Sunday, August 31, 2003

I've been on call this weekend and have seen some wierd stuff, but nothing like this!!!

Thursday, August 28, 2003

Medicaid in the Empire State of the South is suffering from a budget shortfall. Shortfalls to the tune of 500 million to 1 billion over the next two years. The state is kind of between a rock and a hard place here as the reimbursement is so bad already that many primary care physicians aren't accepting Medicaid anymore. What to do?

Monday, August 25, 2003

In this month's Journal of Trauma there is a paper concerning the use of cervical spine CT scans in blunt trauma patients. Their results seem to add weight to the argument that cervical CT is a superior study in determining cervical injury.
Their study consisted of 1,199 patients who where "at risk" for cervical injury over a year period....

In 116 (9.5%) of these patients, a cervical spine injury (fracture or subluxation) was detected. The injury was identified on both CSR and CTC in 75 of these patients. In the remaining 41 patients (3.2%), the CSR results were negative, but injury was detected by CTC. All these injuries missed by CSR required treatment.

Wow. 3.2 percent missed. While 26 of the 41 were treated with cervial collar only, nine required halos and three required surgical stabilization. This is actually an improvement over some other studies cited in this paper. Four other studies were cited from 1999 to 2002. Of the 221 cervical injuries seen in 2946 patients, 132 (60%) were seen on conventional radiographs while 218 (98%) were detected using CT. Even in the latest ATLS material, the standard cervical spine films (lateral from C1-T1, AP, and odontiod views) exclude 85 percent of cervial injury.
EAST has several good guidelines for evaluation of the cervical spine here and here. They currently recommend three views and CT scans of poorly visualized areas as well as CT from the occiput to C2 in patients with expected mental status changes for grater than two days, but as the authors of this study point out..

...If these EAST guidelines had been followed, only 2 of the 41 patients with false-negative CSR (cervical spine radiographs) in this series would have had their injuries identified. None of these 41 patients had inadequate films or suspicious areas so there was no reason to perform CTC(cervical CT).

Other modalities include flextion-extension views and MRI. Flextion-extension views are useful only if flextion greater than 30 degress without pain can be achieved. 30 percent of patients cannot do this. MRI is expensive and can over-call or under-call injuries. Applying this study to your neighborhood should be predicated on the availability of a helical high-speed scanner. Otherwise your patient will spend all day in scan land. I think that I'll take a close look at expanding the use of CT in this area.

Sunday, August 24, 2003

A reader sent a comment regarding an earlier post.
I've heard repeatedly that requiring doctors to work to exhaustion trains them in the ability to work while exhausted, and to provide decent care while doing so. I've heard it enough that I'm willing to believe its possible. What I'm not willing to believe is that its necessary, any more than I was willing to believe, this past week, that I should drive directly from Boston to Baltimore, without stopping, just so that I could get the experience of making driving decisions while exhausted...
The purpose of a residency program is to train physicians, over a period of several years, to treat patients so when they become Big Doctors they are able to do their jobs without supervision. There are no work hour limits for Big Doctors in the real world, so the 80 hour limit may create an artificial environment for the residents. Under these guidelines a resident must leave the hospital after a night of call, even if they have slept all night. Is this how the real world works?
As far as it being "necessary", all physicians, from time to time, must make quick decisions while tired. Would you rather them do it for the first time while they have the supervision of a training program surrounding them, or when they are out on their own without the ACGME looking over their timecard.
Added some new links to the blogroll and sorted them out

Saturday, August 23, 2003

This from the August 2003 Contemporary Surgery (PDF). An editorial from the head of surgical oncology at M.D. Anderson commenting on the impact of the 80 hour limit at his institution. He recounts a phone call with the director of a residency program "which we have had a training relationship for more than 30 years" could no longer rotate residents through.
The 80-hour workweek was the culprit, I was informed. It was forcing a global manpower realignment. Residents were being pulled off a nationally recognized burns rotation at another medical school in the area. Also residents would no longer be able to rotate through a busy, hands-on endoscopy service. Likewise, the total number of residents assigned to one of the best trauma rotations in the country...would be cut signifigantly. All of these alterations were necessitated by the nearly 35% functional decrease in available coverage hours that the 80 hour workweek mandate was creating. (emphasis mine)
In order to sit for the boards the graduating resident must have performed certain numbers and types of procedures. Many of them are performed on "specialty" rotations, such as the ones described above. Because those rotations are being taken away, operative experience will suffer. (See my earlier posts on the matter). Many smaller and not-so-small programs (Mayo and Cleveland Clinic send their residents off for their trauma rotations, I think) send residents out for more core-related rotations that, if eliminated, will have a greater impact on their education. Hiring more residents is not an option because the 5-year spots that are out there aren't being filled as it is. I think that in the next few years there is going to be a dilution of caseload to the point that residencies will last at least six (clinical) years.
Dr. Pollock goes on to praise the intangible benefits of the pre-80 hour era:
I'm not an expert enough to know about the numbers,(statistics used to back up the 80 hour limit) but I do know what cannot be enumerated: the lessons learned late at night or early in the morning, whether working alone or on a team, after having already "been there" for more than the legislated 24 hours. The sense of pride and accomplishment, of being able to surmount the obstacles. These are perhaps the most valuable "take homes" I learned back in that pre-80-hour-week residency milieu.
If hospitals would not use their residents as cheap replacements for phlebotomists, transport aides, or nurses the time spent in the middle of the night would be educational and useful. Most of the bad outcomes I recall from training were not so much from residents being too tired to think, but from them being too lazy to get out of bed. Read the whole thing, and as always I welcome your comments.
Are these people crazy? Don't they realize that burning those cars released more pollutants than they would with normal use.
Via Drudge

Friday, August 22, 2003

I received my first Nigerian e-mail yesterday.....
Dear Friend,
Greeting in the name of the Allah.I am delighted to write this letter to you hoping that you will understand my predicament and respond. I am Dr (Mrs.) Mariam Abacha, wife of the late Nigerian head of state, General Sani Abacha. I am in possession of US$50.5 Million, which I want to invest in your country. For clarification purpose, this money, enclosed in three boxes; is deposited with a security company disguised as a family treasure. It is not an ill-gotten wealth rather; it was generated from my organization - family support program (F.S.P.) This money ($50.5M) was deposited in a private security firm Overseas This transaction is 100% risk free so long as I am involved and I have all necessary documents to back this up. My entire family has lost all we had as our bank accounts were frozen and assets siezed even my Internation Passport but was just released to me two months ago. For your acceptance of this offer to help; I will give you 20% of the total money,another 5% will be used to offset any costs to both parties in the course of the transaction.I and my children wish to use our part of the money to buy a living house for ourselves in your country, and the balance will be kept for investment package also in your country. If we must do this business successfully, we must keep it away from the public. At this Jucture I want to forwarn you of the many scams that go on in my name and names of other dignitries in the country as I have even recieved emails bearing my name. Looking forward to your quick response.
Yours sincerely,
Mrs. Mariam Abacha

Seems like they're learing their lessons well.

Thursday, August 21, 2003

Had a good vacation. Got some non-surgical reading done. Was able to get through The Teeth of the Tiger and John Paul Jones : Sailor, Hero, Father of the American Navy.
A few comments on both...
The Teeth of the Tiger was OK as far as Tom Clancy's work goes. It felt more like his "Op Center" series than his other Jack Ryan books. It was short (only 480 pp) and lacked the military action seen in The Bear and the Dragon or Rainbow Six or the depth of character development sen in Without Remorse. The main action was a twin-brother assassination team using an injection of succinylcholine to kill their victims. Several problems that I see with this:
1. The dose they use is seven milligrams... way too little for an average size person. That dose would be 100-150mg.
2. IM delivery, too much variability of absorption to make a good weapon.
3. If someone was able to intubate or even perform rescue breathing on a victim, it may not work.
4. Patients given succinylcholine have fasciculations which may be noticable.
I've seen the same principle used in a made for TV movie before. The drug was used to incapacitiate, not kill.
John Paul Jones : Sailor, Hero, Father of the American Navy was a well-done historical biography. Jones is presented as a paradox, one who is a self-made man and who wants the navy to be a meritocracy, but who seeks adoration in the aristocracy of his time. Short as far as biographies go, it was able to be handled in about two days.
Glad to be back.

Saturday, August 16, 2003

I'll be away doing the family vacation thing until Thursday. Have a good week.
In the PNHP paper(PDF) the authors state "Four principles shape our vision of reform". They are:

1. Access to comprehensive health care is a human right. It is the responsibility of society, through its government to assure this right. Coverage should not be tied to employment. Private insurance firms' past record disqualifies them from a central role in managing health care.

2. The right to choose and change one's physician is fundamental to patient autonomy. Patients should be free to seek care from any licensed health care professional.

3. Pursuit of corporate profit and personal fortune have no place in caregiving and they create enormous waste. The U.S. already spends enought to provide comprehensive care to all Americans with no increase in total costs. However, the vast health care resources now squandered on bureaucracy (mostly due to efforts to divert costs to other payers or on to patients themselves), profits, marketing, and useless or even harmful medical interventions must be shifted to needed care.

4. In a democracy, the public should set overall health policies. Personal medical decisions must be made by patients with their caregivers, not by corporate or government bureaucrats

Lets take a look at these:
Access to comprehensive care is a human right To society this is an unsettled question. "Human rights" are commonly divided into "negative" rights (Congress shall make no law....) which prevent the government from infringing on one's personal freedom, these usually do not impose a cost on other members of a community, and "positive rights" which state that one has a "right" to something (food, housing, ect..). These rights impose a cost on other members of society. Certainly health care would be a "positive right". As such granting it would be subject to scrutiny. As for the "comprehensive"-ness of coverage, this is what could make or break the system. I agree that a catastrophic medical illness shouldn't bankrupt anybody. The reason that people insure their houses and cars is to prepare for the unexpected. But those types of insurance don't pay for gas or a new coat of paint. Those are paid for by the driver/homeowner, and they know of those costs. Patients today have no idea the true cost of their healthcare. This plan would eliminate co-pays so every day would be free doctorin'.
Coverage should not be tied to employment No disagreement here. Why don't we give individual's the same tax benefits for purchasing health insurance that businesses do.
Private insurance firms past record disqualifies them from a central role in managing health care As if the government has done better with Medicare/Medicaid/VA systems. This plan would eliminate all forms of private insurance. No competition for the government.

The right to choose and change one's physician is fundamental to patient autonomy. Patients should be free to seek care from any licensed health care professional. No argument here.

Pursuit of corporate profit and personal fortune have no place in caregiving and they create enormous waste. Medical innovation requires risk taking and there should be the potential of payoff if the innovation is successful. This is why the drug and medical device industries in America are the worlds finest. If you want the best and brightest to persue medicine, you have to insure that they will make a good living.
The U.S. already spends enought to provide comprehensive care to all Americans with no increase in total costs Really? Show me the figures. Every time someone states that elimination of "bureaucracy" can pay for everything else, look out.

In a democracy, the public should set overall health policies. Personal medical decsions must be made by patients with their caregivers, not by corporate or government bureaucrats This could be a set up for a tyranny of the majority. The health policy of the nation could change with the politacal landscape. Abortion and euthanasia could be subjected to political or economic whim. The personal medical decisions would be, for the most part, be restriced by policies at the national level under a central system.

I encourage all to "read the whole thing" as they say. As always i invite your comments.
DR. SMITH GOES ON VACATION AND this happens. Coincidence?
The awful fate of Teddy Ballgame.
He even has pictures.
A reader e-mailed me to solicit my comments on the "National Payer" plan that appeared in this weeks JAMA (sorry, abstract only). It is a detailed proposal from the Physicians for a National Health Program . This group advocates the creation of a nationwide single-payer health insurance program. A single-payer system goes against my libertarian leanings, but I wanted to learn more aout this group and their positions. A Google search led me to this paper (PDF) that was presented to the Congressional Black Caucus and the Congressional Progressive Caucus in May of 2001. As I read the May 2001 paper I was struck by the similarities between it and the JAMA article. In fact, it is almost identical. Which to me begs the question: Why was this published in JAMA this week?
JAMA's own Instructions for Authors states in part:
Manuscripts are considered with the understanding that they have not been published previously in print or electronic format ..... also:
A complete report following presentation at a meeting or publication of preliminary findings elsewhere (eg, an abstract) can be considered.
These types of papers are usually accompanied by a "Presented at the Association of....Meeting". The May 2001 paper is not even cited in the references for the latest paper. No mention of the May 2001 paper is made in the accompanying editorial. While this may seem like splitting hairs, I think it may be another sign of the rising political activisim in the medical liturature, as seen in The New England Journal of Medicine and The Lancet. (Thanks to Dr. Smith). If JAMA will print a two-year old paper to advance a certain policy position, would it exclude a paper that presented a well-researched contrary view?

The paper is very detailed and I will post more commentary on it later, especially the "Four principles that shape our vision of reform" (pg 8). Overall I find the paper to be somewhat shrill and sprinkled with "class warfare" inferences. For example:
Hospitals could not use any of their operating budget for expansion, profit, excessive executives' incomes, marketing, or major capital purchases or leases (pg 10) (emphasis mine). IMHO physicians should tread lightly when making arguments for reducing what someone should be paid. The public perception of physician income could make that sound like "the pot calling the kettle black".
Also, the alternatives to their plan are referred to in prejudicial terms such as "Defined conrtibution schemes" (pg 20) and The Medicare HMO program and Medicare voucher schemes (pg 22). Why must academic physicians resort to name-calling?
Perhaps the most distressing thing is that the authors call their plan "...an expanded and improved version of Medicare... ". An expanded version of a plan that is not working and will soon be broke.

Friday, August 15, 2003

Noticed the "closing" of the medical blog Five Points. Quite a pity, as I enjoyed reading it. The author states that maintaining a blog takes an inordinate amount of time and passion to pursue effectively. Before I started this I never knew how time consuming this could become. I think that all of the medical blogs are well-done and original. It is my goal to provide a new perspective on things from a surgical standpoint, and not to become a "me too" blog. Thanks to all of you who have stopped by.

Tuesday, August 12, 2003

This column is a good description of how Medicaid has really screwed up here in the Peach State. My office manager tells me that the Acme Surgical Corp. has about $10,000 of Medicaid payments sitting in an account that we cannot reconcile with individual patients. This sort of thing, as well as the lousy reimbursement, are causing providers in my town to pull out of Medicaid.

Friday, August 08, 2003

I've been very busy this week. There has also been an illness and death in my wife's family so I won't be posting until probably Tuesday.

Monday, August 04, 2003


Sunday, August 03, 2003

A reader emailed me about starting a RSS feed. I've poked around a little this weekend and I don't think is as simple as the copy-and-paste work for the site meter or comments I had to do. I may be wrong. If I am any direction from the more experienced bloggers out there will be most appreciated.
At the Acme Surgical Corp. we are attempting to come up with a budget for the next FY. The largest non-professional expenditure is our liability insurance premium. As Dr. Smith has posted:

Yesterday, I discovered that the rate for my insurance went up again, by $6,000. In May, a year's worth of coverage from my current insurance company was $8,000 a year. In June, the price went up to $15,000 a year. Now, in July, they're saying it's $21,000 a year. They won't tell me how much it will cost in September, when I start paying for my own policy. The agent says the company "just won't quote a price for September policies until after August 1."

This is quite insane. The situation with my carrier is going bad as well. The five of us paid $185,000 last year for a 1 million/3 million policy. We have since added a sixth surgeon to the practice and we are quoted a rate which may be as high as $310,000. This with a payout history of $0. We still can't budget for it however, because we won't get a firm number until September, just before the premium is due. Or collection rate is about 27 percent of our billing. So doing the numbers means we have to bill 1.14 million just to make enough to pay the premium. With reimbursement going nowhere but down, expenses must be cut. But which ones?
Well, what about not paying for insurance?
"Going bare" ,or as Medical Economics gently puts it, becoming "self-insured" is a growing trend in Florida. Florida law allows a physician to "self-insured" if they can pay $250,000 of a judgment, if not they may lose their license. This is accomplished either with an escrow account or by a letter of credit form a bank. Many south Florida hospitals have eliminated the requirement to carry coverage for staff membership, and at least one HMO has followed suit.
However, the dangerous part of "self-insurance" is the "self" part. One's personal assets may be placed at risk. A booming industry nowadays is asset protection. If you have time next weekend you can even catch this meeting about salting your money away. (As an aside, some experts recommend an asset-protection plan even with insurance, as another aside a Google for "going bare" is quite an education.
The primary goal of going bare and offshore accounts is to eliminate the physician as the "deep pocket" in a liability suit. This (hopefully) will dissuade a contingency-fee attorney from coming after you if all they can get is $250,000. Hospitals don't like the idea because it because it makes them the "deep pocket". However hospitals faced with a departure of specialists over liabilty insurance may find themselves with little choice than to allow a "bare" staff.
This is probalby the "weapon of mass destruction" in the liability battle. The one who has the most to lose under a "bare" system is the patient. $250,000 maximum is not enough to attract an attorney to take the case or cover medical expenses. But many see no other choice when th alternative is to get out of medicine.
"Going bare" is not an option at this time for me, the boards of both hospitals have rejected attempts to change bylaws to allow dropping of coverage. My politically tuned-in senior partner says there is a move afoot in our community to unite the doctors around this issue, hoping to force the hospitals to give in. Anti-trust? Perhaps Ross would like to comment.

Saturday, August 02, 2003

Following in the footsteps of Rangel and DB I want to put in my own two cents in about this guy who sued his doctor for being late. It's difficult to debate this without getting into a "my time/your time/our time" discussion as between Spicoli and Mr. Hand in Fast Times at Ridgemont High. My time problems are doubled, both by the office and in the OR.
THE OFFICE Postop visits for me can last anywhere from five minutes for uncomplicated hernias and gallbladders to sometimes thirty minutes for a postitive breast biopsy. New patients can also last about 30 minutes for me, longer if I need to prepare their operative consents, H&P, ect... My office staff does a good job about letting my patients know when they will have to wait. This has gotten better since I am no longer on call during my office day. I apologize to the patient if I am late and explain that our appointment won't be rushed. The other side of that is that we have a striict 30 minute no-show policy. This cuts down on the moning patient's tardiness slowing down the rest of the day.
THE OPERATING ROOM This is where most of the delays occur, and the place where I have the least control. I tell my patients that the starting time is only an estimate and that an emergency can push everything back. Cases ahead may run slow, turnover time may be long, and if it is an afternoon case the number of rooms run decreases when the day shift goes home. The hospitals in which I operate do not do a good job of explaining this to the patient. Sometimes the patients do not show up for their pre-operative testing. Because OR time is a limited and time-dependant resource we cancel those patients no questions asked. We just can't wait for them to have their preop workup the day of surgery, because that would make other patients have to wait.
Overall I think this is a very bad decision.

They're even coming after the vets.

Friday, August 01, 2003

Dr. Smith links to an article in The Boston Globe about Brown University's program to offer the first two years of medical school over the internet. This statement kind of cracks me up:
a major goal is to replace the conventional lecture-and-textbook approach of medical school, which Smith calls ''dehumanizing".
What does he mean by this? One of most "humanizing' parts of my medical education was the hours spent in the anatomy lab with my dissection group. It touches one at a visceral level seeing the beauty of the human body, while also humbled by the gift that was given to us by this person and their family. I don't think it can be replaced by a computer simulation. As a surgeon so much of what I do everyday is not only based on sight, but also feel. Maybe in the future the technology will exist to do this, but not today.
For full disclosure, outside of anatomy lab and "pot case" days in second-year pathology I hardly attended class. Sitting in a darkened lecture hall for me is a sure way to induce narcolepsy. I realized I could sleep better in my own bed than their chairs. Out of the 170 members of my class, only about 20 or so attended class every day. We had the note-takers as well as professors who relied heavily on handouts. I actually had classmates who thought that me and my friends had dropped out since they never saw us.
Have a good weekend!
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