30 May 2011

Memorial Day follow-up

Iraq War veteran Don Gomez writes in the Daily Beast:

Like many Americans, I grew up without really understanding the meaning behind Memorial Day. I associated the holiday with barbecues, a day off from school, and sleepy Sunday afternoon movies about submarines and Generals. Even when I was fighting in Iraq, or jumping out of airplanes with the 82nd Airborne Division, it still seemed like an old holiday for old men. As a war veteran, I eventually came to understand the meaning, but I still figured it wouldn’t become my holiday until I was retired and gray.

Ten years of war has changed that. For the quiet few who have shouldered these wars, Memorial Day is no longer an abstract holiday honoring a faceless mass of heroes from a history textbook. It’s a list of names of people you know, reluctantly accumulated and growing ever longer. It’s a reminder of the awkward long-distance phone call to tell a friend that his old squad leader and mentor was killed in an IED blast in Afghanistan. It’s the swirl of emotions felt when informed that a friend was just killed in Iraq, leaving behind a young wife and children. It is the unavoidable sinking feeling, deep in the stomach, of "Why me? Why am I okay?"

When once I may have thought of Memorial Day veterans as old men in wheelchairs, I now think of the young blonde soldier at Walter Reed, painfully fixing her prosthetic leg to her knee for her morning physical training session.

This mirrors my own experience of Memorial Day (not counting the bit about jumping out of airplanes). When I was a kid/adolescent/young man it was about as remote and meaningful as Armistice Day or Colombus Day. Though I don't have the personal experiences that Mr Gomez does, it's fair to say that this has become, once again, a living holiday. Pity it took ten years of war for me and others of our generation to realize that.

Memorial Day

Flogging Molly takes a moment to raise awareness of the epidemic of PTSD in our country's combat veterans.

It's killing me that they played in our state yesterday and I was unable to get there to see them.

27 May 2011

Scenes from Tenerife

I simply cannot get enough of these time-lapse videos. 

El Cielo de Canarias / Canary sky - Tenerife from Daniel López on Vimeo.

Make sure you have HD set to on.

Watching the clouds surge and ebb like water is amazing. If you watch carefully there are a couple of cool bonuses: a "green flash" when the sun sets, a double rainbow, and a lenticular cloud. 

Now I want to visit the Canaries.

26 May 2011

Ethics of refusing informed consent

In my Monday post, I posed a challenging real-life dilemma we recently faced in the ER. As always, I modified the posited case from the actual facts but the broad outlines were true to life: A young person of questionable capacity wants to refuse lifesaving treatment. 


Short answer, for those not interested in the discussion: This case is a no-brainer. You intubate. In this case, sadly, the outcome was not good. As I hinted, early hypoxia in the setting of blunt chest trauma is a bad sign. The patient was intubated, but became progressively more difficult to ventilate over the next couple of days and subsequently died. The family was at the bedside and, from what I understand, they were very happy to be able to be with him in his final hours. On the other hand, due to his drug abuse, he proved extremely difficult to sedate (even on max propofol!) and was agitated and combative, in restraints, until hypoxia began to take its toll. While I am confident I did the "right" thing, the tally sheet is decidedly mixed as to whether was beneficent in its effect.



A key concept here is whether the patient has the capacity to make an informed consent or refusal to treatment. There is a lot of vague thinking and hand-waving that surrounds this issue. I was going to write up an extensive discussion of the requirements for capacity, but my work was done for me by inwhiteink, and much better than I could have. So go read it. Her conclusion:

From the available information, it is unclear if the case patient could manipulate information in a rational manner for this specific situation. We do not know the reasons why he did not want to be intubated. One reason could have been his stated desire to die. ... It may be unfair to assume that he cannot manipulate information in a rational manner simply because he could not state reasons for refusing intubation. However, it is also unfair to assume that he can manipulate information in a rational manner in the absence of data.

Exactly. Contrary to the popular misconceptions, the presense of alcohol or opiates or benzodiazepines does not prima facie render someone incapable. Capacity is demonstrated by the patient's actions/words, as interpreted by a trained physician or other professional. A mental health condition (such as depression/suicidality) can render a patient "not capable," but again, you must show how their condition relates specifically to the treatment the patient wishes to undergo or refuse.

A second consideration is the gravity of the decision in question. There is an important qualitative difference between refusing lifesaving treatment and, say, choosing an outpatient cardiac workup over an inpatient workup. An observer needs a much higher level of confidence in the patient's capacity to allow the former. 

Context also matters. This is why I added the follow-on questions relating to the patient's age and the likelihood of death despite treatment. For example, a patient whose illness is likely to be lethal 98% of the time would not raise any eyebrows should he choose comfort care and refuse invasive curative therapy. Similarly, age naturally (for some) brings an acceptance of death. I have seen many a senior with a wonderful, serene acceptance of the approach of death. If a senior who was not evidently depressed said to me, "Doc, I've lived a great life and I'm with my family and I don't want to go through X," I can accept that as a reasoned decision to refuse care.

In this case, there were a variety of compelling reasons to over-ride the patient's refusal of care. First, this was a very serious, irrevocable decision. It was life-or-death, decide now, no takebacks. You can always withdraw care later, but you can't re-animate the dead if you change your mind. And, um, you can't change your mind if you're dead. The context argued for full treatment. He was young and not at the stage in life when most people view death with equanimity. He had a serious injury but with a reasonable expectation of cure. And I had a strong impression that his capacity was diminished. It wasn't clear-cut, but there was enough doubt that in this case I was not prepared to allow him to die. I would have allowed him to refuse, say, an x-ray of his knee. But not intubation.

So what are the legal and risk management implications here? 

First of all, as pointed out, there are real risks of allowing him to refuse care. Whether or not you get sued, a case like this in which a young patient dies will evoke strong feelings within the care team and the case will be very closely examined in retrospect. Your hospital administrator and quality committees expect that in such cases that all appropriate processes are followed and rigorously documented. Maria suggests a "second opinion" in such cases, which would be a very good idea. This is not just to protect your own ass, but also to protect the patient. When you are literally making life-and-death decisions for someone else, the function of a second opinion/risk management/patient advocate is to double-check your judgement. In such cases, you would be well advised to involve whatever resources are available at your facility - ethics team, chaplain, whatever. If you do follow all the steps, and you get sued after all, your defense will be much stronger for having done all that extra work and having documented the process clearly.

On the other hand, should you decide to treat despite the patient's vigorous objections, you are on much firmer ground. From a simple malpractice point of view, there is a civil tort involving "wrongful death," but not "wrongful living," at least not in this context. You can be at risk for a bad outcome based on delayed diagnosis, etc, but generally not on the theory that you should have allowed him to die. (If there is precedent to the contrary, I'm unaware of it. Childbirth is a separate circumstance.) Though assault and battery charges have at times been levied against physicians who impose treatment on patients against their will, traditionally the courts have shown deference towards the judgment of a treating physician, and have especially given weight to the presumption that preserving life should be the default approach except in clearly defined cases.

So, basically, you are safe in treating and at high risk should you allow him to die. While I would not advocate choosing a course of action solely based on perceived liability risk, this is a case where the ethics and the legal issues point the same direction.

The final point I would address is that of process. What do you have to do to over-ride someone's wishes, or, conversely, to allow them to die, if appropriate? It's not as simple as just holding them down and pushing succinylcholine. The first thing I do, after formulating what I think should be the plan, is see if there is consensus among the care team (meaning the nurses and any other doctors involved). If there is a nurse who feels strongly that you should NOT do something, that conflict needs to be resolved before you move forward. Similary, the family needs to be engaged, if possible, to assess their feeling on what should be done. If the stars align and everybody is in agreement on the course of action, then you're good to go. (Again, I am assuming fairly exigent circumstances.) If there are irreconcilable conflicts, either within the care team or with member(s) of the family, then you are going to need to go up the chain of command. In my facility that generally involves a call to the risk manager or administrator on call; your institution may vary in its procedures.

I'm not surprised that the comments/emails I got on this case were about 9-1 in favor of treatment. It was a no-brainer, by and large. But it was an interesting case because it illustrated the difficulty in assessing decisional capacity and the elements required to over-ride a patient's wishes. And I enjoy taking a specific case and using it as an opportunity to drill down to the essential principles involved. Hope you enjoyed it, too.

25 May 2011

Human factors and patient safety

Every doctor or healthcare provider should watch this video. 


Just A Routine Operation from thinkpublic on Vimeo.

It could never happen to me, right? Wrong. I'm as human and as fallible as those doctors who killed that poor lady, and as those pilots who flew perfectly good aircraft into smoking craters.

Take home points for me?

Situational awareness: never get so focused in on a single thing (like getting the intubation) that you lose sight of the big picture.

Teamwork: know who's in command, know your team, brief the team, and make sure that all team members feel comfortable speaking up if they see a problem.

Which goes back to what I've been saying for years about ER nurses. If you shit on them, if you belittle them or fail to respect them, they won't speak up and you will miss critical opportunities to prevent a mistake. Respect them and keep open channels of communication, and they will save your ass time and again.

My guidelines for blogging about clinical medicine

There's been quite a kerfuffle over the "Unprofessional" post Dr V wrote. A lot of people have been very shrill in denouncing physicians who write about their experiences using social media -- blogs, twitter, facebook, etc -- with particular emphasis on those who do not use their real names.

So, while I won't tell someone how they should blog/tweet, or try to impose my vision of professional standards on a community that clearly is still coming to consensus with public conversations by healthcare workers, I will offer you my personal guidelines and values that I use in determining what I am willing to put into the public domain. These are just my opinions; your mileage may vary. 

As a general principle: patients give physicians and nurses access to intimate details of their lives and they have a reasonable and valid expectations that we will respect their privacy and dignity. When using social media, that does need to be maintained. How you do that requires careful attention and may be controversial regardless of your approach.

Don't blog or tweet anything that you wouldn't want you boss/hospital administration to read. Stress test yourself by informing your employer or CEO about your blog and invite them to read it. That will keep you honest!

HIPPA -- it's the law, and it's a minimum standard for how much de-identified information you can publicly share. I would argue that how far you need to go beyond HIPPA depends on what you are writing, and the tone. If it's a straight-up medical science, such as an educational case report, I would contend that fairly little beyond the minimum information needs to be removed. If the case is unique, intimate or newsworthy, you may need to go a bit further. 

Even though you may not have your name on your blog or twitter, do not think for a moment that you are anonymous. It would take creative hackers about ten minutes to figure out your real name and location (ask me how I know!). A lawyer would also be able to get that info easily. Don't put it out there unless you would be willing to stand by it with your real name there. That said, I think there are good reasons to maintain some degree of anonymity. Every patient I see in the ER gets my card, and I suspect that more than one has gone home and googled me. If one were to find this blog, he or she might be quite upset at the mere prospect that their privacy might be violated. Even the possibility of that I find unacceptable, so I keep my name off the blog. Yes, it's easy enough to find out who I am. But I think it's important to try to protect patients from even the fear that their privacy will be violated.

Which brings me to the next and maybe most important point: don't blog about real patients. This is tricky. When you have a blog (or live on twitter) and you see something noteworthy in the course of your professional life, the reflex is to share it, especially when the audience is a mostly professional one. It feels like you're chatting at the nursing station, but it's more like the hospital elevator or lobby -- a public place. So look carefully at the case, figure out what about it that is worth sharing, and distill it down to that. Then rebuild the case with completely bogus details. Your authenticity is what makes your stories interesting and valuable, so it's challenging to create a realistic fiction which conveys the central pont in a believable manner. I'm sorry to say this, but all of the stories I have ever told on this blog, at least since the very early days, have been made up out of whole cloth. Each story did illustrate a real point that arose out of a real case. But I generalize, fictionalize, and use archetypes to illustrate the concept. I've seen enough patients to be able to build a credible composite. Also, don't do it in real time. Write up a case and let it marinate for a while. The more unique the case, the more obfuscation and time are needed to ensure that your post is not traceable to the incident patient.

When you do write about an appropriately de-identified and fictionalized patient encounter, add some redeeming value. If the central point of your post is "people suck" or "Patients are stupid and I hate them," then just possibly you need to reconsider before you hit publish. As i said above, education is an excellent value-added element for a medical post. Some bloggers write beautiful stories about the human condition, uplifting and sad alike. But there are other stories to tell, about your life on the other side of the gurney, and those are good, too. Sometimes a patient makes you angry or afraid, and those are valid stories to tell. Avoid telling patient stories for their simple prurient interest. If the central point of your story is "can you believe this?" find a better point before you put it out there, or delete it.

Don't eschew humor. People are weird and wonderful and the things they do are hysterical. There's nothing wrong with acknowleding that fact. Many patients, in real life, will laugh at themselves. But don't laugh *at* patients; that is belittling and demeaning. Find the humor and celebrate it. Be positive and affirming. Be self-deprecating. Humor and respect are not incompatible, but it is oh-so-easy to cross the line to the "bad" humor.

This is something new, and it's going to take time for the world to adapt to it. In the old days (defined as prior to 2003) medical conversations were limited to private discussions in the doctors' lounge and the occasional book. Now they take place in the public sphere. I think that's a net positive. It's good for doctors and nurses to be able to easily express their emotions and their experiences. It's also good for patients to be able to see behind the veil of what really goes on in the health care arena. Is it perhaps disconcerting? Yes. Is it easy for frustrated or burnt-out docs to overstep the bounds of propriety? Sure. it is not, however, the medium which is the problem. It is what you say that counts, and how you say it. 

I should also add, as a point of order, that if you go back through the nearly two thousand posts published here over the last six years, you will probably find some which do not live up to these principles. I have certainly learned, matured and evolved as a blogger in this time. In the spirit of intellectual honesty, I don't generally retro-edit or delete posts which turned out poorly. So feel free to play gotcha; it's easy. And I'll plead guilty in advance. 

I hope these guidelines are useful to you, if only to understand where I am coming from. I'm a little disturbed by the prospect of a bunch of busybodies trying to regulate what physicians can share online, so my intent here is to show that an anonymous blogger can approach the task from a principled and positive perspective. Feel free to let me know in the comments how I can do better.

24 May 2011

I don't buy your definition of Unprofessional

So there's this Twitter machine, which you might have heard of. It's all the rage among the kids these days. Doctors have adopted it too, and as happened in the blogosphere there are no shortage of self-righteous, self-appointed internet scolds out there to police our conversations and make sure we all stay in line with their view of how doctors should comport themselves. The most recent is Dr Bryan Vartabedian, who blogs at 33charts and tweets at @Doctor_V. He chose yesterday to attack an anesthesiologist over a middle-of-the-night exchange about a patient with a priapism: Unprofessional Physician Behavior on Twitter

Now, I'm not averse to picking a fight or using strong language on the internet. Nor am I averse to calling someone out by name. You need to be able to handle criticism on the internet. But a couple of things struck me on this.

First, the tone: I have been attacked relentlessly on the internet and I've never hesitated to respond in kind. I took out a little frustration on DrRich the other day, and maybe that was a little over the top, but he's a guy who himself engages in hyperbolic language so I don't feel too bad about it. But It's, well, it's just rude to come out and lay into someone who is generally nice and inoffensive. Not only is it rude, it's self-defeating. You could initiate a conversation and have a teachable moment. But when your headline contains the word "Unprofessional" it takes the teachable moment and makes it an adversarial encounter. 

Furthermore, Dr V high-handedly asserts in his comments, "Regarding outreach, I don’t engage anonymous people."

Isn't that convenient, as well as self-righteous? I understand that DrV has a principled issue with anonymity on the net among medicos. Fair enough. Don't link to them or endorse them. But are the anonymous health care provders some sort of unspeakable unpeople to be shunned? Especially when you are willing to call them out publically? Frankly, it's a jerk move to do so while maintaining that it's beneath you to correspond with him or her.

Then you have the actual substance of the complaint. DrV's central complaint was that there was a little giggle about the nature of the patient's medical condition. I take it that DrV has never read this blog, which at times has been a celebration of the strange mishaps, maladies and sexual proclivities of our fellow human beings. I'm sure his head would explode at these posts. For my part, I try to remain non-judgemental, educational when possible, and respectful, though it's impossible to ignore the very real humor in some cases. Some of my fellow bloggers, and I'll prove myself better than DrV by not pointing fingers, are real assholes with nothing but scorn, contempt, anger and disdain for their patients. They are truly a disgrace to the profession. So if you are looking for physician behavior on the internet which you want to shame and label as "unprofessional," DrV picked a fairly weak case, I think. And if you're going to pick a fight, you really need to have a clear, cut and dried example of behavior which crosses a bright line, which was most definitely not the case in the incident thread.

It's more arrogant, I think, for DrV to impose his personal value system on behavior for which there is not a consensus within the medical community. We all agree that HIPAA is a minimum standard, and that there is a moral obligation to be more protective towards patient privacy than the law's bare requirement. There's a lot of diversity of opinion, however, on where the line is. While DrV asserts that simply "disclosing the details of a case" is unprofessional, if you look at the actual conversation nothing more was disclosed beyond the diagnosis, lack of risk factors, and the duration of symptoms. That's hardly a lot of detail. I should also pont out that she expresses significant empathy for the patient which is to her credit. 

The real issue here is that as a profession we are grappling with how to take the conversations that go on between healthcare providers and adapt to the internet. If this were a private exchange at the nursing station, or at a cocktail party, it would not raise an eyebrow. In the public arena, though, the boundaries are less clear. DrV is clearly an absolutist in his view of the amount of patient information that providers can discuss publicly - zero. He's entitled to his opinion, but clearly a large number of doctors and nurses disagree. I think it is OK to discuss patients so long as it is clearly anonymous, respectful and has some redeeming value. The value may be educational, or it may be in telling a human story. It may be to express a strong emotion that a healthcare provider feels, be it anger, shame, humor, satisfaction, etc. It may just be because the provider wants to tell his or her story. Just because we are doctors does not mean we cannot share our experiences. I took an oath of confidentiality, not silence. I would also point out that every single medical journal has sections in which doctors express their human feelings and experiences. The internet is no different, just self-regulated.

I think we all agree that the internet and social media is a new ecosystem for health care professionals, and that there are landmines which incautious physicians can step on. I think we agree that patients' identities and dignity must be protected. There's more common ground here than disagreement. To DrV, I would suggest that his version of appropriate physician behavior is not universally accepted, and he creates more heat than light by insulting well-meaning and inoffensive physicians.


23 May 2011

Rational Tylenol Packaging

This is interesting: from the Freakonomics blog:

Last time I was in London I had a headache, and went to the nearest Boots to buy something for it.

In U.S. drugstores, I’m accustomed to finding half an aisle devoted to headache pills, with bottles ranging from small to very large — at least 200 pills in them. So that’s what I went looking for in Boots, but no such bottle was to be found. The only options were cardboard packets containing maybe 20 pills, with each pill in its own blister packet. (The pills were also larger than U.S. pills.) Hmm, I thought. I guess Boots finds it can charge a lot for a small amount of headache medicine since most people, when they have a headache, aren’t very price-conscious.

[...] In England and Europe, Tylenol is sold under the name Paracetamol, and that’s used for huge numbers of overdoses, which on the whole aren’t lethal but leave the people with kidney damage and often of dialysis for the rest of their lives. They started doing that about five years ago, and they restrict the numbers, and they put them in plastic blisters so you have to tear them out. And again, you’d think all I have to do is go to six drugstores, you know, buy packets in each of them, all I have to do is just tear them out. But it has cut down the number of overdoses. It’s also cut down the number of serious overdoses that have led to kidney damage. Now, very few people died of an acetaminophen overdose. So it’s been hard to document that it cut the number of deaths, but certainly the number of attempts. The overdoses with it have been cut dramatically.

Hmm. Leaving aside the fact that APAP causes liver failure, not kidney failure, a factual error which makes this ER doctor cringe, this is actually kind of clever. They do something similar with kid's tylenol, which is deliberately sold in small bottles. Children's and Infant's Tylenol generally is sold in concentrations and quantities of 3g or so. The result is that if a curious 20-kg toddler decides to drink an entire bottle, they'll be getting a dose of 150 mg/kg, which is right at the threshold of serious toxicity -- and more importantly, is in an easily treatable range, even in a smaller child.

This makes sense to apply to the adult market. Tylenol is involved in at least 140,000 overdoses in the US annually (according to poison center databases (PDF); it may be much higher since many ER docs do not report tylenol overdoses, since many are non-toxic and we are very comfortable with treating them without poison center guidance).  Of lethal overdoses, tylenol is in the top three, behind only opiates as a class, and cardiovascular drugs. So it's a non-trivial problem. 

Would I, as a consumer, be annoyed at having to peel one of those damned blister packs to take a tylenol? Yes. It would be really irritating. But that's the point. The reason tylenol is so commonly implicated in overdoses is because it's convenient and readily accessible. Fairly few people who gulp half a bottle of tylenol are actually trying to die, few have any clue what the toxic OD is, and most are surprised when I tell them they took a potential lethal dose. It's perceived as a very safe drug. Some patients repetitively OD on tylenol precisely because they beleive from prior experience that it's safe. Putting tylenol in the blister packs woud not cut stop someone who is really determined and who does their homework, but those folks are hard to deter in any event. But it would certainyl cut down on the accidental/opportunistic overdoses.

It would be easy to do and it makes good sense. Which is why I'm quite sure that it'll never happen here in the US. 

A case study in applied ethics

In my professional life, one of the things I frequently have to do is tell someone that I am recommending a course of action that they may not be terribly keen on pursuing. And I know it when I am making the recommendation. "I'm sorry, sir, but I think we are going to need to admit you to the hospital/put this tube in your chest/cut off the remainder of your finger," etc. I am accustomed to getting resistance in these situations and having to convince the patient that there's a good reason to do what I recommend. Usually, patients exhibit good sense and comply. Sometimes they refuse. Generally, I am OK with that. It's the right of a patient to refuse treatment they don't want. I don't take it personally, but it can be a bit frustrating when you have to watch someone make a really bad decision.

But it does bring up an interesting and tricky issue: when is a patient NOT allowed to refuse care?

We had an illustrative and complex case recently along these lines. A young man, in his early 20s, was seen in the ER on three consecutive days for suicidal ideation and non-life-threatening suicidal gestures. In each case he was felt not to be eligible for detainment under our state's law (which sets a fairly high bar for involuntary treatment compared to many other states), and he was able to "contract for safety," for whatever that is worth, and so was released each time. A complicated overlying factor was his heavy dependence on opiates and benzodiazepines.

He returned to the ER following a motor vehicle accident. It was a single-vehicle accident where his car had left the road and hit a tree for no apparent reason. He appeared sleepy on the scene and roused with narcan pre-hospital; the medics assumed that he crashed because he was stoned. In the ER, he admitted taking some pills to get high, and admitted that he still felt somewhat suicidal, but denied that he was trying to kill himself by crashing his car. The urine toxicology test was positive for opiates and benzodiazepines, but a blood alcohol was negative.

He did have multiple injuries. Several broken ribs and pulmonary contusions and a small cerebral contusion. While he was in the ER, his oxygenation began to deteriorate and repeat chest x-ray showed increased opacification suggesting worsening pulmonary contusions/incipient ARDS.

I explained that he was going to require intubation and mechanical ventilation due to the severity of his lung injuries. He refused.

For those familiar with trauma, the early signs of hypoxia and worsening x-ray findings indicate a really bad lung injury which absolutely will require ventilatory support as a life-saving measure. There are not really any other compromise treatment options, at least none that offer reasonable expectations of making a difference.

At this time, the patient was alert and seemingly oriented. He was able to express that he understood that refusing intubation would lead to his death. He was unable to, or chose not to, articulate any reason that he did not want to be intubated. He stated to multiple people that he was comfortable with the idea of dying, and he felt at peace. He was adamant in his refusal of intubation.

At the time these discussions took place, he had received some pain medicine for the rib fractures. His oxygenation was borderline low at 89% on high-flow oxygen, but vital signs were otherwise more or less stable. No family was available. After some time in the ED, his oxygen levels began to decline further and the patient was no longer verbally responsive.

To summarize, this young man, with a long life ahead of him has a lethal injury for which he has clearly refused the only potential life-saving intervention. He has demonstrated the bare minimum elements of an informed refusal of care, and has done so consistently to multiple interviewers. However, his decision-making may have been compromised by his head injury, by low oxygen levels, or by the presence of intoxicants (both recreational and therapeutic). Other complicating factors include his latent suicidal ideation and speculation as to whether his injury may have been self-inflicted.

What would you do if you were the doctor in this situation (or the administrator/ethicist/judge called to offer guidance)? Would you provide supportive care and allow him to die, or would you violate his express wishes and intubate him?

Would it make a difference in your decision if you were told the survival rate for this injury was only 25% even with full treatment?

Would it make a difference if the patient were 75 instead of 25?

Does the possibility that he may have been suicidal invalidate his refusal of care?

Let me know what you think in the comments, and I'll fill in the outcome in a couple of days.

14 May 2011

Walu Ngalindi

Love the night sky, love timelapse.

I'm off on a well-deserved three-day break to Orcas Island. See y'all next week.

12 May 2011

Too Awesome for Words

The largest model airport in the world:

1:87 scale, with 40 autonomously moving airliners that taxi, take off and land at realistic scale speeds, 90 ground vehicles that also move autonomously. 

I used to build models (WWII fighters, mostly) and this just blows my mind. It took $5 million and over half a million man-hours to build. 

More here. The home page, with other miniature cityscapes is here.


11 May 2011

Can we save costs by reducing ER usage? A counter-intuitive take.

When we look at the $2,300 Billion that the US spends every year on health care, and the annual rate of increase of about 5% (inflation-adjusted), it's fairly clear that we need to get costs under control, or health care will bankrupt the country. One area of focus for possible cost savings has been the Emergency Department. The ER is viewed as a very expensive place to provide care, so that's not surprising. It's also viewed as overcrowded, which is true, and that it's used inappropriately by many patients, which is more debatable. 

On that point, there are conflicting perspectives. I have criticized ACEP in the past for promoting misleading statistics, when they have claimed that only 7% of ER patients are "non-urgent." This was based on frank misuse of the triage categorization system and simply does not pass the sniff test for anyone who has ever worked in an ER. A better estimate might be 25-40% of ER cases as non-urgent, or representing conditions which could have been treated elsewhere. However, I'm not sure I'd call this "inappropriate use" since for many patients there is no alternative option. The barrier to this is multifactorial. Unfunded or underfunded patients have limited avenues to access for semi-urgent care because clinics simply turn them away unless they can pay cash. Even funded patients are challenged to find primary care physicians who are able to see them in a timely manner, a problem exacerbated by the shortage of primary care physicians. Furthermore, hospitals in many areas have been complicit in driving up ER utilization by agressively promoting the ER as a convenient place to receive low-wait or no-wait care. 



So, it's a fair question -- are there potential savings to be realized in diverting low-acuity patients away from ERs? Legislators in MA, SC, and WA think there might be, and there have been suggestions that we should take measures to divert the less-urgent patients from the ER, perhaps using payment reforms or financial incentives/penalties to do so. Just yesterday there were hearings in the Senate HELP committee on whether non-urgent use of the ER can be reduced.

The question is whether this would save much money. ACEP says "no." They claim that the Emergency Department care accounts for only 2% of the nation's health care budget, and that reformers won't find much fat to cut here. To me, that 2% number also sounds implausibly low. The nation's ERs see 124 million patients annually. The average charge is about $5,000 for an ER visit (doctor and facility, source: PDF). Assuming a standard discount between charge and cost of about 70% (hard numbers on this are very hard to come by, but it's a good estimate) gives an average cost of an ER visit at $1,500. So that suggests that actual cost of ER care is $187,000,000,000. Given the total health expenditure of $2.3 trillion, we're more like 8% of the total health care budget. ACEP bases their claim on the respected AHRQ survey which found that the 124 million visits cost only $47 billion, or $376 per visit. While I greatly respect the AHRQ, this also, unfortunately, doesn't seem to pass the sniff test. I'd be interested to see a rigorous estimate of the actual cost of emergency medicine's services, and I suspect that it's somewhere between the two estimates. Which means that it's a non-trivial amount of money to be considered, somewhere in the tens to hundreds of billions, and a fair target for cost reductions, if there are any to be had. 

Which brings us to the next question. Since there may be saving to be had, would reducing the number of non-urgent ER visits do much to realize said savings?

This is where I can get back on the ACEP party-line bus, and say, I don't think so. The general concept here is that the marginal cost of an extra ER visit is very low. The ER is already there and the lights are on, the doctor is already there, and the CT scanner is already there (and paid for in advance). Yes, you need to scale up a bit as the patient volume expands, but a study, admittedly a few years old, found that the marginal cost for a low-acuity ER visit was about 7% of the average ER charge, or about 20% of the actual cost of that low-acuity visit. This makes sense, in that the typical low-urgency visit is one that is low resource utilization. It takes fairly little time and almost no ancillary services to diagnose a UTI or a sprained ankle.

Myles Riner, who I know through the ACEP reimbursement committee, put some similarly provocative data over at ACEP's Central Line blog: Much Ado About Very Little – the Deferral of ED Care Boondoggle. He presented some data which he had reviewed from Anthem Blue Cross, which looked at costs attributed to a year's worth of non-admitted ER patients. This includes 637,000 patients, at an average cost of $1,500 per patient, which is much more in line with my real-world experience. His findings mirrored the data-clustering finding I posted last week, in that the most expensive patients are far, far more expensive than the least:

So, assuming (and it's a big assumption) that we could take the bottom 40% of ER patients with regard to their cost -- and I think it's reasonable to assume that cost, acuity and urgency are reasonably correlated -- and successfully redirect them elsewhere, we would save a grand total of 12% of ER costs. Depending which estimate of overall health care costs ERs represent, that would net the economy a savings of $5 billion to $20 billion. (If you could convince only the bottom 20% to go elsewhere, which might be more realistic, then you'd save between $2 and $7 billion.)

That's a drop in the bucket, folks. And it would require major, major restructuring of the health care system, because these people represent nearly 50 million patient encounters. Some of them would give up and not seek medical care if the ER was closed to them, and that would be OK. (I'm thinking of the sunburns and such, the truly trivial complaints). Some would fail to get medical care and get worse; a simple UTI would turn into a case of pyelonephritis, and then present to the ER sicker. Most, however, would need to go to their primary care office or to an urgent care clinic -- resources which at this time either do not exist or do not have capacity to care for this huge volume of patient encounters.

It would also be very difficult to accomplish. Many times it's impossible to predict in advance whether a given ER case will be easy or hard. That blood in the urine could be a simple UTI or it could be renal cell carcinoma. The baby with the rash could be a viral exanthem or it could be meningitis. The heartburn could be heartburn or it could be unstable angina, and you'll never know until you are seen by a provider with the experience and judgement to differentiate the two. So, prospectively, I have no idea how to sort out the 40% who could go somewhere else, even if they had somewhere to go, which they don't, and even if they could be easily deterred, which they can't.

Furthermore, I'd make the argument that, especially for low-resource-utilization patients, the ER provides an efficient, high-value service. In a well-functioning ER (sadly, not the majority of US ERs), a fast-track type patient can be in and out in 45-90 minutes. No appointment needed. Just show up, get seen & treated. For someone who is in pain, or has a challenging job schedule, or child-care responsibilities, there is real value to that sort of service. If you have to take a day off of work to get evaluated for a minor medical problem, that cost is substantial; an ER that can provide the needed care may wind up costing not just the patient but the economy less in the long run. Yes, it costs more than a doctor's office, but since the doctor's office is unavailable for this sort of care for many people, I don't see the validity to that comparison. The fact that a low-to-moderately complex medical problem can be addressed quickly and cheaply in an ER is a measure of the success we have in operating efficiently. 

The best policy, of course, would be to have a network of primary care and urgent care offices which have excess capacity and are open for extended hours, if not 24/7. That would be a better and cheaper way to deliver acute care for a large minority of patients. That doesn't exist, unfortunately, and until it does, the ER remains not only the safety net, but a relatively low-cost alternative for patients who cannot access care elsewhere. Legislators and policymakers are misguided if they think they can achieve significant cost savings by reducing ER utilization. 

The healthcare reform law's constitutionality

A nice review of the law and precedents as it relates to the PPACA from the Yale Law Review, which concludes that the PPACA is "obviously" constitutional based on existing law. For those who don't feel like wading through the entire legal analysis, Kevin Drum at MoJo has summarized the case in a single powerpoint slide:

Though all the usualy caveats apply about the politicization of the Courts, as the 4th circuit court of appeals drew a 3-democrat panel of jurists, and the 6th circuit drew 2 republicans and 1 democrat, and it'll all come down to Anthony Kennedy in the end. 

09 May 2011

More paranoia about the IPAB -- a debunking of Dr Rich

I shouldn't do this. It's madness to try to delve into the minds of conspiracy theorists and try to make sense of their ravings. But I can't help myself; I'm drawn like a moth to the flame. it never ends well. I only wind up with a horde of trolls in the comments telling me that I'm a glib supercilious idiot and should stick to medicine or go die in a fire or something. 

Sometimes it's too hard to stay away. Maybe it was the personal affront I felt in the false imputation of ill motives onto progressives. Maybe it was the gross errors in fact, sitting there ripe for the plucking. I don't know, but I just can't resist a rebuttal to Dr Rich at Covert Rationing, who weaves a technocratic cost control body into a paranoid web of fantasy, concluding that: 

Progressives are dedicated to “progressing” to a perfect society, and they know just how to achieve it. ... Specifically, the Progressive program requires individuals to subsume their own individual interests to the overriding interests of the collective – and human nature just doesn’t function that way. Thus, the Progressive program inevitably relies on a cadre of elites – those who have dedicated themselves to furthering the Progressive program – to set things up the right way for the rest of us, while manipulating we in the teeming masses to let them. And the rest of us, once the correct programs and systems are in place, will at last understand that it was all for our own good.

I suppose this paragraph tells you everything you need to know ... about Dr Rich. Any supposition that he was approaching the view of policy with a fair mind or that he is willing to attribute anything but the worst motivations to those on the other side of the aisle is completely shredded by this paragraph. As rhetoric goes, it's up there with "Conservatives want old people to die in pain." So we can scratch Dr Rich off the list of people who are willing to discuss health care policy with a neutral mindset. He's engaged in a holy war of ideology.

But how does he rank in honesty? Oh, that's not right of me. I shouldn't mirror his approach of automatically assuming the worst motives to someone I disagree with. His errors of fact could be deliberately dishonest, but they could equally result from laziness, ignorance, misinformation, or untreated paranoid psychosis. It's an open question! What is not really open for debate is that his theory is built upon several critical errors of fact.

Let me enumerate them. But first, a tiny bit of background. 

You may have heard that healthcare costs are currently consuming something along the lines of 16% of the US Gross Domestic Product, and increasing at a rate well beyond inflation in general. Most people believe this is a really bad thing and that it is bankrupting the country. Most people believe that we need to do something to constrain the excess cost growth. The recently passed health care reform law -- the PPACA -- does make some modest steps towards this end. Many people believe that it does too little; I am one of them. One provision in the PPACA is the creation of the IPAB, the Independent Payment Advisory Board. I wrote about it a bit last month. If you'd like a summary, the Kaiser Family Foundation has a nice review (PDF). Basically, it will be composed of healthcare experts, doctors, nurses, patients and economists who, if health care costs continue to escalate, will create and institute reforms to control the spiraling costs.

This is where Dr Rich and I diverge in our opinion. I think it's a pragmatic fix to the political paralysis exhibited by Congress over the last two decades in actually cutting costs. He thinks it's a dictatorial body that progressives created to force humanity into a hive-like "collective." His evidence for that, however, lies on faulty understanding of (or slimy dishonesty about) the actual, you know, law.

For example:

1) It has dictatorial powers.

...The IPAB is actually all-powerful.

Once the Chief Actuary of CMS determines that the projected per capita growth rate for Medicare exceeds a certain target growth rate (which it inevitably will), the IPAB is required to submit a so-called “proposal” which will cut healthcare costs sufficiently to bring the growth rate back in line; which is to say, the IPAB will determine what will be paid for and what will not. Then, the Secretary of HHS is required to implement that “proposal” in its entirety, unless Congress acts to block implementation. However, Congress is hamstrung.  The representatives of the people are forbidden from taking any action “that would repeal or otherwise change the recommendations of the Board,” unless it replaces those “recommendations” with its own legislation that would cut healthcare spending to the same target level.

For all practical purposes, then, the cost-cutting “recommendations” which the IPAB would “propose” for “consideration” will be implemented nearly automatically, with the full authority of the Federal government.

And, for all practical purposes, the IPAB will become a new agency of the executive branch, with near-dictatorial authority to cut healthcare spending where and when and for whom it sees fit.

Bold in original, and some rhetorical fluff omitted. So ... wow. This does sound bad. Congress is powerless. It cannot change any of the IPAB recommendations? That's awful. Why even have a Congress if it's going to legislate its authority away? Except, well, it doesn't. Dr Rich does acknowledge one countervailing fact -- Congress can substitute the recommendations of the IPAB with its own! Right there, that does seem to contradict the assertion of DICTATORSHIP that Dr Rich claims. But there's more! Not only can Congress choose to substitute its recommendations for controlling health care costs, Congress can WAIVE the requirement. That'd be Sec 3403 (d)(3)(D):

WAIVER.—This paragraph may be waived or suspended in the Senate only by the affirmative vote of three-fifths of the Members, duly chosen and sworn

So, to summarize, this infringement of LIBERTY by A DICTATORIAL UNELECTED BODY can have its recommendations swapped out by Congress or simply ignored. If you are a conspiracy theorist or a partisan hack, I guess that is dictatorship.

Now some may argue that Congress is too terribly screwed up to act in our interests and that they can never come together to overturn a bad recommendation by IPAB. (I'd also say that's a great illustration of why we need IPAB and an argument for congressional reform.) The argument is that the IPAB becomes a de facto dictatorial board, because the bar is set too high to override its recommendations. We will see, I suppose. Congress manages to get 60 votes together every year to over-ride the SGR, so I don't see why it's impossible that if some controversial rules were handed down by IPAB that Congress wouldn't waive the rules and scrap the recommendations. Is it hard? Yes, but it's supposed to be. But it's not impossible, and it's not dictatorial.

Another bit of epic wrongness Dr Rich engages in is a theory that the IPAB is FOREVER!

It is an immutable entity.

Section 3403, the section that creates the IPAB and spells out its functions, contains some remarkable language that, DrRich suspects, has never been seen before in American legislative history. To wit:

“It shall not be in order in the Senate or the House of Representatives to consider any bill, resolution, amendment, or conference report that would repeal or otherwise change this subsection.”

So, the astounding truth, dear reader, is that the IPAB and all its designated dictatorial functions are in force for perpetuity. Our Congress has passed legislation that purports to bind all future Congresses from altering it in any way.

Now in this, I have to give Dr Rich full credit for good faith argument. He's ignorant, but not being deceitful. I assume. The citation noted above is accurate, and it does sound bad. But in order to understand it you need to a) know a little bit about the arcana of the rules of order used in the Senate and b) know that Congress can NEVER  pass a law that a future Congress can't undo. What the citation above means is that it is not "In Order" to modify or dissolve the IPAB. So, to do so, would require "Unanimous Consent" in the Senate, or a vote of 60 Senators to waive the rules for unanimous consent and vote on an "out of order" proposal to modify or repeal the IPAB.  (Full disclosure: I may have the exact parliamentary details not quite right, but the gist is there and the conclusion is accurate.) So, just as with the recommendations of the IPAB, its structure and continued existence are completely contingent on Congressional action, though with a deliberately-high 60-vote threshold.

Dr Rich also waxes hysterical about the intrusion of the IPAB into the private health care market. He rants a bit about the way the bill was passed, but the gist of his point is this: 

IPAB, at least every two years, [must] “submit to Congress and the President recommendations to slow the growth in national health expenditures” for private (non-Federal) healthcare programs. Furthermore, it designates that these “recommendations” may be implemented by the Secretary of HHS or other Federal agencies “administratively” (that is, without the interference of Congress).

First of all, again, this strikes me as a GOOD thing. My health care premiums are going up 15% a year, and I'd really like to see that slow down. So if (and it's a big if) IPAB has a good idea for a method in controlling private sector spending, then I'm very interested in hearing it. These are categorized "advisory" recommendations and are distinct from the "required" recommendations which pertain directly to the medicare program. And yes, The Secretary of HHS can implement such "advisory" recommendations administratively so long as they are within the existing statutory authority of the Secretary (Sec 3403, (e)(4)), and there are no explicit rules on how Congress may address such rules, which means that they can be over-ruled piecemeal or en bloc by a simple majority of both Houses of Congress, just as any other federal regulation can be: these advisory regulations would not require the 60-vote supermajority rule that the required recommendations would to overturn.


The PPACA does create new board with some unique and unprecedented powers. I can see why this would make some people concerned. Power can be mis-used, and oversight is necessary. I would say that there are at this time many open questions about the IPAB -- remember that it does not yet have a single appointed member, let alone a track record. It may well be toothless or gridlocked by the time it comes into being. It may wind up as powerful as the Federal Reserve. It may achieve wonderful cost savings, or it may eviscerate the commercial underpinnings of American medicine. Lord alone knows. But it has more promise than ANY other federal cost-control proposal to date, and Congress seems to have retained enough power for itself that if the IPAB wind up doing something particularly bad or unpopular, they should not have trouble over-ruling it.

And if somebody tells you that the IPAB is the secret Democratic DEATH PANEL, they're either pushing a particular agenda dishonestly or grievously misinformed.

01 May 2011

I can't add anything to this

Except maybe, "Good Riddance."