Me and My A.E.D.

“Everyone should have BLS training. . . we’ll all be better off because of it”     -Me.

I arrived at my designated gate at Chicago’s O’Hare Airport.  The run there kept the adrenaline level up in my system, though the hubbub was now well behind. I pulled the crumpled boarding pass out of my pocket as I caught my breath. No that’s a hotel receipt. Check the other pocket, there it is, Zone 3, that can’t be that bad; I thought,  there’s gotta be, what maybe 6 or 7 zones, right? “Welcome aboard American Airlines flight to Flint, Michigan” the gate attendant announced. We welcome our platinum medallion, gold medallion, silver medallion, bronze high-flyers, copper star club, as well as plastic fantastic, and purple star members, followed by zones one and two” The last of the passengers was already through the jetway. “Now boarding zone three, welcome aboard”.

After handing over my crumpled boarding pass for scanning, I made my  down the jetway and onto what appeared to be a small but fairly packed little jet. Passengers on each side of the aisle eyed me as I walked past, a few noticed that my jeans were soaked from the knees down. Some caught the odor that  trailed behind, a light of recognition igniting in their eyes as they realized what it was. Does he really smell like that? Is he the one that’s dragging that awful scent through this cabin?

6 hours earlier things had been going very differently for me. My colleagues and I had just given a well received talk at the annual Chest convention. I had reconnected with old friends that I hadn’t seen since training.  I had just personally  thanked Kevin Pho (of KevinMD fame) in the hotel coffee shop for giving our keynote address and getting our membership fired up about the future of medicine and social media. It was with this sense of excitement and renewed enthusiasm that I boarded my plane to catch a connection at O’Hare.

I also distinctly recall that, at the time, my pants were absolutely one-hundred percent completely dry. Continue reading “Me and My A.E.D.”

The Ones that Emory Didn’t Save

It was with much fan-fare that 2 American aid workers were airlifted from across the world and brought to Emory University Medical Center where they began experimental treatment for Ebola. We hope for a full and speedy recovery for them and others like them who do God’s work.

But it appears to me that lost in this conversation are myriad others who need help but never get it. Right now, humanitarian work is being done all over the world, and in very dangerous places. These people  knowingly put their life on the line for others. Yet  tragically, some of them are injured or sickened in the service of others. But for them, the call from the CDC offering to med-evac them out never came. There was a girl, who died of malaria while in Kenya. Or the young man who was serving in Egypt. Or a myriad other aid workers who die while serving their fellow human beings.

Also at issue, and it needs to be asked, at what cost are we saving lives? Who decides who gets what may have been, all told, a hundred thousand dollar medical evacuation? Susan Grant, the Chief Nurse for Emory Healthcare, in an article for The Washington Post rightly downplayed the infection risk posed by bringing these patients here. She went on to say:

“The purpose of any hospital is to care for the ill and advance knowledge about human health. . . As human beings, we all hope that if we were in need of superior health care, our country and its top doctors would help us get better”

This statement brings to mind others that need saving. They don’t work in far away lands, they live here in the U.S, right across town, in fact. They don’t have fancy, exotic diseases.  Their conditions have names like diabetes, heart disease, hypertension, and lung cancer. Right now many of them are getting collection notices for their inability to pay from medical centers like Emory University. Others have been trying to get appointments at tertiary centers  like Emory. Only they’re told that their insurance is not accepted there, or their co-pays and deductibles will be more than they can afford.

How would Ms. Grant justify the incredible expense spent on this endeavor to those people? What would she say about the necessity of this experiment, a clinical trial with an N = 2? Could she really  tell those sweating in the Atlanta heat after their electricity got shut off that this was all really for their benefit?

I don’t know how to solve the ethical dilemma here. While I am hope for a cure on the one hand, I cringe at the highlight this places on those at the bottom end of America’s healthcare disparity gap. Perhaps someday in the distant future they can take solace in knowing that they didn’t suffer for naught. Because if they ever contract ebola, there will be a cure waiting for them.

“When I Was a Resident”: Duty Hour Rules Do Not Define Me

Recently, Rebecca Ulep wrote a rebuke of recent resident duty hour restrictions and their potential negative effects on physician education in a post entitled “When I Was a Resident”: How Duty Hour Rules Are Creating a Lost Generation of Physicians. Many practicing physicians agreed with these sentiments, while most residents did not. Our expanding #PulmCC community brought me  into the acquaintance of one the latter, who agreed to write a post taking the other side of the argument. Scroll down for the article, and hit the link above to read the original post. And follow the #PulmCC hashtag on twitter to keep up with relevant material and participate in future #PulmCC twitter chats. 

I argue with my father a lot. He works as an intensivist at a community hospital in Indianapolis while I am about to graduate from a highly academic internal medicine program in Chicago. Needless to say, we have very different perspectives.

He sometimes expresses views similar to those written in a previous article, “When I Was a Resident”: How Duty Hour Rules Are Creating a Lost Generation of Physicians. I started residency the first year that the new intern duty-hour regulations were put into effect. After explaining these rules to my father, he asked me: “How do you guys learn? When I was a resident, we did not have limits to how many patients we saw. I would be working until five or six in the evening on my post-call day and then stay to work a moonlighting shift.” I, then, delightfully asked him if that was before or after penicillin was discovered.

The field of medicine has undergone many changes (yet we still carry pagers…that’s for another rant), some for better and some for worse. There has been much debate over potential benefits and detriments that come with the changes in duty-hour regulations.  I can only speak to the culture at my own institution, but in my experience, there is one thing that has not changed: the pride we take in our work. This is why I take particular issue with the overly dramatized notions brought up in the aforementioned article. Continue reading ““When I Was a Resident”: Duty Hour Rules Do Not Define Me”

The PROCESS Trial: End of the Line for Central Lines?

A lot of things change for doctors once we’re done with training. Most of us leave behind the ivory tower that is the academic medical center to plow the common fields of private practice. We no longer have the weekly journal clubs, the Grand Rounds, the CME lectures. But what we gain is practical hands-on experience with what works, and what doesn’t. A nuanced knowledge of what’s accepted vs. what’s acceptable.

One such area has been the approach to sepsis. Manny Rivers et al published  their game changing study on early goal directed therapy (EGDT) in the treatment of septic shock in 2001, and the result became scripture in the field of Critical Care Medicine. The knowledge that tying sepsis resuscitation to the measurement of central venous oxygen saturation (ScvO2) and central venous pressure (CVP) using a central venous catheter, lead to a surge of recommendations.

The brain trust spewed forth these recommendations in various forms;  Surviving Sepsis Campaign, Sepsis guidelines, Sepsis bundles, Sepsis video games and Sepsis action figures. Somewhere in that sentence I may have transitioned to hyperbole.

Those of us in clinical practice didn’t always follow the drumbeat. Many of our patients with sepsis it seemed, did just fine without a routine central line or blood transfusions, or dobutamine drips. Why use invasive measures when we don’t really need them, and we’re not really sure that they’re helping? Still, when I talked to my ivory tower friends, the response was same, “We always use central lines and follow the EGDT”, they would say.

In case you’re thinking that I’m a maverick, well, it wasn’t just me. Surveys/studies that have looked at compliance with EGDT show compliance anywhere from as low as 0.1% to just above 50%. Clearly people were pushing back against the guidelines, and many began to publicly question whether results of EGDT could be generalized to the general population with sepsis. Continue reading “The PROCESS Trial: End of the Line for Central Lines?”

How to Fix Healthcare, From a Doctor on the Frontlines: Part 3.

This is the last of a 3 part series by Dr. Moeller, the infamous Doctor on the Frontlines. In this series he explores ways in which our healthcare system is failing, and how it can be improved from the perspective of those who live and breathe healthcare every day. . . doctors. Click the links to read Part 1 and Part 2.

I want every person in America to have access to quality health care all at a reasonable price because our citizens deserve this. Unfortunately, universal access to care at a reasonable price cannot materialize unless lawmakers look to doctors on the front lines of care for specific input.  We as doctors know in many ways why costs are high and why the public is unfortunately misinformed about how it all works.  But we need a representative sample of practicing doctors in Congress discussing these issues so that these “insider” insights can be applied to our current laws. In post, I look at the last of three central  ideas that would lead to better and more affordable care.

3. Health Savings Accounts.

The third solution highlights increasing patients’ roles in their own health, which would lead to more patient satisfaction, and actually lower costs.  This could be accomplished with health savings accounts.  These accounts would be funded by patients with pre-tax dollars and contributions made by employers and/or government subsidy stratified based on the individual’s income and job status.   With actual money in these accounts, patients would be able to discern costs better and use this money as if they were consuming any other good or service, such as handyman services.   This money could grow each year like an investment account and even be passed on to heirs at the time of death, keeping that sense of ownership with loved ones. Continue reading “How to Fix Healthcare, From a Doctor on the Frontlines: Part 3.”

A Dream About U.S. EMR’s; A Reality in th U.K.

I’m back at it again, talking about my continued love/hate relationship with EMR’s. From my conversations with doctors at different hospitals in our region, it seems that most docs appear to be falling into the “hate” column. Meanwhile, I’m still chugging along with the Allscripts Professional EHR that’s been installed in my office. And while it works just fine for the needs of a 3 physician single-specialty outpatient practice, it’s hardly the type of technology that, by itself, can change medical care for the better for a large number of people.

A recent study challenges that notion. In a study published in Chest, researchers in England sought to determine if inhaled steroids are a risk factor for pneumonia among asthmatics. It has already been shown inhaled corticosteroids are associated with an increased risk of pneumonia among patients with COPD. To determine this they looked at a database of medical information known as The Health Information Network (THIN).

In the UK, EMR’s have been in use for years, and general practitioners are encouraged (but not required) to participate in THIN. When a general practice elects to participate in THIN, software is installed in their EMR which runs in the background. The program collects data, while de-identifying it. The anonymized data is then uploaded to THIN, where approved researchers may have access to it.  There is no cost to the practices for participating, and in return for their participation practices not only receive in depth practice metrics, they also receive a percentage of any research revenue generated from the use of the THIN data. At the time that the study was conducted, the database contained data from 9.1 million patients.

But back to the question at hand. From a cohort of 359,172 people with asthma the researchers were able to identify 6857 people with pneumonia, along with 36,312 control subjects.  They were thus able to find a positive correlation between inhaled steroids and pneumonia. (for more on these findings, see my previous post: ) Continue reading “A Dream About U.S. EMR’s; A Reality in th U.K.”

How to Fix Healthcare, From a Doctor on the Frontlines: Part 2.

This is the second of a 3 part series by Dr. Moeller, the infamous Doctor on the Frontlines. In this series he explores ways in which our healthcare system is failing, and how it can be improved from the perspective of those who live and breathe healthcare every day. . . doctors. Click the links to read Part 1 and Part 3.

I want every person in America to have access to quality health care all at a reasonable price because our citizens deserve this. Unfortunately, universal access to care at a reasonable price cannot materialize unless lawmakers look to doctors on the front lines of care for specific input.  We as doctors know in many ways why costs are high and why the public is unfortunately misinformed about how it all works.  But we need a representative sample of practicing doctors in Congress discussing these issues so that these “insider” insights can be applied to our current laws. In this post, I look at the second of three central  ideas that would lead to better and more affordable care.

2. Tort reform.

We as doctors have a calling to help patients.  But, as we all are human, mistakes can happen. It is very important that patients who are injured by mistakes be compensated in a way that the law is supposed to provide.  However, the point of law is to provide reliable decision-making that can sort good health care from bad health care.  Instead, currently, it is run ad hoc jury by jury with no set standards. The system currently favors a doctor if in fact something was done wrongly or it may favor a patient even if no mistake was made.  This unreliability leads to defensive medicine, ordering tests and procedures just to prove that you did something, or excessively documenting trivial facts to prove you looked at everything.  The estimates for defensive medicine has been estimated up to $200 billion per year.  The current laws neglect both the patient and the doctor and drives up costs with administrative and attorney fees.

Here is an example of the evolution of defensive medicine. If a family physician determines a patient’s headache is likely due to tension and there are no warning signs for something serious, the doctor may choose not to order a CT scan and have the patient follow up if symptoms do not improve. Rarely, a tumor or bleeding in the brain could present in such a way despite a normal clinical evaluation by the doctor.  If that patient ends up having a tumor or bleeding, they can sue the doctor for not ordering the CT scan earlier.  In turn, that doctor doesn’t want that to ever happen again, even though he did everything right by using his clinical knowledge to determine nothing serious was likely going on. Continue reading “How to Fix Healthcare, From a Doctor on the Frontlines: Part 2.”

A Comedian Learns That He Has Sleep Apnea (Video)

Sleep Apnea is a serious condition that afflicts millions of people. The condition leads to reduced breathing during sleep which causes reduced oxygen to be delivered to the heart and brain. The condition may increase the risk of developing diabetes, hypertension, stroke, and depression. The reduced sleep quality can also lead to daytime sleepiness which can cause traffic and workplace accidents. In the video above comedian Jo Koy relates how he learned about the diagnosis of sleep apnea (he later got treated). Learn more about the disease and how you can get tested at SleepEducation.com.

How to Fix Healthcare, From a Doctor on the Frontlines: Part 1.

This is the first of a 3 part series by Dr. Moeller, the infamous Doctor on the Frontlines. In this series he explores ways in which our healthcare system is failing, and how it can be improved from the perspective of those who live and breathe healthcare every day. . . doctors. Click the links to read Part 2 and Part 3.

I want every person in America to have access to quality health care all at a reasonable price because our citizens deserve this. Unfortunately, universal access to care at a reasonable price cannot materialize unless lawmakers look to doctors on the front lines of care for specific input.  We as doctors know in many ways why costs are high and why the public is unfortunately misinformed about how it all works.  But we need a representative sample of practicing doctors in Congress discussing these issues so that these “insider” insights can be applied to our current laws.

In this series of  posts I will outline 3 central  ideas that would lead to better and more affordable care.

1. Costs Need to Be Simple and Transparent.

The first idea involves making costs and reimbursement more simplified and transparent.  These changes would help clarify misconceptions about doctor’s pay.  Leaders need to stop attacking doctors for how much they earn because they do not really know how it works.  In all other professions, one gets paid what the bill says.  If a handyman comes in to fix your sink and charges $80, you pay him $80.  If you seek a lawyer, and he says he charges $250/hour and he works 4 hours for you, you owe him $1000.

Unfortunately, the medical billing is unique, confusing, and wrong.  The charges (bills) that patients see in the mail are not what doctors get paid.  These are inflated numbers derived from contracts between hospitals or groups and insurance companies.  A recent New York Times article headlines read “As Hospital Prices Soar, a Stitch Costs $500.”  Sadly, these inflated numbers have nothing to do with what the doctor gets paid. In fact, those bills do not go to the doctor at all, but rather to the hospital.

When a hospital or doctor submits a charge (bill), the insurance companies or Medicare/Medicaid, depending on the patient’s insurance, utilize a fee schedule.  This schedule consists of thousands of codes that give dollar amounts for individual procedures or clinic visits.  Each code has a dollar figure to determine how much to reimburse that doctor.  This is called a “Medicare fee schedule” and insurance companies will pay a certain percentage of the fee based on Medicare.  This can range from 80% to 180% of Medicare depending on the insurance carrier. Continue reading “How to Fix Healthcare, From a Doctor on the Frontlines: Part 1.”

Dear Physicians: You Are Far More Wealthy Than You Know.

-By A. Joseph Layon, MD, FACP.

This article was written in response to Doctor Moeller’s Post: An Open Letter to Washington, D.C. From a Physician on the Front Lines

With interest, I read and re-read Matthew Moeller’s Open Letter.  My son, a first year medical student at Drexel University in Philadelphia, commented that this missive was being discussed by his colleagues in a tone of moral righteousness.  Interesting.

I know, I remember, what it was like to realize that the way to live an authentic life was to engage in providing health care for our people.  I remember debt, struggle, and 120 work-weeks. All of this, I remember.

And I remember being a third year medical student at The University of California, Davis – Sacramento Medical Center.  My professors, between patients on rounds, arguing how disastrous the health care system was becoming, how it was better in the “old days”, how they / we were suffering, how no one really understood what we had to go through.  Well, you get the idea.

While I understand, empathize and remember much of what Doctor Moeller says in his piece, and while he is – in my view on the mark in much of what he writes – I think he misses several points that are worth comment:

1. Medical School Debt: As a member of the Faculty Senate at the University of Florida I once got into a running argument related to the lack of breadth our undergraduates exhibited prior to their entry into professional school; lack of knowledge of history, language, and cultures other than their own.  Medical training is expensive.  In the not so distant past, a huge portion of this expense – certainly in the State of California where I was both an undergraduate and graduate student – was funded through tax revenue.  This was done not to be nice to our medical students, but because education was considered a social investment.  Proportionally, the monies in education have decreased (see Christopher Newfield, Unmaking the Public University – The Forty-Year Assault on the Middle Class, 2008, Harvard University Press), resulting in a grand portion of the debt saddling Doctor Moeller.  Nowhere in Doctor Moeller’s missive do I find any comment upon this.  The very policies that many in our profession cling to – physicians being, oddly to my mind given our work, frequently conservative and in the Republican or Libertarian camps – i.e., anti-taxation policies, put our medical students – and undergraduates, and graduates – at risk.  These policies put our future at risk.  Doctor Moeller rightly notes his difficulties; but Matt, what about the broader picture ?  This isn’t just a medical student issue. Continue reading “Dear Physicians: You Are Far More Wealthy Than You Know.”