Choosing a career

I remember chosing medicine as a career because I wanted to use whatever talent I had to help patients with their health and lives. At that time I was studying engineering. I was one of those people that could not make up their mind what I would do with the rest of my life. I would pick a topic, master it, and then move on to the next interest. Even after I earned my medical degree it took some time for me to pick a specialty. I stopped for a bit of time to direct an emergency medical group and practiced general medicine for several years. It was very interesting and stimulating. Perhaps I learned as much in those four years as I did in medical school and internship. I had no problems in finding specialists to manage problems that went beyond my relative inexperience to help my patients where I left off.

I left emergency medicine because at that time it was not a recognized medical specialty, and only after I left was the specialty formalized with board certification. I was one of the founders of the American College of Emergency Physicians. However I did not see a 'future' for me in ER medicine. There was little if any long term patient involvement.

I rarely had any follow after the patient was discharged from the ER, unless they were admitted. I also found out quickly that ER physicians do not have hospital privileges. (perhaps this has changed). Surgeons, orthopedists, internal medicine doctors openly looked down on ER doctors as those who did not or could not finish specialty training. Becoming an ER doctor had a negative implication on your intelligence and capability..

In those days it was a challenge to have a specialist come in to see an ER patient. Many were uninsured, and less than socially desirable patients. (things have not changed very much), although more patients, and even those with insurance resort to the ER when their physicians are not available. It has always functioned as a pressure relief valve or safety net for those otherwise unable to see a primary care doctor.

There are many reason why medical students chose not to enter general medicine..

The status of nurse practitioners and physician assistants has been elevated to the point where they can diagnose and/or treat 90% of common problems, and they do not have to have hospital staff privileges. Throughout medical school, unless one is fortunate enough to have a family medicine or clinic rotation the general consensus is that the best and brightest do not enter primary care medicine. Those who chose this field are looked askance at and trivialized as not requiring advanced clinical skills. The training programs are top loaded for gaining skills not at medical school, but later in postgraduate training, beyond the internship.

The reimbursement equation has not favored primary care, pediatrics, or internal medicine. The American system is based on procedural coding, not cognitive time or processing. Even the codes presently in existence for evaluation and management are inadequate, especially for time intensive issues. There are no codes for administrative time, medical record keeping, telephone consultations, telemedicine, or patient education time, hence it is either left to medical assistants or worse, ignored entirely.

Health reform will not alter the science of medicine. It will obstruct the smooth flow of our activities, and create time wasting administration which physicians will pay for as an operating expense, whether in private practice, group or government medicine. Administrators have and will control executive functions and physicians

Physicians will continue to care for patients, do research, do surgery, have good and bad outcomes regardless of fines, audits, quality assurance, pay for performance, EMR, incentives, penalties or other nameless ideas.

google Tags: medical careers, specialty medicine, general practice, family practice, cpt codes, bureaucracy, cardiology

Do The Wrong Thing

A day late and a dollar (gazillions) short.

Robert Laszweski tell us:

As the Democrats make their final push to pass their health care bill many of them, and most notably the President, are arguing that it should be passed because it is the “right thing to do whatever the polls say.”

Their argument is powerful: We will never get the perfect bill. If this fails who knows how long it will be before we have another big proposal up for a vote. There are millions of uninsured unable to get coverage because of preexisting conditions or the inability to pay the big premiums and this bill would help them.

Any big health care bill will be full of compromises—political or otherwise. But this bill doesn’t even come close to deserving to be called “health care reform.”

But as an unavoidable moral imperative, enacting this bill would fall way short:

1. It is unsustainable. Promises are being made that cannot be kept. As the President has said many times, we need fundamental health care system reform or the promises we have already made—the Medicare and Medicaid entitlements, for example—will bankrupt us. What few cost containment elements the Democrats seriously considered are now either gone from their final bill or hopelessly watered down—most notably the “Cadillac” tax on high cost benefits and the Medicare cost containment commission.

2. It is paying off the people already profiting the most from the status quo. Many of the big special interests, that will have to change their ways if we are really going to improve the system, are simply being paid off for their support. The drug deal, the hospital deal, promises not to cut or change the way physicians are paid, all add up to more guaranteeing the status quo rather than doing anything that will bring about the systemic change everyone knows is needed.....more:

 

THE TOP TEN BENEFITS AMERICANS WILL RECEIVE IF (WHEN)THE HEALTHCARE BILL PASSES: 

 

The legislation would:       (Maggie Mahar)

Prohibit pre-existing condition exclusions for children in all new plans

1. Provide immediate access to insurance for uninsured Americans who are uninsured because of a pre-existing condition through a temporary high-risk pool;
2. Prohibit dropping people from coverage when they get sick in all individual plans
3. Lower seniors prescription drug prices by beginning to close the donut hole
4. Offer tax credits to small businesses to purchase coverage
5. Eliminate lifetime limits and restrictive annual limits on benefits in all plans
6. Require plans to cover an enrollee’s dependent children until age 
7. Require new plans to cover preventive services and immunization without cost-sharing
8. Ensure consumers have access to an effective internal and external appeals process to appeal new insurance plan decisions
9. Require premium rebates to enrollees from insurers with high administrative expenditures and require public disclosure of the percent of premiums applied to overhead costs. “By enacting these provisions right away, and others over time” the Caucus declares, “we will be able to lower costs for everyone and give all Americans and small businesses more control over their health care choice

My banker called me today

 

This was posted some time ago, However I think that in light of the recent passage of Health Care Reform, it still applies.

My banker called me today to alert me to the fact that my checking account was ‘over-deposited’. There were several deposits from the U.S. Treasury department that were transferred electronically over the weekend following President Obama’s signing the ‘stimulus bill’. My bank (one of those saved from the brink of extinction by a previous large U.S. Treasury check) alerted me to the fact that my check from the U.S. Treasury would take at least two years to clear, (and not count on the cash until they saw the green.) Unlike California my banker does not issue or accept I.O.U.s.

Even with those precautions I was very excited to see a 50 with 9 zeroes after it (5 X 10^th ) dollars on the deposit side of my bank ledger. Given my big interest in Health IT and EMR my thoughts began to wander to my ‘candy store’ ideas about IT and EMRs.

For the past five years my interests drifted away from clinical patient care and ophthalmology have revolved around writing and studying about EMRs and Health Information Exchanges. I have dealt with many vendors, RHIOs, state organizations, ordinary hospitals, ordinary physicians, public health agencies, and other “voluntary champions” for HIT and EMR. Anyone looking for the ‘deeper meaning’ of my rants can read my blog archive over the past four years. Health Train Express is still published on a weekly basis. What I have gleaned about the value of writing a blog is not what I write but what I read and learn about non clinical issues from other bloggers.

Some of the questions I would present to my readers are the following:

1. Can I dip into this fund for paying my cell phone and smartphone bill, if they are used for my medical practice?

2. Can I use these funds to pay for my internet and /or broadband access?

3. My children go to college. Can I employ them to telecommute to transcribe notes, and/or bill for me and buy laptops with these funds?

4. Can I invest these funds in the market to maximize their value.

5. I have a lot of machines that produce a lot of data and they need to be interconnected to my server. Can these funds be used to buy the machines, software, and network?

6. Can I use these funds to attend courses in regard to health IT (most are nearby in Las Vegas or San Diego). Can I take a vendor to lunch?

7. Can I buy pencils, coffee cups, pens, buttons, tic-tac notes, and have ONCHIT logo emblazoned on them?

8. Can I produce a symposium with all expenses paid for the attendees and pay a tidy sum to the speakers?

9. Do you have any other questions?

I called some of my ‘acquaintances’ in ‘industry’ to hear their feedback. There was a lot of heavy breathing and excitement, as they anticipated a tsunami of green dollars washing over their pre-paid homes they had options on during the recent foreclosure auctions. Some were confused about which was the best hybrid vehicle to buy, and most stated they would buy a different one for each day of the month. This in itself would infuse cash into the American Auto market (if they buy American).

I have a few undisclosed wiretaps and email monitoring software.

Here are some of the tidbits I have read and/or heard.

“Harry HealthIT” who is the CEO of EMR RUNAMOK Inc. at his weekly chat conference to his sales reps “This is the break we all have been waiting for. Buy up some smaller companies right away and re label them as EMR RUNAMOK. We can maximize our gain with very little effort or investment in writing software.” Buy one of those voice mail tree software systems so that one person can run the whole company. After we have sold them for a year or two we can sell our company and retire….Change our phone numbers to save money and confuse our clients as well.

And finally can I lobby for a bailout in about two years to offset the reduced reimbursement from medicare and private payors based upon the ‘new efficiencies’ of our ‘Health Information Network System?”

 

Flickr Tags: emr,network,bankers,stimulus funding,health reform,health it,vendors,cell phones,RHIO

Science and Passion

Someone recently pointed out that science and passion are not at opposite poles. The goal of finding truth and objectivity are not the polar opposite of 'faith' . For many years medicine has relied on some treatments that are patently useless or at least questionable. We have placed our faith (and the patient's) in some of these treatments.
As medical students we are supposedly grounded in science, and evidence based medicine. The term 'evidence based medicine' to me is meaningless, invented by insurance companies and parroted by some physicians to be 'politically correct' The term evidence based 'science' is far more meaningful. The practice of medicine is and art as much as science. The placebo effect is evidence based, but not scientific. This is pseudoscience. So, evidence based medicine is NOT based on science.
Do I have faith in evidence based protocols? No, not more than preferred practice patterns, which are time related and dependent upon peer opinion. Preferred practice patterns are not scientific, they are based upon location, availability of treatments, and also dependent upon the FDA approving a treatment. As we all know this can take years to occur.
Effective treatments are often blocked or delayed for orphan diseases by the non-availability or unprofitability of producing certain drugs.
Clniical trials often block access to drugs that are highly effective and denied to patients who are dying or otherwise have no alternative for treatment. Clinical investigators are banned from using their individual judgment by Clinical Trial rules that sanction releasing drugs prematurely, even on a very limited basis outside the treatment protocols, which often are restrictive in regard to prior treatments.
Scientific double blinded trials are restrictive. Controlling all variables outweigh the common sense finding at times.

More Butterflys

 

Health Care Reform is here, or is it?  Frankly the whole thing is so complex that no one really knows how this is going to work, if it does.  True to form our government is telling us we are going to save so much money by spending more money now. 17,000 IRS workers to keep track of who has purchased insurance, and who has not.  There will be a new check box on your 1040 asking you to swear that you have purchased insurance.  Insurers will undoubtedly issue 'stickers' to place on your 1040 forms.

Welcome to Deemocracy .

On Thursday, the California Occupational Safety and Health Standards Board voted to set up a committee to examine whether condoms should be required on all pornographic film shoots within the Golden State.

California has run out of money, but it hasn’t yet run out of things to regulate.

That's a great point. Does the government have the power to force you to buy something simply because you are alive? If that is true, what prevents the government from mandating that everyone must also buy a casket, funeral plot or urn for your ashes.

Flickr Tags: health reform,democracy,irs

The Fallout

 

Health Train Express  has been around since 2005, and in those years I have posted 405 editions. It's been a catharsis, and I have looked forward to writing it. In the process I have made many 'literary giants' as I review the bloglists daily. (what was I doing with my time prior to this?)

Health Reform Expectations:

Most of us may go on practicing medicine as we did prior to the 'health reform' legislation. Truthfully it will change little for physicians, although it may threaten small to medium size practices just because of the bureaucratic overload which is already past implosion and critical mass.

It will however spawn new parasitic administrative functions in government and the private sector of health care.
Extant companies, consultants, legal firms are already marketing their skills to forecast and modify business plans to cope with health reform.

Don't be fooled for a moment that the health reform will be smooth and not subject to major revisions..There will be many roadblocks financially as the attempts are made to enforce the legislation, as well as opposition from providers, insurers, and yes, patients....

 

What we have here as an analogy is the 'fertilization of an egg with sperm' As it develops into an embryo we shall see various combinations, permutations,possible mutations and perhaps even an abortion, or worse a mutant born over the process of several years. Whether the mutant will be dysfunctional, or a working member of society is open to question.

 Timeline for Obamacare Rollout

Just The Beginning

Words from a practicing surgeon::

Truth cannot be legislated!

Good morning!

The sun came up this morning in upper Michigan.  The air is crisp and clean as usual and another beautiful day is beginning.  As always, I'm operating on Monday.  I saw my first patient, a middle aged man with a hernia.  He smiled at me, we shook hands and I answered his last minute questions.  Soon I'll be in the OR doing the same work that I still love.

My patient didn't watch the vote last night.  He wasn't aware of Pelosi's grand victory.  All that matters to him this morning is that I am his surgeon, he trusts me to do my job well, and I will.

What we saw last night was a political manipulation of history.  A re-write of law to move the money around and change some rules.  I don't agree with what was done.  My disagreement is the same this morning as it was last week, last year and 30 years ago.

Politicians are still trying, with complex systems and regulations, to change immutable facts.  It is a grand illusion that only will have a transient political benefit for them, if that.  No amount of ink on paper can change the fact that people cannot purchase services for nothing.

No amount of government regulation will change the science associated with the medical care that we provide.  No new ruling or designation will elevate unqualified individuals into the positions that we have worked so hard to attain.

The stroke of the President's pen won't do any of that.  Most of the nation knows this, even though they may not be able to articulate it easily.  But, those of us in medicine, the working physicians who care for patients everyday know this very well.

History takes a long time to play out.  We saw what happened in Massachusetts earlier this year.  People know a scam when they see it.  I am confident that we will weather this "storm".  But, don't be complacent.  Washington is once again messing with your freedom.  That is too important to ignore.

Personal Health Records

The personal health record is failing patients
By Kevin on emr


A personal health record (PHR) has been touted as a way for patients to better keep track of their health information. Google Health and Microsoft HealthVault lead the way.

But what happens if the company storing your data gets bought, goes bankrupt, or simply decides to discontinue their system?

Well, those who stored their data with Revolution Health are finding out first hand.


The troubled company, which started off with so much fanfare, yet died in a whimper, recently announced they’re shutting down their personal health record service.

According to American Medical News, “Industry insiders say Revolution joins a long list of vendors who launched PHRs with a big splash, only to find little interest from consumers.”

Leaving the data entry to the patient is inefficient, and a sure way to minimize the adoption rate. Indeed, “the most successful PHR-type systems have been created by health care organizations and have benefits to patients, he added, such as e-mailing with physicians, online appointment scheduling and the ability to look at information entered by their physicians.”

That means a successful personal health record have to be well-integrated with, or designed by, existing hospital and physician systems, making it harder for a third-party system, such as the defunct Revolution Health service, to gain traction.



Revolution Health, as you may remember was started by Steve Chase, the AOL whiz kid.Another boom to bust enterprise.

Do The Wrong Thing

Robert Laszweski tell us:

As the Democrats make their final push to pass their health care bill many of them, and most notably the President, are arguing that it should be passed because it is the “right thing to do whatever the polls say.”

Their argument is powerful: We will never get the perfect bill. If this fails who knows how long it will be before we have another big proposal up for a vote. There are millions of uninsured unable to get coverage because of preexisting conditions or the inability to pay the big premiums and this bill would help them.

Any big health care bill will be full of compromises—political or otherwise. But this bill doesn’t even come close to deserving to be called “health care reform.”

But as an unavoidable moral imperative, enacting this bill would fall way short:

1. It is unsustainable. Promises are being made that cannot be kept. As the President has said many times, we need fundamental health care system reform or the promises we have already made—the Medicare and Medicaid entitlements, for example—will bankrupt us. What few cost containment elements the Democrats seriously considered are now either gone from their final bill or hopelessly watered down—most notably the “Cadillac” tax on high cost benefits and the Medicare cost containment commission.

2. It is paying off the people already profiting the most from the status quo. Many of the big special interests, that will have to change their ways if we are really going to improve the system, are simply being paid off for their support. The drug deal, the hospital deal, promises not to cut or change the way physicians are paid, all add up to more guaranteeing the status quo rather than doing anything that will bring about the systemic change everyone knows is needed.....more:

 

THE TOP TEN BENEFITS AMERICANS WILL RECEIVE IF (WHEN)THE HEALTHCARE BILL PASSES: 

 

The legislation would:       (Maggie Mahar)

Prohibit pre-existing condition exclusions for children in all new plans

1. Provide immediate access to insurance for uninsured Americans who are uninsured because of a pre-existing condition through a temporary high-risk pool;
2. Prohibit dropping people from coverage when they get sick in all individual plans
3. Lower seniors prescription drug prices by beginning to close the donut hole
4. Offer tax credits to small businesses to purchase coverage
5. Eliminate lifetime limits and restrictive annual limits on benefits in all plans
6. Require plans to cover an enrollee’s dependent children until age 
7. Require new plans to cover preventive services and immunization without cost-sharing
8. Ensure consumers have access to an effective internal and external appeals process to appeal new insurance plan decisions
9. Require premium rebates to enrollees from insurers with high administrative expenditures and require public disclosure of the percent of premiums applied to overhead costs. “By enacting these provisions right away, and others over time” the Caucus declares, “we will be able to lower costs for everyone and give all Americans and small businesses more control over their health care choice

It makes me sick, I see a lot of that

Distractible MD says it so eloquently and simply: Just ask your doctor what he is “sick of”.

Doctors in training are flooding away from general Internal Medicine, Pediatrics and Family Medicine in droves. Only 2% of medical students plan to go into primary care. It used to be over 50%. A recent Jim Lehrer report discussed the reasons. We’ve been talking about it for years but things have only gotten worse, not better.

The whole premise of health care reform ensures that everyone has access to good quality care. Every nation that provides good, quality access has a strong primary care base that is the foundation. Primary care is valued by the government, the payers, the population and even by the physicians.
We have it all backward. It is time to revamp the system from the bottom up. Frankly I don’t care if we get one more multimillion dollar robot to assist in a rare surgical procedure or one more new “next generation” imaging scanner until we can rationalize how we pay for care.
We have not yet begun the hard work to bring costs under control because there are too many pigs at the trough. One of my favorite teachers said “you can’t clear the swamp until you get the pigs out of the way”.
We have a lot of pigs to move aside so more people can get to the water.

I saw a patient today and looked back at a previous note, which said the following: “stressed out due to insurance.” It didn’t surprise me, and I didn’t find it funny; I see a lot of this.

My very next patient started was a gentleman who has fairly good insurance who I had not seen for a long time. He was not taking his medications as directed, and when asked why he had not come in recently he replied, “I can’t afford to see you, doc. You’re expensive.”

Finally, I saw a patient who told me about a prescription she had filled at one pharmacy for $6. She went to another pharmacy (for reasons of convenience) to get the medication filled, and the charge was $108. I could see the frustration and anger in her eyes. ”How do I know I am not getting the shaft on other medications?” she lamented. I told her that I see a lot of this.

What is the toll that simply having an insane system that demands huge sums of cash, yet does not give back a product worthy of that cost? What is the toll of people suspicious that they are being gouged at the pharmacy, hospital, or doctor’s office? What is the cost of having a healthcare workforce that goes home more consumed by frustration about the system than by the fact that people are sick and suffering?
Our system is very sick, and the fact that it is so sick makes me sick. It makes a lot of us sick.
I see a lot of that.

Last Helicopter out of Saigon

Plagiarized from The Health Care Blog

Last Helicopter Out of Saigon!
By JEFF GOLDSMITH
In popular psychiatry, a classic passive aggressive gambit is “malicious compliance”- intentionally inflicting harm on someone by strictly following a directive, even though the person knows that they are damaging someone by doing so. In Washington, the most skilled practitioner of this dark art is Speaker Nancy Pelosi If health reform craters, Pelosi will disingenuously claim that she did precisely what the President asked of her, and blame the Senate and the President for its failure.
In reality, Pelosi’s “leadership” almost fatally wounded health reform last summer. If the process does collapse, the blame should fall squarely on her shoulders. Her poor political judgment led directly not only to squandering a nearly 80 vote majority, but also exposed embarrassing and ill-timed disunity among Democrats on a signature domestic policy issue. It won’t be the Republicans that killed health reform, but incompetent Democratic Congressional leadership.
PLAGIARIZED FROM KEVIN MD
Electronic medical records need to better focus on patients
By Kevin on emr

The biggest problem with today’s push for electronic medical records is an archaic user interface.
Physician Alexander Friedman, writing a scathing essay in The Wall Street Journal, agrees.
Today’s electronic medical records are written for the benefit of insurance companies, which scrutinize each doctor’s note carefully for billing purposes. But, as Dr. Friedman astutely points out, “thorough, efficient billing doesn’t translate to better care.”
It’s gotten to a point where some doctors print out pages of data to bring to a patient encounter, or scan in dictated notes; both of which defeat the purpose of digital records in the first place.
There are scores of electronic medical records competing the gain market share — but each fails to communicate with one another, and all are burdened with a user interface circa Windows 95 that impedes clinical care.
It’s imperative that we divorce charting from medical billing, update interfaces to today’s standards, and return to why doctors write in the medical chart in the first place — to easier treat and benefit the patient

Reform ? or Revolution !

From my post here you may discern that I was in the 'self pity' mode, last week, something which I like to do once in awhile...'why me?"

Well, I am over that now and into:

'I am mad as hell, and I am not going to take it anymore"  My next swing will be into "charge ahead...Don't look back".  I am sure (or at least hope) most of your can identify with this evolution of mood.

For the past 14 months I have been a civilian contractor for the U.S. Army...I have been 'laid off'....A consequence of the financial crunch facing state and federal governments. Unfortunately I was not the beneficiary of all that "stimulus' money". 

The health reform debate, continues in D.C., in the media, and around town. 

I could 'pull a week's worth of all nighters studying the bills and come away not knowing much more about what would work, and what would not work. 

Frankly as any working physician knows this is very complicated, and in a tight balance financially....changing one aspect would create ripples in the health care economy. 

Promoting the enormous changes in our present Health REFORM  bill would be 'revolutionary, probably counterproductive, and even REVOLUTIONARY.  Not bad, if it brings more freedom, more incentives, and rewards for efficiency.  Measuring outcomes is a slippery slope.  With rapidly evolving medical technology where do we set the bar? 

Health Train Slows Down

Things are a bit slow this morning. A welcome respite. I spoke to wifey, who is still on the "left coast' tending to our adult children, who seem a bit reticent to step off into the world we are leaving them. I thought I would be retired by now, or at least tending to an alternate career, reading, writing, sitting on the park bench playing chess....or on the beach....not so. At times I thought I had my whole life well planned and structured, fool me!!!.
This post is going to be mostly a long ramble...that's what happens when I have a few unstructured moments. For five years or more I have blogged on a variety of subjects, ranging from health information exchanges, EMRs, health reform, generalized sarcasm and humor as well as commentary on my fellow bloggers meanderings.
I often wonder how some of these "overworked" and underpaid younger brethren' have time to write so many blogs. (Do they have 'ghost bloggers' ??).
Some of my favorite medical social media sites are KevinMD,DrWes,Medinnovationblog,The Health Care Blog, WSJ Health Blog, Cutting Through the Crap (written by the former publisher of Surgeon's Blog), Buckeye Surgeon, DistractibleMD, and more.
My guiding light platform is bloglines.com

Like my blog ramble today, things turn on a dime. Just found out I will be 'retiring' on April 2, 2010....that will give me a lot more time to blog. Happy Hospitalist, watch out....you too DistractibleMD.

Hal Scherz will be happy that I have more time to dedicate to Doctors 4 Patient Care.

Perhaps I can find a position in government (I hear they are hiring with all the stimulus money)...

Anyone need an ophthalmologist? ....will work for food !! Pity