28 August 2010

The Ghost/The Hatchlings/The Long Bow

I remember listening to Liz Carroll live in Chicago at the Féis when I was a kid.  This is off her Lake Effect album, but more recently her album Double Play was nominated for a Grammy under Best World Album.

27 August 2010

Friday Flashback - Death of a thousand little cuts

I walked in to work for the morning shift a few weeks ago, staffing the "flex pod" of the ER -- an area of acute care, monitored beds which we open from 10AM-2AM. There was, predictably, a row of patients lined up waiting for me to see them, as the charge nurses love to stack the pod before the doc even arrives. There were, however, no nurses in sight. I signed on to the computer and skimmed through the complaints to see what my morning was going to look like: two chest pains, one shortness of breath, one generalized weakness, one abdominal pain/vomiting. Not too bad; par for the course.

The tech wandered over and dropped the above ECG on my desk, from the generalized weakness patient. Any medical students out there, or readers who remember my previous post, The Wrong Juice, might recognize the wide QRS complexes and peaked T-waves as being highly suspicious for Hyperkalemia, a dangerous elevation of the potassium level in the blood. Elevated potassium will also cause muscle weakness, and is well-known for causing sudden death. It's one of those medical emergencies that make ER docs smile, because it's real, it's dangerous, it's dramatic, and we can fix it. A quick review of this patient's chart showed no history of kidney disease or any reason for elevated potassium, but the ECG changes were decidedly new. So I leaped into action.

Or I would have, except that there were STILL no nurses anywhere to be found. Where the hell were they? I went and briefly said "hi" to the patient and did a cursory history, noted that he did not have so much as an IV line started, and then went looking for a nurse. Finally, one strolled in, carrying her cup of coffee and chatting with the unit clerk; apparently they had gone off to the coffee stand while waiting for me to arrive.

I pounced on her: "The guy in bed D has a really abnormal ECG and I think he might be hyperkalemic, so let's get a line in him and an iStat ASAP."

She looked at me with a blank expression, "Oh, OK. I'll get right on it." And she turned back to the clerk to finish their conversation.

"No, I need you to do this NOW. This guy may well code on us if we don't get cracking!"

Visibly annoyed at my rudeness, she put down her coffee, rolled her eyes to the clerk, and shuffled off to the IV cart. Satisfied that she was on it, I wen on to see the waiting chest pain patient, with the instruction that she was to bring me the iStat as soon as it was back. Ten minutes later, I was finishing up with the chest painer who sounded like he might have unstable angina, and I came back to the nursing station to see the nurse sitting there drinking her coffee and continuing to gossip! "Where's the result on D?" I asked.

Nonchalantly, she replied "Oh, he was a hard stick and I couldn't get it, so I asked Betty to try."

I glanced in the room: there was nobody there. "So where the hell is Betty?"

"I don't know. She said she would be right over."

"Go get her right now and get an line in him!" With a sense of growing anxiety I went in to see the next chest painer, who had a history of several past heart attacks. I rushed through the H&P and came out to see the first nurse and Betty sitting there chatting amiably. "Well, do we have a line?"

"Oh, yes," Betty responded in a voice that made clear that she thought I was silly for being so worked up over such a little thing. She had been around for 30 years and thought all the doctors were like children, to be placated, but of no real importance. "But," she went on, "I got the line but it didn't draw, so I called for the lab to come draw the blood." She turned back to her conversation.

"Aaarrrgh! Get me a needle and I'll draw the damn blood myself!"

"Oh, don't be silly. Lab'll be here any minute." As I rooted through the drawer looking for a needle, I noticed the pulse ox on my next patient, who was short of breath, was 88%. Crap. Gotta prioritize. So I went to see that patient, hoping against hope that there might be SOMEBODY on shift today who would do their job. When I came out, the nurses had not moved, but they did confirm that the blood had been drawn.

"Where are the results?"

"I dunno. Maybe in the lab?"

Ultimately I had to personally walk down to the lab (not far, fortunately) to determine that yes, indeed, the patient's potassium was >9 (normal 3.5-4.5). On my way back I stopped by the charge nurse to discuss with her the fact that I had a very sick patient and the staff did not seem to share my sense of urgency. She promised to kick-start them, and fortunately, I had the patient treated and off to stat dialysis soon enough.

But the rest of the day was no different. Note that during this whole time the nurses weren't exactly jumping on the other patients, either. Getting anything done was like pulling teeth. I hate to rag on nurses, since without them I get nothing done, and many a good nurse has saved my ass. But good lord it's infuriating when you are stuck with the "B" team.

[Addendum: as Gruntdoc pointed out, criticizing nurses can be dangerous to your health, so note it's just the "B Team" that makes me crazy.  And there are docs on the "B Team," too.]

Originally Posted 14 December 2007

25 August 2010

Pediatric fun

caoilinnBlogging will be light for the foreseeable future around here, what with the new baby (thanks to all for the congratulations). I just got off the phone with the pediatrician's office making the first appointment for the little one.

That put me in mind of a story from long ago, about eight years ago, when our first son was born. We had chosen a pediatrician in advance, someone I knew from the hospital. She was the head of the hospitalists and I liked her a lot. So when the baby was a few days old we went in for our first appointment.

When the doctor came into the room I could tell that she didn't recognize me, which is not too surprising given that I was out of context, not wearing my doctor costume, and, honestly, most of our interactions had been over the phone at two AM. She introduced herself to me and then directed most of her attention towards my wife, since as a new mommy my wife was certain to have a lot of questions.

My wife and the doctor hit it off away and within a few minutes they were chatting like old friends. I was content to sit in the corner and play with the baby in my role as Dopey Dad. They had lots to talk about: sleeping issues, breastfeeding, reflux, weight gain, number of dirty/wet diapers, colic, vaccinations, and more. Every so often the doctor would turn to me and ask if I had any questions, which I thought was nice, that she made the deliberate effort to include me in the conversation.

I couldn't resist, however, the opportunity to have a little fun. So, when prompted, I said, "I'm a little concerned that he's going to get dehydrated, being so little and with the breast milk slow to come in. How much water should we be giving him?"

The doctor's eyes got wide for a moment, and she turned her attention fully onto me. She spoke kindly but firmly: "Water is very dangerous for a little baby. You should not give him any water at all. Nothing but breast milk or formula. Do you understand that?" I mumbled an apologetic acknowledgement and the discussion turned back to my wife.

Shortly thereafter, they were discussing supplementing breast milk with formula, and I chimed in, "That reminds me, doc, settle this argument for us. Should we be giving him 2% milk or skim?"  She stopped dead in her tracks and looked at me searchingly. Somehow I managed to keep a straight face. Certain now that she was dealing with a dangerous idiot, she spoke slowly and clearly, "This is important. No cow's milk at all. Nothing should pass his lips but breast milk or formula. No water. No cow's milk. They are not safe for him. Got it?"

Abashed, I agreed with her and went back to playing with the baby. The doctor carried on her discussion with my wife, casting an occasional suspicious glance my way. Eventually they turned their attention to the umbilical stump, which was getting weepy. My wife wondered whether she should clean it with alcohol or hydrogen peroxide. The doctor reassured her that soap and water would be OK, though hydrogen peroxide wouldn't be a bad choice if she felt compelled.

"I don't think we have any peroxide," I ventured. "Would acetone be OK instead?" There was a stunned silence. "What?" I added defensively, "They're both solvents."

Finally my long-suffering wife couldn't take it any longer and started cracking up.  "Doctor," she said, "do you realize who he is?"

She looked at me then, really looked at me for the first time. Suddenly recognition dawned on her face. "Oh you..." she sputtered with rage for a moment, then simply hit me upside the head with the chart she held in her hand.

Can't say I didn't deserve it.

24 August 2010

Set Your Tivos

Phil Plait's Bad Universe is set to premiere on Discovery this week.

I can't wait.

The Irrationality of Physician Specialty Reimbursement

@txmed tweeted an interesting link from Residency Notes, the blog of a thoughtful neurosurgeon in training, regarding the issue of specialty pay.  I've interacted with this author before and recall him as being a pretty reasonable person, and the argument he makes is refreshingly straightforward:
I want to make the argument for why the orthopaedist, the cardiologist, the neurosurgeon deserves to earn more, and considerably more, than the primary care physician. And to make the argument that maybe we’re not so far off the mark with out current reimbursement structure.

I would lay out the argument for the specialist’s pay like this: the training is longer and more difficult, there is a disparity in early earnings and the assumed risk is something much more.
And to some degree these are points which are not in dispute.

The fallacious assumption, however, is that the value generated by the specialty surgeon, and the investment represented in his or her training is accurately reflected in the potential income.  It's also incorrect to assume that the reimbursement system for physicians was designed deliberately to create the existing disparity.

It's a little bit of a straw man to compare a neurosurgeon to a family practitioner.  It's not a fair comparison. Neurosurgery is, I'll grant, really hard. It's also a life-or-death profession in some cases*.  FPs, with all respect, are on the lower end of the critical care/selectivity/prestige spectrum. Let's look for more apples-to-apples comparison. Consider, say, the urologist and the nephrologist.  The duration of postgraduate training is about the same for both. The training is harder for surgeons (whether that's a question of necessity or culture I'll leave for another day) so I'll grant that perhaps there should be a salary premium to the surgeon. And it is true that surgery is a profession which is less forgiving of error, so there is another argument for higher pay for the surgeon.  The general practice of a urologist, however, is not incredibly exacting: kidney stones and cystos and urodynamics are not exactly brain surgery, if you'll forgive a terrible pun. However, the nephrologist generally represents the highest caliber of internist -- their patients are horrendously complex and incredibly difficult to manage. They also make life-altering decisions, nearly as dramatic in their own way as a surgeon's (living on dialysis is rough).  And there is little margin for error in the practice of a nephrologist: their patients are brittle and will go into flash pulmonary edema or life-threatening hyperkalemia at the drop of a hat.  Both specialties lead difficult lifestyles -- I probably call in our nephrologist for emergency dialysis more than I call in a urologist for an emergency foley.  (OK, cheap shot. I apologize.)

If you look at average physician incomes, however, the nephrologist commands a 30% premium above that of a family practitioner, whereas the urologist is at a princely 200% of the "baseline" physician salary.

The same thing plays out across many other specialties. The Infectious Disease specialist makes 110% the FP "baseline" but the Radiologist is 220%. The Pediatric Cardiologist (a largely non-interventional specialty) is 20% above the baseline, but the orthopedist who does joint replacements is 300%.  And for that matter, the income variation among surgeons makes little sense, either. Ortho-Spine is reimbursed 50% more than Ortho-Hand. Why? Is the training that much harder? Is the value provided that much more? Is the surgery that much more intricate? Pick your example. Is Neurosurgery actually twice as hard as pediatric surgery?

So what is the justification for the differential?  There's none.  Sure, you can invent your theories for why the kidney surgeon deserves more money than the kidney doctor, or why the spine surgeon deserves more than the brain surgeon, but it's all a retro-fictional apologetic for the status quo, and more often invented by beneficiaries of the status quo who have an interest in preserving it. The reality is that the reimbursement system as it now exists was a pretty ad hoc creation that has more to do with the political power and tactical maneuverings of proceduralist physicians than a carefully crafted mechanism designed to produce the current state.  The RUC, the committee that created the current RVRBS which dictates physician piecework compensation, is a non-representative committee which somehow surgeons managed to dominate, and they created a system in which proceduralists (and any specialty in which volume could be maximized) could flourish.  The value provided by a given physician specialist and their reimbursement were completely delinked.  It all became about the number of cases they could do, and as minimally invasive procedures grew, as new devices streamlined surgery, as new surgeries and devices were invented, the proceduralists prospered beyond their wildest dreams.

http://images1.makefive.com/images/200934/94ccb702ce71fea8.jpgSince the health care budget pie is something of a zero sum game, the windfall for the surgeons came at a price for the primary care doctors. (Note that while we bemoan the plight of PCPs, all cognitive-based physicians have suffered, from the infectious disease specialists to neurologists to endocrinologists, etc.)  The rate of change of actual take home salaries for office-based docs is well below the rate of inflation over the least decade.  And it's only getting worse.  Is it any wonder that 2% of medical students intend to go into primary care?

Ultimately, the economic issue at hand is not whether the surgeon "deserves" more than the office-based physician. As Clint Eastwood said in Unforgiven, "Deserving's got nothing to do with it."  It's an arbitrary and irrational system. The question is whether the incentive provided by the income and other benefits is effective in producing the desired behaviors. Well, doctor pay and prestige is still adequate to keep med schools full, so doctoring money overall is clearly adequate.  But the income available to primary care doctors (in addition to the lifestyle factors and other fringe benefits/drawbacks) is clearly inadequate. Medical students flock to specialty training and the dearth of family physicians is generating real problems for access to care. The use of foreign-trained physicians to fill that gap is a temporizing measure, not a vindication of the compensation strategy.  In order to maintain (and reconstitute) the primary care industry, a dramatic revision to physician compensation is needed.

* Note that not all neurosurgery is brain surgery. The most disgustingly wealthy physicians are the neurosurgeons who whore themselves out to assembly-line laminectomies and diskectomies, whether or not patients actually benefit from them. The "best" neurosurgeons tend to be those who do complex cranio/angio stuff in academic centers. I suppose nothing could ever demonstrate the disconnect between value and compensation like the community-academic pay disparity, regardless of specialty.

23 August 2010

Your WTF moment for the day

I'm sure there is, somewhere, somehow, an explanation for this. It may even be a rational explanation, though it's kind of hard to imagine.  But still...

Now I want you to consider the prerequisite conditions for this photo to exist.

1.  Someone out there has a pet squirrel, or,
1a. There is an ethically challenged zookeeper

2.  This person has taught his or her squirrel to sit still for pictures, or,
2a. This person has a dead squirrel whose picture he takes (less likely)

3. This person has chosen to play elaborate dress-up games with his squirrel*

4. The decision was made to dress up the squirrel as, of all possible roles and costumes, the highest religious authority of a religion to which 1 billion human beings subscribe: the Pope

5.  In order to bestow adequate Pontifical Glory on His Holiness the Squirrel, a miniature and highly detailed version of the Vatican needed to be constructed.  (Of course)

There's a lot of insanity in each and every one of the above conditions. Even with 6.7 billion human beings living on Earth at this moment, it still seems statistically improbable that ALL of them were satisfied at the same time.  Still, there you have it: photographic proof that it is so!

Insert joke about the Nestorian Schism of 431 AD here.

*Human language has existed for about 100,000 years, and the English language has been spoken for maybe 1,500 years, yet it is highly possible that this is the first time that this exact sentiment has ever been expressed.

21 August 2010

Lego iPad Stand (hardcore geekery)

What I do when I am bored:

Background here -- my wife is in the hospital after a (planned and uneventful) C-section with our new baby girl. Grandma is taking a shift at the hospital and I am home with the other kids. Number One Son was going to have a Lego-themed birthday party this week, until events intervened, and in anticipation of the party my wife had been buying Legos by the pound. (Seriously -- you can buy five pounds of Legos on eBay for like twenty dollars!  That's a lot of Legos.  What a wonderful world we live in.)   So we have huge bins of sorted Legos in the front room and the boys wanted to play.  So we did.  In between epic battles of Jedis vs orcs (don't ask), I built myself this work of art:

stand front

It's an iPad stand. I'm pretty pleased with it. It's sturdy and safe and well engineered to hold the iPad securely.

It also folds flat so it can go in my bag with a minimum of fuss
And yes, I will be taking it to work in case any of my partners are insufficiently impressed with my nerd-fu. (Meetings, not clinical use.)

It will take the iPad in portrait or landscape orientations.
front portrait

front landscape

The angle adjusts, though not easily, and I have it set for what I think is the optimum viewing angle.
stand rear
Uploaded with plasq's Skitch!

It will hold the naked iPad, which I use rarely, or the iPad in my DodoCase (tm). I can plug in the iPad for charging/syncing, and the cord coils securely when not in use. It's stylishly rendered in Stormtrooper white and Imperial black, and it has the symbol of the Old Republic on the front. Of course.

At this time I predict that my readership is currently divided between those of you feeling contempt/disgust and those who are feeling unmitigated envy. To the latter group I say this: you are my people.  You get me.

Also, I note I am not the first person to do this.  Not even close.  But I really have to admire this infinitely-adjustable motorized version.  But a) I don't have the motor/hydraulic push arm and b) it looks too fragile to travel and c) I don't really view angle adjustment as a killer feature, so I'm not going to try to replicate it.  Don't think I wasn't tempted.

20 August 2010

Friday Flashback - A Plea

To whom it may concern:

IF: you are a patient who has a complex ongoing medical problem, for example: cancer for which you are being treated; a major surgery for which you have had a series of awful complications; a recent transplanted organ; or some extremely rare genetic condition,

AND IF: your treatment is being coordinated by doctors at The Big Hospital Downtown

THEN: please, please, please for the love of God, do not come to my ER.

It's not that we don't want to see you. We would love to, but the fact is that we will not be able to care for you properly at our hospital, so don't come here. It's that simple. We are not bad doctors here, nor are we unused to to complex patients. Believe me, we have lots of cancer patients here, and our surgeons have lots of complications of their own, etc, etc, etc. But your doctors are not here. And your records are not here. I may not be able to get your records, and even if I do, it will take me hours and I will probably not get everything I wanted. Your care will be delayed and possibly harmed. And I may have trouble reaching your doctors because I don't know the secret access number to the paging services at The Big Hospital. And even if I am able to get your doctors on the phone, they don't know me, which means they won't trust me. They may assume that I am an idiot (a common prejudice towards community docs by academics), in which case they won't listen to a word I say. They may think that I am trying to "dump" a problem patient back on them, in which case they will resist any recommendation that I transfer you back to their hospital. Worse, they may actively try to "dump" a difficult case on us by refusing to accept you back. (It's funny how doctors' sense of "ownership" of a patient diminishes when the patient shows up at a distant hospital.) Or I may just get a resident who doesn't know you and doesn't give a crap; it's hard to get an academic attending on the phone at 2AM. And what's more, if the doctors at The Big Hospital Downtown refuse to accept you in transfer, it's also possible that my specialists here will also refuse to take you on as a patient. They aren't supposed to, but it is predictable that they will tell me that you should just "go back Downtown." And then you, and I, are stuck in the middle with nowhere to go.

So don't come here. If you think you are getting worse, get in the car and drive yourself back to the Mecca where you were treated. By the way, that means don't call 911 for convenience of transport. They will ignore your protestations that you want to go Downtown and take you to the closest hospital, because they don't want to be out of service for an hour and half driving to the next county.

This is all assuming that you are not experiencing a true emergency. If you have sudden trouble breathing, or collapse, or have some other true, acute problem, then we are here for you.

Otherwise, don't come to my ER.

Thank you.

Originally Posted 17 December 2007

17 August 2010

The greatest thing I've ever seen

Oh yes they do!

A Conservative alternative to the PPACA

The Hill's health care blog flagged an interesting proposal from the conservative Heritage Foundation on "Getting Health Care Reform Right."  It's pretty depressing stuff in that it's both incoherent and devoid of any real solutions.  It's a sad point in our political discourse when one half of the ideological duet has nothing, nothing at all to offer.  To sum up, Heritage proposes:
  1. Repeal Obamacare
  2. Privatize everything
  3. Profit!
OK, I oversimplify, but not by much.

The good:
End or repeal the tax deduction for employer sponsored health care.
This is actually part of the the hated Obamacare, but the cap is probably too high and phases in late.  And I think it's actually structured as an excise tax on expensive plans, but it's fundamentally the same thing. Still, it's the one useful part of the whole thing.

The incoherent:
States should take the lead in health care reform by ... structuring a consumer-based marketplace for health insurance, and expanding affordable health care options for their citizens, including setting up pooling arrangements to protect persons with pre-existing conditions... existing health care spending, such as Medicaid ... should be redirected to help low-income individuals and families purchase private health insurance..
State-run consumer-based marketplaces? Check. In Obamacare.
High risk pools? Check.  Also in Obamacare.
Pre-existing condition exclusion? Check. In Obamacare.
Premium assistance for low-income consumers to purchase private healthcare insurance? Check. In Obamacare.
   Of course the key distinction Heritage is making is that these should be initiated by the states, because "Oh Gosh, health care is so different in each state that a one-size fits all solution could never work." This is, in my opinion, not true federalism speaking, just the cynical certainty that few of the states would actually do anything to institute such marketplaces.  How many states have them now?  Why would that change if PPACA were repealed?  The Heritage folks are the fierce defenders of the status quo and their real intent here is to ensure that nothing happens, and some of these battles are easier to fight state-by-state.  I admit that I was hoping that health reform would have more dramatically altered or eliminated Medicaid, as is suggested by Heritage. But it is just bizarre that they advocate repeal and replace with, well, much the same thing as they are fighting to repeal.

The disingenuous:
The federal government should promote interstate commerce in health insurance.
This is code for "allow health plans to avoid regulation by domiciling in the states with the weakest regulatory structure." If you want to have a discussion about deregulating the insurance industry, do so openly and honestly. It would be a disaster, by the way, but make an honest proposal if that's what you're after.

The delusional:
 Medicare should be a defined-contribution system in which the government provides a contribution for benefits and seniors are able to apply their contribution to the health plan that suits them best. Medicaid should be restructured to mainstream healthy moms and kids into private health insurance through premium assistance.
    This is just a crock; a bait-and-switch by an organization/ideology which has hated and tried to kill Social Security programs for 75 years.  Starting with Medicaid: Premium assistance is a laughably unworkable replacement for Medicaid, unless you are going to quadruple the amount of money plowed into the program. Medicaid is already expensive from a budgetary point of view and the only reason it works to the limited extent that it does is because it can price-fix the market at unsustainably low rates.  If poor folks were shunted off into private plans, these plans would have to pay doctors and hospitals reasonable reimbursement rates (not a terrible thing from my perspective), but then the per-beneficiary cost would be way higher!  Is the "consumer" who already lives below the poverty level going to be able to make up the difference?  No way. Is the insurer willing to eat the difference? No. Can you legislate that health care providers have to accept the same crappy rates they currently get? Yes, but then you haven't really changed anything, just recreated the failed boondoggle of Medicare Advantage on a smaller scale.  Don't get me wrong, Medicaid is broken and I wish that the government would just federalize medicaid. But privatizing it is exactly the opposite of the right path.  Unless you want to kill it, which Heritage does.
    As for Medicare, this too is a bogus plan. "Shift to defined contribution" is translated as "shift the risk of future cost increase onto patients."  Does it work?  Sure, in that the costs get shifted off the books and the government is insulated from the future risk. And no, in that the goal of the program -- ensuring every retired American has health care insurance -- would be severely compromised when future unsustainable cost increases happen. This is a dishonest proposal designed to kill Medicare, make no mistake about it.

Also: Private health insurance must be portable—that is, owned by Americans so they can take their package from job to job.
Well, this is a modest proposal. Sounds simple enough -- it's just like care insurance, or like the individual health insurance market now, right?  Well, yes with the minor detail that it would mean the end of the employer-sponsored model we have had since WWII. This would quite simply require the end of the group plan. Now, the Wyden-Bennett Healthy Americans Act would have done just that and there's a fair argument in favor of that as a policy.  But it's a pretty major proposal to slip in without addressing the consequences.

So there you have it. Your conservative alternative to the existing Health Care Reform in a nutshell.  No serious attempt to address the number of uninsured. No tangible cost controls. Kill off Medicare and Medicaid, deregulate private health insurance, and let the wonders of the private market work their magic!  It'll be a Randian paradise!


16 August 2010

Of course you realize that THIS MEANS WAR

I have a partner who I will call Ziggy.  Ziggy is a super nice guy, quiet and gentle-spoken, and one of the absolute favorite docs among the nursing staff. For some reason, the way many of the nurses have chosen to express their love for him is to hassle him endlessly, using any pretext they can to try to get a rise out of him.  He is so placid, though, that it pretty much never works, but he enjoys the give-and-take.

The other day he came into his afternoon shift several hours early. He had a meeting to attend and some administrative work to do, and having finished that he announced that he was going to take a nap in the doctor's sleep room and could someone be sure to wake him at two (when he was scheduled to start working).

Predictably, the nurses decided this was a perfect opportunity for a prank.  The sleep room is in an out-of-the way place, where nobody but the docs or housekeeping ever go. So a few of the nurses took it upon themselves to booby-trap the door.  They carefully balanced mayo stands leaning up against the door with open containers full of hundreds of tongue depressor blades on top, open pails of water on the lintel, mops and brooms and all sorts of detritus and obstacles behind that.  For a solid hour they went back and forth, laughing and giggling and whispering about what a great trick it was going to be.

So it was with a crestfallen look that they saw Ziggy walk in the front door at five minutes to two, clean and dry and carrying a fresh cup of coffee. The ringleader casually asked, "Hey there, Zig, what's going on? How was your nap?"

Ziggy said, "Oh, I didn't get one. Someone else was using the sleep room so I went to the cafe instead."

The conspirators exchanged nervous glances.  "Who was using the sleep room?"

"Dr Carlos." Carlos is the medical director of the entire ED. "He said he had a big meeting with the CEO and wanted to rest up before it."

Several faces went pale.  A couple of the conspirators dashed off to disarm the trap but returned to report that it was too late. The guilty parties decided to play dumb and everybody went back to their routines, a bit anxiously.  As Ziggy settled in at his station by me, I gave him an inquiring look.  "They got me pretty good," he said in a whisper, "but I wasn't going to give them the satisfaction."

Shortly afterward, I was wandering over to the Cafe myself and musing on a couple of business items I had to deal with.  I was running down my mental checklist and one to-do item was to call Carlos. That gave me the glimmer of an idea, and suddenly it hit me. I called Carlos (who was in fact at home that day) and filled him in on the situation. A former firefighter, he loves a prank as much as anybody and quickly signed on to the counter-conspiracy.

Shortly afterwards, the ED phone rang. It was Dr Carlos. He spoke with the charge nurse, very calmly, and explained that he had been the victim of a practical joke and as a result had to meet with the CEO while he was dripping wet. (The charge nurse knew nothing of the pranking.)  He explained that he was not very happy and would like her to identify the guilty parties and ask them to meet with him in his office after their shifts were over.

The charge nurse was horrified and apologized profusely. There were a large number of very serious hushed conversations over the next couple of hours as the guilty parties slowly ratted one another out. Eventually it culminated in them all calling Dr Carlos personally and apologizing, and Dr Carlos was gracious enough to accept their apologies and that closed the matter as far as he was concerned.

I'm not sure at what point the nurses figured out they had been had.  Ziggy and I had been trying our best to keep our shit together while this all played out, but it was really hard. Eventually I left and I think they all ganged up on poor Ziggy and beat the truth out of him.  They were not very happy about their super prank backfiring on them.

When I showed up for my next shift I was surprised to be the subject of baleful glares from nearly the entire nursing corps.  Lisa (the ringleader) approached me and jabbed me in the chest.  "You've been a bad monkey.  We know what you did."

I was actually surprised (having forgotten about the whole thing) and protested ignorance. She wasn't having any of it. "You know what you did. Don't play stupid. I'm just giving you notice now.  You'd better be watching your back, and your front, too, for that matter."  I brought in a big bag of candy for my next shift, but they said it wasn't good enough and that they are still going to "get me."

So I guess I've got to start taking some defensive measures -- park in unusual places and be sure to keep extra clothes in the trunk, just in case.  We spent some time chewing it over during the night shift, though, and it was generally agreed it was the best prank we've seen since PB left us.

But now I have to live in fear.

13 August 2010

Friday Flashback - Pac NW

How to know you're from the Pacific Northwest

1. You know the state flower (Mildew).
2. You feel guilty throwing aluminum cans or paper in the trash.

3. Use the statement "sun break" and know what it means.

4. You know more than 10 ways to order coffee.

5. You know more people who own boats than air conditioners.
6. You feel overdressed wearing a suit to a nice restaurant.’
7. You stand on a deserted corner in the rain waiting for the "Walk" Signal.

8. You consider that if it has no snow or has not recently erupted, it is not a real mountain.
9. You can taste the difference between Starbucks, Seattle's Best, and Veneto's.
10. You know the difference between Chinook, Coho, and Sockeye Salmon.

11. You know how to pronounce Sequim, Puyallup, Issaquah, Oregon, Yakima, and Willamette.
12. You consider swimming an indoor sport.

13. You can tell the difference between Japanese, Chinese, and Thai food.
14. In winter, you go to work in the dark and come home in the dark - While only working eight-hour days.
15. You never go camping without waterproof matches and a poncho.
16. You are not fazed by "Today's forecast: showers followed by rain," And then; "Tomorrow's forecast: rain followed by showers."
17. You have no concept of humidity without precipitation.
18. You know that Boring is a town in Oregon and not just a State of Mind.
19. You can point to at least two volcanoes, even if you cannot see through the cloud cover.
20. You notice, "The mountain is out" when it is a pretty day and you can actually SEE it.
21. You put on your shorts when the temperature gets above 50, but still wear your hiking boots and parka.
22. You switch to your sandals when it gets about 60, but keep the socks on.
23. You have actually used your mountain bike on a mountain.
24. You think people who use umbrellas are either wimps or tourists.
25. You buy new sunglasses every year, because you cannot find the old ones after such a long time.
26. You measure distance in hours.
27. You often switch from "heat" to "a/c" in the same day.
28 You design your kid's Halloween costume to fit under a raincoat.
29. You know all the important seasons: Almost Winter, Winter, Still Raining (Spring), Road Construction (Summer), Deer & Elk Season (Fall).

(Source unknown)

12 August 2010

Impenetrable medical billing journalism

Every news story about the ER just has to begin with a patient story. I think that's in the Constitution, it's such a universal thing. The New York Times had a halfway decent story about ER billing and a couple of minor changes in the PPACA (ie. health reform law). But the obligatory patient story really stopped me right in my tracks:
DURING a snowstorm last winter, my 6-year-old son fell and cut his chin — not outside on the ice, but inside on the tile bathroom floor. My husband walked our son, Charlie, through the knee-high snow to the local emergency room. Charlie’s gash was small, less than half an inch long, but deep. The hospital called in a plastic surgeon, who put 14 tiny stitches into his chin. Charlie called the incident “the worst day of my life” — mostly because he had to spend hours in a hospital instead of throwing snowballs. Weeks later, when the bills arrived, we had our own bad day. The total charges for his minor spill came to $5,398. The largest single charge was a shocking $4,950 from the plastic surgeon.
There are so many WTF elements for this story I don't know what to say:
  • They called in a plastic surgeon in for a 1 cm chin laceration? (either the parents were hyperdemanding or the ER doc was incredibly lame)
  • The surgeon put 14 stitches in a 1 cm laceration? (even for a three layer closure that is an insane number)
  • $4950 for a 1 cm lac?
The last item there is the most staggering. Just for reference, a typical code for the repair of such a laceration would be 12051 -- Intermediate repair laceration face, <2.5cm. This carries a value of 6.57 RVUs (non-facility) and a medicare reimbursement of $236. If there were something truly complex here (highly doubtful based on the description) then a complex repair might be justified -- 13151 -- which carries 10.14 RVUs and a medicare reimbursement of $365. Now it's not uncommon for a physician to set their gross fee schedule at 400% of medicare (which is after all a terrible payer). So "reasonable" charges for these codes range from $1000-1500. For the charge to come out at $5000, one of several things must be the case: either the author omitted a material detail, like maybe there was also a mandibular fracture; the author confused a facility bill with a physician bill; or the plastic surgeon had a fee schedule somewhere north of 1600% of medicare.

I suspect that the facility bill was actually the big one. $5000 is still pretty steep for an ER visit absent major diagnostic work, but it's conceivable. Ultimately, it's an exercise in futility to try to make sense of media reports of medical bills, even in an article ostensibly about understanding your bill! So I'll focus on the one bit which I heartily endorse:

DON’T GO THERE If your situation is not dire — you twisted your ankle or have a persistent sore throat, say, or your child receives a small burn — call your doctor first and ask for advice.

While this might sound obvious, many people routinely head to the E.R. for nonurgent problems. The top three reasons for emergency room visits in 2007 were for sprains and strains, superficial injuries and contusions, and upper respiratory infections, according to Ryan Mutter, a senior economist at the federal Agency for Healthcare Research and Quality. [...] Another good alternative to the E.R. is an urgent care center. There are now 8,700 of them across the country. They are typically faster and cheaper than E.R.’s. Urgent care centers specialize in treating mild injuries like sprains, broken toes and fingers and mild cuts.
Wasn't I just saying something along these lines yesterday? Also good advice:
MAKE AN OFFER If the final bill is beyond your means, it will pay to bargain — particularly if you do not have insurance.

“The majority of hospitals will discount private paying patients’ bills,” Ms. Leone said. “Most hospitals are generous in their discounts.”

You can negotiate even when you have insurance. Negotiate with doctors, too, over their individual bills.

ACT QUICKLY Unpaid hospital bills are usually forwarded to collection agencies that report uncollectible accounts to credit agencies. When faced with exorbitant bills, don’t hesitate to contact the hospital’s billing department and start a dialogue.
Very true. I know we bend over backwards to avoid sending patients to collections. It pisses people off, generates complaints to the hospital and our office, and generally nets us little actual revenue. We will happily take a large amount off the bill if it means we collect something on an account which otherwise would get us nothing.

11 August 2010

In which I shall depart from the party line

The conventional wisdom has been that as the crisis in American healthcare has deepened, as the number of uninsured Americans grew and the access to primary care dwindled, the nation's ERs have been choked with patients seeking primary care, with non-urgent complaints, with trivial stuff that chokes up the departments and distracts staff from the truly ill patients with real emergencies.

ACEP and the house of Emergency Medicine have pushed back hard on this perception. They contend that most ER patients are in fact in the ER appropriately and that the real problem is a lack of inpatient beds which force admitted patients to be boarded in the ER, thus exacerbating the overcrowding crisis. ACEP is right to focus on patient boarding -- it's a real problem, and it's a more tractable problem. But I've always thought it strains credulity to claim that there are few non-urgent patients in the ER.  It actually seems a self-serving bit of fiction, designed to protect the turf, protect the business, to justify further investment in the ER.

I saw this triumphant tweet from ACEP's public affairs office yesterday:

Twitter / ACEP: Full CDC report, only 7% n ...

And my initial response was: hogwash.  7% of patients non-urgent?  No way.

So I started by actually reading the linked publication: the National Health Statistic Reports 2007 Emergency Department Summary (warning: PDF). The methodology is simple: they looked at a statistically valid sample of ER visits and complied the descriptive data, including triage level.  Apparently everyone uses the 5-level triage scale now, or enough that they could extrapolate to national figures, and I am sure that their statistical prowess far exceeds my own, so I'm not going to quibble with the results.  As stated, only 7.9% of ER patients were triaged at the lowest level of urgency.  The triage scale, for those not familiar, is this:
Triage Levels
Sensible enough.  So are the PR guys at ACEP right?  Are 92.1% of patients in the ER in fact, emergent?  Maayyybe. But I think not. Note that green category, "semi-urgent."  That includes another 21% of patients. Now this is where things really get subjective. What's the difference between a level 4 and 5 triage?  What's the difference between Semi- and Non-urgent?  I have no idea. Sure, there's a definition (green means the patient should been seen in 61-120 minutes), but in my experience the triage nurse simply picks a level kind of arbitrarily when the patient is on the low end of the spectrum.  Quite frankly, the nurses tend to use green as "non-urgent" and blue as "so fricking non-urgent that I am mad at you for coming to the ER."  So my contention would be that the more accurate interpretation of the NHSR report reflects the reality that somewhere around 29% of ER patients are not true emergencies.

This is also consistent with the larger trend we have been seeing in medicine - the rate of ER visits over the last decade has increased at twice the rate of population growth. To some degree this is due to the aging of the population and the increase in the number of Americans living with chronic disease. It is also, I suspect, due to the slow death of primary care and the rise in the number of uninsured and medicaid patient who effectively have no access to primary care. (It's worth noting that the uninsured patients in the NHSR report skew to the lower acuities.) 

This is also consistent with my experience. It's reasonable to take triage acuity as a sense of whether a patient had, prospectively, a potential emergency. But when you do look retrospectively at diagnoses, it paints a very different picture. Of the 22 million pediatric visits, about 9% were due to otitis media and URI's alone. When I look at the most common diagnoses in our ER (a relatively high-acuity ER) I see a lot of not-exactly-emergent diagnoses on the list:
  • Lumbar sprain
  • Bronchitis
  • Headache
  • Migraine
  • UTI
  • Unspecified Viral Infection
  • Lumbago (really?)
  • Otitis Media
I admit that it's hard to sort of from a list of diagnoses whether a patient really "belonged" in the ER. A 18 year-old female with cystitis and an 88 year-old with urosepsis might both show up under the same primary diagnosis. But still, lots of "urgent care" stuff there.

Now none of this is to say that I blame patients for coming to the ER with these complaints. Generally they are doing the best they can in the system we have. If there were primary care docs and urgent care clinics who could care for their urgent problems, many would choose to go there. Even more would choose to go to urgent cares if they had an economic incentive to do so -- like a higher co-pay.  However, the ER is "free" for many and we are open 24/7 with no appointment needed, so we become the convenience clinic in addition to the safety net.

In an ideal world, we would have a front desk with two doors behind it: one to the main ER and one to an urgent care clinic.  Or even if we had the ability to screen patients and refer them to clinic appointments.  But EMTALA makes such endeavors dicey: you make mistakes with that sort of policy and you can be in a world of trouble.  Moreover, the economics of office-based practice are so marginal and the crummy payer mix of the average ER makes it worse, so few hospitals or medical groups are eager to open up such urgent care centers. So we are stuck seeing all comers, the emergent as well as the urgent and the semi/non-urgent.  It's not an ideal situation, but it is not going to change any time soon.

It does not behoove ACEP, however, to make and persistently repeat claims which are false or misleading about the acuity of the patients we serve. It reduces our credibility in the policy debates and wastes energy on an issue which is a distraction from the other (more tractable) issues challenging the emergency care system.

06 August 2010

Friday Flashback - Things which will blow your Wa

Wa is very important to me. From my limited understanding, "wa" is a concept in Japanese culture referring to an internal sense of harmony and well-being. I shelter, protect and cultivate my wa religiously. It is what gets me through difficult shifts without going mad.

So yesterday, I arrived home from a birthday party with the kids, still in my swimsuit and wet from the pool. Tired and utterly relaxed, I had a beer out from the fridge and on the counter with the bottle opener in my hand.

The Phone Rings.

"Hi, Doctor. It's Jennifer in the ER. Are you coming in to work this evening? We were expecting you at 6:30."
"I don't think I am working today."
"We have you as the 6:30 doc on the schedule. Did you make a trade?"
"Um, no. Let me check my schedule and get back to you."

My Outlook calendar has me quite clearly as OFF today, but the master ER schedule does show me as working. Crap! How did that happen?

I ultimately got to work only an hour late (only!) and that was only by virtue of a very quick change of clothes and some serious extralegal driving. Fortunately, my partner whose shift had been scheduled to end at 6:30 was gracious in accepting my humble apologies.

But my wa was completely and utterly blown.

Predictably, the shift wound up being like crap. Nothing worked. I never got my flow, the rhythm, the groove. Nobody had an obvious diagnosis. Hospitalists were all rightly skeptical at half-baked admissions. Pissed-off patients wound up walking out dissatisfied. I kept losing track of patients (Room four? I thought they were discharged an hour ago!) and orders somehow kept appearing on the charts for the wrong patients (thank god for alert nurses who repeatedly saved my ass). And all attributable to the fact that I arrived late, flustered, and not in the right frame of mind for the shift. Man, I'm no good at all without my wa.

Sigh. And I am working again at 6:30 tonight.

Originally Posted 3 July 2007

05 August 2010

Advice for EM Senior Residents

Fellow blogger and EM senior resident (how time flies) Graham Walker asked me if I had any opinions about how a graduating resident should approach the job search, and if I had any advice on how to avoid getting screwed.  Silly Graham! Of course I have opinions!  And having been prompted, I will happily share them. 

1. Know what you want. 
There are so many practice types out there and so many options that an undifferentiated job search is almost hopeless. There are academic hospitals, community hospitals, big hospitals, trauma centers, little hospitals, urban, suburban, county, rural hospitals. There are small groups, multi-hospital groups, national groups. There are democratic partnerships and oligarchies. There are places where you can be a partner, an employee, or an independent contractor. There are places which are poorly compensated and highly compensated and everything in between. 
Define your priorities and develop a search.

If you are particularly invested in, say, a certain geographic area, that may restrict other variables.  The southeast, I hear, is highly penetrated by large contract management groups. The pacific northwest has almost no academics. If you know what the most important variables are to you, you will be able to refine a search strategy that will get you in the best possible place. There is no such thing as a job which will be perfect for everybody. So you need to filter out the ones that might be fine jobs but are not right for you, and you need to know in advance what's negotiable to you.

2. Never take a job just for the money. 
Relative salaries are important and should be considered, but there is so much more to a career than a paycheck.  Consider your overall goals, and try to figure out where you will be happiest and most fulfilled. If you're well paid but hate your partners, or don't trust them, that's a terrible situation to find yourself in down the road.  

3.  Beware the lure of academics.  
It seems like every resident I interview wants to stay in academics, and offers up a regretful explanation for why they are settling for practice in (shudder) the community. Why? Because academics are all they've ever known. They went to college, med school and then residency, and have never worked outside of a teaching environment. So they think that's the whole world of medicine.  But there are not as many academic jobs as there are graduates, they don't pay as well, and there are almost no academic jobs in our neck of the woods, so graduating residents have to "go native" and practice in community-based ERs.   This is, however, a feature not a bug: there is way more to medicine than you will encounter in the ivory tower, and it can be highly fulfilling and important. Academic practices are right for some, but it shouldn't be the default position, and there's no need to feel guilty about leaving the teaching environment.  

4. Determine your market position.
By which I mean, is your desired job in a buyer's or seller's market? Every interaction with an employer is a negotiation, and knowing your relative position is critical to knowing your strength in the give and take of recruiting. You need to know how much leverage you have and tailor your strategy to the situation.  Are you an exceptional candidate or a marginal one? (This kind of self-insight is very hard, BTW.) If you are applying for a job which is highly competitive or if you are a candidate without distinguishing features (or with blemishes) you will need to work harder to market yourself and you will have much less leverage to make requests/demands from a potential employer. On the other hand, if you are applying for a position where they have a harder time recruiting you have more capability to ask for sweeteners (or reject unfair requests).  Remember that the employer is ultimately in the stronger position and if you come on too strong or seem arrogant then they may well walk away. Refusal to negotiate at all is in many cases a red flag, but do recognize that some factors are non-negotiable to some groups. You can't negotiate a higher salary than the rest of the partners in a true democratic group. But maybe you can decrease the amount of time you will have to spend on the night shift before you become a partner.  You're unlikely to get a employer to cut a special deal for you on the malpractice premium, but you may be able to get a signing bonus, moving expenses, or schedule parity. Whether and how hard to press for concessions depends on your position.

5. Avoid recruiters
I say this with some hesitation, anticipating the flood of objections from the recruiting profession. But in my experience, they add little value from the point of view of the applicant. Bear in mind that the typical fee for a headhunter is about $25,000 for an emergency physician. That's a ton of money that in reality will be deducted from your signing bonus and first year salary. (If you are applying without a recruiter, it's not a bad idea to ask the employer if they are also using recruiters and would be willing to apply the recruiting fee to a signing bonus/moving expenses/debt repayment etc.) There are some cases where a recruiter is useful, especially if you don't know or care where you want to work on a geographic basis. But also bear in mind that the groups that need headhunters tend not to be the best practices (which is why they need to use a headhunter) and that you should approach them with a sense of wariness to understand why it is they felt they needed to engage the services of a recruiter.  Recruiters can offer value if you don't much care where you work, geographically, but have particular requirements for the type of practice you are willing to consider. Caveat emptor.

6. Understand the potential employer 
There are a ton of models of emergency medicine practices. Some are hospital employees (fewer these days) or employees of hospital owned practices. Some are private partnerships, or corporations owned by one or a few privileged docs. Some are corporate chains.  Know who the employing agency is, and who owns it and in what degree. Know who is the contracted agent with the hospital. Understand the employment model (employee, partner, IC, etc).  Understand the governance of the group.  Understand the compensation model and boil it down to a figure which can be compared to other potential employers on an hour for hour basis.

7. Read the contract.
I cannot emphasize this strongly enough, but read it and be comfortable that you understand it. Strongly consider having an attorney read it for you, especially a longer or more complex contract. Do not agree to work without a contract. One old time concern for ER docs was noncompete clauses; this is less of a concern now, as they are generally not enforceable. However, I would still ask for a noncompete clause to be removed from the contract. It is not unreasonable for there to be a noncompete clause with regard to the hospital contract. (i.e. you cannot bid against the group for the hospital contract.) More salient are termination clauses: how much notice is required on either side? "For cause" termination should be highly restricted to really bad things, like felony conviction or exclusion from medicare and watch out for catch all "good behavior" clauses. Termination without cause should have reasonable notice 3 or 6 months) and generally the notice requirement to quit should not exceed the notice the employer can give you to fire you without cause. Most critically, any promises the employer makes in the interview (especially with regard to compensation, partnership, and scheduling) should be reflected in the contract or accompanying documentation. If the employer is not willing to put these assurances in writing, that is a big red flag. 

8. Practice Stability and Strength
Basically you want to know if you sign on to a position whether it will be there and materially the same in the first year or two.  You'll never get a direct answer to this question, at least not in a troubled practice. But there are some proxy questions you can ask and get verified. For example, the tenure of the medical director. How long has he or she been in place? Why did the old one leave, if it was recent? How many medical directors have there been in the last five years? Obviously high turnover in critical leadership positions is a concerning sign. Similarly, you should ask about the tenure of the contract; a longstanding contract is reassuring (though no guarantee). Ask the number of recent physician departures and why. Can you contact recently departed docs? They are in a position to give an unvarnished view of the practice.  What's the relationship with the hospital adminstration? Broad questions like this will get nowhere -- ask the employer to describe recent challenges with the hospital CEO and how they worked past them. Ask the employer for a roster for all their docs and if you have permission to contact any of them. Ask whether the practice receives a subsidy from the hospital and what the basis is for that subsidy. (Large subsidies may destabilize a practice.) Does the practice have other business lines (an urgent care clinic, or a billing company for example) and how is the revenue from those lines shared among the docs? What is the practice manager's plan for the future of the group? What are the group's biggest strategic threats and biggest opportunities?   

9. Transparency
Many groups give their non-partner physicians the mushroom treatment. As a potential applicant you have some freedom to ask awkward questions and expect an answer. Ask whether the group has open books for all partners to review.  What is the pay differential between new hires and partners? Do all partners get paid the same? Do all partners have the same schedule priority? How do physician adminstrators get paid? The Medical Director/managing partner deserves compensation, and in some groups this compensation is substantial, but should be transparent.  Are board meetings open to all interested docs, or partners-only, or board members only? What are the requirements for being able to serve on the board? How often to these positions open up?

10. Practice Management
How well the group is run, the attention to the detail and the professionalism that the administrators bring to the practice will have a large effect on how stable and profitable the practice is.  So these are salient (and often overlooked) points to hit:  Who does the coding/billing? Who owns the billing company? Self coding (which is now uncommon) should be a red flag both due to lost revenue and poor compliance. If the parent hospital does the billing (also now uncommon) this is also a red flag; generally hospitals don't much care about the pro-fee, which is much smaller than the facility fee, and they leave a lot of money on the table.  What's the cost of billing and coding? Anything under 5% of gross revenue is disturbingly cheap, anything over 11% is too rich.  What's the group's overhead costs? If more than about 25% of gross revenue is going to expenses, you need to wonder about the group's management.  Also get the details of the malpractice policy. How is the premium calculated? Per patient, per physician? What are the limits? Who provides it? What's the malpractice environment in the state, and how many carriers operate there? Who provides the policy?

11. Compensation
This could be a whole other post on its own. The permutations of ER physician compensation are seemingly infinite. They boil down to: fee-for-service, productivity, and hourly.  Fee-for service is where you literally get to keep the revenue you bring in from the patients you see. You see an uninsured patient, you work for free. You see a fully insured patient, you get paid. This model is less common outside of boutique practices and independent contractor practices these days. Productivity is a model where there is a formula (usually of bewildering complexity) which relates the dollars you bill or the RVUs you generate to the practice's net revenue. Therefore, you get paid on a piece-work basis in a manner which is more blinded to the payer status of an individual patient.  Hourly is just that, a flat hourly rate.  Then you have the hybrid models. For example, you could have a practice where 70% of your compensation is a guaranteed hourly base, 25% is productivity, and 5% is "citizenship" or some such fluff.  For all intents, I would consider any model where more than 50% of income is a flat rate to be "hourly."  The spread between low and high producers is so attenuated in such "base pay" systems that it really kills the incentive to be productive and efficient. If you're making $150/hr you've very little incentive to break your back to make an extra $3/hr. The behavior of the partners in such systems is effectively identical to the flat rate systems. Not that this is a negative -- for some groups, a flat rate does work best (especially groups with a lot of single coverage). Just recognize it for what it is.

Also, know how the compensation is paid, temporally. I know a practice which pays a very low monthly salary and amasses a huge pile of money which is distributed in the form of "bonuses" on December 31. Our group tries to pay out every cent as it comes in. There's no wrong answer to this, but each has implications. When you keep the bank account empty, you are susceptible to cash flow problems should the revenue fluctuate (which it always does).  When you defer income, you need to learn to live on a smaller monthly budget and also there is a temptation for those in power to be less than entirely equitable in the distribution of that huge pile of money.

12. Ways in which employers can attempt to screw new hires:
Sadly, there is a long history in the field of medicine, including emergency medicine, of screwing the new guys. They're naive and they don't have access to the data, so they have to "pay their dues" until such time as the partners decide to (maybe) let them into the club and share the revenue (in part generated from screwing the next generation of new guys).  It's a vicious cycle, and unless you end up with a truly democratic group, you may have to suck it up and endure it.  Some tricks the practice can pull:
Partnership.  It's not guaranteed, and shouldn't be. If I hire someone and I don't like them or they fail their boards, I am not going to make them a partner and no promise I can make on the day of hire will change that. BUT, there should be an upper limit on how long I can drag my feet, as an employer. One to two years is reasonable. Longer is highly dubious (especially if non-partners are paid less). By the end of two years an employer knows if they want to keep you around or not, and if they are not willing to make you are partner at that time it is just because they want to keep stealing from you for another year or two or three.
Buy ins. If you are buying into a practice, you may have to cough up a significant chunk of change. That's reasonable. The practice has a net value, and if retiring partners take their equity with them that has to be replaced by new partners contributing their share. This can easily be $100K or more. However, if you were paid less than the value of the revenue you generated in the "trial period" before you became a partner, that should be offset against the buy-in costs. Otherwise, once again, the partners are simply using their position to steal from you. They buy-in should represent no more than the fraction of the real value of the accounts receivable that you will own once you are a partner -- it should not be inflated. You should feel free to ask for supporting documentation for the valuation of the buy-in.
Equity games. What is "your" fraction of the corporation?  If there are x partners, you should be offered the ability to buy 1/x the outstanding shares. There are some practices (EMP cough cough) in which a few senior partners own a million shares and new partners can buy a few thousand shares. This is simple math -- how many outstanding shares are there? How many partners are there? How many shares will I be eligible to purchase?
Schedule games.  It's no secret that the older you get, the more obnoxious night and weekend shifts become. Younger docs may well be asked to work more than their fair share. I do not endorse this practice, and I think that if a doc is required or asked to take on this burden it should be compensated. If it is not, be certain there is a distinct time frame in which schedule equity will be established. One to two years is tolerable. "Until old Bill retires" is not.
Shift loads. Make sure your contract spells out how scheduling will occur. Specifically, is there a guaranteed number of shifts you will get? It's easy to sort-of fire someone by just not putting them on the schedule. Also, if your practice is over or understaffed, how will the extra shifts or short shifts be distributed? This should be explained in writing, either in the contract or in a written addendum. Will you be required to work a resident-level number of shifts at first?
Salary games. Some practices have compensation schemes which are deliberately obtuse.  When you interview they will vaguely describe the complex mechanism, which will probably make some sort of sense based on their practice model. But it creates a situation in which it's almost impossible to make an apples-to-apples comparison of one practice vs another. A potential employer should be able to answer this simple question: what was the hourly compensation of your median physician last year, including salary, retirement, health, CME and vacation benefits?
Benefit games. Benefits can be complex. Doctors are in high tax brackets and there is good reason to use the benefit structure to minimize the docs' tax burden.  So to have very large healthcare or CME accounts makes sense, and retirement plans can be huge -- some plans allow you to put away almost $50,000 a year!  As a young graduate you may not want that, but it does make sense. Be sure that as a new employee you have the same access to benefits as all the others, and that there is no staged-vesting plan that will tie you to the group for an excessive time.  1-3 years is reasonable. Anything more is concerning.
Notice and termination. The contract should spell out how much notice you need to give to quit and how much notice they need to give you to fire you without cause. Ideally, these should be symmetric. It's unfair if I ask for six months' notice if you want to leave but I can fire you with 30 days' notice. 90 days is pretty standard.

Don't worry about being too inquisitive. If there is a practice which for some reason is uncomfortable answering this sort of detailed question, I have to wonder why. Even if the reason is benign, you should ask yourself whether you are comfortable working with partners whom you cannot fully trust. Moreover, I judge applicants not only by their credentials but also on the questions they ask. A candidate who has done his or her homework and knows which questions to ask is more impressive than one who is willing to sign whatever piece of paper I put on the table. And if you have to get screwed, which may be the case if there's only one practice hiring in the city where your wife's family lives, at least you will know what you are getting into ahead of time rather than receiving a nasty surprise a year and half into your new job.

These are the items which occur to me off the top of my head that graduating residents should be mindful of when they hit the interview trail. I'll add more as they come to me.  Now if you'll excuse me, I have to go interview a candidate now and see whether he'll be one I can screw.

That's a joke.

An unusual set of skills

An alert reader, um, alerted me to this related piece in Slate:
We Can't Save You
How to tell emergency room patients that they're dying.
he ER is not an easy place to come to these realizations or assess their consequences. A handful of physicians are trying to change that. Doctors like Tammie Quest, board-certified in both palliative and emergency medicine, hope to bring the deliberative goal-setting, symptom-controlling ethos of palliative care into the adrenaline-charged, "tube 'em and move 'em" ER. Palliative/emergency medicine collaboration remains rare, but it's growing as both fields seek to create a more "patient-centered" approach to emergency care for the seriously ill or the dying, to improve symptom management, enhance family support, and ensure that the patient understands the likely outcomes once they get on that high-tech conveyor belt of 21st-century emergency medicine.
ER and Palliative care certified?  That's an interesting mix. We have a great palliative care service where we work (in fact it just won the national "Circle of Life" award).  It makes a lot of sense to have a palliative care nurse stationed in (or routinely rounding on) the ER, though.  I think I am going to suggest that to our hospice folks.

Happy International Beer Day

Hey I didn't know today was international beer day!  Cool.  Sadly, I will be abstinent since I am heading to work in a few hours and will be there past midnight, but I did consume a beer last night just after midnight when I got home, so I have honored the spirit of the sacred hop.

Also, how's this for a tidbit you probably didn't know:

If you’re a fan of craft beer and microbreweries as opposed to say Bud Light or Coors, you should say a little thank you to Jimmy Carter. Carter could very well be the hero of International Beer Day.

To make a long story short, prohibition led to the dismantling of many small breweries around the nation. When prohibition was lifted, government tightly regulated the market, and small scale producers were essentially shut out of the beer market altogether. Regulations imposed at the time greatly benefited the large beer makers. In 1979, Carter deregulated the beer industry, opening  back up to craft brewers. As the chart below illustrates, this had a really amazing effect on the beer industry:




That’s the number of large and small-scale breweries in the US. You can see how the large brewers continued to consolidate and grow and absorb more and more market share right up to the point where Carter deregulated the industry.

Well, Jimmy Carter, hero of deregulation!  Who'd have thunk it? (Note of course that the graph simply shows the number of brewers, not, sadly, the amount of beer brewed or the market share. That graph would look rather different.)

More on Letting Go

Dr Gawande, in his New Yorker piece on hospice, relates the story of a young woman with terminal cancer who progresses down the pathway to intubation and the ICU at the end of her life. He writes:

This is a modern tragedy, replayed millions of times over. When there is no way of knowing exactly how long our skeins will run—and when we imagine ourselves to have much more time than we do—our every impulse is to fight, to die with chemo in our veins or a tube in our throats or fresh sutures in our flesh. The fact that we may be shortening or worsening the time we have left hardly seems to register. We imagine that we can wait until the doctors tell us that there is nothing more they can do. But rarely is there nothing more that doctors can do. They can give toxic drugs of unknown efficacy, operate to try to remove part of the tumor, put in a feeding tube if a person can’t eat: there’s always something. We want these choices. We don’t want anyone—certainly not bureaucrats or the marketplace—to limit them. But that doesn’t mean we are eager to make the choices ourselves. Instead, most often, we make no choice at all. We fall back on the default, and the default is: Do Something.

If this is true in medicine in general it is doubly true in the ER.  There are a number of reasons for this -- the position of the ER to see people at the point of transition into acute dying, the fact that we don't know our patients, the fact that we often have to make treatment decisions based on incomplete information, the fear of litigation, and the fact that we are kind of a bunch of adrenaline junkies.

The other day I saw an elderly man with a very serious illness. He had a slow GI bleed and got his hematocrit down to 15. Yes, that's not a typo: he was a functional anaerobe by the time I saw him. He was a vasculopath, and eventually he tipped over into multi-organ system failure. It wasn't until he infarcted his small intestine that the pain brought him in to see me. 

It was pretty obvious he was on his last day -- his lactate was 16, and when your lactate exceeds your hematocrit, well, that is a grim sign indeed.  He also was having an MI, and in renal failure and in early CHF.  His pH was 6.8, which is the lowest I can recall ever seeing. I got his pain controlled and instituted the standard resuscitative measures -- fluids, blood, antibiotics, etc.  Once his pain was managed he was actually lucid and in good spirits and able to chat with his family while the nurses and respiratory therapists hovered over him.

Predictably, the massive fluid bolus began to back up into the lungs and he became progressively more short of breath. The family and nurses and RTs all became progressively more distressed by his labored breathing.  At one point I faced a delegation of three nurses and two RTs imploring me to intubate. Quite frankly, that was my reflex as well. Intubation for ventilatory support is pretty standard care at this point, and I was on the verge of telling them to get things set up. But a strange reluctance seized me. With "Letting Go" fresh in my mind I said I would go talk to the patient and family instead.

I laid things on the table for them. I looked the patient in the eye and told him that this was it, that "You are going to die from this, and probably today." This is an exceedingly hard thing to say to someone, by the way. I asked him how he wanted to spend his final hours -- sedated and intubated (but comfortable), or awake and able to spend time with his loved ones, with pain medicines as needed.  This was, as you might imagine, a tough conversation and one I might well have shied away from in the past. Frankly, it would have been way easier to simply put him down, intubate him, and ship him up to the ICU for the intensivists to deal with.  The wife was not quite ready to let go, and I had to make it clear that this decision point was not going to change the outcome -- it was not giving up, only recognizing the inevitable and choosing the manner in which it would come to pass.

He chose to be awake and spend the time he had with the people he loved. We slammed on the brakes of the medical machinery and started a morphine drip. He still went to the ICU, but with "comfort care" goals and a consult to the palliative care team. 

I'm really happy we did what we did -- or more importantly, what we did not do.  It was not the path of least resistance, not at all. Some of the nurses had a tough time with it emotionally, but I think it was generally recognized that this was the best possible outcome.  This was an easier case because it was so clearly not survivable, but the many many cases with more uncertainty are in a different category, where the default to "Do Something" leads to a lot of human misery.

And I am not sure what to do about that.

Wonderfully grim

strip for August / 04 / 2010From the wonderful and fairly deranged Overcompensating webcomic.  I just love the existentialist verbiage in the second panel: "Time just crawls until you become an adult, then it transforms into a rotting bullet train that makes random stops at seemingly endless points of boredom and regret..."

Sartre would have been proud of that metaphor.

04 August 2010

The Cliff

I finally got a chance to read Atul Gawande's recent piece in the New Yorker, titled "Letting go," on hospice care and the medical profession's systematic failure in managing the dying process. It's an amazing article, and Gawande is an amazing writer. One graf jumped out at me:

One Saturday morning last winter, I met with a woman I had operated on the night before. She had been undergoing a procedure for the removal of an ovarian cyst when the gynecologist who was operating on her discovered that she had metastatic colon cancer. I was summoned, as a general surgeon, to see what could be done. I removed a section of her colon that had a large cancerous mass, but the cancer had already spread widely. I had not been able to get it all. Now I introduced myself. She said a resident had told her that a tumor was found and part of her colon had been excised.

Yes, I said. I’d been able to take out “the main area of involvement.” I explained how much bowel was removed, what the recovery would be like—everything except how much cancer there was. But then I remembered how timid I’d been with Sara Monopoli, and all those studies about how much doctors beat around the bush. So when she asked me to tell her more about the cancer, I explained that it had spread not only to her ovaries but also to her lymph nodes. I said that it had not been possible to remove all the disease. But I found myself almost immediately minimizing what I’d said. “We’ll bring in an oncologist,” I hastened to add.

“Chemotherapy can be very effective in these situations.”

She absorbed the news in silence, looking down at the blankets drawn over her mutinous body. Then she looked up at me. “Am I going to die?”

I flinched. “No, no,” I said. “Of course not.”

A few days later, I tried again. “We don’t have a cure,” I explained. “But treatment can hold the disease down for a long time.” The goal, I said, was to “prolong your life” as much as possible.

I’ve seen her regularly in the months since, as she embarked on chemotherapy. She has done well. So far, the cancer is in check. Once, I asked her and her husband about our initial conversations. They don’t remember them very fondly.

“That one phrase that you used—‘prolong your life’—it just . . .” She didn’t want to sound critical.

“It was kind of blunt,” her husband said.

“It sounded harsh,” she echoed. She felt as if I’d dropped her off a cliff.

This was striking in part because I have had to have this conversation many times over the last few months. This is not exactly a normal part of the practice of Emergency Medicine. In fact, I had this conversation just yesterday, and it went badly.

This was not a subtle diagnosis -- a sixtyish year old man with back pain and a huge, lumpy liver on exam. I got the CT and it showed innumerable nodular mets in the liver (probably colon primary but not certain). I sat own to tell him and broke the news as I usually do, along the lines of "Well, I got the scan results, and it gives us an explanation for the symptoms you have been having, but unfortunately, it's not very good news." (Pause here for the patient and family to brace themselves.) "We saw a number of spots on your liver. Based on the way they looked on the scan and based on what we have seen in the past with similar images I can tell you that this is almost certainly cancer."

This is generally where we go off-script. Once you drop the C-bomb, the reactions are all over the map. From tears to hysterics to calm questions, you never know where the conversation is going to go.

In this case, the wife reacted fairly typically with a gasp and tears, but the patient just kind of stared at me and said "OK, then." I thought, either he didn't hear me or he's in denial. I'd better emphasize the point a bit. So I added that while we didn't know the primary site of the cancer, it probably came from somewhere else and once cancer spreads to the liver, it is much more serious. Still no reaction.

"Do you understand?" I asked, and finally he responded.

"Yup," he said, "It's about what I figured. I've had a pretty good run. Thanks, though. I guess I'll be on my way." I tried to engage him in the next step -- seeing his doctor, an oncologist, chemo, etc, but he was uninterested. "No, I'm just gonna let this thing run its course."

Ah hell, I thought, I overdid it. Now he's already being fatalistic. Eventually I got him to agree to meet with his doctor and the oncologist (his wife was my ally in getting him to concede even that much). Lord alone knows whether he'll follow through with anything more.

He was probably shocked and maybe depressed, too, but I felt a little bad about dropping him off of the proverbial cliff.