in managing the family's request is to walk it back and attempt to build trust with the family.  Many people have no idea what ER doctors do, what our experience and training is, and some education can terminate the difficult interaction.  My general approach is to explain that ER physicians train extensively in plastic and reconstructive surgery (which was true for me, anyway. YMMV.) and that I had planned on specializing in plastics but realized that my attention span was short enough that ER was a better fit (also true).  Further, I explain, injuries like this one are the sort of thing I fix every single day and I have a lot of experience at it.  (This line seems to be more effective now that I have a bit of gray in my hair.)   I project confidence that I can do this; people pick up on that sort of thing, and any waffling from the doc is utterly fatal to getting buy-in from the family.  Then I offer the hook: I offer to go ahead and fix this up now and arrange follow-up with the surgeon to ensure that it heals as well as it possibly can.  This is having prefaced the discussion with the fact that there will be a scar no matter what -- some people have a slightly mystical notion of the powers of a plastic surgeon.  With my exceptional interpersonal skills (cough cough) I rarely have any problems with this approach.

So what when that fails?  When the family irrationally insists on an inappropriate consult?  For clear-cut cases, I tell the family flat-out that the surgeon will not come in for this.  They don't like that, but it's the truth.  But for the "gray zone" cases, I generally make the call.  I'm often surprised by the response I get.  Depending on the time of day, the person on call, and how the stock market is doing I can get very divergent answers.  Most commonly, however, the surgeon asks me if I am comfortable doing the repair, and if I am, they ask me to do it.

It hasn't happened to me that I recall, but there is always the possibility that you get off on the wrong foot with the family, or they're just really high-strung, and they draw a line in the sand: you are not going to touch my child.  This is when creative thinking can be your friend.   I know that I can compel the plastic surgeon to come in; EMTALA and all that.  But it's a bad decision to do so; you burn bridges that way, and soon enough either you're out of a job or your call schedule has no plastic surgeon on it.  My opinion is that a reasonable compromise approach to the adamant demand for a plastic surgeon is this: the ER doctor should extensively irrigate the wound and place a temporary closure, whether it be steri-strips or a couple of stitches to tack the meat back together.  In return for not having their rear end dragged out of bed at midnight, it's fair to ask the surgeon to commit to seeing the patient in the office within a reasonable timeframe for a definitive closure.

In fact, I have used this approach for cases that I knew would require a plastic surgeon.   When you have a nasty wound that is going to require revision, flap undermining, etc, but doesn't need to be done in the OR, there's an argument to be made that the surgeon may be able to better accomplish it in the controlled environment of the office surgical suite, where they have the all their tools and an assistant and all the time they need.  Moreover, I think it's highly likely that a surgeon will do better work at 9AM than at 2AM.  The time-sensitive aspects of wound management are irrigation and hemostasis: if the ER doc can do them in the middle of the night, the surgeon can do a lovely repair in the morning.

So, SPSOLU, there's my answer for you: offer to see them in the morning.  And if the family complains about having to have more than one procedure on their delicate child, explain that's the price of having a specialist perform the repair.

08 October 2009

Home for a Rest

I've only been away for four days, not a month, but I do need a rest.  Regular posting to resume shortly...

04 October 2009

Differential, schmifferential

Nice dodge there, Dr. Shadowfax. I'd like to review a couple of journal articles for all the ER folks out there who may not be familiar with the pediatric literature, to aid you in the management of patients such as the school-age kid with pleocytosis. I'm not sure about the literature in the adult world, since I stopped caring following it closely a dozen years ago or more. In the world of kids though, it can be devilishly tricky to figure out which kids have aseptic (viral) and which have bacterial meningitis, particularly since the incredibly effective vaccines for Haemophilus influenza B and Streptococcus pneumonia have drastically reduced the number of kids who get bacterial meningitis in the first place.

Enter Dr. Lise Nigrovic from haavad (say hi while you're in Boston, Dr. S!), and her group's development of a multivariable predictive model to distinguish the two entities. Using a set of nearly 700 patients with meningitis (1:4 ratio of bacterial to viral meningitis), they first randomly-selected 1/3 of them as the "derivation set." They then analyzed this subgroup to find the variables that differ in patients with bacterial vs. viral sources of infection. They found a model that used a Bacterial Meningitis Score (BMS) with one point for any of the following:

  • CSF Protein >= 80
  • CSF ANC >= 1,000
  • Peripheral ANC >= 10,000
  • Seizure before or at presentation
Plus 2 points for:
  • CSF Gram Stain + for bacteria
Interestingly, the types of white cells found in the CSF did not enter this model. Using these variables, they used the other 2/3 of patients as the "validation set." In these patients a BMS of 0 was found to have a negative predictive value for bacterial meningitis of 100%!! OK, OK, nothing is 100% in medicine, but this is pretty close with confidence intervals 97-100%. The sensitivity of a BMS >=2 for predicting bacterial meningitis was also impressively high, 87%.

This study has since been validated in a multicenter study done in the era of widespread Pneumococcal-vaccine use.

Certainly there are many reasons for admitting a child at low risk (BMS = 0) of bacterial meningitis: vomiting, intractable pain, lack of appropriate follow-up, or lack of an appropriate (or sufficiently reassured) caregiver. However in many instances the BMS can be a useful tool in changing your disposition from "slam-dunk admit" to "home to rest and recover."

  1. Development and Validation of a Multivariable Predictive Model to Distinguish Bacterial From Aseptic Meningitis in Children in the Post-Haemophilus influenzae Era. PEDIATRICS Vol. 110 No. 4 October 2002, pp. 712-719
  2. Clinical Prediction Rule for Identifying Children With Cerebrospinal Fluid Pleocytosis at Very Low Risk of Bacterial Meningitis. JAMA Vol. 297 No. 1, January 3, 2007

I'm Shipping up to Boston

For ACEP's Scientific Assembly.  Expect to socialize and drink heavily in the evenings.  Any medtweeps heading there should email me or send me a DM on Twitter if you want to get together.

03 October 2009

Dodged one


Saw a nine-year old with a headache today.  His dad brought him in, and explained that all the men in his family get migraines; he figured this was his son's first one.  The kid seemed perfectly well, with a positive Cheetos sign and my gut instinct was that I would discharge him with no work-up.  But when I flexed his neck fully, he winced.

Just a tiny bit, for a fleeting moment.  I almost missed it.  I asked him, "Did that hurt?"  He said no, without hesitation.  Flexed it again.  No resistance, not a shred, but again the minuscule flicker of discomfort across his face.  "That hurt, didn't it?"  He assured me that it did not.

I decided to tap him. 

Very satisfying tap: first poke, as it should be, and almost painless for the lad.  Positive white cells on the tap, and a non-reassuring differential (almost all neutrophils, indicating possible bacterial meningitis).  Weird -- he looked great, still eating Cheetos when I got the tap results.  Not even a fever.

I'm hoping it's viral, for his sake.  But still: I came that close to just sending him home.

I should buy myself a lottery ticket.

His dad should buy one, too.

01 October 2009

It's The Stocks, Stupid

A couple of weeks ago the good Dr. Shadowfax treated us to a humorous cartoon explaining the healthcare debate. In the cartoon we see that Medicare only spends around 3% of the money it receives on administrative overhead, whereas private insurers typically spend 3-6 times that amount while paying their executives obscene amounts of cash as a reward for denying patients the care they need.

Catron gave a dismissive comment regarding the severe lack of education on the economic nature of the problem. While he mentions the simplistic cartoon portrayal of the Healthcare Industry, he did not offer any evidence or argument on why this was the case. It made me start to think about economic models of the insurance industry in general, and specifically how this applies to Healthcare.

One of the key insights relates to understanding that many companies are not in the business you think that they are in. With a tip of the hat to Douglas Adams, think of how Xerox is not actually in the copy machine business. They are in the business of selling toner cartridges (Gillete is in a similar business model). If you are an insurance company, you are not in the business of distributing risk; rather, you are in the banking business. Insurance companies have a lag period between when a claim is made and when they pay out each claim. In the meantime, they have collected premiums from a large pool of individuals, and put this money to work on making more money through investment in a variety of instruments: bonds, stocks, etc. If they are smart about their investing (or lucky, as I suspect), then they end up with high profits. This can lead to lower premiums when the stock market is doing well, and higher premiums when the stock market is doing poorly. I first learned of this trend through an analysis of Malpractice Insurance Premiums, (link is to PDF file) which correlate well with stocks' performance, and poorly with $$ spent on claims.

What would happen if the 14 billion Healthcare insurance industry was taken over by an entity like Medicare? That enormous sum of money would no longer be contributing to the growth of the stock market through private insurance investment. I have a suspicion that this is the chief reason that the Republican party holds such a deep opposition to a public plan option, and to Healthcare Reform in general.

So although the portrayal of the economic reality in the cartoon might have been simplistic, it does raise a very valid point. Are we choosing to continue to give our money to a profit-based system that incentivizes maximum returns, or will we instead choose an efficiency-based system that incentivizes delivery of Healthcare?

Introducing: Dr. Matlatzinca

Greetings and salutations to all of Dr. Shadowfax's loyal readers!
Allow me to briefly introduce myself: I'm a pediatrician working primarily in a hospital setting. I was born and grew up south of the border, but came to the USA at the start of college. It was then that I met Dr. Shadowfax, and I have had the privilege of calling him one of my best friends for most of my adult life. Although we did part of our medical training in different locations, we are now both living in the Pacific Northwest where we can be found discussing patients, riding our bikes, and pulling each other out of snowbanks.

He and I have enjoyed numerous discussions on various topics, including many that he has covered on this blog. I have been considering my own blog; however I realize that I am not nearly prolific enough in my writing to merit an audience. The good Dr. Shadowfax has consented to let me post some of my ideas on his blog, and I hope to prove myself up to the challenge of maintaining the high-quality discussion y'all have come to expect.

Mna na h Eireann (Women of Ireland)

More on Malpractice

Ezra kindly responds to my post from Friday with a more reasoned stance than "just don't commit malpractice." His response, however, boils down to two main theses:
  1. Frivolous Lawsuits are not as common as generally thought, and
  2. Standardization can reduce the opportunity for error and thus decrease the frequency of medical malpractice suits.
Well, yes, but I'm not sure that addresses the typical physician's complaints regarding the current med-mal system.

For example, the "frivolous" moniker is a pretty ambiguous term, especially to doctors' loose understanding of legal terminology. To a physician, a "frivolous" case is one in which there was no error -- where the standard of care was met, but perhaps the outcome was bad. Or to put it another way, doctors tend to feel that when they are vindicated in court, it's prima facie evidence that the case was frivolous. This conviction is bolstered by the little-recognized fact that physicians win the vast majority of cases that actually go to trial, and the vast majority of claims filed do not result in a financial settlement. So physicians who go through the wringer of even a successful malpractice defense cannot be blamed for coming away with the feeling that the whole exercise was frivolous. On the other hand, the more accurate definition of a "frivolous" case is that it was a case with no merit whatsoever, a much more stringent qualification. This would require, for example, no patient injury, or a suit against a physician who truly did not provide relevant care to the injured patient. These cases are in all likelihood quite uncommon and it does not help the dialogue between frustrated physicians and policy wonks that we each seem to be using the term frivolous differently.

What bothers physicians more, however, about the current system, is the disconnect between actual negligence and compensation. Ezra cites himself, circa 2006, which links an NEJM study I'd reviewed at the time but had since forgotten [PDF link]. It's interesting that the conclusions of the authors would be diametrically opposed to those of a typical physician (especially a physician defendant). The authors conclude that "Claims that lack evidence of error are not uncommon, but most are denied compensation." Which, as far as that goes, is good. Mostly.

But the problem is that the sensitivity and specificity -- the accuracy, in non-med-stat-speak -- of the system is quite poor. Of cases where the reviewers felt there was evidence of an error, only 73% were compensated. Call those the "True Positives." And of cases where there was no evidence of physician error, only 72% were resolved without compensation -- call those the "True Negatives." Is there a medical test in use which has a sensitivity and specificity of only 72%? No! That's better than flipping a coin, but not by a lot. In more than a quarter of cases this study tackled, the system got the outcome wrong. Physicians are used to substantially more accuracy than than in the tools we use in our daily practice, and it's maddening to be judged by a system which is so terribly imprecise. (Some of us cynics might suspect that the real-world performance of the system is even worse than 72%.)

This is why physicians are so adamant about the need for medical malpractice reform. There is a disconnect between actual negligence and the likelihood that you will have to pay an award. The docs' reflex is just to cap awards so the financial risk is limited. But that does not address the problem of verdicts simply being wrong -- both ways. That would require a more fundamental solution like special health courts. That sort of reform would have the great benefit of protecting physicians from unjust verdicts, but would also better ensure that injured patients were justly compensated.

Further, Ezra hits the nail on the head with his caveat "this debate is poorly served by the term 'malpractice.'" Malpractice is a term used very loosely by different writers, as shorthand for "doctors who injure patients." Unfortunately, there's a lot of conflation of the three separate ways physicians can hurt patients, and each requires a different level of concern and a different mode of redress:
  • Systemic Errors
  • Medical Errors
  • Negligence
Systemic Errors are the ones that get me most interested, and are possibly the most lethal things health care workers do. Consider the ICU nurse who does not practice good hand hygiene and blithely spreads MRSA among the several patients she may care for in a given day. Or the lazy ER doctor who doesn't bother to drape the patient and scrub his hands before putting in a central line. Ezra made note of the huge advances anesthesiology has made in addressing these errors and, resultantly, reducing patient harm and malpractice liability over the years. It's a pity this approach hasn't spread to the rest of the house of medicine more rapidly, but the truth is that the aviation metaphor applies most aptly to anesthesia: they do the same thing every time, day in and day out, and standardization is relatively easy. It's only in the last few years that smart people like Peter Pronovost have realized that there are things which can be standardized in the ICU and the OR in the same way, with huge benefits. We're even looking at these measures for the ER, but that is more challenging give what a chaotic environment it can be and how infrequently we see certain pathologies. Having said all that, systemic errors are not malpractice and in most cases are not appropriate for compensation by the medical liability system. More on that later.

Medical Errors are harder to define, but there are certainly cases where the doc did something that seemed right at the time but it turned out terribly wrong. A real example: I once saw a woman with a headache. She had a history of chronic migraines, came to the ER frequently for them, and this seemed more or less typical for her. I gave her some pain meds and sent her home with no work-up. Turned out it was a ruptured aneurysm, and I saw her again the next day before sending her to the neurosurgeon. There were a couple of little clues there, but honestly, there was no way on earth that I could have figured it out on the first presentation. Fortunately, the ending was happy for both of us. This, however, seems to fit the IOM Definition of an error: "Failure to complete a planned action as intended, or the use of an incorrect plan of action to achieve a given aim." My plan of action: analgesia & observation, was incorrect. It was incorrect for reasons that may not have been preventable, in that they were due largely to "patient factors," but it fits the definition nonetheless. The prevention of these errors is as huge as the entire scope of medical knowledge; it defies elimination as long as doctors are fallible human beings. With attention and commitment, I think that the house of medicine is making progress, and I can't decide if they are huge strides or baby steps. But we are working on it. Again, however, these errors are also in many or most cases not malpractice and should not be compensated in the courts.

Negligence is something different and should be considered as beyond a simple error. Different states define the term differently, but in general it might be defined as "the failure to do something which a reasonably prudent person would do under like circumstances." Of course, what is prudent and what is negligent varies greatly in the eye of the beholder and based on the details of a given case. But the key is this: the absence of negligence does not require perfection, just prudence. Or, as the old line in medical risk management goes: "You're allowed to be wrong, but you're not allowed to be negligent." A bad outcome or even the presence of a medical error as defined above are not in themselves demonstrative of negligence. Systematic errors almost by definition cannot be negligent in that it presupposes that everybody in a given system was imprudent and unreasonable (at least in the case of evolving science and quality standards; once industry standards are well in place, deviation from those could be negligent). Negligence is supposed to be a higher degree of screw-up, the sort of thing that when another doc hears about the case they say, "Oh no, he didn't really do that, did he?" It's not just an error, it's a flagrant error. At least that's how it's supposed to be. And it's negligence that is supposed to be addressed in the medical liability system.

My point in breaking out these different types of injuries is this: the first two classes of patient injury, those due to systemic errors and those due to medical errors, are not in and of themselves "malpractice" and should not be compensated in the tort system. Negligence is required before it is malpractice. Unfortunately the extreme subjectivity of that term and the variability from state to state and county to county, in addition to the randomness of juries makes it hard to draw a line in the sand and separate the two. The specific details of any given case, of course, are highly determinative of whether negligence was present. But it would be very helpful to the dialogue and to the possibilities for health care reform as well as medical malpractice reform if those of us who write about health care related issues were more precise in our terminology and if we could all avoid lumping all these problems together.