medical blog – Page 3 – The Caduceus blog

January 18, 2014May 17, 2014

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.”

January 4, 2014January 24, 2014

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.”

December 7, 2013December 16, 2013

Remember When We Used to Prescribe Inhaled Steroids for Asthma and COPD?

Press Release: Annual Conference of the Universal College of Chest Physicians October 2085; New Chicago, Mars.

The annual conference enjoyed another record attendance today as attendees flocked to Dr. Ramachandran III’rds keynote address reviewing exploits of physicians in the early part of the century. Dr. Ramachandran highlighted some key decisions and their consequences, such as the ACGME’s decree in 2032 that all residents should be swaddled before their scheduled hourly nap times. This of course led to the now infamous Great Hospital Apocalypses of 2033, 2034, and 2035.

Perhaps nearly as intriguing was the plight of inhaled corticosteroids for the treatment of respiratory diseases like asthma and COPD in the beginning of the 21^st century. The period began with greater awareness and concern regarding the use of long acting beta agonist (LABA) bronchodilators such salmeterol. That risk was highlighted by findings published in the SMART trial (access through Chest archives here). There was increased concern regarding the potential harm caused by LABA which culminated in the placement of warnings on medications which contained LABA bronchodilators. These medications, experts said, were to be prescribed with extreme caution because of the possible increase in harm, particularly among children.

Scholars of the early 21^st century thus highly recommended that asthmatics, especially children, be started on steroid inhalers before having to resort to using inhaled LABAs. Many also theorized that inhaled steroids had a protective effect when combined with LABA’s, possibly ameliorating their potential danger. Thus many at the time recommended a strategy of not using LABA inhalers at all, unless also simultaneously prescribing an inhaled steroid.

However, problems with this approach started to appear late in the first decade of the century. The TORCH study, a trial using combined inhaled LABA/inhaled steroids in adults with COPD suggested that there was an increased incidence of pneumonia among those treated with inhaled steroids. Early in the second decade a pivotal study then demonstrated that asthmatic children treated with inhaled steroids ended up being about half an inch shorter than they might have otherwise been (interestingly, a later study in 2035 correlated the reduced height with a statistically significant decrease in NBA dunking). Continue reading “Remember When We Used to Prescribe Inhaled Steroids for Asthma and COPD?”

November 9, 2013November 24, 2013

5 Ways Healthcare Reform May Impact Medical Education

Guest Post by Ta’Rikah Jones

Unless Congress completely smothers the Affordable Care Act (ACA), its changes will shake healthcare to the foundations as millions of people gain access to insurance and expanded medical care.

The ACA’s goal is to move Americans toward a health insurance umbrella for everyone while striving to control costs and drastically alter the insurance industry. Potentially every facet of healthcare could be affected, from the doctor’s office to research labs. Changes could even reach into healthcare education.

The law will change the number of patients seeking care, how much doctors are paid and may make some med school students even more uneasy about school loans.

These are some ways the ACA may affect medical education:

1. More primary care

The law seeks to foster primary care and boosts Medicare payments to primary and internal medicine physicians significantly while lowering payments for subspecialty doctors. Also, payment and coverage for preventative care would rise along with primary care.

This could slow the drop in students who pursue primary care in medical school. For years students migrated into more lucrative subspecialties, leaving only a small percentage of students interested in general medicine.

The act also calls for expanding some scholarship and repayment programs for primary care doctors and expands nurse and primary care training.

Continue reading “5 Ways Healthcare Reform May Impact Medical Education”

October 27, 2013May 16, 2014

How to Attend a Medical Conference Without Actually Being There.

Well, I’ve done it again. It seems that every time I try to make the early registration deadline for a conference, something seems to come up. One of the kids gets sick, a transmission breaks, I have a crazy week at work, you know, life.

Unlike previous years however, I’m very excited to say that I will be making it to the American College of Chest Physician’s annual scientific meeting at the end of October.

While I wasn’t able to make it to the conference every year, it turns out that I didn’t have to miss everything because I had a new and unique tool at my disposal. A tool that allowed me to catch a surprising amount of the action and actually obtain some of the benefits of the conference without actually being there: social media. Continue reading “How to Attend a Medical Conference Without Actually Being There.”

September 14, 2013September 3, 2013

Infographic: 10 Revolutionary Medical Advancements on the Horizon.

I’ve said it never and I’ll say it again: Ya gotta love infographics! How else could you turn an otherwise random and often sleep-inducing jumble of important looking illustrations and maybe facts into an eye catching array that draws you in like a fly to a plasma screen? So compelling, their like the pop-up books of science. Such an obvious idea, right? Yet their still new enough to set off your spell check. (Go ahead, open up Word. I’ll wait. See?)

So I was joyed to accept an invitation to post Caduceusblog’s first-ever infographic. Thanks to the graphic smiths at Master’s in Health Administration Degrees for submitting this post (even if they are a bit numerically challenged;). You can see the original post here

Continue reading “Infographic: 10 Revolutionary Medical Advancements on the Horizon.”

August 31, 2013September 3, 2013

Smartphone App Allows COPD Patients to Individualize Their Care.

Health-care technology advocates have long been preaching about the potential of smartphones and other types of disruptive technology to improve health-care delivery. We in organized medicine have been slow to answer the call. Studies that showcase the ability of these tools in major medical journals are rare. However, in a recent issue of CHEST, we see a welcome addition to the medical literature.

In this study, researchers taught patients with COPD to create daily symptom diaries on smartphones (BlackBerry 8700s). The results were uploaded to a research server and the program alerted staff when certain predetermined criteria were met. Using the data, researchers were able to accurately and quickly identify patients who were having an exacerbation of their COPD. They were also able to collect data on both the timing and length of the exacerbation.

This has exciting implications. Perhaps this kind of patient centered data could be used to identify patients with severe symptoms and prevent hospitalizations, or to serve as a measure of response in clinical trials to various interterventions. The possible applications are numerous.

Though there is one aspect of this study that, as a tech geek, leaves me ambivalent. Should I be excited that even an obsolete smartphone could prove to be so useful? Or depressed that even an obsolete smartphone is so far ahead of current medical technology?

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This article is also posted at the ACCP Thought Leaders Blog.

August 17, 2013July 30, 2013

The War Is Not Over: PTSD Common Among ICU Survivors.

The ICU is a terrifying place. The noise, the alarms, the invasive tubes and wires, and the loss of control all contribute to an overall feeling of anxiety and stress in patients and in families. Add to that the emotional burden of being ill or having a sick family member or friend, and you have a perfect storm for the development of post traumatic stress disorder.

As a health-care provider working in the ICU, it is easy to forget how desensitized we are to this environment. Recently, I took a phone call from my wife (who is a nonmedical professional) in the ICU. After a few minutes, she asked in a panicked voice, “Do you need to go get that alarm”?! And of course, it was a “first-level” alarm that I had completely tuned out and hadn’t even noticed. Looking around the ICU as I write this, I’m certain that I’m not the only one who is numb to these stimuli.

In a recent issue of CHEST, Dr. Bienvenu and colleagues report the findings of a study looking at posttraumatic stress disorder in the survivors of acute lung injury. They interviewed 60 survivors of acute lung injury 1 to 5 years after their hospitalizations. The authors compared a self-reported screening tool and a clinician-administered tool. They found that 27% of patients in this cohort had PTSD or partial PTSD, and that the self-reported screening tool was a reliable method of assessing PTSD in this population. This is promising, since a self-reported tool can gain more widespread use and may be able to help future investigators better determine factors associated with the development of PTSD in the ICU survivors.

Determining who would be likely to develop PTSD would be an important advance in critical care. Often I think we are surprised at how even our “good” outcomes can have long-standing functional problems following their ICU course. In the perfectly titled accompanying editorial Surviving the ICU Does Not Mean That the War Is Over, Dr. Schelling tells the story of one patient who survived extracorporeal membrane oxygenation (ECMO) only to report horrific memories of scenes from an apocalyptic warfare. These memories significantly impacted his quality of life and functional recovery, even though his overall outcome was “good.”

These studies add to the growing literature about the long-term effects of our treatments. I’d be eager to see more. We do not consider this important area of quality enough. With studies like this to help give us better tools, hopefully we will see more investigations into the long-term impacts of the life-saving therapies we provide.

Chris Carroll, MD, FCCP is a Pediatric Intensivist at Connecticut Children’s Medical Center, and my Social Media co-editor at Chest Journal. He is on twitter @ChrisCarrollMD. Be sure to check out our posts at the ACCP Thought Leaders Blog, where this article was originally posted.

July 20, 2013October 24, 2013

“When I Was a Resident”: How Duty Hour Rules Are Creating a Lost Generation of Physicians.

This article was written by a Pulmonary, Critical Care Fellow who completed residency after recent resident duty hour restrictions went into effect.

During my internal medicine residency, we were allowed to work a maximum of 30 hours per shift. You would do a 24 hour call in the hospital , then round on your patients post-call and go home by noon. This was the norm. I completed 5-6 of these shifts per month during my entire 3 years of residency. Even then, when timidly telling my attending physicians that it was time for me to go home after fulfilling my 30 hours of duty and barely being able to keep my eyes open, they would respond with the old clichéd phrase “Well, when I was a resident……” The sentence would usually end with something about how they used to work for 3 days straight with no sleep, no shower, and on and on. Just like your Dad telling you “When I was a kid, I would walk to school, barefoot, in 6 feet of snow…..uphill.” At least that’s what my Dad would say, and I would sigh and roll my eyes. I never thought I would agree with such a cliché. But now, as a 2nd year Pulmonary and Critical Care fellow, I frequently find myself repeating these same exact words: “When I was a resident..” and let’s face it, that was only 2 years ago.

I completed my residency prior to the “new” duty hour limitations that went into effect in 2011. The new regulations limit residents from working more than 16 hours straight; after 16 hours, they must have a mandatory “nap” time. This has forced many institutions to change the call schedule to so-called “block nights”. Residents are only allowed to work 12 hours during a call shift. They work 12 hours and may stay for an additional 1-2 hours after for educational lectures and sign-out, but otherwise, they are off duty. I have even found that many resident physicians will not even return a page after 7 am because apparently that would be a violation of duty hours.

Shortening duty hours to a maximum of 16 hours at a time has not, in my opinion, improved resident physicians experience in any surmountable way. It seems detrimental if anything. Studies including the one recently published in JAMA, would seem to support the view that shortened hours may not in fact be beneficial to residents or their patients.

Because of the changes in work hours, residents are becoming less educated, less experienced, and more apt to push work off onto someone else or to leave it altogether. They have a decreasing sense of patient responsibility and motivation. I frequently hear, “Oh, I have to leave, can’t go over my duty hours,” even when there is still patient care to be done. I’m not asking that residents be asked to stay beyond what’s reasonable (and I know “reasonable” is still the big debate), but I do think these increased restrictions on allotted time in the hospital are molding a generation of residents who are less than motivated. Many are being instilling with bad habits and a poor work ethic.

Now, I know, maybe I am just one of those people. The overachiever who expects a lot from myself, and from others. I am, after all, a pulmonary/critical care fellow, so I do have that type of personality. But I know the majority of my colleagues agree with me: the general consensus is that these duty hour restrictions are instilling a lackadaisical apathy in many of the underclassman. Not all, but many. We are teaching them that it’s OK to do the minimum, and that there’s not a need to go above and beyond. It’s OK that you weren’t able to put that arterial line in because you put in your 12 hours, and I know you were busy.

In my opinion, this is not acceptable. Continue reading ““When I Was a Resident”: How Duty Hour Rules Are Creating a Lost Generation of Physicians.”

July 6, 2013June 6, 2013

5 Things No One Taught Me in Residency

Below is a Repost of a previous article, that is appropriate to this time of year.

Since medical school, I’ve gone through an additional 6 years of training, read countless volumes of medical literature, and had the fortune of having some great teachers. Through it all, experience has been the greatest teacher, which I suppose is what training is about. I’ve watched with interest as advice has been hashed out on the web around this time of year to new trainees on all matter of subjects. And much of it is good and useful, to be sure.
Being the helpful person that I am, I naturally want to do my part. What, I thought, could I contribute to this discussion that hasn’t been said already?
To that end I’ve come up with my own list of of trivial and only slightly helpful tidbits of information, based on my own experiences over the last 11 years post graduation. Here I give you my top 5 list of things that no one ever told me in medical training. . .but should have. Enjoy.

1. Before conducting a family meeting, go the restroom. Scan your face for things that might appear distracting or unseemly, like nasal boogies or lettuce stuck in your teeth, and quickly remove them. If you are one of the few convertible drivers with hair, pay special attention to this area; the “mad scientist” look is generally not one which inspires confidence in these situations.

2. Using hospital Jello-O and graham crackers as the base of your food pyramid makes for a reasonably strong pyramid. At least as strong as any other pyramid that has a soft mushy substance at its base.

3. Sometimes an appropriately discharged patient will refuse to leave the hospital. Follow your hospital’s policy in these situations. If it is your hospital’s policy to call security, then do so. However it would be wise to have your patient fill out the house officer rating/feedback form before doing so.

4. If your attending physician gives you an answer that seems wishy-washy, it’s because they don’t know the answer. They still know a heck of a lot more than you, though.

5. When entering a room to declare death on a patient, whose family is in the room, make sure your pager is on vibrate. Particularly remember to silence any cutesy ring tones (such as Cee Lo Green or the Benny Hill theme) that might bring unwanted awkwardness to an otherwise somber moment.

Thank you and Good Luck!