29 November 2009

Fricking Awesome

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

25 November 2009

Words Absolutely Fail Me

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

24 November 2009

The best political blog post I have read this week

TAPPED Archive | The American Prospect
Which Party Is Best Prepared to Save Us From the Robot Apocalypse?

Arthur C. Clarke famously said, “Any sufficiently advanced technology is indistinguishable from magic.” But if science fiction has taught us anything, it’s that any sufficiently advanced technology will inevitably rise up to enslave us. So if you want to get ready for the day when your Roomba declares that maybe it’s time for you to start crawling around on the floor sucking up dust, it might be a good idea to evaluate the Republican and Democratic approaches to this problem.
Best line: "Just as the GOP doesn’t really think there’s a health-care crisis, they don’t seem to be concerned about a robot uprising."

Yes, it's silly.  Still, go read it.

What if the Earth had rings?


POTUS assigns some homework

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

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

While the whole piece is worth a read, I'll provide a summary of the summary, or at least the bits that I found interesting.  My observations and comments in italics:
"[MIT Healthcare economist] Gruber may be especially effusive. But the Senate blueprint ... also is winning praise from other leading health reformers like Mark McClellan, the former director of the Center for Medicare and Medicaid Services under George W. Bush."
Um, I guess this is good. McClellan is a wonk, not just a politico.  But I was not overly impressed with the direction he led CMS.  But some bipartisan support is nice, if ultimately only symbolically.
"[T]he Reid bill maintains virtually all of Baucus ideas' for shifting the medical payment system away from today's fee-for-service model toward an approach that more closely links compensation for providers to results for patients."
It's a baby step away from fee for service, just a baby step.  Will the results be dramatic, modest, or marginal?  That's the trillion-dollar question.
"The CBO projected that the bill would reduce the federal deficit by $130 billion over its first decade."
Not news but always worth repeating.
"[T]axing high-end insurance plans ... Economists argue that such a tax will help curtail the growth of private health insurance premiums by creating incentives to limit the costs of plans to a tax-free amount."
I'm astonished that this will be so effective (to the tune of $35 Billion per year) given that the tax is on plans costing more than $23K annually.  Who has a plan costing that much?  It does effectively put a hard cap on premium costs as they continue to inflate, or at least causes consumers to bear more of the cost for such plans.
"[C]hange the way providers are paid for delivering care to Medicare recipients; the hope was that once Medicare instituted these reforms, private insurers would also adopt many of them."
I think you can count on that.
"[T]o reward Medicare providers who deliver care more efficiently and penalize those that don't. ... hospitals under current law must report on their performance in treating patients for common conditions like heart problems and pneumonia; under the bill, their Medicare payments, for the first time, would be affected by their ranking on those reports. Hospitals would also be penalized if they readmit too many patients after surgery or allow too many to acquire infections while in the hospital itself. Another provision would begin the process of applying such "value-based purchasing" toward other providers like hospice providers and inpatient rehabilitation facilities."
We all knew this was coming when McClellan started P4P.  It's good (I think) to see it finally implemented, but it's hardly a novelty in the health reform world.
"The Finance Bill proposed automatic reimbursement reductions for doctors who order up the most care for Medicare recipients with similar medical and demographic characteristics. That was meant to respond to the research showing big disparities in spending on medical services for similarly-situated patients in different communities. ... the final bill takes a less direct route toward a similar end. It requires Medicare to begin studying the utilization patterns of doctors participating in the program. And then it establishes a "values based payment modifier" that would, in a budget-neutral manner, increase reimbursements for physicians found to deliver high-quality care at lower cost, and reduce them for physicians at the other end of that spectrum."
Wow.  I was unaware of this.  Would it be unfair to call this the "Gawande provision?"  That New Yorker article was highly influential.  As someone who works in a "high quality low cost" system, I like the idea of being paid for being more efficient -- we have been penalized for many years.  I like that it is budget neutral.  I worry that since it does not decouple payment from volume, that the low-efficiency area practices may respond by simply further increasing volume to make up for lost revenue.  When it's a revenue neutral game, there will always be someone at the bottom -- will this polarize practice patterns or reduce the disparities?  I don't know.
"[E]ncourages groups of providers to establish doctor-led "accountable care organizations" to more comprehensively manage patients' care by allowing them to share in any savings for Medicare they produce. It also establishes a voluntary national pilot of "bundled" payments that would encourage hospitals, doctors and other providers to work more closely together. Another pilot program would test coordinated home-based care for chronically ill seniors."
Pilot programs don't excite me too much.  Bundling worries me, that physicians will become highly subordinate to the hospitals, not in terms of practice style as much as the economics.  How do you work out revenue-sharing, especially when the physicians have little leverage?  Beyond that, these are intriguing but small cost-saving possibilities.
"[The] independent "Medicare Advisory Board" ... to offer cost-saving proposals when Medicare spending rises too fast; Congress could not reject its proposals without substituting equivalent savings. Since the board would be prohibited from offering changes that raise taxes or "ration care," and since the legislation initially exempts hospitals from its recommendations, it could choose to promote the sort of payment reforms the bill establishes. (More prosaically it might also clear away some of the expensive coverage mandates that Congress imposes on Medicare under pressure from different elements of the medical industry)"
This is pretty potent, and possibly a force for good.  It's a very big threat especially to the medical device industry, which for too long has been able to escape any rigorous cost-benefit analysis for new devices.  Which is not to say that the innovation is bad, but the costs have escalated dramatically and this may bring some rationality back to the system. 
"[A] second institution the legislation creates: a Center for Medicare and Medicaid Innovation in the Health and Human Services Department. Though this center has received much less attention than the Medicare Commission, it could have a comparable effect. It would receive $1 billion annually to test payment reforms; in a little known provision, the bill authorizes the HHS Secretary to implement nationwide, without any congressional action, any reform that department actuaries certify will reduce long-term spending."
Wow.  That really flew under my radar.  It sounds like it has pretty broad powers, and a broad scope.  This could be extremely effective at controlling costs, and de-politicizes the process of reforming payments, which is good.  I worry about the reforms that it might ultimately recommend.   Definitely a double-edged sword, from the perspective of a health care cost generator practicing physician.
"Another Republican cost-containment priority missing from the bill is meaningful medical malpractice reform. (The bill only encourages states to think about it.)"
Yes, this is a pity.  However, I blame this entirely on the Republicans.  We know that the Democrats have been four-square against tort reform for time out of mind.  There is no way they were going to put it in their bill on their own.   If Chuck Grassley had offered five solid GOP votes for the overall package in return for real malpractice reform, I am sure that Obama would have jumped at it.  Who wouldn't?  There would have been no last-minute drama over whether the bill was going to pass, the compromises would have been made in committee, and both the Democrats and GOP would have been able to claim to their constituencies that they had accomplished long-standing objectives.  Instead, the GOP chose immutable opposition as their strategy and as a result the bill reflects not one of their priorities.  Reap the whirlwind, boys.

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

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

H1N1 Impact

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

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

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

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

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

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

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

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

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

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

23 November 2009

I love me some graphs

Especially interactive graphs.

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

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

20 November 2009

Friday Night

Off to the ER.  Enjoy yourselves some classic Tull:

19 November 2009

Awful and horrible and disgusting

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

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

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

Senate HCR Reax

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

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

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

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

How patients face Bad News

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

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

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

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

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

Option 3: Incomprehension.   A real challenge when it's genuine:
"So it'll just ... grow back again, will it?"  I've heard the equivalent of that many times.  "So they'll just cut out that liver mass then, will they?"  No, it's metastatic.  They can't cut it out.  "Right then, so after they cut it out, I'll be fine."  No, I just told you they can't cut it out.  To be fair, I suspect many cases of supposed incomprehension are just paralysis with a facade of incomprehension.  Denial, if you will.

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

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

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

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

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

But it's still never fun.

18 November 2009

it's a cartoon so it must be cute

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

via ERP

Back Doors

This post at The Central Line caught my eye:

Texas Recognizes ABPS Certification

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

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

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

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

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

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

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

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

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

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

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

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

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

16 November 2009

Urban Legend ER

Best line:
"You know how we each ingest eight spiders a year in our sleep?"
"Of course.  I am a doctor, aren't I?"

Truth is:
The real ER has far weirder stuff every bloody day.

Lessons from the H1N1 Pandemic

Daily Kos: DemFromCT
There'll be more lessons to learn, but every institution need to be planning for the next pandemic. Maybe it'll be needed in the spring when a third wave hits, and maybe it won't be needed for a few years to come. But pandemics happen. And when they do, they mean shortages (staff, space and stuff.) Internalize that, be prepared, and expect to be flexible in your response.

DemFromCT is one of the editors over at the Great Orange Satan, and is thereby an evil godless leftist, but he also happens to be an academic pediatric pulmonologist.   He lists seven important lessons from the H1N1 Pandemic (so far) and how they might be applied to the next coming pandemic (H5N1 anybody?).  Worth a read.

Also, a pretty graph:


Paging Dr Feelgood

The patient's mother was livid.  "What do you mean you're not going to give my kid Tamiflu?  You just said he had influenza, didn't you?"

I sighed, and squared my shoulders just a bit more, "Yes, while I'm almost certain this is influenza, we're not treating routinely with Tamiflu.  It only shortens the duration of illness by a very small time, less than a day.  And for healthy kids like yours, it does not seem necessary for prevention of any of the complications of influenza."

"But I was here last week with his brother," she retorted, "and we saw Dr Feelgood, and he said that it was essential that we start the treatment immediately!"

"It is true that if you are going to treat with antivirals that you need to start within the first twenty-four hours.  The CDC, however, has released guidelines regarding which patients need to be treated.  For children, that is primarily those under two years of age and those with co-existing conditions like asthma which predispose them to complications.  Again, little Billy here is seven and perfectly healthy, so he does not require the medication."

"Then why did Dr Feelgood prescribe it for his brother?  He's healthy, too, but he got the medicine, and he got better faster because of it."

"I really shouldn't say why Dr Feelgood did what he did, because I haven't seen your other child.  But the CDC is not recommending routine antiviral treatment of healthy schoolchildren."

"So what am I supposed to do?  Just let him suffer?  You didn't even do a test!  How do you know it's influenza?  Dr Feelgood at least tested him!  You're not doing anything!"

"I haven't been doing the tests since they have proven rather inaccurate. In short, if I test Billy and the test is negative, I'm not going to believe it because his symptoms are so classic for influenza and he has a brother with the flu.  So if you are not going to believe the test result, and if it's not going to change your management, why do the test?"

She started gathering her things. "I just can't believe this. You are doing nothing for my son, who is clearly desperately ill.  You're the worst doctor I've ever seen and I am never coming back here.   This whole thing has been a huge waste of time.  Why did I even come in here if you weren't going to help us?"

"You could have called his pediatrician, you know," I added, "seeing that it's a Monday morning.  I'm sure they would have made time to see him."

"He would have given us the Tamiflu, too!" she shot back.

He probably would have
, I thought to myself as I went back to the nursing station and picked up the next chart.  It was a whole family checking in because they were exposed to the flu, and they wanted Tamiflu prophylaxis. Seems their neighbors had been exposed, and Dr Feelgood had given the whole family prescriptions.

Note to self: next time I see Dr Feelgood, I'm going to kick his ass so hard his prostate's going to get impacted in his esophagus.

Only problem is that there isn't just one Dr Feelgood.  I'm surrounded by them.  In the ER, in the primary care offices, and (especially) in the urgent care centers.  I understand why docs do it: you see a patient who looks absolutely miserable, and you want to do something for them.  You want to make them better.  And there's a drug for this!  It's even got "flu" right in the name!  So you know it's gotta do something!  Right?  It's the hardest thing in the world for a doctor to do when you see someone legitimately ill: to put your hands in your pockets and back slowly away from the patient.  I'm not immune.  I confess: in moments of weakness I have written a couple of Tamiflu prescriptions that were not indicated, just because I felt bad for the patients.

Still, it's maddening to see how many docs are out there flaunting the guidelines.  Patients talk to one another, they see the inconsistencies in treatment, and they get mad.  And the docs who are doing the right thing and following the best practices are the ones that get grief over it.  It really ticks me off.

And I don't even want to look at my Press-Ganey numbers for this quarter.

12 November 2009

The Bad Hire

Anonymous (or another reader of the same name) asked me: "Why would a bad hiring position be very hard to undo? Is it because due to the all the investment you have placed on this new employee? Or it also looks bad on your part if you had to fire them?"

Great question -- These are fun to run through, not because they're terribly tricky questions, but because it's useful to really formalize your thinking process.

The first downside of a bad hiring decision is of course the direct costs.  You didn't know it was a bad hiring decision when you made it, and you can make an argument that it isn't a bad decision until or unless you have problems.  Those problems, whatever they happen to be, will pose direct costs to your practice.  Whether it's pissed off nurses due to jerky behavior or pissed off patients due to poor department flow management, there's a cost there.  Worse, if it's a real bad decision, there are human costs from bad care and quite possibly direct legal costs from liability.  You can get rid of a problem physician, and get through the rough patch, but it takes a while to recover your credibility as a leader that you are able to select the right candidates for your department, and it takes a while for your nursing staff/medical staff/administration to get over the negative impressions of your group that were fostered by the problem doc.

Then you have the opportunity costs  You pick a bad apple and they make trouble.  Chances are, you could have had someone better.  Unless you are in a noncompetitive practice environment where you need to pay recruiters to bring you docs, you should be considering multiple candidates for each position.  When you pick someone who turns out to be a liability, you could have had someone who was an asset instead.  You never get a chance to recoup that lost time.

Then there's the simple fact that it's not easy to fire a doctor.  Good practice requires that you have standards and procedures you follow before termination.  Barring an egregious matter, you generally need to make multiple efforts to meet with (and document) discussions with the doc to let him or her know there are concerns, give clear examples of the concerns, and give them an opportunity to improve.  Then you need to document their response to the intervention.  This is good practice because in most cases it eliminates the need to consider a termination, but also because if you do progress to that step, a well-documented remediation process provides great legal protection against any allegations of improper firing.

Then, as a matter of process: we have a democratic group and I don't possess autocratic power to fire people at a whim.  I would have to go to our HR committee multiple times and make a case for the necessity of the action.  We're a soft-hearted bunch and it can be hard to convince our partners that there is no other good option.  And when a doc is let go, it has a pretty significant negative effect on the morale of the group (especially if that doc's problems had been kept private prior to dismissal).

And finally, doctors are very litigious when their careers are threatened.  They have the resources and a strong motivation to seek legal counsel and fight a termination.  That can get expensive.  Unless it's iron-clad termination for cause, you can either wind up paying to buy a doc out of his or her contract, or you can lawyer up and slug it out.  Unless you have really carefully created a paper trail establishing the reasons for the firing, and scrupulously abided by the terms of the employment contract, an involuntary termination carries significant legal risk.  Sometimes you can convince a doc to resign quietly in the interest of preserving their career -- a termination is a black mark on future credentialling checks.  But again, there's a big risk if they choose to lawyer up instead.

Then finally, I just hate it.  It's a miserable thing to have to fire someone.  It's a very personal assault on their whole being, the profession they have dedicated their adult life to, and it makes me feel sick.  It's even worse if it was someone I hired, because it feels like a personal failure on my part.  To have someone move out here, relocate their family, and then have to fire them is awful.  Fortunately, this is not something I have had to do much, but I dread it extremely.  Which isn't to say that I shy away from it, when necessary, but I loathe the need and work very hard to obviate it.

So this is why I'm willing to spend so much time on my recruiting decisions.  Getting the best people is the key to a successful and prosperous physician group, but getting the wrong person causes hours and hours of headache and heartache.

That's not funny

One more thing on hiring that I have learned the hard way: No joke is ever funny to a candidate who does not ultimately get the job.

This is very difficult for me.  I am commonly described as a "wiseass;" I see the humor in just about every situation, and have a hard time not keeping a running commentary on the things that amuse me.  It's very hard for me to hold it in, especially when something about a candidate's CV is interesting or amusing.   Recruits put a lot of personal information on their CV, much of it things that I am not supposed to discuss in an employment setting -- religion, sexual orientation, family status, as well as hobbies and personal interests.  So when I interview the gay mormon from Saudi Arabia, it's so hard not to crack wise about the incongruity.  If I met them in a bar (not that a mormon from Saudi Arabia would be likely to hang out in a bar), it'd totally be fair game, and once they are a partner, it's fair game.  But if they don't get the job, and I made a comment about, say, their unusual hobby of competitive kite-flying, they're going to wonder whether that was why and they going to be pissed.  I don't want that, and it can even get me in trouble, which I definitely don't want.

But it's so hard to hold back.  I have literally had to bite my tongue to keep from cracking wise in interviews.  That sort of restraint is just not in my constitution. 

Why oh why does everything have to have so many buried layers of humor?

Interpersonal skills

In a comment on my last post, faithful reader and frequent commenter Anonymous asked, "How do you get a good reading on interpersonal skills in a brief interview?"

That's a good question.  I suppose the simplest answer is, you don't, at least not in any sort of comprehensive way.  In some cases you can -- a person who is warm, engaging, and able to hold up their end of a lively conversation in an interview setting is always going to be near the top of my list.  But I make a lot of allowances for people in their interviews -- they are nervous, know they are being watched and judged, it is a high-stakes encounter for them, and most people are a lot more constrained in an interview than they are in their day-to-day lives.  I make the interview as informal as possible, bring a casual, conversational tone to the meeting and do everything I can to encourage them to open up and just chat.  We usually take them to lunch and see how they hold up in a more social setting.  (In one case we took a guy to a bar and filled him with beer before interviewing him -- but that was a special case.)  I typically spend three hours with a prospective candidate.  In most cases I get a sense of the sort of person they are, but many interviewees are still reserved enough that I come away with no clear sense of their interpersonal skills.

So we check references.  Thoroughly and exhaustively.

A lot of people have been surprised by this -- they say "well, everybody just picks references that like them so what are you ever going to learn from reference checking?"  To some degree that is true -- every residency director has a real interest in getting his residents jobs and they tend to give a positive appraisal of their trainees.  So you've got to work it.  The key here is to call all the references; don't just accept a letter of reference, and ask very detailed questions.  You start off letting the reference free-form about the candidate, which is usually positive.  But I follow up with a structured questionnaire which asks about their stress management skills, their relationship with the nursing staff, their frustration tolerance, their ability to make decisions, their ability to move the department, their strengths and their "areas for growth."  It's amazing how a general "Yeah, this guy is solid" reference can open up in details when you delve a little deeper.  Better yet, when one reference gives me a piece of information, I can cross-check that with the next and ask them to expand on it.  Also, having been doing this job for a few years, I have gotten to know some of the key referrers and have a relationship with them where they are more comfortable giving me frank insights into their residents.

The most valuable tool, however, it to check nursing references.  Nurses are startlingly candid and will usually give you the inside story on a candidate.   I ask all potential recruits to provide at least two nursing references.  Better yet, I call the nursing station at two AM and ask for the charge nurse.  The most accurate predictor of how well a doc does in our group is how they treat and get along with the nursing staff.  The clinical quality of most new residents is exceptional; they all seem to graduate with the essential knowledge base.  But those that can't understand that Emergency Medicine is a team sport, those that can't play nice in the sandbox, they are the ones that tend to flame out early in almost any practice setting.  The best reference I ever got was to call a nursing station and tell the charge nurse I was checking on Doc X. In an anguished voice, she exclaimed "You can't have him!"  Done -- hired.  (Yes, I ask permission before calling.)

None of this is fool-proof, of course, and references can always just lie to you.  For that reason I tend to prefer candidates who are referred by people I know (and especially those I work with) since those referrers put their credibility on the line and can be better trusted.   I swear by the process, though, since I have had more than a few people who looked fine on paper, and comported themselves well enough in their interview, and I was expecting to make them an offer.  After the reference check, however, there were red flags all over the place and we decided not to hire them.   However, I find that since most of the people who apply with us are good people, I do less as a detective to suss out the Bad Stuff, but rather to positively sort the candidates.  The references which are consistently glowing and full of superlatives rise to the top over those which are merely solid.

But Oh Boy is it a lot of work.   (BTW this entire post was composed while waiting for a reference to call me back.  Grr.)  It pays off in the end, though.  A bad hiring decision is very hard to undo.

11 November 2009

Physician Skills

We're elbow deep in the recruiting season, and it's been a real pleasure so far this year.  I've been fortunate to meet a wide variety of candidates who are incredibly accomplished.  I'm glad that I didn't have to compete against this crowd when I was coming out of residency!  It's so much fun to meet so many young, excellent Emergency Physicians, and my only regret is that I don't have jobs to offer all of them.

One interesting divide has emerged, however.  When you think about the requisite skills and qualities of an exceptional Emergency Physician, the elements that come to mind include knowledge base, interpersonal skills, communication skills, energy level, ability to multitask, decisiveness, and that sort of thing.  Most of the candidates I have interviewed so far have these capabilities, some to a very high degree, some less so.  It can make for a tricky decision -- do I rate the guy with great interpersonal skills above or below the guy with awesome academic credentials but only good interpersonal skills?  And many other permutations of the same conundrum.   Most of the time the hiring decisions are driven by these relevant skills.

There is, however, a small subset of candidates who may or may not be exceptional physicians who completely disqualify themselves from serious consideration from the very beginning: the computer illiterate.

You can spot them a mile away.  They don't email their CVs to me -- it comes via regular mail or, worse, by fax.  That's a huge red flag.  Sometimes it's just that they are a little old-fashioned, and there is something to be said for the visual appeal of a nicely designed resume on high-quality paper.  I'm OK with that.  But if I ask for an electronic copy of their CV, and they can't manage to get me one, or, worse, if they don't even have an email address listed on their CV, that's even more concerning.  It's fair to say that the likelihood I'll offer a job to someone who can't format a CV and attach it to an email is effectively zero.

Why does this matter?  We are ER docs!  We're not emailing patients, and computer skills have no bearing on one's ability to provide medical care to patients, right?  It seems wrong to base hiring decisions for highly trained professionals on an unrelated skill set, doesn't it?

Unfortunately, in this modern age, if an employee can't use a computer effectively, they are a liability.   Our group performs most of its essential communications via email.  We have a repository of key documents on our own website.   We study, take tests, and acquire new skills on computers.  More saliently, our hospital has an ED Information System which our docs must work within in order to provide care and to access old records, and soon we too will be performing patient documentation on an Electronic Medical Record.   A physician who cannot efficiently integrate a computer into his or her daily workflow will be incapable of working in the modern ER.

The vast majority of docs I interview are coming out of residency, which means that they are likely young and likely have a high degree of comfort with computers; some more than I (which is saying something!).  For those of you who are reading this blog, it is pretty likely that you, too, are computer-savvy enough to get by.  But a number of veteran docs, folks who I am sure have a wealth of clinical experience and would otherwise be a huge asset to any medical practice, simply never bothered (or actively refused) to gain basic computer skills.  And for me, they're unemployable.  Which is a pity for them and for us.

Just one more way in which we all need to continually adapt and learn through the course of our careers.

08 November 2009

Performance Art

Now that Bush is no longer in office, I had wondered what Jon Stewart would do with nobody to mock.  Clearly, he has found his muse:

The Daily Show With Jon StewartMon - Thurs 11p / 10c
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For someone who generally sucks at impressions, he has Beck's mannerisms down pat. There truly is a sickness in country when someone like Beck has a multi-million member following.

07 November 2009

Go for the gusto


I wish I had a helmet like that.

06 November 2009

The death of irony

A man protesting the purported government takeover of healthcare at the Capitol yesterday suffered an apparent cardiac arrest. He was resuscitated by government-employed medical personnel.

More ominously, a man standing just beyond the TV cameras apparently suffered a heart attack 20 minutes after event began. Medical personnel from the Capitol physician's office -- an entity that could, quite accurately, be labeled government-run health care -- rushed over, attaching electrodes to his chest and giving him oxygen and an IV drip.

This turned into an unwanted visual for the speakers, as a D.C. ambulance and firetruck, lights flashing, pulled in just behind the lawmakers. A path was made through the media section, and the patient, attended to by about 10 government medical personnel, was being wheeled away on a stretcher just as House Minority Leader John Boehner (R-Ohio) stepped to the microphone. "Join us in defeating Pelosi care!" he exhorted. A few members stole a glance at the stretcher. Boehner may have been distracted as well. He told the crowd he would read from the Constitution, then read the "we hold these truths" bit from the Declaration of Independence.




05 November 2009

04 November 2009

Leaving on t a jet plane

I've got a lot to say these days, but I've been working 12-hour days and now I'm off to Denver for a whirlwind visit.  Our ER is rolling out a new EMR and we are visiting some sites that have successful implementations.  Sorry Luke, but I'll only be in town 24 hours.  Maybe next time.

My flight tomorrow is at 5:45 AM.  Ugh.  I didn't even know airplanes could fly at that hour -- I thought the air was too dense for them or some such.  Gah.

Hopefully I'll have more time to blog next week.

This is bad, very bad

Healthcare provision seeks to embrace prayer treatments -- latimes.com
Reporting from Washington - Backed by some of the most powerful members of the Senate, a little-noticed provision in the healthcare overhaul bill would require insurers to consider covering Christian Science prayer treatments as medical expenses.

The provision was inserted by Sen. Orrin G. Hatch (R-Utah) with the support of Democratic Sens. John F. Kerry and the late Edward M. Kennedy, both of Massachusetts, home to the headquarters of the Church of Christ, Scientist.

The measure would put Christian Science prayer treatments -- which substitute for or supplement medical treatments -- on the same footing as clinical medicine. While not mentioning the church by name, it would prohibit discrimination against "religious and spiritual healthcare."

Well, as Kevin Drum says, "It's true that not everything that seems like a slippery slope really is one, but this really is one. If it passes, can you imagine how this would play out among the Colorado Springs set within a few years? The mind reels."  Yeah, every religious group out there will be in looking for their piece of the prayer-healing pie.  The good news?  Nancy Pelosi stripped a similar provision out of the House bill, based on concerns it wasn't constitutional.  Good for her.  Let's hope she sticks to her guns on that point in conference committee.


03 November 2009

Responsible Governing is Hard

As has been noted on this blog, the new House health care reform bill does not contain a fix for the Sustainable Growth Rate problem.  To recap, the SGR is a formula enacted as a part of the 1997 Medicare reforms which was intended to ensure that spending on physician services did not grow faster than GDP.  Unfortunately, the number of medicare beneficiaries did increase, as did their age and complexity, and the SGR quickly mandated progressively deep cuts in physician reimbursement.  Each year, Congress averted or mitigated those cuts, kicking the can down the road to next year.  When the spending cuts have been averted, generally they have been deficit financed -- no effort was made to find any offset or increased revenue to pay for the physician reimbursement fix.  As a result of a decade's worth of inaction, in 2010, physicians face a potential 21% cut in reimbursement.

It's important to note that when the CBO calculates the long-term deficit, it is obligated to assume that Congress will allow the cuts to go through as scheduled, even though that has never happened and politically is incredibly unlikely to come to pass.  So the current deficit projections are something of an elaborate fiction, including the expiration of tax cuts which will never expire and spending cuts which will never be allowed to take place.  The White House Budget Office has more discretion; the Bush administration used to do the same thing with regard to deficit projections, pretending the deficit was smaller than it really was; Obama's Budget Office did away with these tricks, assumed that the cuts would be blocked, and gave a more honest, larger projection of the federal deficit.

The initial plan was just to repeal the SGR, and that was part of HR 3200, the initial House health reform bill, and a key point in securing the support of the AMA.  The problem with that was that there was political pressure to keep the cost of health care reform under $100 Billion per year, a somewhat arbitrary but symbolically important figure, and the cost of repealing the SGR problem amounts to $250 Billion over ten years, or $25 Billion per year.  So it was dropped from the final bills, and Congress is planning on addressing the SGR in a separate piece of legislation.

Enter HR 3961, The Medicare Physician Payment Reform Act of 2009.  According to its summary[PDF]:
[This] legislation will repeal a 21 percent fee reduction scheduled for January 2010 and replace it with a stable system that ends the cycle of threats of ever-larger fee cuts followed by short-term patches. Permanent reform of physician payments in Medicare will guarantee that Medicare beneficiaries continue to enjoy the excellent access to care that they do today. It will also follow the President’s lead by ending a budget gimmick that artificially reduces the deficit by assuming physician payments will be cut by 40 percent over the next several years even though Congress has consistently intervened to prevent those cuts from occurring.
Sounds great, right?  And even better, they're being fiscally responsible, making statutory the "Pay-Go" principle:
The Medicare Physician Payment Reform legislation will be considered in the House under a procedure which will add the text of H.R. 2920, the Statutory PAYGO Act of 2009, as passed by the House on July 22nd before being sent to the Senate. The “pay as you go” principle of budget discipline requires Congress to find a way to pay for any new spending, outside of an economic crisis.
Wow.  These Democrats in Congress are the most responsible, principled, courageous lawmakers ever.  So, let's read on and see where they found the money to offset the SGR fix.  A new tax on soda pop?  Cuts to the F-22 program?  I can't wait to find out!
A previous Congress established the policy for paying Medicare doctors, so the update for 2010 is not a new policy to be paid for. The Statutory PAYGO Act would apply this principle to all new tax and spending policies, and would allow Congress to exclude the impact of continuing policies currently in place, including Medicare payments to physicians. The Medicare Physician Payment Reform Act would not increase total payments to physicians above what they are today and therefore, would not be subject to the paygo requirement.

So, let me get this straight, in the very same bill, indeed in the very same paragraph of your press release, you are going to:
a) Champion the fiscally conservative Pay-as-you-go principal that you are encoding into law, and
b) Define $250 Billion in previously-unaccounted-for spending as "not new" and allow it to accrue to the deficit.

Wow.  That's chutzpah, on the Bushian level.  It's also criminally reckless and dishonest.

I feel some sympathy for these guys -- they're facing withering criticism over $90 Billion in new annual spending for health care (while a $680 Billion defense appropriation passes with barely a peep), and they are desperate to find cover to minimize the apparent costs.  It even makes sense to split the SGR fix off into another vehicle, since it's not truly part of the health insurance & delivery reforms proposed -- it's a repair for a mistake Congress made in 1997.  I also understand that if they were to honestly account for the cost, it might well sink the whole effort.  But geez, try a little subtlety!  If you're going to lie to us, at least make the deception plausible.  Better yet, don't even try to look responsible, just kick the can down another 12 months (like the Senate apparently plans to) and come up with a fiscally responsible fix then.  (The risk of that, I assume, would be to lose the support of the AMA for the health reform in general.)

The take-home here is that there is generally little to no political advantage in fiscally responsible policy-making, and there is significant downside risk.  It's true of all parties, to some degree, and it's painful to see the Democrats falling into the same short-sighted trap which has created the huge general budget crisis that we are facing in the coming years.