Wednesday, August 31, 2005

Blast from the Past......
The Rebel Doctor is providing updates from the heavily hit city of Jackson, Miss. There had been rumors that we would be receiving some patients from Mississippi or Alabama, but so far we have not.
The tragedy is truly unimaginable.
In a flashback to the 70's gas lines were all over town today with rumors of stations rationing gas or cutting off gas after a certain time today.
Seems the same is going on in Atlanta.

Tuesday, August 30, 2005

Grand Rounds XLIX....
This week at Healthy Concerns.

Sunday, August 28, 2005

Catch as catch can....
From last weeks Newsweek in the "My Turn" column comes this tale of a family members frustration with getting in touch with modern medicine: I Shouldn't Have Had To Beg for a Prognosis. It was also reprinted in today's Atlanta Journal Constitution, as the patient in the story was a reporter for the AJC.
Aug. 22, 2005 issue - I was once a stalker. My victims—yes, there were several—were high on the social scale, but they were not celebrities. They were doctors.

My husband, Doug, died recently after a sudden illness put him in an intensive-care unit for 38 days. Being new to the world of hospitals, I stumbled around blindly for days before I figured out what all family members starved for up-to-date details about the health of their loved ones learn quickly: information comes from the doctor, and in order to get that information you must be present when the doctor visits the patient each day, whenever that may be.

I understand that what with juggling office hours and visits to hospitalized patients, doctors have demanding schedules. But do they understand that when your loved one is in the hospital, the rest of your life doesn't just go away? Hospitals operate on the premise that we, the family, must make ourselves readily accessible to the doctor—not by phone but in person—or else the doctor is not accountable.

Any time you are not in the patient's room (and, indeed, the hospital prefers that you not linger there), it is assumed that you are in the waiting room. When the doctor arrives, the nurse calls to let you know. If you've stepped out to grab something to eat, make phone calls with some degree of privacy or dash home to feed kids or pets, there's a good chance you'll miss the doctor unless you've networked with others who are waiting and they are able to summon you quickly.

If you miss the doctor, don't expect him to call you later with a report on how your loved one is doing. And forget about calling him at his office. Some receptionists won't even pretend to deliver a request to the doctor for a phone call from anyone other than a patient's ICU nurse.

To make matters worse, there isn't just one doctor. My husband had eight—not uncommon with critically ill patients. Some of Doug's physicians made their rounds before visiting hours. Those I could do nothing about. Most tended to come around midmorning, but a few mavericks appeared in the afternoon or evening, varying their schedules daily. I sometimes bagged my quarry as late as 8:30 p.m.

By Doug's second day of hospitalization, I was panicky and grasping at straws. The virus that had given him breathing problems had attacked several areas of his body. I could not communicate with him: a respirator was breathing for him and he was sedated. But the cardiologist told me that Doug was doing reasonably well, and I naively took solace in this mild pronouncement. That is, until a lung specialist zipped into the room, put his stethoscope to Doug's chest and said, "He's not getting better. He's worse. He may die. Any questions?" I was too stunned to be coherent.

Later, a nephrologist informed me that Doug's kidneys were failing and he needed dialysis. I told this doctor what the prior two specialists had said, hoping he could reconcile their conflicting reports. Instead, he plied me with questions about their findings that I could not answer.

After he left, I fled the room, gasping for breath, to tearfully summon Doug's parents from Florida and call his brother in New Jersey. When I returned to the ICU, his nurse told me somewhat indignantly that she'd been trying to find me, as there were more doctors to see. Oh, boy!

Finally, a specialist in infectious diseases appeared. He seemed sympathetic to my bewilderment, so I begged for an explanation: was Doug holding his own or dying? This doctor, bless him, took the time to explain that each of the doctors I'd seen had given an assessment only of the particular organ system he specialized in, not of Doug's overall condition. So although his heart was doing reasonably well, his lungs and kidneys were failing and he was definitely in danger of dying.

I hold no grudge against the hospital that treated my husband, and I encountered a number of compassionate nurses and doctors during Doug's hospital stay. As far as I know, they did everything in their power to help him, and I am grateful for that. But it seems that it's no one's job to ensure that the family has a clear picture of what is happening. If specialists are uncomfortable discussing anything outside their area of expertise—perhaps because of a fear of lawsuits or because they haven't had time to familiarize themselves with the facts—then the hospital needs to designate someone to fill in the information gaps. I had to do this myself by gleaning tips from sympathetic doctors and nurses, and learning how to decipher medical jargon.

Deep into the Information Age, why is this still a do-it-yourself process?
I certainly can empathize with the author's frustration. In today's environment of "ccommitteeomittee" the idea of the "big picture" can be lost. All of the specialists only feel comfortable discussing their particular areas of practice. Not only do the physicians do a poor job of communicating with the family, but as her conversation with the nephrologist indicates, the inter-physician conversation is lacking as well. The job of "filling in the information gaps" could be filled by the patient's primary care physician. They could, in theory, serve to "filter" the information from all of the specialists, but even they may not be able to answer all of the questions involved. They could also serve to facilitate communication between the physicians as well.
Ms. Payne asks: But do they understand that when your loved one is in the hospital, the rest of your life doesn't just go away?
Some do, some don't. If the family spokesperson wishes to speak with me and they are not around at visiting time, I will call them. I have never had my office staff serve as a wall to block a patient's family from speaking to me.
The problem, as always, is time.
While Ms. Payne has only her husband to worry about these physicians my have several critically ill patients to see. This is in addition to the other hospitalized patients and their office. There is simply not enough time to have a sit down with families when they are available.
The nurse as a source of information about the plan gets the short shrift, IMHO. The nurses at my hospital serve as an excellent conduit from the physician to the family and I will provide the nurse with my plan during rounds. Certainly family famliy wishes to speak to me I will make the effort to do so, but since the nurse (hopefully) knows everyone's impressions and plans, these could be passed onto the family.

Saturday, August 20, 2005

Toiling Away....
On call this weekend and several things have kept me away from posting. Thanks for all the advice about smartphones. I chose the Treo since it seemed to be best at what I wanted it to do, mainly keep my schedule and serve as a phone. Some of my partners got the Samsung and they are happy with their choice as well.

Tuesday, August 16, 2005

Grand Rounds XLVII.....
This week at Circadiana.

Friday, August 12, 2005

More on Canada....
John Fund in today's Wall Street Journal comments on the Canadian Supreme Court ruling concerning private health care:Canada's 'Free' Health Care Has a High Price Tag
For many Canadians their 37-year-old universal health-care system is the symbol of their national identity. Last November, Canadian Broadcasting held a contest to pick the greatest Canadian ever. The clear winner out of 1.1 million votes cast was Tommy Douglas, a politician known as the "father" of Canada's nationalized medicine.

But last June, a majority of Canada's Supreme Court struck down a Quebec law that banned private health insurance and held that the public system inflicted cruel and unusual punishment on many of its patients. The Fraser Institute has found it takes an average of 17.9 weeks between the time a patient makes an appointment to see a general practitioner and when he can then see a specialist. He will then be treated by a system that ranks 13th out of 22 advanced countries in access to MRI technology; 17th out of 21 in access to CT scanners and seventh out of 22 in access to radiation machines. The safety valve in the system is that nearby U.S. hospitals can provide treatment for emergency cases and patients willing to pay.

But Canada's public care doesn't save money. As the satirist P.J. O'Rourke once noted, "If you think health care is expensive now, wait until you see what it costs when it's free." When adjusted for the age of its population, Canada vies with Iceland and Switzerland as the highest spender on health care among the 28 most developed nations with universal systems. Dr. David Gratzer, a Toronto physician affiliated with the Manhattan Institute, calculates that a Canadian earning $35,000 a year pays a stunning $7,350 in health-care taxes.

Canada's Supreme Court was scathing in its indictment of the system. "Access to a waiting list is not access to health care," the court ruled. "Delays in the public health care system are widespread . . . in some serious cases, patients die as a result of waiting lists." The court struck down a Quebec law banning private medical insurance, which should lead to successful challenges to similar laws in other provinces. While last week the court stayed the impact of its ruling in Quebec for a year, a nationwide debate on why Canada is the only country other than Cuba and North Korea to ban private insurance and private care has finally broken out.
Yes, lets make our system like Cuba and North Korea. Can we please!!!
The prohibition is viewed as bizarre in other nations with universal health care. Sweden has long allowed private insurance for elective services. In Australia, private hospitals provide a third of the nation's capacity. In Germany and the Netherlands, anyone above a certain income threshold is allowed to leave the public system.

In Canada, the ban on private insurance results in truly loopy law. Dr. Sheldon Elman, the personal physician for Liberal Prime Minister Paul Martin, says the system is "disastrously terrible" in key areas. "You can buy an MRI for your dog and you cannot buy it for your daughter," he told the Montreal Gazette.
The old "floor versus ceiling" debate again.
You'd think the court's ruling would lead to dramatic changes. A new Ipsos-Reid poll finds that 83% of doctors view the court's decision "favorably." But only 52% of Canadians, who have been conditioned for years to think that their health care is free, share that view. That has led to an abundance of caution among politicians. "The opposition Conservative Party has been extremely timid in proposing changes and this year even called for creating a new prescription drug benefit," notes Michel Kelly-Gagnon, president of the Montreal Economic Institute.

Take Alberta, the country's energy capital and the province that most represents Canadian individualism. With oil at $65 a barrel, it is awash in revenue and could afford to forego the health-care money it gets from the federal government. But for a decade Conservative premier Ralph Klein has claimed he faced sanctions by federal officials if he went too far on reform. The June Supreme Court decision gave him the legal and political cover to be bold. Nonetheless, his new "third way" proposal to reform health care expressly bans Albertans from buying insurance to bypass waiting lists. It would instead allow them to buy insurance to upgrade to a better hospital room.
Fluff your pillow while you continue to wait?
"Klein probably misses having the feds to blame for his inaction," says Ezra Levant, publisher of the Western Standard, a feisty Calgary-based magazine. "Luckily, free market entrepreneurs will fill the void, and they'll have the courts on their side if politicians try to stop them."

A milestone in private health care could come this October, when the Copeman Healthcare Center plans to open a Vancouver facility that offers an array of elective services, no waiting times, and even house calls for an annual fee of $2,300 a year. The British Columbia nurses union denounces the clinic as "check-book medicine" and is demanding it be blocked from opening.

Those who believe Canada's debate isn't relevant to the U.S. should think again. The Vermont House has approved a bill to establish a government-run health care system. So too has the California State Senate. Nationally, a 1997 law pushed through by the Clinton administration banned Medicare patients from paying for a medical service covered by Medicare unless the physician agreed to forego reimbursement from all Medicare patients for two years. Regulatory modifications have softened the restriction, but it remains on Medicare's books. Could it be revived under a Hillary Clinton administration?

A good way to prevent bad policy in the U.S. is to encourage reform in Canada. The door is already open. Ontario officials haven't acted on their threats to close the dozens of private clinics operating there. Maybe it's time the Mayo Clinic or another major U.S. health care provider tested the limits of Nafta and floated stories that it wants to enter the Canadian market. The nationalistic feelings that would stir up might finally prompt Canadian politicians to accept home-grown private care.

If Canada wants to stop sending people to an early grave it will have to modify a health-care ideology that its own Supreme Court concludes is "disconnected from reality."

Have a nice weekend.

Wednesday, August 10, 2005

Supply and Demand.....
Brought to my attention by Shrinkette, a New York Times column from a OB/GYN resident describing the woes of his chosen profession as it relates to finding residents: Wanted: Workaholics to Become Obstetricians
In the last decade, the number of students entering the specialty has plummeted. In 1996 and 1997, applicants for obstetrics and gynecology residencies were lined up around the block. Since then, the number of applicants has gone into free fall. Only 743 graduating medical students in the United States applied for 1,142 residency slots in 2004. More than a third of the slots went to foreign medical graduates or remained empty.

Men in particular shy away from the specialty. In 1999, more than 40 percent of graduating residents were men. This year, men make up only 10 to 15 percent of the applicants. During my residency interview at Columbia, Dr. Richard Berkowitz, a prominent high-risk obstetrician, assessed the extent of the crisis. "I've been through the best of times and the worst of times," he said. "This is the worst of times."
The problem? Lifestyle:
More than any time in the past, medical students want careers with predictable schedules.

They want to go to their children's soccer games, read for pleasure and not be called in to the hospital at night.

Specialties like dermatology, radiology and anesthesiology offer flexibility. Obstetrics and gynecology does not, and students are turning away from the most demanding specialties in unprecedented numbers.

Obstetrics is consuming and unpredictable. The hours are long and caring for sick patients can blot out all other priorities. The stakes are high: very often you are caring for two patients and not one, and bad outcomes can be catastrophic for a family.

Red State Moron comments on the "workaholic" aspects of obstetrical training and practice, something he has first-hand experience with. There is also a link to a USA Today story about the use of laborists by hospitals (similar to hospitalists or emergency surgeons). This post is about how supply and demand has worked in Dr. Friedman's favor now, but may not in the future. Currently supply and demand has gave Dr. Friedman, much to his surprise, the opportunity to interview at a high-level programs:
Oddly, as an ambitious medical student I benefited from this. I applied to 26 residency programs, most affiliated with famous hospitals and prestigious universities. I expected to get interviews at about half, with serious interest from a couple of places.

But soon after my demographic information went online, interview requests flooded my in-box.

Every program I applied to offered me an interview, many even before they saw objective criteria like my grades and board scores.
So he was able to match at a very prestigious program, one that may not have been open to him otherwise. But unfortunately the medical system does not respond to market forces concerning reimbursement. So in a few years, despite the reduced numbers of obstetricians, Dr. Friedman will likely find that while he has taken the place of 1.5 OB/GYN's he may not be seeing the money of 1.5 OB/GYN's.
If medicine did operate as a free market the looming shortage of OB/GYN's would allow for each individual to raise their rates. OB/GYN would become more appealing and more individuals would choose OB/GYN as a career, or more OB/GYN's would move into an area and prices would reach an equilibrium. If medicine operated as a free market, that is.
Grand Rounds XLVI..
I'm a day late to the party. Dr. Emer has assembled an excellent selection of this weeks best of the medical blogosphere.

Monday, August 08, 2005

More on Specialty Hospitals....
While walking along a street in the seaside town where I was vacationing last week I came across the Tuesday edition of The Wall Street Journal in a newspaper machine and had to hit Ms. Parker up for fifty cents, since I could not let an article entitled: A Surgeon Earns Riches, Enmity By Plucking Profitable Patients to slip past.
In a 2000 speech, neurosurgeon Larry Teuber asked rhetorically why doctors would want to open a hospital dedicated to surgery. "Profit, profit, profit," ran his answer. When it comes to taking business from general hospitals, "you can't believe how easy it is," he said.

Dr. Teuber, the founder of the Black Hills Surgery Center here, soon proved his point. The company that owns Black Hills went public last year, bringing Dr. Teuber a $9 million payday. He and his wife own six airplanes and a vacation home in Jackson Hole, Wyo. When his children's hockey teams needed a rink, he put up $600,000 to help build one.
Nice work if you can get it. The bad blood is certainly flowing pretty thick:
At one point, Dr. Teuber sent anonymous letters to Regional patients encouraging them to sue a doctor there for malpractice. His bare-knuckles strategy has cost him some friendships. Timothy Frost, a radiologist who went to medical school with Dr. Teuber and practices at Regional, says he no longer speaks with his old colleague. Dr. Frost's wife was maid of honor at Dr. Teuber's wedding, but the wives no longer socialize. Black Hills "has spelled the end of any true collegiality in the Rapid City medical community," says Robert Ferrell, a Regional surgeon

There's more:
Competition between the two hospitals has been especially fierce in neurosurgery, Dr. Teuber's field. Regional performed 764 neurosurgery operations in 1996. By 2000, the number had dwindled to just 187. Regional began to fight back. In 2001 it recruited Steven Schwartz, who was fresh out of residency. Although not yet board-certified in the specialty, Dr. Schwartz quickly started doing as many as several procedures a day. That year, the number of neurosurgery cases at Regional rose to 336, and it continued climbing to 531 in 2002.

In early 2002, Dr. Teuber confirms, he anonymously mailed letters to three of Dr. Schwartz's patients, alleging their operations may have been botched. He says he heard about the cases from doctors who consulted him. He enclosed with the letters a photocopy of a malpractice lawyer's advertisement from the phone book. Dr. Teuber says he mailed the letters because Regional had been covering up for the surgeon's poor work. The hospital denies that.

Dr. Schwartz has since had many malpractice suits filed against him. At least 20 are still pending, including a suit brought by one of the patients Dr. Teuber prodded. Many of the suits also name Regional. They allege that Dr. Schwartz performed unnecessary surgery, operated on the wrong side of patients' spines and fused the wrong disks in patients' backs. The South Dakota State Board of Medical and Osteopathic Examiners later placed Dr. Schwartz on probation. His lawyer, Lonnie Braun, denies the allegations of malpractice.

Some of the plaintiffs say Regional protected Dr. Schwartz because it was under competitive pressure. A suit brought by Miriam Conley, a Rapid City woman who alleges Dr. Schwartz operated on the wrong disk in her back, says Regional "intentionally concealed" his mistakes because his surgeries otherwise "would be performed in facilities competing with Rapid City Regional Hospital."

Regional was forced to pay a $6 million Medicare fine in late 2002 to settle federal allegations that it gave some local cancer doctors office space, staff and other benefits to induce them to refer patients to the hospital. Federal law bars inducements for Medicare-patient referrals. Dr. Teuber prepared an inch-thick, bound paperback book detailing the case, and he says his staff placed copies in the mailbox of every doctor at Regional.

As a result of that incident and the anonymous letters, Regional took away Dr. Teuber's privileges at the hospital, meaning he could no longer perform surgery there. His neurosurgery-practice partners at Black Hills soon quit the staff of Regional or took leaves of absence.

The contrasts between the surgery center and the hospital are highlighted:
Regional is a typical general hospital. It has an emergency room and 366 beds. It handles nearly all the births in town, performs cancer and cardiac surgery, and cares for the mentally ill. The hospital has linoleum floors, shared rooms for most patients and a menu that runs toward meatloaf.

At Black Hills, there is no emergency room or maternity ward. Eighty percent of its procedures are either in neurosurgery -- the brain and the spinal cord -- or for orthopedic problems involving bones, ligaments and the like. Most patients stay only a day or two in one of its 23 carpeted private rooms, each of which comes with a laptop computer, wireless Internet service and chocolates. Recent menu selections included prime rib, creme brulee and a choice of wines.
Regional has suffered both economically and procedurally:
Black Hills had $19.2 million in net income on revenue of $45.2 million last year, according to Medical Facilities filings. Regional's $8.3 million operating loss came on revenue of $247.5 million, according to its annual report. Its net income, which also includes investment returns, fell to $187,155 last year from $21.5 million in 2001.

Figures on outpatient orthopedic surgery illustrate the damage at Regional. Between 1997 and 2003 the number of such operations fell by 52% to 845 cases. The proportion of the patients who had private insurance, which pays more generously, fell to 19% from 39%.
While at Black Hills quite a few nails are getting hammered:
Since Dr. Teuber's center opened in 1997, the rate of outpatient surgery in Rapid City has doubled. It now has one of the highest rates of back surgery in the country, according to data compiled by Dartmouth Medical School researchers.
The usual accusations of "cherry picking" are thrown about:
Regional says its surgical patients tend to come to the operating table nowadays with more ailments. That hits the bottom line because Medicare and private insurers pay a flat fee for many types of surgery, regardless of the patient's underlying health. Black Hills acknowledges it treats fewer of the complicated cases.

An example is hip replacement, one of the most common types of orthopedic surgery performed at Black Hills and Regional. In Rapid City, Medicare pays $9,700 for a hip replacement. A recent study by the Medicare Payment Advisory Commission, a federal body that advises Congress on Medicare issues, suggests that a hospital replacing the hip of an otherwise healthy patient would keep about $1,350 of that after costs. But replacing the hip of a sick patient -- say, one with diabetes, emphysema and heart problems -- would saddle a hospital with a loss of about $4,000 because those patients often require specialized anesthesia, extra nursing care and a longer hospital stay.

In general, Regional has been saddled with "a monopoly on low-paying services," says Charles Hart, chief executive of the health system that owns the hospital. One example is its neonatal intensive care unit, which wrote off $13 million in uncollected charges from the middle of 2003 through end of last year.

One recent morning in the unit, a 37-day-old baby who weighed just one pound at birth was sleeping in a $30,000 incubator. The child required intensive nursing care and was expected to remain in the hospital for several months, said his doctor, Steven Benn.

The baby's mother was a Medicaid patient, which meant that Regional would only recover about half of the $465,000 in costs that it expected to incur in caring for the infant, the hospital said. Patients on Medicaid, the federal-state program for the poor, account for 13.3% of Regional's total. At Black Hills, the figure is 4%.
Dr. Teuber replies:
Dr. Teuber has little sympathy for Regional. He says providing services like neonatal care and an emergency room are part of the public mission that qualifies Regional as a nonprofit and gains it a tax exemption.

Dr. Teuber says Regional administrators have gotten too comfortable with the hospital's longtime monopoly status. For example, when Regional does a hip replacement it lets the surgeon choose the brand of artificial hip. That means many brands are used, and Regional pays a higher price for each. Black Hills, by contrast, uses a single brand and negotiates deep discounts with the supplier, Dr. Teuber says.
On the latter I agree with Dr. Teuber. One of the best ways to cut costs is by standardization. But hospitals don't want to alienate their "high dollar" specialists by restricting supplies. Would that change if the orthopedists knew that the rep is making more off the case than they are? The numbers I have from a conference handout reveal that in 2002 Medicare reimbursement for a "metal on metal" total hip implant was $1,452 while the implant itself cost $7,988. Given the usual 20 percent commission the rep received $1,597. You can do the math.
But Dr. Teuber also speaks of the "public mission" of Rapid City Regional. The author of the article does not ask the good doctor what his "public mission" is, or should be. The question that is at the core of the specialty hospital debate is what does a physician owe his or her community? One of the reasons that I and my partners are supportive of the local trauma hospital is that we, our families, and our friends drive on the streets of our community and if we or they were injured, we would want the best care available. If all of your specialists are elsewhere, who will provide that care?
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