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3 Ways Obamacare is Destroying American Healthcare.

As I was watching CNN news recently, I noted in the headlines different ways Obamacare is failing.  Current problems discussed were the customers’ sticker shock of high deductible plans (up to $12,700 for families), the president blaming the insurance companies for having substandard plans, and the people blaming the president for losing their current insurance.

One patient even complained, “My new health care plan tripled in price, and now, it is like having a third loan to deal with, including my car and home loan.”

The current law and regulations being implemented under Obamacare will ultimately lead to sicker patients and low quality care for three reasons:

1.  Older doctors will retire early fed up with the system. These older doctors feel that the loss of a patient-physician relationship and the burdensome regulations (ie. paperwork) will choke off their ability to provide good care.  In addition, their expenses are increasing with these new regulations.  Add in the projected cuts in reimbursement up to 26%, and their livelihood will be threatened. These cuts could force these doctors out of practice or force them to stop seeing Medicare patients simply because their expenses (which rise yearly) are exceeding their declining reimbursement, which has declined steadily over the past several years already. Continue reading “3 Ways Obamacare is Destroying American Healthcare.”

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How a Journal Club and a Blog Challenged the Mighty NEJM

Could this be end of the Tonka-Scope?

Much has been written about how Web 2.0 tools can change the healthcare landscape.  It would appear a recent set of circumstances has upped the ante.

This story begins with a recent study that attempted to tackle the problem of ICU infections. ICU infections are a challenging problem, patients who are admitted to the ICU are at risk of worsening illness and death from infections such as MRSA which can be acquired while in the ICU setting. To counteract this risk, current practice is the performance of surveillance cultures on people who are admitted to intensive care. If the person tests positive for certain infections they are placed in isolation (and health care providers are asked to wear silly gowns and share a useless stethoscope).

The success of this strategy is dubious, ranging from successful in some studies to nearly useless in others. Based upon my personal observations of my own hospital’s isolation practices, my only conclusion has been that yellow is not a good look for me.

But I digress. In this study, patients underwent “universal decontamination” with chlorhexidine, a commonly used antiseptic. The study found a dramatic drop in the numbers of MRSA infections and bloodstream infections. The study was peer reviewed and published in the flagship of medical publishing, the New England Journal of Medicine (sorry JAMA). Continue reading “How a Journal Club and a Blog Challenged the Mighty NEJM”

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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.”

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“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.”

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Why Medical Education Should Embrace Social Media

Social Media and Medical Education: Access Denied.

-By Rebecca Hastings, D.O.

I have never been very computer or tech savvy.  I’m not up-to-date on the latest technology, but I do have a smart phone and a laptop which I use for their very basic purposes; and I do admit I have a Facebook account, mostly for keeping in touch with friends and family and, you know, the daily grind.  Up until recently, I had no idea how to “Tweet” or what Twitter was really all about.  A physician mentor of mine suggested that I start a Twitter account and take advantage of the vast amount of knowledge floating around in Twitter world.  I was hesitant at first since my free time is limited and I didn’t really need any additional distractions from my fellowship.  Plus, I definitely didn’t need to join another social media network to share pictures and read about everyone’s daily happenings.  But, I trust my mentor and appreciate his guidance, so I signed up.  And WOW!  Information overload at my fingertips!!  Within a few minutes, I became a “follower” of JAMA, Chest, Cleveland Clinic, Johns Hopkins, New England Journal of Medicine, the Annals of Internal Medicine and numerous other large medical journals and institutions.  Granted, I may have also become a “follower” of a couple fitness magazines and my beloved Kansas Jayhawks, but the majority of my Twitter thread consists of these professional organizations.  I had immediate access to hundreds of tweets from these prestigious institutions across the world.  These world-renowned entities were “tweeting” about medical information, both past and present.  They were sharing everything from major review articles to personal reflections and comic strips.  Not only were the major institutions sharing these, but other physicians were sharing their professional opinions and other articles that they found important and interesting.  By signing up for Twitter, I had opened my eyes to a whole new world of medical education.

At first, I mostly just browsed articles and topics that were posted.  But the more I read, the more I wanted to share.  I felt like others were helping me, so why not share the knowledge.   One afternoon, I sat down in the fellow call room on a break.  I had been browsing my Twitter feed on my phone and there were a couple of interesting articles and commentaries I wanted to read.  But low and behold, when signing in, a big red box comes across the screen stating “Access Denied.”  Ok, so I know Twitter is technically considered social media, but why can’t social media be used as an educational tool?  Large renowned institutions and organizations are tweeting valuable information pertaining to my livelihood and I can’t access it “on the job” where I’m supposed to be gaining an education. Continue reading “Why Medical Education Should Embrace Social Media”

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Should a Medical College Dean Take Money from Pharma?

One of the first posts I wrote here, was a about how pharmaceutical reps provide lunch for physicians while presenting information about a medication that they are promoting.  The post, and others like it, have generated visceral reactions on the part of the public. A similar article to the one that I wrote (also on kevinmd) prompted comments like “Get over yourself and buy your own lunch” and “I’m certainly glad that you are not my doctor”.

The opinions were so strong I was invited to speak on CNN about the topic. In particular, I was asked to speak about all the other extravagant things that physicians get from drug companies. I ultimately did not do the interview on account of me not having any experience with receiving any of the extravagant things they were talking about. It seemed to me that individual physicians receiving lunch was (excuse the pun) small potatoes compared to what happens behind closed doors in the halls of power. While upcoming rules will soon provide the public with a window into the value of goods provided to physicians by drug companies, they will provide little insight about where pharma has its greatest and most effective influence: behind the closed doors of those halls with thought leaders, opinion makers and legislators.

To that point, a story came to my attention recently that reminded me about that fact. The Dean of Weill Cornell Medical College, a prestigious and highly regarded medical school, has apparently kept close financial ties with industry, as reported in the the college’s newspaper.  The college’s Dean, a highly accomplished and awarded physician researcher, has retained positions with a major pharmaceutical company and a laboratory equipment company. In these roles last year she reportedly received about $260,000 from one of the companies and about $277,000 from the other last year. The Cornell Daily Sun also reports that she has apparently received millions of dollars in compensation from both companies over the years as well as more than a million dollars worth of shares and stock options in the companies. Continue reading “Should a Medical College Dean Take Money from Pharma?”

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Offer Hospice Patients a Smile.

Hospitals are busy places to work. The work is fast paced, and never seems to stop. For most physicians, the work ends when the work is done, or until you fall over, whichever comes first. So as a consultant, when I am seeing a patient wherein there is no longer anything that I am contributing to a patient’s care it’s routine that a physician would “sign off” the case, meaning I would not continue to see the patient on a daily basis but would be available if I were needed. Sure, I might have a good repoire with a patient, and some even tell me that I have a nice smile, but it hardly seems like a reason to continue to bill their insurance company without actually contributing any expertise. Despite how nice I think my smile is, I have yet to find an insurance company  willing to pay to see it.

It’s no surprise then, that in such a busy workplace the physicians-in-training that I regularly work with would want to sign off a case as soon as possible. Unlike most of their bosses, they get paid the same no matter how many patients they see. There’s no incentive for them to see more, and if they see too many, it becomes difficult to learn anything.

So for many specialists who round on patients in a hospital, and for physicians in training in particular, the typical approach to a patient who has enrolled in hospice or decided to otherwise stop all treatments other than comfort measures, is to sign off the case.

For those patients, the thought is, most of them are waiting to be discharged home or to another facility, and have accepted that the end of life is coming. In such situations families are typically grieving, making end of life arrangements or simply trying to spend as much time with their loved one as possible before the end comes. Why would it be necessary then for a specialist or a team of physicians to enter the room of such a person, ask a plethora of unnecessary questions, perform an exam and offer meaningless platitudes like “hang in there! you’re doing great!”?.  All this to a person whose one certainty is that they’re not doing great, and they’re most definitely not going to be able to “hang in there”!

Thus my approach has been to sign off such patients, and based on what I’ve seen, it’s the approach of most other physicians as well. I had always thought that ridding people of my pestering presence at the end of their lives was the most reasonable and humane thing I could do.

But things changed for me recently, when my own father entered hospice. He was in the hospital for a few weeks, and being a physician himself, he knew the end was coming. My mother, of course found it difficult to let go. After 50 years together, who could blame her? She agreed grudgingly to hospice, but needed constant reassurance that it was the right thing to do. I remember the constant look of consternation and worry etched on her face in the days after he was enrolled in hospice (but was still in the hospital). One by one, the physicians who had convinced her that there was nothing more to be done, disappeared. The physicians who reassured her that he would be well taken care of no longer visited, at just the time that she needed their reassurance more than ever. Her face wore a look that said, “Are we doing the right thing? Are they just trying to get rid of us?” Despite having a pulmonary, critical care physician for a son, there are some things you just need to hear from your doctors, the people who have been taking care of you, the professionals who know you.

Ultimately she came to accept the inevitable, she’s a strong person, and she knew she had no choice. He passed away peacefully.

But that experience taught me to change something in my own practice. I still round with my physicians-in-training, as I always have, we still sign off those patients who are going into hospice as we always have, so  the team does not needlessly pester a person at the end of their life. Instead, I walk into the room by myself, I perform no exam, I ask no medical questions. I offer them nothing but my smile. And it’s for free.

Related Articles: An “Untouchable” Who Touched the Lives of Many.   Code Status and Living Wills, and Why They Might Not Matter.

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Where Medical Reports Go to Die.

It happens thousands of times a day, all across the country. People go to their doctor’s office after some testing has been performed. The physician, unaware that any testing has been ordered by another physician, asks their usual questions. The patient, awaiting an opinion rendered on the recently performed test begins to answer the doctor’s questions with increasing impatience and trepidation, fearing the worst. “Why is he asking so many questions. . . why is he not telling me the results? Did my cholesterol panel show cancer?” And finally the question comes to the fore;

“ Doctor did you get my test results?”

“No, what test did you have”

“But I told them to send it to you!!” Continue reading “Where Medical Reports Go to Die.”

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Healthcare Armageddon 5: The Crux of the Problem

There’s a central theme running through many of these “Truth About Health Care” posts that I write. Whether it comes to medical centers putting out press releases that are nothing more than thinly veiled advertising, or drug companies trying to get physicians to write more prescriptions, it comes down to the fact that there’s a whole lot of competing interests out there trying to get a bigger slice of a shrinking money-pie. And the pie is about to shrink a whole lot faster. . . Continue reading “Healthcare Armageddon 5: The Crux of the Problem”