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Sunday, November 30, 2008


Post  tryptophane tremors

Why are there  not enough

Primary Careologists?

This sounds very familiar. The problem with medical school begins in the first year. Most of the two preclinical years have little to do with practicing medicine. Those trained in some basic science in the last several years of college realize very quickly that medicine has little to do with science or curiosity about science and/or health. It is more like elementary school for doctors…just like you learned reading, writing and rythmatic to prepare you for middle school, and high school to learn trig, algebra and calculus. What you learn during those first two years is nomenclature, and linguisitics…much like any vocation which has specific terms. Lawyers learn how to speak ‘lawyerese’, computer scientists learn ‘geekology’. These first two years expand your vocabulary, which few other people can or will understand.

The second two years of medical school expose medical students to some clinical work, which they will perform only if the intern and resident are overwhelmed with their duties, don't want to be bothered, since they consider it 'scut work'. If the clinical material is scarce it will be monopolized by the intern/resident. Actually the medical student rotation may bear little resemblance to the actual clinical work that a mature physician will do in his practice. Ordinary medical stuff is usually lacking in a university or tertiary medical center where formal training takes place.

So what actually occurs is that each medical student must make a choice of what he will do with very little chance to experience a specialty or general practice prior to having to select a specialty or match for postgraduate training. In addition to this major shortcoming, the free standing postgraduate year of what used to be called internship is now called pgy 0, or 1, whatever the term is these days. This is also another reason why PCP, or primary care providers are so rare. (this used to be called general practice or family practice for you really young guys.) Many young doctors used to take an internship, then go out and practice general medicine for a few years to get a real taste of what they like or don’t like about each brand of medicine. Yes, Johnny it is possible to do this, and quite safely if apprenticed with an older physician. I did it in the U.S. Navy aboard a floating naval ship LPD-10  in the middle of a war.

Primary Care Can  Be Fun


The Well  Deck (partially submerged) on LPD 10 

U.S.S. JUNEAU (L)    SUPPLY SHIP (R) underway refueling, and  transfer of doctor as well.  (not for the squeamish)..the cable goes up and down about 50 feet as the ships ride the waves.


I was able to do so because of my strong general medicine training in med school and INTERNSHIP. This is because the internship required and demanded competency in general medical,pediatric, surgical and OB/GYN.( I and my classmates delivered over 100 babies during our senior year of med school. Those who had OB in their third year also did the same.) After the navy experience I chose to do general medicine and even became medical director of an emergency department…. It was 6 years before I specialized, some by choice and others by necessity.

Early on I was not sure what I liked or disliked. The clinical part of medicine bears little if any relationship to the science of what you study in the first two years of medical school. You may love endocrinology, or cardiac physiology, but find the clinical aspects of gyn, proctology, or cardiac resuscitation, or surgery revolting. You may like ENT but the thought of treating nosebleeds at 2AM a turn off.

The bread and butter of medicine has little to do with what you see or do at University Tertiary Medical School.

And you are being trained by a guy with one more year of training than you have experienced. Not only that, but he or she will be ranking you, in many cases. Those ‘professors’ who run the department are off giving lectures, writing speeches, or patting some other professor from eithr your institution or another one, on the back.

Being on call every other night, or dealing with very sick patients has little resemblance in internship to practicing general medicine, pediatrics, or other specialties. The journey through med school and internship may be more a journey of avoidance rather than seeking fulfillment.

Sometimes doctors near or at the end of their formal training are uncomfortable entering the ‘real world’. Some chose to go on because of this and subspecialize, some even do multiple fellowships, in neurology, ophthalmology, oculoplastic surgery or other areas.

Some even decide to avoid ‘real medicine’ by becoming academicians. (which is another whole story on dysfunctional adult behavior)

When you reach the pinnacle of success in your own practice and look outward at your colleagues you will find clusters of physicians in a group who trained at one particular institution or another…the Harvard guys, the Yale guys, the UCLA guys…

all self selected into their own tier. My experience is that they are neither smarter or dumber that the rest. Only some patients think that is really important. I often times would have to ‘bail them out or show them some ‘ordinary thing’ that they never saw at the IVORY tower university. Perhaps they saw 100 cases of Sarcoid or Wegener’s granulomatosis, but never managed an Alzheimer patient, or chronic congestive heart failure,nor managed a new diabetic that was not in severe ketoacidosis

And finally our realm of medicine has been invaded by nurse practitioners, physician assistants, retail health clinics, and more.........Why go to school to study over 15 years to do a job that a nurse can be trained to do.  No, the won't have the depth of knowledge or experience....but the insurers, and payors could care less.  The only ones hassled for credentials are the MDs and specialists.....

Most young doctors don't realize that 90% of what they will  do is in an outpatient setting, so who really needs a hospital unless your insurer requires it, and then you can find either a hospitalist or specialist to do all the hospital or paperwork...

Friday, November 28, 2008

Health and Human Services

Quackbooster nominated for HHS Secretary.

Cabinet Secretarys seem to play musical chairs and/or musical titles.  HHS Secretary Mike Leavitt was formerly head of the EPA.

from  Quackwatch:

Tom Daschle, who is President-Elect Barack Obama's nominee for Secretary of Health and Human Services, provided strong support to unscientific practitioners while serving in the U.S. Congress from 1979-2003.

Daschle has not made intentions clear as to whether or not he will run again for office; however, he  signed on as a Senior Policy Advisor with the K Street law firm Alston & Bird.[15][16] Health care interests, including CVS Caremark, the National Association for Home Care and Hospice, Abbott Laboratories and HealthSouth, are among the firm's lobbying clients.[4] The firm was paid $5.8 million between January and September 2008 to represent companies and associations before Congress and the executive branch, with 60 percent of that money coming from the health industry 

from Wikipedia:

Daschle was first author on a book concerning health care coverage which was published on February 19, 2008, titled "Critical: What We Can Do About the Health-Care Crisis". One review stated "Daschle's book delineates the weaknesses of previous attempts at national health coverage, outlines the complex economic factors and medical issues affecting coverage and sets forth plans for change."[22]

You may recall that Daschle failed to be re-elected to his senate seat. He also, in June 2008 lost the democratic primary in South Dakota. 

From Quackwatch, a web site dedicated to exposing Medical Quackery,

During several sessions, he was a prime supporter of "access to treatment" legislation intended to weaken state licensing boards. A 1997 version, for example, would have given individuals the right to have nearly any desired treatment and permitted practitioners to provide any treatment that would not pose an "unreasonable risk." 

Although couched as efforts to preserve patient freedom, such bills would thwart regulation of physicians who engage in quack practices such as chelation therapy.

Tom Daschle has been a fervent supporter of Barak Obama during his presidential campaign.  It is not his commitment toward improving health care in America, but a 'political appointment as payback for supporting newly elected Barak Obama.

I hope that the AMA and all specialty societies have pounced on their lobbyists, congressional committees and sends out an email to all members to write their congressman to oppose this nomination and not confirm  his nomination. 

Thursday, November 27, 2008

World AIDs Day

Logo of World AIDS Day

December 1st next week marks another annual event.

HIV/AIDS awareness day, presents an opportunity to educate, promote testing,and obtain posters, marketing materials and plan an event for your area.

The web site asks bloggers to participate in a  number of ways.


There are many ways.

Take Action

There are many ways you can take action in response to HIV/AIDS:

  • get tested for HIV
  • practice safe methods to prevent HIV
  • decide not to engage in high risk behaviors
  • talk about HIV prevention with family, friends, and colleagues
  • provide support to people living with HIV/AIDS
  • get involved with or host an event for World AIDS Day in your community Tags: ,,

Wednesday, November 26, 2008

Engage with Grace


Again, re-posted from November 2008


This weekend there is a 'BLOG RALLY' taking place. Matthew Holt of The Health Care Blog promoting  Engage with Grace.

The blog link contains video and text regarding this worthwhile viral marketing message regarding end of life care.

One of the issues regarding the escalation of health care costs is the magnitude of expenses during the last one or two years of life.

Engage with Grace addresses this issue and calls  for promoting the message.

HealthCare in America, written by Kenneth Fisher,   M.D.  also the author of  " In Defiance of Death" (available at Amazon) closely mirrors what Engage with Grace is all about.

Dr. Fisher is featured on "Monday Night Live" sponsored by Kalamazoo Community Access TV.

Tuesday, November 25, 2008


Quote of the day:

I have been through some terrible things in my life, some of which actually happened. - Mark Twain


Are you examining and possibly treating  a cyberchondriac


Perhaps our review of symptoms should now include a new category under mental health. An important question may be 'how many hours a week do you spend searching the internet?'

As reported in the New York Times,

"If that headache plaguing you this morning led you first to a Web search and then to the conclusion that you must have a brain tumor, you may instead be suffering from cyberchondria

A recent research report completed by Microsoft (those folks who now bring us "Health Vault" reveals the nature of web searches in the are of health and medicine.  The article written by Ryen White and Eric Horvitz .

The authors posit,   "This information can assist people who are not healthcare professionals to better understand health and disease, and to provide them with feasible explanations for symptoms. However, the Web has the potential to increase the anxieties of people who have little or no medical training, especially when Web search is employed as a diagnostic procedure. . . . Our results show that Web search engines have the potential to escalate medical concerns. . . . We also demonstrate the persistence of post-session anxiety following escalations.....Our findings underscore the potential costs and challenges of cyberchondria."

The search cohort was highly biased because the participants all worked for Microsoft, a group most likely more knowledgable and with access to internet search engines on a daily basis.

And so my fellow bloggers, Val Jones, Edwin Leap, Emergiblog, Rural Doctoring, Suture for a Living, and the Happy Hospitalist, add this to your diagnostic acumen.

The question for us, is 'does this drive up the cost of healthcare?"

Wait one,  I am going to run a "google' on that....



Sunday, November 23, 2008


Whoops! In the last post I credited Dr Rowsey as the 'inventor of lasik'.  I was mistaken.  However, he is a certified VIS-X instructor. A change has been made in the original aticle.

Friday, November 21, 2008

Health Train at The Mission Inn

I spent the afternoon yesterday with my former classmate who has had an illustrious career in Ophthalmology.

John James Rowsey MD, a corneal specialist, and former Chairman of the Department f Ophthalmology at University of South Florida  travelled to California from Florida to ask how to get  physicians involved and become stakeholders in health care reform.

ideaman_DV_20081114084847.jpg  Idea Man

  I am not sure I gave him an adequate answer while we were enjoying a fabulous brunch at a National Historic Landmark,

The Mission Inn Hotel & Spa

The Mission Inn in Riverside, CA.


I could not immediately crystallize my thoughts , but this morning I have a long laundry list of ideas.

Jim works for and with Senator Tom Coburn (Oklahoma) travelling each month to a different state to present details of bills pending in congress regarding health care reform.  On this trip he spoke to the Los Angeles County Medical Association and the Orange County Medical Association.

How to become a stakeholder in healthcare reform?

1. Contrary to popular opinion and recomendations by our illustrious professional societies, group lobbying is now stigmatized by 'earmarks'  and 'buying votes'. The addition of individualized advising is even more effective.  If you want to slow down or defeat a purpose, give it to a committee and medical organizations who will surely discuss it to death, and by the time it is presented the advice will be moderated, fuzzy, and  not have it's original message or intent.  A LONE VOICE IS EASILY HEARD IN THE WILDERNESS OF CHAOS AND CONFUSION

2. Knowledge is Power

a.You would not attempt to do a new procedure without careful study and skills.  So too is advising congressional, and state elected officials. 

b. Develop a solid knowledge base about issues, and background history.  There are many sources on the internet by experts in health care policy reform.


Power Players  Senator Henry Waxman, Tom Daschle,

SematorsTed Kennedy and Hillary Clinton 

Senator Tom Coburn,  Max Baucus


Experts: Stuart M. Butler, PhD     Edmund F.Haisimair,

Robert E. Moffit Ph.D.,   Dennis G. Smith,  

Nina OwcharenkoJoseph AntosScott Gottlieb, M.D.,  Aparna Mathur, Brian Klepper, David KibbeSarah Arnquist

Resources:  The Heritage Foundation,

Center for Healthcare Transformation,  Robert Wood Johnson Foundation

Books:  Google Books

Blogs:  The Baucus PlanHealth Care & Communications BlogHealth Train Express

Wall Street Journal HealthBlog,  The HealthCare Blog, Richard Reece MD at Medinnovation (he has written ten books on health care reform, the latest ones, being:  Voices of Health Reform, Naviagating the Maze of Health Coverage and Accessm, and Innovation Driven Health Care.

In the interest of limited space I have had to leave out many other experts.

3. Avoid being driven by financial concerns.

The financial concerns should be addressed  in the context of patient care, patient access, outcomes, and quality of health care.

4. Patient (Consumer) Involvement 

Print and place in your waiting areas one page 'shout out' topics on healthcare reform. Place a highly visible poster alerting your patients to this information. Have a topic of the month.  If your clinic or office has a monthly newsletter, devote a section to health care reform issues.


This approach worked very well from the 'come from behind' politicians who wound up being the front runners in the final election. (McCain and Obama)

It also may serve healthcare reform issues as well.  Sponsors can include  chambers of commerce, Lions Clubs, Kiwanis, Public Libraries,  and other community service organizations, as well as senior service centers.

Seizing on the momentum of the presidential election and the promise of change on a historic scale, a grassroots "conversation" about health care reform under the Obama administration began Thursday with town hall meetings around the nation, including several in the Bay Area.

Participate in SERMO and/or iMedexchange, both social media networking sites. SERMO has a section on politics and health reform.

  1. There is more, much more, however this will give you a starting point.

Thursday, November 20, 2008

Health Train Daschle

What's your take on this new announcement today regarding Tom Daschle's most likely nomination to replace Mike Leavitt as head of HHS.?

What is the connection here? What does Tom Daschle really know about health care? We could at least say that Mike is a physician, MD.

Mr Daschle recently published a book "

Critical: What We Can Do About the Health-Care Crisis


Since 2007, Daschle has been an advisor to the law firm of Alston & Bird LLP. Although Daschle is not a registered lobbyist, his firm was paid $5.8 million between January and September to represent companies and associations before Congress and the executive branch, with 60% of that money coming from the health industry.  I didn't see any physician representation in the list of associations he represented in D.C.

Another familiar name that signed on with Alston & Bird after he left Bush's administration is Tom Scully, aslo a former head of CMS.


Health IT insiders say they support President-elect Barack Obama's reported pick of former Sen. Tom Daschle (D-S.D.) to be the next HHS secretary, Healthcare IT News reports.

The Obama transition team has not yet formally announced the nomination, but sources are confirming that Daschle has accepted the position.

Sources also report that Daschle will serve as the top health care adviser, or health care czar, to the Obama White House, Healthcare IT News reports.

John Halamka, CIO of Beth Israel Deaconess Medical Center in Boston,

said Daschle has "a deep understanding of the need to increase the value of health care in this country by reducing costs and enhancing quality."

Former Speaker of the House Newt Gingrich (R-Ga.) said, "Sen. Daschle has long been committed to reforming health care so that all Americans get quality, effective care," adding, "Daschle promotes greater transparency, paying for quality care and a fully electronic health system."


You can check in on this issue with your representatives in D.C. Let them know if this is a thumbs up appointment or thumbs down.

What are the issues Daschle is focusing upon?

Daschle says Medicare should pay more for care that leads to good outcomes, and should stop paying for unnecessary or harmful treatments .    He also argues that all Americans should be required to buy health insurance — a key difference from Obama, 

Perhaps the most striking part of Daschle’s plan is his call to create a Federal Health Board, modeled on the Federal Reserve Board that manages monetary policy. The basic idea is to create an institution, run by experts, that answers to the government but is “largely insulated from the politics and passions of the moment,” he writes.  Perhaps most importantly, the Board would assess the effectiveness and costs of various treatments.

“Like monetary policy, health-care policy shouldn’t be subject to the whims of subcommittee chairmen and special interests,” Daschle continues. 

According to what I read this promises to be a battle of the titans, Kennedy,Clinton, Henry Waxman,

Tuesday, November 18, 2008

Health Train Next Stop Bagdad

Panel Confirms Gulf War Syndrome Is Real and Causes Are Definable

WASHINGTON, Nov. 17 -- The Gulf War illness was caused by pyridostigmine bromide pills taken by U.S. troops to neutralize the effects of nerve gas attacks and by exposure to neurotoxic insecticides, according to a VA advisory panel.

These two factors amounted to a definable scientifically valid illness with significant nervous system symptoms often still affecting veterans of the 1991 conflict in Kuwait and Iraq, said the Research Advisory Committee on Gulf War Veterans' Illnesses

At the same time, the report exonerated a number of other suspects in symptoms reported by returning veterans of Operation Desert Storm, including depleted uranium, anthrax vaccine, infectious diseases, and stress. Much of the report echoed a meta-analysis on acetylcholinesterase inhibitor exposure published earlier this year by Beatrice A. Golomb, M.D., Ph.D., of the University of California San Diego, a member of the committee. (See Chemical Exposures in Gulf War Caused Veterans' Illness)

The committee was chaired by James H. Binns, former principal deputy assistant secretary of defense. Its scientific director was Roberta F. White, Ph.D., chair of environmental health in Boston University's School of Public Health

Commentary by the author: 

It's only taken more than fifteen years to figure this one out. My guess is that a fourth year medical student had the answer years ago....  Of course this was probably obfuscated by the Pentagon, the VA, and the DOD. 

There is little doubt that this syndrome has also affected our troops during our presence in Iraq over the past 6 years. The government will probably launch another study spending millions more to prove this as well.

Physicians now must advocate for our warriors to be compensated and treated adequately.  Any 'stigmata' assigned to them for '" seeking disability" or medical care by the VA warrants more priority than bailing out the financial crooks and sociopaths. responsible for wrecking our economy, be they corporate executives, investment banks, credit card companies,

'nuff said

Sunday, November 16, 2008

Health Train Survey

The results of my survey on Sermo have just been released.

I am posting the question and the results here




If Obama wins Tuesday, I think Wednesday I'll get up, take my kids to school, go to work, come home, have a beer with my wife and soak in the hot tub. Get over yourselves, people, you sound like a bunch of Nostradamus wannabees.






Respondent-added answer

Be afraid, be very afraid.



Respondent-added answer

All those anti-Obama doctors will be investigated by Medicare and the IRS. BestGuess will be Secretary of Health and Human Services.



Respondent-added answer

I will be very sad.



Respondent-added answer

STOP already!



   Answer added by respondent

View full results for this posting

Select your answer:





It will mean the end of free markets and democracy as we know it................

It will mean the end of free markets and democracy as we know it................

All those anti-Obama doctors will be investigated by Medicare and the IRS. BestGuess will be Secretary of Health and Human Services.

All those anti-Obama doctors will be investigated by Medicare and the IRS. BestGuess will be Secretary of Health and Human Services.

November 5th and further will be just fine...nothing changes that dramatically in the US with the election of one person.

November 5th and further will be just fine...nothing changes that dramatically in the US with the election of one person.

Expect more bread and circuses, and massive federal deficits as far as the eye can see.

Expect more bread and circuses, and massive federal deficits as far as the eye can see.

If Obama wins Tuesday, I think Wednesday I'll get up, take my kids to school, go to work, come home, have a beer with my wife and soak in the hot tub. Get over yourselves, people, you sound like a bunch of Nostradamus wannabees.

If Obama wins Tuesday, I think Wednesday I'll get up, take my kids to school, go to work, come home, have a beer with my wife and soak in the hot tub. Get over yourselves, people, you sound like a bunch of Nostradamus wannabees.

Be afraid, be very afraid.

Be afraid, be very afraid.

Whether he wins or loses, Sermo will be a better place without all these biased opinionated political posts.

Whether he wins or loses, Sermo will be a better place without all these biased opinionated political posts.

I will be very sad.

I will be very sad.

STOP already!

STOP already!

I'd like to add my own answer

Enter your answer here

I'm not interested

I'm not interested

Why rate a posting?
Your ratings history is used to determine which postings get recommended to you. The more postings you rate, the more valuable these recommendations will be. It's an easy way to ensure that you see the content most important to you on Sermo.

What if Obama wins?

For the sake of argument, imagine (and you may not have to) on Tuesday Obama is elected.  Do you think he has the ability to transform free market capitalism into limited sociallism affecting only the healtcare sector, without major disruption to the industry? 

Do you think the congress will approve what he wants.  How will business react to his proposed changes.

Does his election really reflect the desire to transform health care into a socialized universal payor system,  or a reaction to the last 8 years?  Is this a move for making things better, or just a knee jerk reaction to CHANGE?

I'm not interested


business, capitalism, free market, payor, socialized, universal

Category: Politics & Reform

Posting ID: 28747

Posted on November 02, 2008 by gmlevinmd123

View most recent

Comments (25)


Whatagas  Anesthesiology

Posted Nov 02, 2008 at 3:33 PM

His election has much less to do with the general public's desire to change healthcare and almost everything to do with the notion that George Bush, and by extension, the republicans, have driven America in a direction where the world hates us, we can no longer have reasonable (i.e. non-polarized) debate on important issues, we are ignoring the biggest threat to the planet's existence (global warming) since that big meteor 65 million years ago, we are reigniting the crusades, and we are ignoring the plight of the 1/3 of the world's population that lives in abject poverty, all while throwing away our own future for the sake of next quarter's earnings.
Obama represents, rightly or wrongly, a return to the premise that Americans are fair, reasonable, charitable people who want to succeed by virtue of competition, not brute force. The fact that he intends to socialize and possibly destroy health care is a secondary concern.

davids1959  Psychiatry

Posted Nov 02, 2008 at 3:34 PM

Voters are not making their decisions on the candidates health care policies. That said Obama is not advocating, "transform free market capitalism into limited sociallism affecting only the healtcare sector." He is proposing universal axis to care.

sflyn1  Ophthalmology

Edited Nov 02, 2008 at 3:42 PM

I think these discussions would be both more productive and less tense if we refrained from using emotionally-charged words such as 'socialism' when framing the debate.

nsmurali  Gastroenterology

Edited Nov 02, 2008 at 3:50 PM

The problems facing us are so grave that neither candidate has proposed solid solutions. Their talking points were prepared 2 years ago and they had no clue of the looming economic crisis. My guess is we will have some kind of a "Medicaid for all" type of catastrophic coverage and the rest of the stuff will take a back seat. Unless the connection between jobs and healthcare insurance is severed, it is unlikely that US can create well paying jobs. We will see more under $100K/year jobs leaving the country for more competitive markets. . All along the lobbyists were very powerful. Now these insurance companies have been weakened, the American industries have been mortally wounded. In the same context, if solution(s) to the healthcare inequities are not found this time around, we probably will never have an economically viable healthcare system in this country.
It is too simplistic to say Obama is trying to spread the wealth. That is pure nonsense. No one has any answers. One thing for sure. If we go on like this, we will not have to spend any more money on a national security force as the US will no longer be attractive to anyone including the terrorists!

suvarov  Internal Medicine

Posted Nov 02, 2008 at 4:34 PM

"Socialism" is no more charged than, say "capitalism", which is to say, not at all.
And almost no voters are paying attention to either candidate on healthcare. That isn't what this election is about.

epector  Family Medicine

Posted Nov 02, 2008 at 4:36 PM

Agree with sflyn1. Avoid terms like "capitalist," "free market" (a joke because for physicians there IS no free market. Payers, patients, employers, & govt hold us hostage and we play by others' rules, we are not free!), "socialist" (what exactly is this? Communism, fascism, government regulation, government payment?). Another loaded, confusing terms: access (and Davids1959, I think "access to insurance" is what has largely been debated, not access to CARE.). I think most of us favor reducing health care disparities that are identifiable based on economic condition, race, gender, or age; but we can likely never eradicate maldistribution of physician workforce or specialties, "the poor ye have always with you," and all countries have a system the wealthier can access independently of a govt-run system.
What I hope may come from my own miniscule efforts, and all intelligent discussions of health care reform, is to FIRST identify problems, THEN identify possible solutions, WITHOUT labels or ideology getting in the way. IMHO, ideology has been part of the difficulty the last 8 years.
What will happen if Obama is elected? The sun will rise on Wednesday, he will take office in January, study many issues for 6 to 9 months, develop some agenda items, Congress will debate them for another year, and maybe about 2011 we will see something resembling "change," and coherent programs and processes. Then Obama will begin his reelection campaign, and the Congress will need to be the ones carrying the torch for meaningful health reform. We "little people" need to keep applying pressure throughout this period, regardless of who assumes office in January. A vigorous leader is only one part of the solution. We are also part...and must stay vocal!

c130nav  Anesthesiology

Posted Nov 02, 2008 at 4:51 PM

If Obama is elected and the democrats obtain a super majority in Congress, I think you will see a number of changes within 6 months.
Listen to Barney Frank lately? Already making plans.

c130nav  Anesthesiology

Posted Nov 02, 2008 at 4:53 PM

Recent bumper sticker :
Your wallet . . . the only place where Democrats want to drill.

sayaah  Otolaryngology

Posted Nov 02, 2008 at 5:19 PM

First, Obama is first and foremost a politician and probably smart enough to know better to lead more from the middle than the extremes.
Second, the economy is going to put a damper on most big spending programs and probable tax hikes for a while.
Third, neither Onama or Congress - Reid, Pelosi, Frank, Conyers, Schummer, Kennedy - are going to sit idly by and let the other determine what is going to happen.
Fourth, in 2006 many of the Democrats winning were moderates and conservatives and will not go along with far left proposals. Will have to see who is elected now.
Fifth, there is no doubt the pendulum will swing back to the left, after Reagan and Bush 43. Remember Clinton, after the Hillary's health care fiasco, governed from the middle. Under Bush 43 the pendulum went far to pro corporate side - Bush was not a compassionate conservative as he said, but a corporate conservative.
Very likely Washington will become more liberal than it has been but not as much as many fear and not as much as some would hope.
For the decades the Democrats controlled Congress it was controlled by a coalition of northern liberals and southern conservatives and the southerners being re-elected more, had the positions of power. so it was not a liberal Congress. In 1964 with LBJ's landslide the Democrats had a super majority and LBJ had great difficulty getting the civil rights legislation passed because of the southerners, many Democrats, filibustering.
There is an old saying that when the Democrats form a firing squad that they form a circle. I doubt if that has changed.

healdoc  Family Medicine

Edited Nov 02, 2008 at 5:24 PM

maldistribution of doctors, not enough general doctors, not enough med schools, these are some of the problems,
maybe some specialists should do part time general practice, maybe just 10% of their practice
we rely too much on foreign doctors

rarmstrong  Surgery, General

Posted Nov 02, 2008 at 6:38 PM

I believe that epector is correct. The realities of an Obama presidency will not resemble the campaign rhetoric. The realities of sitting at the desk in the Oval office will be sobering. There will be some changes and policy shifts, there will be impassioned speeches on the Senate floor...and then the standard business of government will proceed...slowly, as it always has. Business and industry will continue to function. The war in Iraq will quiet down as it already is doing. We will negotiate for a permanent military presence in Iraq, similar to Germany and Korea, which is what John McCain has been referring to all along. Health care, for us, won't change much, but there will be more regulation.

sflyn1  Ophthalmology

Posted Nov 02, 2008 at 6:44 PM

epector writes:
<What I hope may come from my own miniscule efforts, and all intelligent discussions of health care reform, is to FIRST identify problems, THEN identify possible solutions, WITHOUT labels or ideology getting in the way. IMHO, ideology has been part of the difficulty the last 8 years. >
A breath of fresh air. Amen.

arcmdface  Endocrinology

Posted Nov 02, 2008 at 7:02 PM

Agree with nsmurali. I would like to add that it was the super-strong Unions that mortally wounded the big 3 carmakers (part of which were the unsustainable costs of labor contracts). Obama will encourage a resurgance of that leading to more jobs migrating out of the country. McCain on the other hand is going to squeeze more out of Medicare with more RACs. etc. I still p/o ed about him not voting for the Medicare bill this summer.
Neither of the candidates has even a slightest of ideas about curing the ills of the health care situation. The system has to be either a completely capitalistic one or completely socialistic. This current situation is not sustainable.

rarmstrong  Surgery, General

Posted Nov 02, 2008 at 7:13 PM

We have a very mixed system currently, neither capitalist or socialist, that has existed for a long time. It has been tweaked, squeezed and played with for years, and this has resulted in what we have today...a mess. Changing it is a political nightmare, for anyone, from any party. It is likely to hobble along, crippled by waste and excess, for many more years, as the party in power takes credit for very, very small changes(improvements).

edwestrfld  Anesthesiology

Posted Nov 02, 2008 at 7:52 PM

Arizona is going to be an interesting test case, as we are getting ready to pass an amendment to the state constitution that would forbid any entity, government, or otherwise from restricting or abridging your freedom to choose who you want providing your health care and how you pay for it.

BestGuess  Psychiatry

Posted Nov 02, 2008 at 8:05 PM

Obama iis not advocating socialism. Whatever gave you that idea?

daverey60  Family Medicine

Posted Nov 02, 2008 at 8:10 PM

There is more to life than Medicine. Yes, we are deep in it, and are sustained (or demolished) by it. Healthcare reform is not the only issue here, and as fate would have it, no one candidate has the "cure-all" for all our ails. There had never been a candidate that had all the answers- not before, not now, not ever. I think it is quite clear that we can not see a perfect president. If we want one, or try to push for one, we are as at fault as our patients and the lawyers who try to assume we're all infallible as physicians.
I agree with epector that choosing a president is just the start. Change in this system is slow. We are all trying to move a mountain, figuratively speaking. It takes time. It may even take a few terms if we want change.
God help us (sorry to "offend" the atheists among us).

cazzon  Family Medicine

Posted Nov 02, 2008 at 10:03 PM

After eight years of an A'ho, we'll now get to try B'HO. But if he sells out to lobbyists, you can just call him ho'.

dmmmd1  Gastroenterology

Posted Nov 02, 2008 at 10:17 PM

<<Obama iis not advocating socialism. Whatever gave you that idea?>>
His own words. Most popular, his unrehearsed explanation to the plumber, of why he wanted to spread the man's wealth around. The implication being that although the man would have worked hard for his money, there were others who needed it more.
"From each according to his ability, to each according to his needs." Socialism, pure and simple.

sflyn1  Ophthalmology

Posted Nov 02, 2008 at 10:29 PM

<"From each according to his ability, to each according to his needs." Socialism, pure and simple. >
Uh, no. That's communism. "To each according to their contribution" is socialism.

c130nav  Anesthesiology

Posted Nov 02, 2008 at 10:43 PM

So, Obama is advocating communism ?!

sflyn1  Ophthalmology

Posted Nov 02, 2008 at 10:54 PM

That's right, c130. Obama is advocating communism.

bzaneh  Emergency Medicine

Posted Nov 02, 2008 at 11:13 PM

The problem is he is not going far enough to socialize medicine. He backed away from a one-payer system to everyone with a job has to buy insurance. The insurance companies will still rule. We either need to go to an insurance-less system where everyone pays out of pocket or negotiates a payment scheme with each provider; or a system where everyone is covered for a set list of medical events and diseases and the government pays all without denial of care or denial of reimbursement. The problem with the later is that it will cost us 30% to 40 % tax on every dollar you earn.

cazzon  Family Medicine

Posted Nov 03, 2008 at 9:54 AM

Tax hikes during a recession are a disastrous idea. Will B'HO's admin emulate the Jimmy Carter years, or the FDR years?
The question you should ask is, what if McCain wins? That is a scary thought. If there aren't riots in the streets by the "disenfranchised", you can bet the ballots will be tied up in the courts for weeks. And that would be just as disastrous.

nsmurali  Gastroenterology

Posted Nov 03, 2008 at 11:34 AM

It is a matter of demand and supply. As far as medical services are concerned I anticipate a very steep drop( as much as 50%) from current rates for everything--procedures to drugs. ...American industry is fighting for its life. We have such a defunct education system that employable grads will not be coming forth for two decades even if we were to make drastic changes today. One glimmer of hope.., the best and brightest will enter manufacturing area ans hopefully the sciences instead of going to wallstreet.

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Saturday, November 15, 2008

Health Train Express

For the next week or so I will not be posting at Health Train Express.  I will be over at my other blog  THE VIEW FROM HERE

Tank up, turn off, and tune in for rants about politicians,economists, and our esteemed leaders...

I will be posting daily..


Thursday, November 13, 2008

Health Train Security Alert


Like all professionals, we physicians need to be policed. There are some of us  (not me)  who are impaired, drug dependent, and present a risk to patients.. Certainly today with 'transparency' as the new  buzz word it is now expected that consumers will have a seat on the medical board as reviewers and decision makers.

This blog is transparent and read by physicians, administrators, pundits and yes, even 'consumers' (I prefer patients).

In California the administrative functions of the Medical Board have changed drastically in the past year. Enforcement issues have been taken away from the Medical Board.  It was found that the 'diversion program'  for physicians who are impaired was flawed and inadquate to guarrantee patient protection. The diversion program has been terminated.

In California all licensed providers receive a quarterly report about disciplinary actions against providers, including podiatrists, allied health care licensed providers.  I don't see dentists, or optometrists on this list, so they are most likely policed by a different agency.  They are held to a different standard, although they now provide many medical functions dispensing medications.  Is the system prejudiced against MDs?

When this "brochure" arrives I rush to open it and scan it for people I know or have known. This month I was shocked to find two colleagues who I know fairly well.  One is an anesthesiologist who attended to almost all of my patients I operated on as an ophthalmologist for over 15 years.

I never had a problem with him, my patients in fact would always comment how he made them feel secure.  His anesthesia techniques were very good. If I had a problem or he had a problem he usually noticed it early on.  I know because I had a year or so of anesthesia training before I opted out to specialize in ophthalmology. (I was a late bloomer, who enjoyed it all, and could not make up my mind).. A problem for many students who are forced to chose early because our post graduate system no longer has flexible internships with exposure to general practice in the first post graduate year.  I digress.

Apparently after 30 years as an anesthesiologist he retired and took several years off.  He became a physician for the corrections department.  Of course his general medical skills needed updating.

After he was hired he was offered remedial training and also the opportunity to take an evaluation.  He was not told that his employment would depend on his passing this test.  As it turned out he did poorly on the  test and it was determined that his skills were not up to caring for prisoners....I do not know if he was offered supervision or time to have remedial CME.  His medical certificate was revoked.  I also noted that it is no longer called a 'license', but a certificate.

A second colleagues's name appeared in the list.  This doctor was a psychiatrist who I knew for over four years.

His back ground was impeccable, and he devoted his career to poor patients, either in the medi-cal system or indigent.  He dealt with patients who had serious mental illnesses, ranging from bipolar disorder, to psychosis, alcoholics, and drug dependent patients. Among his patients the ones in question were among the most ill, with poor outcomes and chances of improvement.  They were very time intensive. He developed a social and sexual relationship with one patient, and expert testimony determined that this was not a predatory behavior for him, but a circumstance that developed out of this patient's serious physicial illness.  The event ocurred out of the office, and he was seduced during a period of extreme stress arising out of a recent divorce, severe financial problesm from a failed investment in an imaging center.

He was also accused of keeping poor medical records.

This psychiatrist trained in the days where psychiatric history's were sacrosanct. Psychiatrists were taught to be very careful in what they documented in the patient's chart. This was a habit he carried with him throughout his career.  He practiced in a private setting as well as a county mental health center for many years without this being an issue.  It became an issue for 'the system' when he was supervising an 'intern' who complained about 'inadequate record keeping'.. (who was supervising who?)

He was also accused of not giving adequate informed consent.


Informed consent implies that a patient can understand what he is told or reads.   The times I saw him as a patient to deal with my own stresses he gave me a yellow sheet which outlined the reactions, side effects, and drug interactions.  Even as a physician, I had difficulties understanding some of the material.

Was this determination based upon a patient complaint, or what was not in the chart?

How would an impaired psychotic or drug dependent patient understand and be truly informed??  Dr P worked with severely ill patients,  in a very busy mental health clinic with time constraints limited by the 'system'  He barely had time to evaluate a patient, document the visit, write the prescriptions, give informed consent and get it signed.  He had minimal if any assistance, and most of the  time did not have a psychologist to deal with issues he did not have time to complete.  The county however, had no difficulty providing administrators and clerks to process financial paper work for billing and other issues.

Perhaps he should have complained to his supervisor or the county.  He would probably have been terminated.  Government never accepts their portion of accountability for anything.

The county, state or federal system lives on bureaucracy and paper work.  Many of these patients are on ten or more medications for medical conditions as well as psychotropic medications. Physicians are policed and reviewed to be certain their records are complete, so why wasn't this caught well before he faced administrative or board discipline?

Yes, physicians need to be accountable and live up to a higher standard than 'ordinary people'.  Physicians have the duty to put their patient's welfare before their own.  At times this places them in a compromised position.

These issues become more critical and more prevalent with the increase in rationing, decreasing reimbursement, increased patient loads and the real world time constraints resulting from the growing crisis in health care delivery.


Wednesday, November 12, 2008

Why is Healthcare so Expensive

This, found in Planet Money as a feature on NPR.

Today, NPR featured this video which simplifies the problem(s)

Planet Money explains further.......................

Health Train Express has found that there are many prolific writers from the likes of the WSJ, NPR, and many other sources in the media and the business world who  are addressing healthcare financing.  In some cases they seem to have a better grasp of the big picture while we physicians flail about just trying to survive and earn our daily bread.  Despite that none or few of these writers  have ever had the day to day and night to night responsibilty for human lives they seem to or think they have all the problems accounted for..  Yet their solutions do and would have enormous collateral 'damages' to health care as we know it.

The laws of unintended consequences, and perhaps some of the laws of intended consequences must come into play.

Other weblog stuff:

John Hamlaka explains the demise of  AHIC and it's replacement by   a new organization

John D. Halamka, MD, MS, is Chief Information Officer of the CareGroup Health System, Chief Information Officer and Dean for Technology at Harvard Medical School, Chairman of the New England Health Electronic Data Interchange Network (NEHEN), CEO of MA-SHARE (the Regional Health Information Organization), Chair of the US Healthcare Information Technology Standards Panel (HITSP), and a practicing Emergency Physician

What are the ERs doing about Overcrowding?


Some are wondering what effect the looming credit crisis is having on health care Tags: ,,

Monday, November 10, 2008

Health Train Overload


Sunni Muslims ride the train home after attending annual religious ceremonies in Multan, Pakistan.

Health Train Engineer Ratings today had an interesting topic about the value of doctor rating sites on the internet.  John Grohel and Ruth Given elaborate on the worth, value, and the economics of these web sites as sources of valid and credible information for patients.

Some of these sites should have their title "Buy  your Grades"...These sites are not even secure...what is to stop hacking in to the 'teacher's"  grading books??  The whole issue seems a bit sophomoric.

1. It is not unbiased

2. Who reviews and rates the comments

3. Is there any credibility and accountability for ratings and/or comments.

4. Do the rated physicians have the ability to offer answers to criticisms??


2 ??

'nuff said?

Health Train Reports

Pay for Performance:  It's a no way street, since medicare has failed to live up to it 's promise.  Providers are struggling to determine what went wrong...Not a win-win situation, and a loser for both sides.  The experiment to improve outcomes by requiring coding for certain behavior on the part of providers and rewarding them for the same is flawed fundamentally by a rigid set of parameters to measure, which in the long run will most likely evolve with time.  It's going to be the dog chasing it's own tail.   Most providers do not have the time or resources for this unless it is a substantial size group.  2 percent  incentives for hiring administrators and software to perform this function is offset by increased overhead.  This amounts to negative reinforcement if payers and CMS decide to penalize those who do not conform to a very questionable mandate.

The effects of medical group practice and physician payment methods on costs of care.

AMA survey results:This study indicates that payment methods at both the medical group practice and physician levels influence the cost of care.  However, the methods by which that influence is manifest is not clear.

Many doctors are still trying to figure out what went wrong with the 2007 PQRI.

Confidential physician feedback reports from last year's initiative, which for the first time offered Medicare bonuses for successfully reporting quality measures, became available to participating practices starting in August. Since then, many participants have been struggling to make sense of the information that they received -- if they were able to access it at all.  Only about 20% of 408 physicians surveyed in September by the American Medical Association were able to download their 2007 feedback reports, which told each doctor whether he or she reported enough measures to qualify for a bonus. Nearly 60% of those who sought assistance from the Centers for Medicare & Medicaid Services in accessing the confidential reports said they received little to no help from the agency.

In the interest of efficiency CMS has contracted with new companies to process payments.

Never you mind that the new companies are unable to perform.

How will CMS deal with increasing complexity of coding, transition to ICD 10, and vendors who are ill prepared to assume the responsibility for payments to providers?

And how will CMS deal with audits and repayments by providers?

Sunday, November 9, 2008


A long time ago in a distant past my parents told me that if I became a physician I would always have work to do. They also told me I would probably never be a rich man.  I did not pursue medicine as a 'job'  My very worth is embedded in being a physician and surgeon... Like most physicians I wonder what I could do if I    could no longer care for patients. 

At times while it is exhausting and saddled with many 'duties' such as becoming a secretary filling out forms, entering data and patient histories into an electronic health record.  While most clerical personell earn about 10-15 dollars/ hour my pay grade is far above that figure.  For me it is a good deal. The downside for providers is less ability to see an increasing number of patients..For payors and medicare it is  poor economics to pay the physician  to do secretarial work.  As medicare and payors increase the bureaucracy and regulatory requirements there reaches a rate of diminishing return.

An analogy to this is what Hubbert calls "Peak  Oil".  named after Dr. M. King Hubbert, Geophysicist.


This eponym describes the phenomenon where it takes more energy to pump oil out of the earth than  what it yields in energy.  This is due to the necessity of pumping water into the well to force crude oil to the surface, drilling deeper, and drilling further offshore and in remote locations (cost of transportation)

Add to that, the political, ecologic, and economic aspects of legislative hurdles, environmental protection, and building infrastructure.

We are now entering the era of "Peak Medicine".

Dr. Phil Roth, unknown to me has already described this phenomenon in his blog, Peak Oil Medicine.

Peak Oil is well described in this video.

I think there are many parallels between Peak Oil and what is occuring in medicine and health care.

The emphasis has been to control costs by ratcheting down reimbursements, increasing bureaucracy and regulation, while at the same time ,demand is increasing due to aging, and increasing;y expensive  technology.


Health care employment is one area of the economy that continues to enjoy steady growth. Health finance experts tell us that medical care is increasingly a larger percent of the GDP. Is this because the remainder of the GDP is contracting due to outsourcing, an automobile industry in shambles, exporting production of telecommunications, electronics, and NAFTA.  Are the statistics skewed?