Sunday, April 13, 2014

Attention Physicians, Your Government Just Flipped You The Bird

According to a 2012 study by Jackson Healthcare, the percentage rate of U.S. Physician compensation is among the lowest of western nations.  In 2011 physician's salaries compromised 8.6 percent of the nations total health care costs.  This is in comparison to 15 percent in Germany, 11 percent in France, and 11.6 percent in Australia.  Detractors point to the fact that although the percentages speak for themselves, if you look at the total number of dollars (Per capita health spending in the U.S. is double that of the average for the twelve other OECD countries), physicians are still compensated quite well.  Either way, in our bloated costly system, physician services are comparatively already discounted.

So it was with great pomp and circumstances, as well as consternation from various physician sources, that the government released data for all payments made by medicare to physicians in the year 2012.   Lauded as a win for transparency, the administration argued that making such information public would lead to a reduction in fraud, greater research into healthcare costs, and empower citizen investigators to crack the code of our overwrought system.

In reality, the so called "data dump" was exactly just that.  Refuse.  The information didn't account for the percentage of each physicians practice as medicare vs private insurance.  There was no recognition of pass through costs (medications, chemotherapy, etc.).  There was no adjustment for range or severity of illness of each physicians patient population.

Besides physicians, it is unclear that this information will really interest anyone.  The government and the FEDs already know who are the largest medicare billers, they were privy to the information previously.  The public is so overwhelmed with the ACA, surgical report cards, physicians rating sites, and the like, it is unclear that they will take the time or have the expertise to actually interpret the data.  Previous studies suggest that patients could give a hoot about such information.  And even if they could, finding a doctor who takes their insurance and hasn't been narrowed out of a network is hard enough.

I can assume that the only real reasoning to release such information was to send physicians a clear and unmistakable message.  We are being told not so subtly that we are being watched:

Get on board with what is happening, or there will be consequences.

That's right.  Our government just flipped us the bird.

Sunday, April 6, 2014

Why I don't Always Follow Guidelines, My Response To Barron Lerner

Barron Lerner thinks he understands doctor's motives.  In his recent article in the Atlantic he laments that physicians act on tradition and emotion over adopting new science.  In defense of his position, he sites the example of how cardiologists use angioplasty and coronary artery bypass to treat coronary disease.  He states:

cardiologists have been remarkably slow to abandon the old hypothesis, continuing to perform hundreds of thousands of bypass operations and angioplasties annually not only in the setting of heart attacks (when they are appropriate) but also to try to prevent them.

He, of course, makes this statement without acknowledging that scientific data has only become more clear on such issues in the last ten or so years.  He ignores the fact that this has been an area of great controversy in which experts and the not so scientific guidelines disagreed over decades.  In other words, it's not that greedy doctors were just breaking the rules as a ploy to make money, there were actually highly respected leaders on both sides making persuasive arguments.  And furthermore, just because a cardiac intervention isn't in the setting of an acute heart attack, doesn't mean it is not appropriate.  

Lerner then pivots to discuss the new cholesterol and hypertension guidelines.  

In the case of cholesterol, the new guidelines, promulgated by a joint American College of Cardiology-American Heart Association task force, discourage the standard practice of checking patients’ cholesterol counts and choosing among a series of medications to lower them to specific levels. Instead, the group recommends treating all patients who fall into specific risk groups with a particular agent—the statins—and not following their levels.

What he fails to mention is that these guidelines have changed over the years based not on any new evidence, but more on the whims of the so called "experts" chosen to give their opinions.  These are the same experts who told us to shoot for an ldl of 70, treat low hdl with niacin, and use non statin lipid lowering drugs like Zetia.  All of which have fallen out of favor.  These are also the same experts who often make an income consulting for pharmaceutical companies who stand to benefit from such guidelines.  

The same can be said from the hypertension guidelines.  It seems every year some group is telling us what we should be shooting for which is often a new, random number.  The data, however, most of the time is lacking.

The problem is, the latest scientific data/theory is often wrong.  Their are countless examples of this in the literature.

Many anti arrythmics killed people.
Raising HDL cholesterol did not benefit anyone.
Vitamin E is useless.
Measuring homocysteine and CRP are rarely helpful.
Vitamin D does not treat heart disease!

The job of a physician is to evaluate the data and use this information to benefit his patients.  We are not expected, or required, to blindly follow guidelines.  So you'll have to excuse me if I'm not jumping to follow the new cholesterol dictates.

I didn't when I was told to get every one's LDL down to seventy.  I didn't when I was pushed to use gemfibrozil and niacin.  And I sure as hell won't now, until the scientific data that went into such decisions makes sense.

Saturday, March 29, 2014

I'm Sounding The Death Knell

It was a particularly challenging case.  On the car ride into the hospital, I found myself doing something that I rarely do.  I called a local allergist for an inpatient consult.  Most allergy issues are not an emergency.  So it is odd indeed to summon this particular kind of physician into the medical wards.  His nurse took the message and promised that she would plug my mobile number into his pager.

A few minutes later we were discussing the particulars of the case.  He was excited by the details.  This was something that he had only seen a few times in his career.  He rattled off a number of questions and I answered them to the best of my ability.  I was standing in the hospital lobby by now. I didn't want to risk venturing up to the patient room for fear of losing my mobile connection in the stairwell.

I was about to give the floor and room number when the allergist interrupted me with an unexpected question.

Do you work for the medical group?

He was referring to the large hospital based practice that had recently bought up almost all other physicians in the area.  I knew that he had joined them, but generally don't consider such alignments when making decisions about who to consult on a particular case.  I always try to call the best physician for the job regardless of who they work for.  I paused for a moment before telling him that I was still part of an independent practice.  Although I could sense the hesitation in his voice, I would have never in a lifetime expected what came out of his mouth next.

Oh, um sorry, I only do inpatient consults for physicians who are part of the medical group.

It was such an abrupt surprise, I hung up the phone dumb founded before thinking of the litany of questions that were now pummeling through my head.  Since when does the politics of corporate medicine replace helping those in need?

I'm sounding the Death Knell.

The primacy of patients in our healthcare system has now ended.

Thursday, March 20, 2014

Malcolm Gladwell Is Wrong, Tell Them That You Love Them

Malcolm Gladwell thinks we should tell people whats it's really like to be a doctor.  And by God I have invested the last seven years in doing just that.  I have written countless blogs, given lectures, and traveled to Ireland.  I have coined the term Caring 2.0 to describe the bidirectional flow of empathy.  Patients will tell us what it is like to suffer with disease, and we will tell them of our own battles.  Forged somewhere in the molten lava of truth and disclosure, a deeper relationship will arise.  We will heal not only with our hands, but with our hearts.  In the process, the oozing festering gash of our painful existence will somehow be allayed.


I was wrong.  Years, pages, and a book of poetry later, I have found that my most captive audience is not my patients nor the populace in general, but healthcare professionals.  That's right.  The doctors and nurses are the ones who get the most out of my writing.  It took me nearly a decade to realize that I am preaching to the choir.  It's my fellow PTSD'ers that find release by reading my words.

We are wounded soldiers searching not for a pat on the back nor a bow of recognition as much as knowing glance.  To share with other human beings the impossibly difficult situations we face only has resonance for those stuck in similarly claustrophobic corners.

Do I want to know all the near misses that occur yearly in our aviation system?  Do I want to hear about the accidental deaths by friendly fire in Iraq? NO.  We want to believe that flying is utterly safe, that our military only protects, and that pain and suffering are twentieth century problems long resolved by our excellent medical innovations.

Your average lay person only wants to hear of death when they are forced to.  Face it when mom and dad are taking their last breaths, but otherwise push it back to the farthest reaches of the denying mind.

We physicians need to tell each other,  We need to confide in our brethren.  For those of us stuck in the thick mud of human destruction, the divide is too great for the uninitiated.

But there is something we can do to fight the colossal mess of what Healthcare has become today.

Instead of trying to explain the tangled mess of our daily lives to our patients, we should instead assure them that we are on their side.  We should tell them that we won't stand for the destruction of humanism in medicine by the cold calculus of technology.

We should tell them that we love them.

Tuesday, March 11, 2014

A Review Of The White Coat Investor

As physicians go, I feel like a relatively savvy businessperson.  Although I don't talk about it on this website, I have owned and run a number of small businesses and been a landlord for years.  So when James Dahle sent me a copy of his book, The White Coat Investor, A Doctor's Guide to Personal Finance and Investing, I was both curious and skeptical.   What was the guy going to teach me?

Before diving in, I took a few moments to glance at his blog.  My few moments turned into hours.  The site is a trove of important and often perplexing subjects that physicians (as well as other small business people) face.  Ever contemplated these issues before:

To buy or rent property?
What defines good disability insurance?
Term or whole life?

These, as well as many other topics, are covered in a concise and digestible manner.  I urge you to take a look.

The book is an easy read.  In the first few chapters, James sets the stage for why we need to learn this important information.  Physicians are facing the Big Squeeze of rising tuition, low reimbursements, and increasing regulatory hassle.  Becoming a millionaire by age forty is quite feasible, but takes a certain amount of planning and know how.  One must be aware of how to convert high income into wealth.

Chapters four and five are indispensable for physicians in training.  Here James dissects how our decisions early on influence our future fortunes.  Such topics as loan forgiveness programs, and whether to buy property during residency are covered.  These are issues that I would have never dreamed about when I was in training, but should have!

For me, an established physician, the heart of the book comes in the next flurry of chapters.  He opens with simple enough advice, Live Like A Resident.  But as the pages march forward, the discussions become more topical and complex.  He handles debt repayment, retirement savings, and the basics of investing with common sense and clarity.  There is a particularly strong and well thought out section about the role of financial advisers.

The last few chapters cover topics that all established physicians struggles with.  Here we learn about asset protection, estate planning, and income tax management.  Any small business person or high income generator needs to understand these topic thoroughly.

In conclusion, for the medical student, struggling resident, or new attending with little financial knowledge, I believe this book is a must read that will save a small fortune both in terms of monetary well being as well as frustration.  For the more advanced investor like myself, these chapters form a stellar check list for us to rate ourselves against.  After reading this book, I clearly understand the strength and weakness of my own financial plan.

I've made a few changes already!

Saturday, March 1, 2014

Proof Of Life

It's not that I was stressed out about being alone with the kids.  My wife had gone out of town before. It was the darn mornings.  I'm used to racing out of the house at the crack of dawn, when the rest of my family is still asleep.  My most productive hours of the day are before most people even wake up.  With my wife gone, the mornings with the kids were all mine.

Accordingly, I lounged in bed an extra few minutes before dragging myself into the shower.  Unlike most mornings, there was really no rush.   The kids wouldn't be up for another half hour, at least.  When they did awake, I would busy myself with their needs: dressing, breakfast, and of course, the dreaded hair.

For the next few days, managing my six year old daughter's hair was my sole responsibility.  And this terrified me more than a crashing octogenarian on life support.  Barely able to pull together my own personal appearance on a daily basis, preparing girl hair was definitely going to be a challenge.

It wasn't that I hadn't been prepped.  My wife, daughter, and I had a practice session before her departure.  But we all know that anything can go wrong on game day.

So there my daughter stood on a step stool as I tried valiantly to brush out the curly unruliness of sleep from the tangled tendrils.  Occasionally the brush would stick and she would protest whimperingly until I withdrew pressure.  As I had been taught, I parted the red sea evenly forming a straight line on top.  But as the slope of her head dove down, the part became a mangled twist of tributaries forking and bending towards the nape of the neck.

I grabbed a clump of hair clumsily, trying to entangle the band into a pony tail.  With each second that past, my daughter became more wiggly underneath my hands.  She hummed a nondescript tune and darted back and forth randomly.

My brow furrowed and the sweat formed at the base of my receding hair line.  My ineptness of hand was interrupted by the clarity of thoughts coalescing in my brain.  On any given day, at this time in the morning, I could find myself entrenched in the human condition.  Ensnared in an end of life discussion, examining a pus filled wound, or lamenting on the lack of response to a last ditch treatment.

You can't be in this profession long without realizing that the joys and pains of life are but fleeting flights of fancy.  Happiness is neither a place or a thing, it's a series of disconnected moments.  The more of these we have, the more we recognize, the closer to nirvana we come.

And we often recall the big ones: when our eyes first locked with that of lover, or a child slithered through the birth canal and into this great state of ineptitude that we all share.

But I can't help but think that there is a certain divineness in the minutia.  Standing in the kitchen with   my daughter's hair slipping through my hands as she dances to a silent song that only plays in her six year old brain, I can't help but think there is something important happening here,

I can't help but think that this is one of those moments.

One of those moments that make a life.

Sunday, February 23, 2014

Are You A Physician Or A Secretary?

I'm no economist.  In fact I have never taken any business or accounting classes in my life.  But it doesn't take a formal education to get this.  We are speeding down the wrong path.

The call at three in the morning woke me from a deep sleep.  I fumbled and strained to hear the whispered voice of the apologetic nurse.  Apparently Mrs. Thompson had scraped her arm against the wheel chair, and suffered a minor abrasion.  No harm, no foul.  Except that ever since the state had come in  and eviscerated the nursing home protocols, extra precautions were being taken.  Some things just won't be left till the morning anymore.

My early trip to the hospital was no better.  My personal assistant called to say that I had to re do the form to get one of my patients a walker.  Although I had signed it by hand, we had typed in the date.  Apparently the medical equipment company required that the date also be written in ink.  It sounds minor, but I had to find a fax machine, wait for the fax to arrive, write in the date, and fax back.  All, of course, needed to be done immediately.

Luckily my hospitalized patient was getting better.  And since it was neither an admission nor discharge day, I just might escape without wasting too much time on paperwork.  As I was putting on my coat, the head nurse stopped me in my tracks.

"I just need to notify you that your patient claims she is missing fifty dollars, and can you sign this form acknowledging that you have been informed."

What?  Since when did I become a policeman?  Since when did take charge of all criminal activities that take place inside the hospital walls?  

Healthcare is being overrun.  Government induced regulation and documentation are creating mental gridlock.  The dictates of our forms and procedures are tying up those with the physical and intellectual know how to care for patients.

Why can't you get an appointment with your doctor?  Why are diagnoses being missed?  Why is the quality of healthcare in the United States declining rapidly?  Stop querying big data and start looking at the hunched backs and sore shoulders of the people who are inputting that data.

We are turning our physicians and nurses into scribes, field workers, and secretaries.  Those who create the most value, who took the most time and money to train, are being overloaded with menial and level inappropriate tasks.

No small business would be naive enough to operate this way.

Why then, should one of the largest sectors of our economy.