Wow. Very nice rant from Graham. Another ED basher gets is head handed to him.
AMNews: Sept. 21, 2009. Should you keep patients from commenting online? … American Medical News
What do physicians have in common with restaurants, dry cleaners and plumbers? All are being critiqued online by the public.
Is there anything you can do about it? Yes. Have your patients sign a contract promising not to talk about you online.
First, this sort of thing just feeds the idea that docs are out of touch at best. (The people who would sign this are the kind who wouldn’t even think about it anyway, or are willing to lie to get the medical care they came for). Really, this is as stupid as a Loyalty Oath.
Second, if I’m a patient and my doc handed me one of these, I’d laugh and walk out. I hope you will, too.
Please don’t tow it. (What follows is just stream of consciousness crud to see if I remember how to type. It’s not interesting. Go read Kevin, or Rob, or Kim).
Yes, I’m in quite the slump. I’ve had several terrifically interesting, challenging cases recently, but they’re “So interesting” I cannot blog about them. I cannot figure out a way to anonymize them to my satisfaction.
(I know my blogs’ in a slump, as today I only had one comment-spam attempt. When even the spammers give up, you know it’s bad).
The irony is that I’m going to BlogWorld (where bloggers will congregate) and I’m in the worst blog-slump I’ve had. And blogging about blogging is fully as interesting as this post. You see my predicament.
As an aside, by youngest child, just left for college, texted me last night she was disappointed that I hadn’t done a blog post about her birthday, which was earlier this month. It was a conscious decision, as just because I have a blog I try not to use my family for filler (unless they agree in advance). So, nice to know she wouldn’t have minded much.
I’m having an interesting adjustment to the Empty Nest. It’s only been a few weeks, but with just the two of us we’ve discovered how quiet the house really is (and that the cat squeaks when she walks. Seriously). So, I’m in an adjustment period, and this too shall pass.
Alert on Doctors’ Abuse of Propofol, Drug Suspected in Michael Jackson’s Death – WSJ.com
Abuse of the sedative suspected in Michael Jackson’s death is a growing problem among medical professionals, increasing pressure on the government to restrict it as a controlled substance.
So, doctors (a very very few) abuse this drug, so the answer is to…restrict its prescribing to doctors.
One way universal coverage can save costs | DB’s Medical Rants
An ER physician justifies an admission for expediency. This patient needed an outpatient evaluation, but our dysfunctional health care “system” make him consider inpatient evaluation the best option.
So this patient spent 3 days in the hospital, at an outrageous cost, to obtain the evaluation. Of course the ER physician justifies the admission.
I know nothing of this particular case, but I’ve been in the same situation: a patient who needs an eval by a good internist, or a specialist, but it’s the patient has no insurance/it’s a long holiday and the patient cannot wait/the patient is unlikely to follow up as an outpatient/ it takes little imagination to understand why this is occasionally done. So, we get the patient admitted, usually to an overworked hospitalist who nonetheless understands the patients’ plight and admits them.
That’s right: it’s not the ER doc who admits patients. It takes two to tango, and to admit. The admission Dr. Centor is raving about here was done NOT by an EM physician, but an internist. All any ER doc can do is plead their patients’ case, but it’s the internist who makes the decision. Sounds like some displacement…
“Expediency”. One persons’ expedience is anothers’ outstanding, expedited care. Just because it’s inconvenient for Internal Medicne doesn’t make an admission wrong. That the system is screwed up and costs several fortunes isn’t the fault of ER docs.
As there is a shortage of primary care docs in this country, his last paragraph (go read the rest) fails to impress. We could go Single Payor/Universal care tomorrow and there would still be a primary care shortage for a decade, and that’s assuming primary care gets paid like they should.
DB is a very good blogger, and a terrible Emergency Medicine bigot. Too bad, he’s missing out on the most interesting group of docs, personal and professional, ever.
My first thought: I’m willing to bet drugs (legal, clean, prescribed by a doctor) were involved, and that a review of the records will show some questionable prescribing. First Do No Harm, unless it’s a celebrity? Why are docs willing to engage in this kind of horrible, destructive prescribing? It’s reprehensible.
If it is doc-assisted, please relieve society of this doc’s license.
Anna Nicole Smith, anyone? Elvis? A string in between? This doc-assisted destruction has to stop.
(All of this presumes the most likely, a doc involved; if not, Mea Culpa). Oh, and Matt wants me to say: no actual individual doc, living or dead, is implied in this post.
Second: somewhere in Beverly Hills there’s a Plastic Surgery group applying for TARP funds.
Dr. Val does a nice Fisk! Yes, docs make a decently good living. No, it’s not why the health care system is in trouble.
Dr. Wes: An Open Letter To Patients Regarding Health Reform
Dear Mr. and Ms. Patient,
It has come to my attention that in order for your to enjoy success as patients in the new era of health care reform, you must start working now to prevent illnesses that might befall you. Do not, under any circumstances, eat or drink too much.
A nice rant in favor of all of us doing something. The Devil remains the Details….
Nice rant. This talk of socializing healthcare really is bringing us all together, isn’t it?
I have learned the Western Way of politeness: when meeting a stranger look them in the eye and give a firm handshake. I do this quite a lot in this ‘patient satisfaction’ world, shaking the hands of not just the patients but also their families. (And sometimes you’d think I’d learn).
I’m wondering if we need some sort of socially acceptable way to say ‘I’d shake your hand but given that this is a hospital where illness concentrates, let’s not’. Seems like a good tradeoff from a risk-benefit standpoint.
Yes, I use the alcohol-based foam gels between patients, and when I pass a dispenser, and when I think about it. I’m pretty obsessive about it. I’m not advocating not touching patients appropriately, just seems like something we should be able to change.
I’ve never cooked lobsters but was reminded of the trick to the recipe today: if you try to put lobsters into boiling water you’ll have a big fight and it won’t go well, but put them in cool water and slowly turn up the heat, by the time they realize there’s a problem they’re cooked.
I thought about this while turning sideways between gurneys in the hall to get through to the next patient of many.
The temperature in my ED continues to climb, but I’ve been here so long it just seems like it’s getting a little warm.
ED’s everywhere have rising census, increasing demands, physical plants that aren’t keeping up with the crush.
Coal mines have canaries. Medicine has lobsters.
It’s getting warm, but there’s plenty of time.
Texas College of Emergency Physicians has a new website, it’s good looking and easy to navigate.
They sent me a temporary login and temp password, so I went to fill in the information. I didn’t finish. Way too many ‘required’ fields in their registration section. It’s really none of their business what hospital I’m practicing at, but I’d have to fill all of that in, with phone numbers and zip codes, to be an online member.
Here’s a .pdf file of the statement, signed by the President of the AMA and several professional organizations and specialty boards.
It is well written and well intentioned. It’s also just filled with the gobbledygook that comes from big groups that don’t get the problem. It’s ideal from a big-group perspective, in that all but one or two of the goals is already underway, and the hardest one isn’t under their control (interoperable EMR’s).
As the letter is 3 1/2 pages long I could spend a lot of time analyzing every aspect (several of which I agree with), but I’m going to focus on the thing that jumped out at me.
…We are committed to creating a cultural transformation that better supports delivery of the highest quality care for individual patients and communities and which, among other strategies, will allow for a more appropriate allocation of finite resources. These two elements are extremely important, and we hold ourselves accountable to achieve them.
Buzz-words: “cultural transformation” and “appropriate allocation of finite resources” are the two that make me cringe, but feel free to find your own. What does ‘cultural transformation’ even mean? There’s no vision for changing any culture in the document (it’s a nice list of goals to increase efficiency, but that’s not a ‘cultural transformation’). It talks about being patient centered then talks about all the things medicine needs to do, and nothing about the patient. It’s patently dumb to continue to see the self-contradictory statements ‘highest quality care for the individual’ and ‘appropriate allocation of finite resources’ jammed together unironically. As a physician my duty is to my patient, not some theoretical need of another patient or patients with the same or different concerns. The idea individual docs will act paternalistically about the husbanding of resources while engaging in a true beneficent relationship with their patient makes no sense (thanks, mandatory ethics class).
You know what would be a cultural transformation? Cost transparency in medicine, linked to patients spending their own money on their care*. It’s irrelevant what an MRI costs if you’re not paying for it directly. Think there wouldn’t be some competition in the marketplace then? Of course, to do that you’d have to get the government and insurance companies out of the way, let doctor groups negotiate just like every other industry, etc. There’s a culture change.
Free=more. There is no Nirvana where people get everything they want for free that doesn’t cause shortages and skyrocketing costs. There has to be some moderator on the continuous and enormous increase in healthcare spending, a point everyone agrees on. In the current model prices are invisible, payment is unfathomably byzantine and not borne directly by the patient (unless you’re uncovered, then you’re really in a tough spot), so there’s little reason not to get another MRI, CT ‘just to be sure’, etc. Prices spiral.
So, give us a market, get Uncle out of the way (mostly), and let people decide on their care based on a true cost/benefit ratio. There’s a real cultural transformation.
* Yes, I am aware most people with health insurance pay through payroll deductions, and it can be a very very big number; yes, you are paying for your care but in a very inefficient way, paying monthly and probably not using care monthly. Additionally, what you’re paying usually isn’t the entire cost your employer pays.
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.