Archives for January 2009

Other signs the economy is sagging

I just answered the door to find a representative from a Big Name financial firm cold calling door-to-door to drum up business.  Wow.

DB’s Med Rants slurs EP’s

A doctor I used to think had it together shows himself to be yet another ED basher, and a rather arrogant one to boot.

In a blog post today Dr. Centor unloads egregious tripe on me and my colleagues:

The second major concern is over use of technology in the emergency department.  Ask any practicing physician about testing in the ED.  Patients have too many imaging studies.  I think we all understand why those studies are done, but a significant percentage are clearly unnecessary.

Now clearly, ER physicians have a high exposure to malpractice claims.  When in doubt, they image.  The emergency department is often overwhelmed with patients, so technology trumps the history and physical examination.  We need a multispecialty panel to develop reasonable standards for technology use in the ED.

In case you missed it I’ll rephrase: there are too many imaging tests in the ED because EP’s are too lazy or stupid to do a history and a physical exam, so we just CT everybody.  Additionally, EM isn’t an actual specialty, so other specialties need to meet and tell them what to do.

The contempt he (and apparently his friends) hold the ED in is inexplicable though sadly common.  I’d like to have him explain the patronizing ‘I think we all know why these studies are done’ that’s not doublespeak for ‘they aren’t as smart as we internists are’.

First the monetary rebuttal to this load: as of 2006, ED care was 3.5% of the total healthcare budget.  Squeeze out all the negative imaging studies and it’d be less, but getting a margin out of 3.5% to make a dent in total healthcare expenditures would be difficult to say the least.

EP’s image patients after a history, a physical examination, and in order to rule out life threats while still focusing on the most likely diagnosis.  The statement “when in doubt, they image” is both dismissively arrogant and ill informed.  Are there a large number of scans done in EDs?  Yes.  I’ve called Dr. Centor on this bias hobby horse of his before, but he doesn’t want to hear it.


As for needing ‘multispecialty panels to develop reasonable standards for imaging in the ED’, he’s ignoring two very important things.  First, EM is an actual specialty with its own standards and unique fund of knowledge, since 1979.  From ACEP:

In 1979 emergency medicine was recognized as the 23rd medical specialty, a major milestone for ACEP and its members. The American Board of Emergency Medicine, the independent certifying body for the specialty, was also established and the first certification exam was given in 1980.

Second, EP’s do the studies they do because they have a higher diagnostic yield in the shortest amount of time.  A urologist would prefer an IVP for that hematuria and flank pain, but the CT will pick up the renal artery dissection a lot better than the IVP ever will.  EM is past needing specialists telling us their worms’-eye-view imaging recommendations, thanks just the same. 


Dr. Centor’s proposals about the ED are unwarranted from an economic perspective and unfounded from the medical.  Let’s hope nobody offers him that Health Czar post, and that if there is such a person they focus on actual problems and not peeves. 

Doctor’s death ‘tremendous loss’ for UTHSC

Doctor’s death ‘tremendous loss’ for UTHSC
Dr. Michael Sanchez, who in a few months as director of University Hospital’s busy emergency department slashed waiting times and reduced the number of patients turned away because of overcrowding, was struck and killed while jogging Sunday afternoon.

His own emergency department colleagues tried to save Sanchez without recognizing him because of the extent of his injuries. Only after he was pronounced dead did they learn it was Sanchez, hospital staff said.

Horrible, for all concerned.  Sounds like a good ED administrator.

White Coat Rants joins EPMonthly

One of my favorite EM bloggers joins my favorite EP Newspaper:

To those of you who have followed me from my old blog … welcome back.

To everyone who has followed a link to this blog from EP Monthly … welcome.

I go by the pseudonym of WhiteCoat. I’m a practicing ED physician who has a blogging addiction. I started writing a blog called WhiteCoat Rants about a year and a half ago…WhiteCoat

Emergency Physicians Monthly and I decided to combine forces to bring our readers the best of EP Monthly’s written publication and a good look at the medical blogosphere. My old readers can check out all the great articles that EP Monthly has to offer and EP Monthly’s readers can put up with my ranting. Great deal, huh?

I certainly should be, and best of luck to both!  Now to update my links…

Cal Supremes Rule Balance Billing by Emergency Physicians Unconstitutional

All California EP’s now involuntary HMO contract signatories (LA Times):

Winding up in the emergency room is bad enough. But the California Supreme Court ruled Thursday that patients no longer have to worry about getting billed for emergency treatment charges that their HMOs fail to pay.

Health maintenance organizations and patient advocates hailed the decision as an important protection against gouging by hospitals and physicians. But doctors said it would encourage greedy HMOs to underpay them and that that could put emergency rooms in jeopardy.

The decision resolves one part of a contentious debate that has vexed courts, lawmakers and regulators for years. But it leaves open the question of what constitutes reasonable payment for emergency services. Regulations require HMOs to pay hospitals and physicians reasonable fees but do not set out specific amounts.

I’ve been following medical policy for a while, and fortunately HMO penetration of the market is pretty low where I practice.  For all the time I’ve been watching, I’ve never heard that HMO’s pay too much for anything; indeed, they drive a very hard bargain (they aren’t stupid, and they don’t like to part with money).

Because their hard bargains work against the interests of the docs (the ones providing medical care) many times docs would rather not sign a bad deal, and choose to a) bill for the value of their service, and b) put pressure on the HMO through the patient to bargain better.  I’m not in Cal, and don’t know the details of the negotiations they had recently, but apparently when no bargain was struck between the Cal docs and HMO’s under a legislatively-sponsored negotiation, that’s the pretext for this decision.

Docs can sue the HMO for the balance of the bill, which will never happen as the legal fees would vastly outstrip the balance of the individual bill (though I wonder about class-action in this case…I’m not a lawyer, can anyone fill me in?)

Another reason for docs not already practicing in Cal to choose somewhere else.

Update: Shadowfax weighs in, and points out that now insurers have no reason to negotiate with EP’s’ as there’s no leverage to bargain with.

Los Angeles Times: Passengers pounce on man who made threats aboard L.A.-bound flight

More confirmation that the rules have changed:

Los Angeles Times: Passengers pounce on man who made threats aboard L.A.-bound flight

“I thought this guy was going to open the door. I was thinking, ‘I’m not going to go down with the plane,’ ” said Llewellyn, 26, a 6-foot guitarist, who was flying into Los Angeles from Atlanta on Wednesday morning for a TV appearance with hip-hop artist Asher Roth.

Along with half a dozen other passengers, Llewellyn ran down the aisle into the galley area and jumped on the man, pulling him away from the door.

“He was struggling hard-core,” Llewellyn said. “I was holding down his arm. Somebody had a foot on his head. Everyone was holding down a different body part. He was going nuts. I was telling him to chill because he’s not going any place.”

The jet landed safely and no bomb was found. Still, local and federal authorities credited Llewellyn and the other good Samaritans with helping save the day.

The days of sit still and pray are over, they died on September 11th.  Now let’s hope he doesn’t get sued: he was being a Good Samaritan, after all, but wasn’t rendering medical aid.

Aggravated DocSurg: Why I fail at generating cash here…

Aggravated DocSurg: Why I fail at generating cash here…

Dang, I thought I was the only one getting these solicitations…

(For the record, I replied that I had a $10,000/day fee, paid thirty days in advance; didn’t get a reply).

Hot Air » Blog Archive » What you get with a nanny state: A large, powerful nanny

Hot Air » Blog Archive » What you get with a nanny state: A large, powerful nanny

Do you still think that diet and exercise choices are no one else’s business? Not when other people pay your medical bills. If I have to pay for my neighbor’s doctor bills, I’m going to demand that he stops smoking, stops eating pizza five nights a week, and starts getting some exercise. If necessary, I’ll find a way to make him stop.

America: Land of the Free Medicine and the Home of the Brave Nanny.  And before you think ‘nobody would do that’ go to a homeowners’ association meeting,  wonder at the level of concern about grass length and fence height, then consider how these same people will like your Krispy Kremes.

Grand Rounds for January 6th: Profit in medicine and other cool stuff! at

Grand Rounds for January 6th: Profit in medicine and other cool stuff! at

The most literary EM Blogger hosts Grand Rounds!

Better Health » What Does The Surgeon General Do?

Better Health » What Does The Surgeon General Do?

Dr. Val has a nice Q&A with Dr. Carmona (current Surgeon General) about what the office actually does.

Way to go Dr. Val!

Self Magazine Bleg…

From a reader, and a folowing question:

Hi GruntDoc,

At the gym last night I came upon a relatively recent issue of Self
Magazine (the womens’ fitness mag) in which you and KevinMD were cited as
blogs for health-conscious women to read. I had to chuckle a little because
I doubt this mag would be your targeted reader. I wish I had stolen it to
tell you what issue and page but the brawny trainer had the stink eye on me.
I think it was Dec or Jan. check it out!!

So, anyone have a copy of the article in Self Magazine about medical bloggers? It’s not one of my regular reads…

AMNews: Jan. 5, 2009. Supreme Court asked to examine Texas peer review case … American Medical News

AMNews: Jan. 5, 2009. Supreme Court asked to examine Texas peer review case … American Medical News
The U.S. Supreme Court could be the next stop for a lawsuit that peer reviewers have followed closely. A Dallas cardiologist is asking the high court, which only takes up a small number of cases it is requested to consider each year, to review his lawsuit claiming unlawful peer review.

The case has led physicians serving on peer review panels and hospital officials to worry that peer review immunity could be eroded. And it has given physicians who believe they were improperly peer reviewed hope for retribution.

Interesting.  I only know of peer-review inside my own division, and don’t know anything about this case other than what’s in the news.  I can understand a need for checks and balances in any system, but wonder if tearing peer review apart is the right answer.

Updated: I should clarify the basic problem with peer review, and what’s at stake.

Peer review is meant to be just that, a review of a doctors’ work viewed through the eyes of their peers, i.e., docs who do the same work.  Ideally, they’re the perfect people to throw the flag when there’s a foul, and as far as I know (and, lawyers, that’s all I know) it works like it’s supposed to.

Nearly without exception those subjected to discipline will complain of personality conflict, or business conflict, and there’s the rub: determining whose complaint about their discipline is meritorius and those who are covering their troubles with obfuscation.  It doesn’t help that peers who do the review in the non-hospital based disciplines are nominally colleagues but are also competitors with egos and agendas.  It is a given that those ase motives are left at the closed door of peer review, but there’s always going to be friction over an adverse decision.

I’d like to point out here that just because peer review is unhappy with someone doesn’t automatically result in adverse action, there’s usually the hospital Medical Board or Credentials Committee that has to actually impose a discipine, so there is some outside oversight (which relies on the peer review for the nuance of whether care was appropriate for their discipline).  If this sounds incestuous it’s not supposed to, nor is it supposed to be in practice.

Again, all I know of this case is what I’ve read in the papers, and so far (knock wood) I haven’t fallen afoul of a peer review action, but I (and everyone else in my position) has recourse in the event of an adverse review.

So, again I hope peer review is left intact as a tool for self-policing.

Michael Yon – Online Magazine – Bullies

Michael Yon – Online Magazine: Border Bullies

Empowered bureaucratic bullies. We can, and certainly should, do better.


Why does this bathroom always smell funny?



richard[WINTERS]md: Seductive Detail

richard[WINTERS]md: Seductive Detail

Wow.  A new year brings a new post.  Could this be a trend?

Revived from the Dead.  For now.