What Doctor's Think

Quote of the day:

Three may keep a secret, if two of them are dead. - Benjamin Franklin

Here is what fuels our "health train"

Doctor Insights

Doctors directly influence more than a third of the entire USA health care economy. Consider these important facts:

• 902,000: number of physicians in the USA in 2005
• $2.1 trillion: USA healthcare expenditures in 2006
• $274 billion: sales of physician-prescribed medications in 2006
• $587 billion: cost of various patient services and devices ordered by physicians and healthcare providers in 2004

These figures are from  What Doctor's Think.

Health Train Express -- Derailed

“It is better to know some of the questions than all of the answers.”
James Thurber (1894 -1961)

 

When I named my blog several years ago I did not quite realize the analogy would have so many applications to health care.

Our "train" is certainly not travelling a straight line on the track. In fact at times the train seems to have left the track.

One unfortunate observation is that like our country overall there is no  ten year or twenty year cohesive plan. Healthcare has become a hodge podge of entities and chaos.  In fact if we can plan beyond next month  running our medical practices we are lucky.

A train with a locomotive at each end pulling in opposite directions won't move very far.

Hijinx 101

Enough gloom and doom with healthcare, medicare, universal care, dental care, heart care, bone care, who cares, an NO CARE for this week.

Norman Vincent Peale decided for the rest of us that "laughter is the best medicine".  Now that is not on  medicare part D., so Idon't know how to order it, or if it requires a special RX pad.

The sad fact is that most of you "intelligient" docs got where you are due to you ability to adapt, work hard, and check off the boxes that your teachers wanted you to check off.   Creativity has been smashed beyond recognition in clinical care.

So, to cheer you all up I am including some links to stimulate the "other" side of your brain. 

I am saddled with being left handed, which it turned out has been a boon to my career as an ophthalmologist. ( I never could play the ukelele.)

Sit back, relax on this fine Sunday morning and enjoy the hijinx of the Y and Z generation.  There  is still hope if we "old guys" get out of the way.  This one's for you....Buckeye Surgeon, Surgeons blog,Panda Bear ( I miss your blogging), Kevin MD, THCB, and more.

Revision 3.0

Twit.tv

Future in Biotech

Queen

I am a Twit

You Tube--Healthcare

Pirates of the Healthcare-I-bean  (very funny)

Burf

Progenitorovox

Ecstasy

Marrying for Healthcare

Remix Mayday

Light up Your Lighter

The Future (may load slowly..be patient)

There is hope!!!!

The Flawed SGR Formula

When more is less...............

Quote of the day:
Democracy means government by discussion, but it is only effective if you can stop people talking. - Clement Atlee

 

Usually before I start my blog writing I do some surfing around for current news in the blogosphere. Buckeye Surgeon has a few interesting links that are germane.  The Wall Street Journal blog cuts right to the Chase.  It's not difficult to see how payors enjoy playing us against one another....divide and conquer techniques which have been demonstrated to be quite effective thus far. No specialty or primarycare physicians should take glee in reaping benefits as a result of these tactics.  Remember, first they came for "them" then they came for "me". 

 

To quote Buckeye Surgeon,

"There's plenty of money to go around. The discrepancy in pay between the GI doc and the PCP is not the reason why health care is so expensive. The giant HMO's and the pharmaceutical conglomerates would love to have you believe that. There's a reason both are multi-billion dollar industries. Let's not nickel and dime each other. A united front is our only hope of ensuring that the backbone of the American health care system, i.e. the physicians, does not deteriorate into a collection of second- rate, infighting, backstabbing special interests."

Conductors for the Health Train Express

Quote of the day:
Politicians are the same all over. They promise to build a bridge even where there is no river. - Nikita Khrushchev

 

It's been a very long time since I have been on a train. I remember them as walking down the aisles of passenger cars punching your ticket.  Do they still exist?

I think "Health Train Express"  needs fewer ticket punchers.

When was the last time you thought about a Surgeon General?

The last one I remember was  David Satcher , before that the memorable  C. Everett Koop .   I am not certain why but the most memorable Surgeon Generals  had beards.

The complete List of Surgeon Generals is here.

Another Surgeon General was Jocelyn Elders,  who I like to call the "equal opportunity"  Surgeon General.  She was both a woman and an African-American . General Elders was a very outspoken leader....she was however politically incorrect, a proponent for sex education, introducing Condom in public school.  She was summarily drummed out...

Some of these "Generals" actually were Admirals...but I have not heard of any called "Surgeon Admirals".

Whatever  has happened to our current  surgeon general?

Rear Admiral Steven K. Galson, M.D., M.P.H.

Since October 2007, Rear Admiral Steven K. Galson, M.D., M.P.H., has served as the Acting Surgeon General of the United States. As the nation's top public health physician, the Surgeon General communicates the best science, evidence, and data to the American people in order for them to make healthy choices that impact their health, safety, and security. Additionally, he serves as the operational Commander of the Commissioned Corps of the United States Public Health Service, a uniformed force of 6,000 health professional officers dedicated to promoting, protecting, and advancing the health and safety of the people of the United States.

I am sure he is an excellent Surgeon General, but why has been "acting"  for so long.  Is this a rehearsal, or Audition for the part?

Now you ask what does any of this have to do with caring for patients.....???Nothing, nada...............just like most of what we read, or hear about medical care.

E-Life

Will the Last Physician in America Please Turn off the Lights.

 

E-life is the title of a book written by the late Tom Ferguson M.D regarding the use of the internet by patients.

Dr. Ferguson virtually led the movement to advocate informed self-care as the starting point for good health, and to promote a new kind of relationship between knowledgeable medical consumers and medical professionals. His goal was to encourage medical professionals to treat clients as equal partners in achieving better outcomes and change the entrenched practices of the traditional top-down hierarchy of the doctor-patient relationship. With the advent of broad access to the internet, Dr. Ferguson's long history of advocacy of information-empowered medical consumers positioned him to be a leading proponent of online health information resources.

Now, you may ask how does this relate to the "HealthTrain Express"??  It is obvious to me that there are many tracks for our health train, which are all running at the same  moment in time. Dr Ferguson's ideas can be found on The Health Care Blog, written by well known medical-pundit,  Matthew Holt.  Many physicians welcome input from their patients, as it has become much more common recently for patients to bring in a print out from the internet. The "Y' generation now brings in internet information rather than the magazine articles we are all used to.  I see some rather 'novel ideas' and at times this refreshes my knowledge or motivates me to dig a little deeper into things that need refreshing.  It takes a bit more time to deal with this, but I feel this is an important feature which demonstrates "buy in"  and self awareness on the part of my patients for their disease.   As demands increase upon us patient motivation and responsibility are important aspects of their care. The internet is a welcome addition to my practice.

Memorial Day

Quote of the day:
Men live in a fantasy world. I know this because I am one, and I actually receive my mail there. - Scott Adams

 

The above quote has nothing to do with my post today.

Today is a bittersweet day for many Americans. We celebrate today in a variety of ways, picnics, trips to the river,  barbecues with friends, and relatives. Many Americans bear fresh grief from the loss  of a loved one, a husband,  a mother or a father, sister or brother, uncles, (aunts).  

We live near a national cemetery and today there will be a procession of automobiles, motorcycles, and families.  There  will be flowers and mementos left at gravesides.

For me this particular national cemetery is personal and special.

We tend to forget that not all who are  buried there were killed in action, but were veterans who served, and their spouses.

My father and  mother were  born in New York,my wife's mother and family were born in  California,  yet by some alignment of the universe, they  were all buried here, just two miles from our home.  I anticipate my wife and I will lie here together as well.

Our children will be able to visit " the family plot".

We should also remember the physicians,and nurses,and other healthcare providers who serve our country, some  have died in the course of military service and others in civilian service, the ones who  die in air ambulances that crash, or contract a fatal infectious disease while caring for others.

We live in a poignant moment for our country and the world.

Despite our challenges we as physicians must remember our moral compass at a time when politicians, and citizens  struggle to make a correct decision,  when there is no one decision to be made.

My  thoughts are on all who served,   and some  who died so that I,my  friends and children live  in  our country, although imperfect, strives for the ideals of freedom, liberty and individual rights.

Clarence This is Stupid Stuff

Today I am reading Leavitt's Blog. As most MDs will recognize this name as gentleman who is the Head of HHS. I am not sure, but I believe this is a Cabinet Level Position, or at least on a level commensurate with the Head of a Major Federal Agency. I made a comment on his blog, and lo and behold it appeared. (moderated, too). In a land where "titles" and certificates, outcomes and credentials outweigh all other measures of intelligence, competence, and malpractice coverage I come to the table with merely an MD and Board Certification in a surgical specialty.

It took me 15 years post high school graduation (including involuntary military service in the Navy during Vietnam), which by the way turned out to be one of the most interesting and rewarding periods of my life, to get to a point where I paid real money to purchase a medical practice (now called medical business), which took another five years to pay off. Throughout a great deal of this time I was paying off my medical school loans.During residency I also moonlighted a great deal to support my family. I am one of those rare birds that actually used my general medical knowledge practicing family medicine and emergency medicine for four years prior to residency. Another time well spent where I learned to appreciate my specialty was actually a small niche in the scheme of health care.

In those days of early medicare and non existencey, a great deal of medical services were actually given away because it was possible to cost shift and absorb non paying patients, indigent patients in your practice without going bankrupt.

In today's real world the invention of "needs" to satisfy neurotic patients, such as refractive laser surgery, cosmetic botox, restylane injections, nip and tucks, fancy lasers for vein and skin treatments and other cosmetic surgery has allowed some primary care physicians and specialists to continue having an economically sound business model and also to allow them to continue to see Medicare/AND/OR Medicaid patients. Managed care also sucks off this since they do not pay enough to support medical and/or surgical care.

So cost shifting still takes place and it is what keeps the system running. Of course medicare nor other pencil pushers measure this....except those who deliver the care at their doorstep.

Medical practices now have " profit centers" pandering to the latest high visibility newsworthy procedure of the month and snake oil remedies.

To reiterate what Forrest Gump said "Stupid is what stupid does". The stupidity and lameness of it all is apparent ....However it is difficult to measure common sense there aren't any health insurance carriers, or government agencies that have set up a committee, or algorithm to measure common sense. Stupidity is apparent to the eyes of the beholder, and invention to serve a need, such as imaginary numbers, the square root of -1.

I also read Medinnovation Blog, written by Richard Reece MD who is a retired? pathologist who writes about medical economic issues ranging from primarycare challenges to physician IT, and Physician Culture. He is always a good read, and I wish he had a column in a highly visible medium such as the Wall Street Journal, a column in Time Magazine, or a Bill OReilly segment.

Mr OReilly should cover some health care subjects....if I hear anymore about Democratic primaries, I will surely vomit.

More Mike Leavitt

Quote of the day:
The men who really believe in themselves are all in lunatic asylums. - G. K. Chesterton

Mike Leavitt Interview with Modern Healthcare

Mike Leavitt's Blog

Mr. Leavitt pre-supposes that our health care system is not an "economic system", and that much of what ails our healthcare system can be "cured" by satisfying the hypothesis that there are" Four Cornerstones "to a health economy.

He elaborates further,   

Leavitt: History will determine whether in fact I had the impact I aspired to. I can tell you my vision of healthcare. I can report to you the progress, and I can also acknowledge that nothing happens in a system as large as healthcare in a short period of time.
I came to this role with a clear vision that the primary challenge was to take a large, rapidly growing, robust sector of the economy and begin to mold it into an economic system. It was then, and continues to be my view, that healthcare has not achieved economic-system status. There’s nothing about our sector that would qualify it as a system. It is not electronically connected. There are no methods of measuring value. People don’t know the cost of it. They don’t know the quality of it and the incentives do not contribute to the system’s success. All of those, I think, are classic definitions of an economic system.
Early in my tenure I laid out a framework. I am grateful to say that that framework appears to be adopted widely. I refer to it as the Four Cornerstones. The Four Cornerstones are: electronic medical records that are interoperable; quality measures that are standardized; cost-of-care measures that are standardized; and then incentives. Significant progress has been made on that large work plan, and I think a movement toward value-driven healthcare has developed, and I believe it’s gaining momentum. Will it in fact play out to meet my aspiration? Only time will tell, but I can say this: No ounce of energy has been wasted in the last three years and four months, nor will it in the remaining 264 days."

 

It is obvious to any healthcare provider that it is true that our system is large, diverse, byzantine and dysfunctional. Many health pundits other than myself regularly attest to this fact.  These include other well known bloggers in the health care field, such as Richard Reece MD (medinnovation blog) Matt Holt and THCB blog.  Official titles make me nervous.  I like to look at who signs their paychecks to see what  is the ultimate motivation

Mother's Day Blog

Thought I would take the day off from blogging to wish all the Mom's a Happy Day, without whom there would be no bloggers.

UNTANGLING THE MESS

Quote of the day:

The capacity of human beings to bore one another seems to be vastly greater than that of any other animal. - H. L. Mencken

If you are a provider, patient, insurance company, hospital or some other health care provider, few have the luxury or liberty to stand back and analyze what would work to improve healthcare in America.  Since Medicare's inception there have been uncounted mid course corrections to make the system work, contain costs, improve quality and affordabilty for patents.All of this has produced the "Gordian Knot"  Each time the knot grows larger and tighter, now threatening it's very existence.

The question is , do we unravel the knot, and how?  Or do we throw it out (with the baby) and start over?

We have failed to do the appropriate preventive maintenance with patches and glue, and the present system may beirredeemable.

Of course remaking the system at the same time we are caring for our patients seems overwhelming.

However, probably no more than what we as physicians and hosptials and patients endure to receive the care we give and receive with our present system.  During the last 15 years the incremental changes, p aradigm shifts, closure of hospitals and ERs, Machiavellian reimbursement systems forced a restructuring of business models that have reduced efficiency and in my humble opinon disrutped care for thousands, maybe millions of cases.  Provider groups, iPAs, HMOs have gone bankrupt, sold, merged, and attempts to corporatize medicne in some cases have suceeded economically, but altered the basic physician-patient relationship.  Today's system bears little recognition to the  system I graduated into in 1968.   However much of our society, and values have also changed.  Perhaps I am a dinosaur with my ideals and values. 

 

At the same time I am composing this diatribe, I read other blogs to find that others have the same ideas. (It must be a resonance in the universe)

Edwin Leap's blog today articulates the underlying karma of what most physicians think and feel.

Rather than plagiarize this comments, I direct you the man himself.

Edwin Leap

My suggestion?  Get the government out of it all.  If you do, the poor will likely get better care, since we’ll be able to screen out and turn away those who abuse their privilege.  And doctors, that pesky, generally unimportant part of the medical equation, will actually return to hospitals and be available; out of a sense of duty, professionalism, entrepreneurial spirit and genuine compassion without federal compulsion.

It’s unlikely to happen, but a doctor can dream.  ‘And then I saw a scarecrow and some flying monkeys and a witch, and a hospital where I was in charge and could always do what I thought was right, oh Auntie Em, it was wonderful!’

Yours,

Edwin

Jaundiced View

Quote of the day:

Nostalgia isn't what it used to be. - Peter De Vries

 

By now most readers who come to my blog realize they "don't always get what you waahnt" (Mick Jaeger), and " you can't get noosaatisfaaction".  You try and you try....but. You probably get my drift here.

When I think about today's medical practice I often drift off into days long gone by, the Doobie Brothers, Chambers Brothers, amongst others.  Perhaps I like the fantasia of it all....much more pleasant than the daily self importance of dealing with absolute garbage in my daily practice.  The good thing is almost all of it is automatic on my part.  My favorite thing is now listening to my patients ,  not so much about their disease state, but about their lives.  I usually can figure out what is going on just by listening to their history. There are large parts of my practice that are mechanistic and technical.  I am constantly amazed at the people living in this small city of about 60,000 just south of Riverside.

1. I have been given several books from patients who detailed their lives in concentration camps, who escaped Hungary in the 1950s during the "Hungarian Revolution".  In California it is fairly easy to start off after your history with a "so where are you from".

Far more interesting than looking at a computer screen is drawing out the patient and his(her) concern and how his disease affects his life, work, hobbies....and his "family".

Although there may be an upside in the transition of digitizing the medical record in an EMR, it will require someone to input data, and checking off boxes does not quite convey history and/or physical findings precisely.

Butterfly Effect

Quote of the day:

You see, wire telegraph is a kind of a very, very long cat. You pull his tail in New York and his head is meowing in Los Angeles. Do you understand this? And radio operates exactly the same way: you send signals here, they receive them there. The only difference is that there is no cat. - Albert Einstein

 

Those of you who are physicists or students of chaos theory know what the butterfly effect is.  This is a theory that someone turning on a fan in Brazil can cause a domino effect which causes a tornado in Kansas. It can be applied to politics, weather-forcasting, and even health care and health care policy. It is the law of unintended consequences......a coconut falling off a tree in Jamaica causing a series of earthquakes in California.

Few forsaw the effect of Medicare introduction in the 1960s and what would cascade forward with the huge growth of senior citizens, increased longevity, decreased birth rates, inflationary booms and recessions.  The necessity of managed care, evolution of integrated healthcare delivery systems to cope with increasing technologies, demand for health care services.  The economic effects of poor reimbursement to primary (used to be called, family doctors, or general practitioners) care providers that would transform primary care in many localities to "triage" offices.

The uptick in consumer directed medicine and internet social networking allows a transfer of heath information among consumers, (patients) prior to physician office visits.  This too is health information exchange, at the grass roots level.

In Health Information Exchanges in relation to medical care

ie, patient goes to doctor, doctor sees patient, doctor treats patient  Besides, say opponents, a computer in the same room situated between a doctor and a patient changes the human chemistry between the two. Some things are best expressed through the head of a pen rather than the click of mouse. Computers are not magical machines. Computers are human too(ls)