Archives for July 2009

Dr. Wes: PI

Dr. Wes: The Careful Exam


Captain Atopic : Degranulated: Grand Rounds 5:45

Captain Atopic : Degranulated: Grand Rounds

Skinny tire themed.

Dalrymple: There Is No ‘Right’ to Health Care –

Dalrymple: There Is No ‘Right’ to Health Care –

If there is a right to health care, someone has the duty to provide it. Inevitably, that “someone” is the government. Concrete benefits in pursuance of abstract rights, however, can be provided by the government only by constant coercion.

You don’t say.

Salaried docs vs. fee for service

The Happy Hospitalist, generally an excellent blogger, wrote yesterday about how salaried docs must be delivering better care than those greedy FFS docs, because the Cleveland Clinic does a terrific job with docs on a salary.  I suspect their excellent outcomes have nothing to do with reimbursement model and a lot more to do with systemness and a strong gatekeeper model.

He totally missed the elephant in the room in the Big Group Clinic model: who gets the money for doing the work.

He cites as an example a GI doc who left the Clinic for independent practice and quadrupled his income.  Let’s say he’s working as hard as he did in the Clinic; is he billing more than the Clinic did?  I doubt the Clinic wasn’t billing the usual amount for the work, so 3/4 of this docs’ billing went where?

I suspect it went into the overhead of the Clinic.  This isn’t a knock on them, it works for their group, so fine.  Other groups do essentially the same thing.  It’s legal and morally defensible, and some docs don’t mind being salaried.

Salaried docs in a big Multispecialty Clinic have different incomes, but not as radically disparate as the non-clinic model.  As a way to somewhat equalize RVRBS issues it works (I wouldn’t want to be in the room when salaries come up, though).

What salaries do not do is get docs to work harder, see more patients.  Some docs are very dedicated, motivated people who would work for rent and grocery money.  Others on a salary would do the minimum: if every patient is more work and more liability without more pay, well, why work more/harder?  As an incentive to produce nothing beats getting paid for it.

(This isn’t an endorsement of excessive or un-necessary procedures; there are greedy jerks in all professions).

Also, a happy side effect of getting paid for what you do rather than for having a pulse is those who work hard resent those that don’t (but who would make the same on salary) a whole lot less.  Way less inter-group stress.

Salaries aren’t all bad, but they’re not the Key to Great Healthcare.

Discolsure: I’ve worked ED’s both ways, and much prefer fee for service.

Dallas-Fort Worth hospitals turn to social networking sites to educate, market services | Top Stories |

Dallas-Fort Worth hospitals turn to social networking sites to educate, market services | Top Stories |

In the last year, a growing number of hospitals have discovered social media and they’re using it to educate the public, market their services and address health issues.

“It’s not about seeing how many Facebook friends we can make or how many Twitter followers we can get,” said Tim Hanners, senior vice president of corporate and community affairs for Cook Children’s Medical Center. “It’s a communication tool.”

I’m quoted in this article as well.  I do want to point out that the Twitter-enabled surgery was in Africa (and covered widely then, about 4 months ago), and was NOT at my hospital.

Same article cross-posted in the Houston Chronicle!  HT Dr. Bates

EMR / Labs call for input

Okay folks, I’m going to call on your wisdom and ask that you help me improve our EMR.

I noticed right after our EMR started, with Rh testing: I would look in past labs to see if my patient (pregnant with vaginal bleeding) had a documented Rh.  Yes, it turns out, many had had more than 5 (even when positive), because we had no way to access those prior tests.  Now we do, with the EMR.

I want to take this a step further, and make a list of tests we can start ‘flagging’ that don’t need to be repeated because some things don’t change.  No sense doing the same thing over and over if the result’s going to be the same.

Here’s my first pass:

  • Rh (if positive)
  • G6PD
  • HIV (if positive)
  • Sickle Cell screens
  • All those heritable clotting disease tests (Factor V Leiden, Protein C, Protein S, etc).

I wouldn’t restrict anyone’s’ ability to re-order (confirmatory test) but would have the prior result pop up in the ordering box for that test.  Usually these are re-ordered in ignorance that it was done before.

Here’s a place an EMR can actually contribute to cost savings!

Please put your recommendations for other tests that don’t need repeating in the comments.  I’ll make a compilation post when other recommendations peter out.

Health Care Rx: The Short Answer Is No – Colleen Conway-Welch

Health Care Rx: The Short Answer Is No – Colleen Conway-Welch
The Short Answer Is No

The short answer is no, not until transformational change occurs in the infrastructure of health care delivery. The system today is so broken that, if the infrastructure is fixed and incentives re-aligned, we could deliver twice the health care to twice the people at half the cost but we won’t achieve this by simply throwing money at it.

Fix healthcare?  Yes!  The author has some good ideas.  Let’s start here, then see where we need to go.

I am back from vacation

So, what did I miss the last six days?

RealClearPolitics – Socialized Medicine? Bring It On

Sometimes you can see the trees, and think it’s a forest:

RealClearPolitics – Socialized Medicine? Bring It On

In the last two months, I have spent many hours accompanying a loved one to hospital emergency rooms — all of them privately operated. The rap on what is sometimes called socialized medicine is that if the government ran the system, the wait would be interminable. Well, I am here to tell you that even when the government does not run the system, the wait can be interminable.

This presumes that a “Privately Operated” ED isn’t essentially a government operation.

That presumption is incorrect.  The future of Government Medicine is presaged with EMTALA, and the ED.  No market, no choices -> your local ED.  No competition beyond billboards and ‘customer satisfaction surveys’.

I’m not making light of their very average care, and I’m sorry about it, but the  entirely unsupportable claim that ED care inside a pure government monopoly is evidence that we need to send all medicine off the cliff is a) silly and b) totally unsupported by current data.

“I had some average care, so let’s socialize medicine”.  Umm, no.

On vacation

On Vacation


From my 2003 vacation…

MedBlogs Grand Rounds 5:43

Medicine and Technology by Dr. Joseph Kim [part of the HCPLive Network]: Grand Rounds July 14, 2009: Technology and Healthcare

Looks very good.

I’ve been remiss in posting Grand Rounds links, partly because that’s all this blog was for a while (and it’d be impolite for you to point out what it is now).

I’ll do better.

Go, read.

Another Horrible ED Sign

The patient with a Loving Family, a Job, Good Insurance and an abnormal test.  Terrible.

When they come in, with their abnormal test (a sono in this case) from an outside place, from a doctor who sends them to your ED with ‘you need more tests’, it’s hard to keep the stiff upper lip.  The family, well dressed and pleasant, just make it worse.  I know what’s coming.  I’d encourage them to run for the door, if I thought it’d help.

The sono usually says “…blah blah blah mass in the blah blahfurther imaging is recommendedblah“.

While this usually isn’t a true emergency, let’s face it: the patient deserves an answer and their doctor has given up (or in) and has sent them to me.  (And it’s not like I don’t know how to order CT’s, I do).

While waiting for the CT you imagine it’s all going to be nothing, unlike the ones before.  Very very occasionally it’s good news, and relief all around.

The vast majority of the time that CT has been utterly horrible news for everyone involved.  There are tears, and referrals, and ‘…I don’t know for certain, you need a biopsy, because diagnosis leads to prognosis…’ and I feel rotten for about a week.  Unlike the family, for whom I’ve just unmasked Death, who get to have him as a constant companion.

I don’t know if it’s because they seem so normal, or I see myself in everyone in the room, or guilt.  Dunno.  But it’s horrible.

‘City of Fort Worth’ debuts at Pima

From the Star Telegram:

Star-Telegram.comThe final B-36 Peacemaker off the assembly line in west Fort Worth hadn’t been seen in public since an overland trip from Fort Worth to Tucson, Ariz., in 2005.

Now the 10-engine, nuclear-capable Cold War bomber has been rolled out at the Pima Air & Space Museum after exhaustive restoration.

Nice picture of the refurbished aircraft in the article.

It was embarrassing Fort Worth couldn’t take care of its namesake, but it’s terrific the aircraft historians at the Pima Museum have given her the home she needed.


Older posts here on this topic:

B-36 Museum in Fort Worth

A Homeless Veteran of the Cold War

The City of Fort Worth moves to Arizona

So, my bad habit is decreasing my pain!

From Scientific American

Why the #$%! Do We Swear? For Pain Relief

Dropping the F-bomb or other expletives may not only be an expression of agony, but also a means to alleviate it

Bad language could be good for you, a new study shows. For the first time, psychologists have found that swearing may serve an important function in relieving pain.

I knew the sailor words were useful…

Don’t tick off people with talent

United is wishing they’d thought of that…