It’s Not Easy Being Right

Justice, and the American Way

The Title of the Post today is a take off from Kermit the Frog, “It’s not easy being Green” (unless you are Al Gore)

There is some good news in the fight for ‘freedom” and opposing laws that are counter to the U.S. Constitution.

ATLANTA (AP) - Judges on a federal appeals court panel on Wednesday repeatedly raised questions about President Barack Obama's health care overhaul, expressing unease with the requirement that virtually all Americans carry health insurance or face penalties.

All three judges on the 11th Circuit Court of Appeals panel questioned whether upholding the landmark law could open the door to Congress adopting other sweeping economic mandates. The panel is made up of two Democratic appointees and one Republican appointee.

During almost three hours of oral arguments, the judges asked pointed questions about the so-called individual mandate, which the federal government says is needed to expand coverage to tens of millions of uninsured Americans. With other challenges to the law before other federal appeals courts, lawyers expect that its fate will ultimately be decided by the U.S. Supreme Court.

Hope ?

del.icio.us Tags: justice,constitution,Affordable care act,Federal appeals court,Atlanta,11th circuit court

Prezi A novel way to present

 

I decided to use a  new presentation application for variety.

 

NHIN-National Health Information Network on Prezi

Where to Go Not to Die (Hospitals)

Thomson Reuters today announced the top 10 Health Care Systems. And there are surprises in the list.

1. Advocate Health Care*  ― Oak Brook, IL

2. Cape Cod Healthcare ― Hyannis, MA

3. Care Group Healthcare System ― Boston, MA

4. Kettering Health Network* ― Dayton, OH
5. Maury Regional Healthcare System ― Columbia, TN

6. Mayo Foundation**  ― Rochester, MN

7. North Shore University Health System ― Evanston, IL

8. OhioHealth* ― Columbus, OH

9. Partners Healthcare ― Boston, MA

10. Spectrum Health** ― Grand Rapids, MI

Health Train’s first observation is that there were three systems in the Boston, MA market, one of which is in a relatively small town on Cape Cod.

Secondly many are in what I consider, smaller markets and finally there were only two systems that has been on the list more than once, and three that have been on it twice. This may be an indication of the effects of outcome studies and penalties for ‘never events’.  Hospitals seem to be paying attention to updated guidelines to ensure patient safety.

Overall Jean Chenoweth, senior VP for Performance Improvement at Thomson Reuters said, 

"To produce consistent, strong performance across multiple hospitals, health system leaders must be providing crystal clear goals and communication as well as the means for staff to execute effectively,"  Chenoweth went on to say, “These systems are positioned well  as we move into the era of health reform”.   The Train is on the move !

The performance of 258 health systems were judged on these metrics:

 

• In-hospital mortality

Medical complications


Patient safety

Average length of stay


30-day mortality rate (post-discharge)

30-day readmission rate (post discharge)

Adherence to clinical standards of care (evidence-based core measures published by the Centers for Medicare and Medicaid Services


Hospital Consumer Assessment of Healthcare Providers and Systems patient survey score (part of a national initiative sponsored by the U.S. Department of Health and Human Services to measure the quality of care in hospitals). 



More details can be found here

del.icio.us Tags: top 100 health systems,thomson reuter,health reform,outcomes,jean chenoweth

Graduation Season in Medicine

 

Here’s a great graduation speech by Zdogg MD who also blogs.

Zdogg raps at  ZDoggMD

I cannot add much to this soliloquy except to say  “Right On”  Remember those days when we were fresh as picked carrots or celery. Ready to overcome all obstacles, then chewed up by life, medicine, and finally our wonderful government.

Mature Physicians May Quit

Mature Physicians May Quit Rather than Recertify

Although many statistics elaborate on how much money physicians earn, these figures, and averages are very distorted.. Averages are very misleading. A few extremely high earners will distort the average. Real statistics including medians, standard deviations, probability factors would reveal the truth about physician earnings.  As overhead continues to rise and reimbursements decline, as well as patient volume being forced to expand Health Train   predicts a rapid decline in physician-surgeon numbers.

Many have already abandoned their private practices and have joined group practices, not only to relieve stress, but also as a transition to a non clinical or even non medical career, using their relatively free time to become educated in business or begin a career in technology, sales, or related biomedical career, consulting for pharma or other medically related business.

Orthopedic surgeon Lee Hieb, M.D., current president of the Association of American Physicians and Surgeons (AAPS), writes that she had to spend time studying theory of joint replacements, which she never does, instead of focusing on spine surgery, her specialty. Then she needed to hire a lawyer because bureaucrats were refusing to allow her to sit for the examination—for lack of a signature sheet on her application.

 

Recertification has become a cottage industry of bureaucrats and testing agencies, dragging with them a few university physicians,” she writes, in the summer 2011 issue of the Journal of American Physicians and Surgeons.

Many physicians are choosing not to recertify. According to the American Board of Internal Medicine, 23 percent of general internists and 40 percent of subspecialists are not renewing their internal medicine certification.

The added requirement of re-certification, while well intentioned, is expensive in it’s own right, and creates loss of income while preparing for the exam and absence from the practice. It is unnecessary and redundant. The addition of unsubstantiated ‘evidence based medicine’ is also ridiculous given the intense study and scientific method of peer reviewed journals in the training process.  Obviously whoever writes these ‘protocols’ is far out of the training loop, and exists in the past by at least a decade.   It should not be in the domain of insurance companies, nor Medicare to set standards when hospital credentialing and medical boards set a standard for medical licensure in each state by requiring documented CME every two years to be eligible for re-licensure. The American Boards were duped into providing these examination without taking these factors into account, rolling over fearing another government agency would take it over. Once again our ‘leaders’ who are mostly academics compromise to appear compliant and cooperative as agents of a government that is out of control.

If these entities want assurance that doctors are up to date let them query state medical licensing agencies, or hospitals. They now  represent consumers, rather than doctors. In California the power and authority have now been given to political figures on our licensing board, in the name of ‘enforcement’, alluding to physician inability to police themselves

In the airline industry who pays for pilot testing and recertification? The airlines. So perhaps hospitals and insurers should do the same for physicians.

Okay I am on the far left (or is it right?)  It really does not matter because I am way out on a limb bringing this up, but I  also know that in the elevator or in the doctor’s lounge, these major annoyance are always discussed by colleagues.

Okay so it may be worthwhile to certify or recertify in skills and newer procedures, but this is in the domain of hospital specialty departments, and is actually served better with peer pressure and education.

I am also getting  suspicious that doctor lounges and elevators are monitored. I know elevators have cameras…why not microphones. I am almost fearful my laptop is monitored with my camera, microphone, and maybe even a key logger….laugh if you will at my pseudo-paranoia, but think about the things that have happened in our dis-belief already.

Physicians & Surgeons alike are retiring early, frustrated, overwhelmed and discouraged, in an environment where physicians are in short supply. While there is an imbalance between numbers of PCPs and Specialists there is no over abundance of specialists. Take a look at wait times to see a specialist….there is your true indicator….not a meaningless misleading ratio.

Common sense must prevail, yet I see no indication that our representatives use common sense (or is it ‘evidence based medicine?) or fathom this simple measure.

del.icio.us Tags: enforcement,continuing medical education,medical boards,AAPS,Doctors Tea Party,PCP,Primary care,Specialty care,mad as hell

Is Health Care a Right?

 

This edition of Health Train will be an aggregation of videos on American Health Care Reform. The sources are many, the opinions diverse.

Learn more about it because it may happen to you unless changes are brought about in the coming 2012 election. 

Alita Eck MD

Town Hall Meeting Q&A Part II

Town Hall Meeting Q&A Part I

Phil Gingrey (R-Ga)

Yaron Brook PhD.  The Immorality of Government

Health Care is Not a Right   Leonard Peikof

Health Care is Not a Right Part II  Leonard……….

Debate: Is Health Care a Right? Barak Obama

Health Insurance is not a right

Ron Paul on Many Issues with Larry King

"Seinfeld Rips Larry King": more than 3 million views.

"Ron Paul nails Larry King": less than 100,000 views.

America is 30 times more interested in sitcoms than in the future of their nation.

del.icio.us Tags: ron paul,health reform,health rights,larry king

What every Patient and Doctor Needs to Watch and Read

 

The Doctor's Story: How Obamacare is hurting the patient-physician relationship

Your life is at risk !

A frightening perspective, no physicians at the table, but it is what it is.

If you don’t want to watch the whole video or don’t have time (and what MD has time?) You may read their testimonies below:

1.Jane Orient MD        2, Richard Amerling MD

Jane Orient MD is a former VA Physician, now in private practice. She compares VA medicine with it’s bureaucracy and comparing the efficiency private practice.

Richard Amerling MD is a practicing hospital physician. His commentaries are personal opinion and do not represent the hospital.

Your New Health Care System

A system designed to fail. When will common sense guide our leaders?

In the video above, Dr (Congressman) Burgess elaborates on possible outcomes and questions about ACOs.

Capital requirements rule out Physicians running an ACO. However doctors ultimately responsible to patient.  Rules are not favorable to that outcome.

Will the Physician be accountable to the patient or the ACO?

Injunctive Relief should not be necessary since officers of the federal government should respond to court orders (may be doubtful).

Ultimately 2012 election will become a referendum for APPA, if President Obama loses most likely outcome is legislation to either repeal APPA or significant revision.

Congressman Michael Burgess M.D. (R,Texas) wrote the book, “Doctor in The House” 

Dr. Jane Orient stated that the ultimate pay for performance and/or quality is the patient.

The presenters are highly articulate, and accurate. I recommend this presentation to everyone.

del.icio.us Tags: Jane Orient,Michael Burgess,Richard Amerling,ACO,Obamacare

Specialist-o-Phobia

 

    

 

Have you noticed the recent trend against specialty physicians? Now I am not against primary care, and since the ‘policy-wonks’ and those who know more about medicine than I do,  have determined that primary  care needs incentives to attract medical students away from those ‘highly lucrative’ specialties such as plastic surgery, orthopedic surgery, interventional cardiology, and neurosurgery and others for a choice of primary care.

Our federal government believes in equal opportunity, except in medicine, and even more so if you wish to become a family doctor.There are incentives sponsored by cities, states, Indian reservations, public health service, and more if one wants to become a family doctor in turn for serving in a community. There aren’t many of those for specialists, except perhaps for psychiatrists.

  All students have equal opportunity to specialize provided they can navigate the competition for residency spaces in their chosen specialty.

Three specialty groups qualify as primary care in certain settings, OB/GYN, Pediatrics, Internal Medicine,and Emergency medicine (if one choses to be listed as a primary care physician (have I forgotten anyone?). Wikipedia defines a PCP as a physician/medical doctor who provides both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis.

Arguments about the quality of care comparing PCPs to specialists have abounded since I  began practicing 40 years ago.

Studies that compare the knowledge base and quality of care provided by generalists versus specialists usually find that the specialists are more knowledgeable and provide better care.^[3][4] However, these studies examine the quality of care in the domain of the specialists. In addition, these studies need to account for clustering of patients and physicians.^[5] 

Studies of the quality of preventive health care find the opposite results – primary care physicians perform best. An analysis of elderly patients found that patients seeing generalists, as compared to patients seeing specialists. (would you expect a cardiologist or orthopedic surgeon to give vaccinations?) This measure of quality is open to much criticism.

I have nothing against primary care doctors. In fact I practiced general medicine in the Navy, and following that for several years in family practice and emergency medicine. I had an exceptional clinical training during medical school, and also in internship.  I had a chance to practice independently in the Navy as well with my duty station on a Naval Aircraft Carrier.  Perhaps I am biased now, because today I see few specialists who are capable of practicing general medicine. They in fact rely on PCPs and/or FPs and internists to screen their patients for surgery thereby increasing their work load significantly. Specialists know more and more about less and less as time goes by. 
In fact it takes a very very smart doc to practice general medicine. It is a  very interesting and varied practice, and also quite demanding.

Most specialists do not pick their specialty based on income alone. It is a mixture of lifestyle, knowledge base and the proven ability to exceed or show interest in the specialty to have attracted the attention of a mentor or department head of an elective rotation earlier in their career, usually in medical school. Our current medical education system is now throttled by the fact that there are few free standing PGY-0 programs (that’s medical-ese for internship.   Thus a medical student by the first part of the fourth year has to make a  decision based upon medical school experience in an academic environment. (in most cases not like real clinical practice in the real world)

The  ultimate slap in the face for specialists is the blatant prejudice in the HITECH Act and stimulus funding for electronic medical records and meaningful use. 

The Regional extension Centers are specifically designed to develop an HIT workforce and to assist doctors in developing EMRs and funded by the feds allows primary care doctors to use the resource for free, while specialists are required to pay a fee for  service. OUTRAGEOUS ! We specialists pay our taxes as well.

The entire structure of HITECH is biased toward publicly funded entities, community health centers, (federally qualified, of course) (do these entities pay taxes?)  The APPA (stimulus) mandates that the Secretary of HHS a lot these funds at his (her) discretion within the parameters of the act.

Is it too late to change these limitations for incentives, and/or RECs? The regulations blatantly discriminate against more than 3/4 of all physicians, they prioritize PAs. NPs over MDs.

All of the above are issues taking place in the setting of:

Shortages of primary care physicians are an increasing problem in many developed countries. In the United States, the number of medical students entering family practice training dropped by 50% between 1997 and 2005.^[16] In 1998, half of internal medicine residents chose primary care, but by 2006, over 80% became specialists.^[17] A survey Research by the University of Missouri-Columbia (UMC) and the U.S. Department of Health and Human Services predicts that by 2025 the United States will be short 35,000 to 44,000 adult care primary care physicians.^[18]

In 2004, the median income of specialists in the US was twice that of PCPs, and the gap is widening.^[   Causes parallel the evolutionary changes occurring in the US medical system: payment based on quantity of services delivered, not quality; aging of the population increases the prevalence and complexity of chronic health conditions, most of which are handled in primary care settings; and increasing emphasis on life-style changes and preventative measures, often poorly covered by health insurance or not at all.

Where is the AMA and the other societies in this mix. I haven’t heard much about protesting this inequality. Perhaps we should involve our patients in this quest for equal opportunity.

del.icio.us Tags: primary care,specialty care,hitech,regional extension center,emr,hie,hit,physician incomes

Why Health Reform and Medicare Reform is so Difficult

 

Here’s a classic intercourse and debate between Republicans and Democrats…Watch The video:

Do reasonable men disagree reasonably? Or is that hype for the media and the public?

del.icio.us Tags: video,republicans,democrats,medicare reform

10 Dumb Things To Do At The Doc’s Office.

 

 

Plagiarized from CNN News

These tips and instructions for patients should be printed on a placque in several places in every medical office, clinic and hospital..

From interviews with a gynecologist, a cardiologist, a rehabilitative medicine specialist, a fertility doctor and an internist, here are the Top 10 things patients do to mess up their own care.

1. You talk on your cell phone. (my favorite bugaboo..just plain bad manners)

This is your health we're talking about. Other calls can wait. Turn the (f**king) thing off.

2. You lie.

"I need to treat you the best way I can, so if you're gay, tell me. If you drink a bottle of tequila every night, I need to know. If you're having an affair and not using condoms, let me know," says Rankin, who blogs at "Owning Pink." "I promise I won't judge you."

3. You do a sloppy job describing your pain.

Is it stabbing or burning? Sudden or constant? Tingling or hot? The answers will help your doctor make the right diagnosis.

"You should describe the exact location, how intense the pain was, what provoked it and how long it lasted," says Dr. Nieca Goldberg, director of the New York University Women's Heart Program.

The week before your appointment, keep a diary of your pain and your other symptoms, too, advises Dr. Loren Fishman, a clinical professor of rehabilitative medicine at Columbia University College of Physicians and Surgeons. He suggests using this time to also think about the questions you want to ask your doctor and what you hope to get out of your appointment.

4. You don't state up front all the reasons for your visit.

If your ear hurts, your knee pops out when you run and you have a sty in your eye, state all three concerns at the beginning of the appointment so your doctor can plan your visit efficiently, advises Dr. Howard Beckman, an internist and clinical professor of medicine at the University of Rochester.

5. You don't state up front your expectations for your visit. ( all doctors hate it when the patient on the way out tells you what they really were here for.)

If you have certain hopes or expectations -- the doctor will pop that sty in your eye or prescribe antibiotics for your sore ear -- say so. The doctor can then explain if your expectations are realistic, and you'll be happier in the end.

"Sometimes patients are out of proportion to what the reality is, like the 44-year-old woman who hopes to get pregnant in one IVF cycle," says Dr. Jamie Grifo, program director of the New York University Fertility Center. "If they don't communicate their expectations, then I can't address them."

6. You don't know what medications you're taking.

"Patients should bring a list of medications they're actually taking, not what they believe they are supposed to be taking, or what they think I want them to take," Beckman advises.

If you take supplements, Rankin suggests you bring them in, since supplements aren't standardized like prescription drugs, and your doctor will want to see all the ingredients.

7. You leave with unspoken questions and concerns.

If a question's in your head, ask it, even if you think the doctor is rushed. If you're worried your headache might be a brain tumor, say it even if you think you sound like a hypochondriac.

8. You don't bring your medical records or images with you.

Yes, even in this day and age, many doctors rely on the fax machine to send medical records to and fro. Faxes goof up, so unless you absolutely, positively know your doctor has your records and images from another office, bring them with you, doctors advise.

9. You're too scared to disagree with your doctor.

If your doctor suggests you need an antidepressant and you don't want to take it, say so instead of nodding your head, taking the prescription and throwing it away the minute you're out the door. Or if she suggests a medication you can't afford, just say so.

"I know many of you are programmed not to question your doctor, but we can't read your mind, so we need you to communicate," Rankin says. "If the treatment plan I suggest doesn't resonate with the intuitive wisdom of your Inner Healer, please tell me, instead of ignoring what I suggest."

10. You don't comply with the treatment plan.

For doctors, this is the granddaddy of them all. If you've followed all the advice above, you should have a treatment plan that makes sense to you and one you're able to execute. (If you didn’t or couldn’t tell your doctor why. no money, lost medications, made you sick, don’t believe in medications)

"Please follow through and do what you've agreed to do," Rankin says. "And if you don't, please tell me so I don't mistakenly assume the treatment failed. I won't jump all over you. I just need to know."

del.icio.us Tags: doctor visits,treatment plans,things not to do

USB & Your Health

 

This afternoon I was at my local Drugstore in line waiting for my prescription medication.  I regularly scan the shelves to see how technology is impacting the retail pharmacy business. There are the usual blood pressure monitors, glucometers, pregnancy tests,  STD tests, HIV tests, etc.

Even with all the hype about PHR, there has been a paucity and near absence of products which are supposed to make home health monitoring accessible to the patient’s physician.

Today I saw a glimmer of hope. My eye caught “USB” on a package, and no I was not in the electronics department.  Closer investigation revealed the Bayer’s CONTOUR USB meter. It looks quite like a standard USB flash device. Closer inspection reveals a few important differences.

The  device has two ends, the first has the usual insertion slot for test strips, the other end has a standard USB connection with a protective cap.

Overall the CONTOUR is the same size as a standard stick. On one side is a highly visible digital display for the measure blood glucose, and the time at which is was recorded. Software is available for Mac, Windows, to interface with a laptop, or desktop.  There was no mention for handheld portable devices, or interfaces for smartphones.

Health Train thinks that this may be a beginning, however the utility of the CONTOUR is severely hampered by the lack of it’s ability to transmit data directly to an online PHR. Perhaps this is the next step. Perhaps this will be a function of the PC software. At any rate Baxter fails to give it the final “kill”.

The software (which must be downloaded from an online source at Baxter does allow storage with graphs and trends for blood glucose levels as well as the ability to print results and graphs in  a pdf format.

Health Train can see a project for Health 2.0 Challenge to develop the glucometer which would plug directly into an iPhone, Android, or RIM smartphone and beam a report directly to the PHR or doctors EMR.

The price-point is amazingly low. My pharmacy was selling it for $ 75.00, about the same price as some of the high end standard glucometers.

A standard User Manual is available from their web site:

del.icio.us Tags: glucometer,usb glucometer,baxter contour,diabetes,monitoring,phr

The Reform Is Not the Change

According to Joseph Flower who writes in The Health Care Blog this weekend, Health Reform is not the Change, but rather The Catalyst, and according to him, “The enabler, and an accelerator of the change we are going through. It is not the change itself, and is not even the cause of it, because the change is driven by much larger economic and demographic factors, especially by the crushing cost of healthcare. If the reform law were to go away, the change would not go away.”

I agree with Joe. Many readers ask me if I am for or against health reform. My short answer is ‘yes’, to both.  Anyone who is vested in the present system, i.e., physicians, hospitals, health plans, pharma, payers, etc. exist with a certain level of ‘tension’ with their partners and ungarners. The tension with present system for most systems is near a breaking point. The question all are asking ‘Will this get better with a change, stay the same, or get much worse.

No doubt there will be ‘pain’ with reforms. Change seems to be difficult for most, however the human condition and potential for change is enormous with adaptability and acclimatization to seemingly impossible challenges, physically, intellectually and emotionally.  Let’s face it, Health Reform involves all of it. Fortunately our DNA was designed for changes to occur.

del.icio.us Tags: health reform,catalyst,joe flower,the health care blog,health train express NPR

A Story of Drug Addiction, Sadness and Love

Although the original version of this song by Mylene Farmer earned better critical acclaim, this version by “Moby” fits the Health Train Express for  physicians and families dealing with fatal illnesses and drug addiction will find these videos  breathtaking. I hope you will all enjoy this musical interlude:: “Blue Noir”

Moby Version

I also cannot help but include Mylene Farmer’s version of, ‘Blue Noir”

Mylene Farmer

The music and video above are copyright by the artist and the label. They should not be copied for commercial purposes. 

GML