Fasten your seatbelt, it’s going to be a bumpy ride, if you can get there at all. If you wish to read Jonathon Rauch’s popular article in National Journal Review, read on…..comparing Airline Travel and Health Care. otherwise watch the video.
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Friday, July 8, 2011
A Marxist Turned Libertarian on The Health Train
In preparing for today’s journey on the Health Train my travels took me to a video by Thomas Sowell. Dr. Sowell was born a poor African-American black man (as opposed to a poor white African American (which is a real possibility, although statistically unlikely), whose innate intelligence, drive, and smart choices enabled his gifts. He chose to follow the ideas and the man who mentored him rather than the institutions that brought them together.
Thomas Sowell indicates that his mentor was Milton Friedman, a name well known to those interested in economic theory. Here is the video….it should spark some controversy and lead you to learn more about Mr. Sowell and more important, the simplicity and detail about how Government Medicine works and why it does not work well.
Dr. Sowell’s opinions are at times controversial. (Wikipedia)
Dr Sowell has been a senior fellow at the Hoover Institute of Stanford University (1980-present)
Sowell has been criticized for various remarks such as a comparison he
made between President Barack Obama and Adolf Hitler in an editorial for Investor's Business Daily[26] after the creation of a relief fund for the BP oil spill. This has been criticized by liberal groups such as Media Matters[27] and the Democratic National Committee.[28] However, Republicans such as Sarah Palin[28] and Representative Louie Gohmert[29] have endorsed Sowell's comparison. Sowell was also criticized for an editorial in which he stated that the Democratic Party played the Race card, instigating ethnic divisions and separatism, and argued that a similar situation occurred between the Tutsis and the Hutus in Rwanda.[30][31]Which List Do You Want to be On?
Tweeting has added a new dimension for connecting to others with similar interests. The short 140 character only slightly exceeds my short attention span. I can quickly absorb and scan through tens of ideas between patients, while waiting in the doctor’s lounge to start a surgery, and G-d forbid waiting for an attorney to give a deposition.
A tweet attracted my attention from @MtnMd, ,Founder&Chief Medical Officer of eMedicalMall, technology company serving medical community & patients to improve health care. @ MtnMD also posts a blog,
Sprocket, a compendium of lists divided into categories of credibilty. Sprocket is now added to my followed blogs, I find it useful as a starting point to expand my meager knowledge base of social media stars in medicine.
Medical State of Mind
Medicine has gradually been drawn into a state of mind where legalese and bureaucracy have replaced medical and scientific results. “Evidence based medicine” has surpassed scientific results, or empirical outcomes as the arbiter for treatment choice. Anecdotal clinical opinion has been replaced by ‘hearsay’, and humans are enhanced or even replaced at times by machines.
Evidence Based Medicine can best be graphically modeled by the ‘evidence pyramid’ a term borrowed from the food pyramid:
The pyramid best outlines the progress in medicine, and the addition of 4 new levels of critical analysis of treatments.
Clinical medicine is never stationary,nor should it be, without which there would be no progress.
Has blogging enhanced medical practice? I say yes, and the evidence is the exponential use of the social media, which allow practitioners to share knowledge on a daily basis, not only in science, and clinical practice, but in the management of medical business. It can be accomplished from the office, home, even on the street. The same resources are present almost no matter where you are working.
3D imaging is becoming available which will enhance mobile CT, MRI, and Optical Coherence Tomography and remote telemedical applications.
Nanotechnology is now better understood and wishful ideas about it’s applications are becoming a reality in drug delivery systems, manufacturing of better, stronger and more durable products. These will slowly infiltrate our biomedical devices in the operating room, endoscopic equipment and electronic equipment, including computers.
Physicians and patients alike will have another ‘gee-whiz’ device.
L-R Physician, Patient
Drug Delivery System
Hopefully this new ‘paradigm’ will bear fruit, and not deceive us.
a field manual to fallacies in thinking
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Friday, July 1, 2011
Welcome new Interns and Residents
Another July 1st arrives at the Medical Centers of America. Educated observers remark at the fresh neatly pressed white coats entering the hospital. At the same time these fresh young eager newbies enter there are others exiting, looking a bit scraggly, with facial hair and coats that are a bit yellowish in places.
Most of these new entrants have already accomplished registration, parking lot ID cards for their cards, and obtained personal ID badges, computer access codes, locker keys, and been directed to where their incoming mail is deposited.
Some are already familiar with electronic medical records, while some may not be, however all will have to learn a new EMR system (unless they went to Medical School at this Medical Center)
Some people know better than to be admitted to a teaching facility during July, and certainly not in the first week, certain that new interns and residents will make errors, and forbid, ‘A Never Event’.
Now there will be additional stress and inefficiency as the new house officers struggle taking three times as long to enter data into an EMR as it does to see and care for you, the patient. However I am told, “This is progress”
Many changes have taken place over the 4 decades I have been in clinical medicine. Work hour limitation rules,, Specific competency certification and documentation of procedures and the numbers performed by each trainee, also a bevy of new numbers, NPINs, DEAs,UPINs, Medicare, Medicaid, MD license, and many more.
Most are carrying their own preference for a smart phone..pagers are almost gone, iPads and lightweight notebooks are in. Many are comparing their iPhone apps or Android apps seizing opportunity where it may be.
eMail and Chat are out, Social Media is in. So much in fact that major health centers have developed strict guidelines for the use of Twitter, Facebook and lesser known social networks.
Health Blog Q&A: Mayo Clinic’s New Center for Social Media announced the creation of a Center for Social Media.
Washington University, St. Louis has promulgated Social Media Guidelines
The Wall Street Journal weighs in with advice for tweeting for new medical residents.
The Mayo Clinic’s social media statistics read; Twitter 60,000 followers (paltry compared to Lady Gaga), although their YouTube channel is said to be the most popular medical provider channel. Their Facebook page enumerates over 20,000 connections (or friends)
Mayo Clinic
The Use of Social Media in the Patient Care Environment:
3 commentaries on Social Media Admonitions
del.icio.us Tags: twitter,facebook,tweeps,social media,mayo clinic,cleveland clinic,geisinger,interns,resident physicians,emr,white coat
ACO's and CMS
The Accountable Care Organization is really an accounting mechanism and may have little to do with quality of care, or improving outcomes. Commonly called, “ACO” in health care circles it holds a high place in current opinion and controversy revolving around health reform.
Added to the mix are claims that HIT is an essential component of ACO. Health IT is essential not only to accountable care organizations (ACO) but also healthcare in general, said HIT advocate Kathleen Sebelius, MPA, Secretary of the U.S. Department of Health & Human Services (pictured), at today's Second National Accountable Care Organization Summit in Washington, D.C.
Reactions from organizations and providers have ranged from lukewarm ambivalence to visceral outrage from some of the leading health systems and professional physician associations. CMS is currently reviewing 1,200 comments after it issued the draft rules in March and is expected to take the comments into consideration before issuing a final rule.
Some health systems reacted with letters to HHS with suggestions based upon their own plans and projections for developing integrated health systems. In reviewing many of these projects it becomes apparent that the ACO moniker applies to many forms of integrated health systems. Some have been in development for five or more years.
12 ACO Developments Between Hospitals, Payors and Health Systems
At the same time, some health systems have implemented ACOs of their own design without HHS mandates or guidelines. Some are in different stages of planning and implementation.
The process is gradual and some have utilized their early iteration of integration as a base for further progress for their organizations. That is as it should be. For HHS, CMS or any governmental organization to mandate how this will be done is foolish and probably very wasteful.
One of the barriers to ACOs, organizations and providers have criticized, are the associated start-up costs of implementing such an overhaul of the system for Medicare payments away from fee-for-volume In addition, ACOs present legal challenges in which antitrust laws may prevent market dominance that could be an indirect result of organizational and provider collaboration. In addition, there are challenges in patient notification of ACO participation.
Several large prominent Health Systems, such as the Mayo Clinic, Cleveland Clinic, Geisinger Health System, and Intermountain Health Care have either indicated they will not participate in ACOs or have blasted CMS. Numerous physician groups, the AMA, AMGA, AAFP, and ACP call into question the ability to form ACOs without massive disruption of health care.
The Center for Medicare and Medicaid Services (CMS) has released it's draft rule, 42 CFR Part 425, a proposed ruling in the Fedral Register, Vol 76, No 67/April 7, 2011), not quite as long as the Patient Affordable Care Act (1200 pages) however 127 pages
The current iteration of ACO by HHS is by no means final. Secretary Sibelius acknowledged that the proposed draft was just that, a proposal. CMS is currently reviewing 1,200 comments after it issued the draft rules in March and is expected to take the comments into consideration before issuing a final rule.
Wednesday, June 29, 2011
ePatient Dave is In The Room
Some of us talk about the “elephant in the room’ which everyone knows about but ignores. We also may make the same mistake about the person across from you in the examination room.
Watch this video….Dave deBronkart is not only articulate and entertaining at this TED talk, he has some original ideas about communicating ideas to patients.
Let’s see if Google or some other software can develop this one. If Facebook and twitter are worth so much money, how much would these advances make for our patients.
follow ideas on twitter glevin1 facebook/gmlevin
Tuesday, June 28, 2011
Darwinian Social Media Engagement
The Health Train Express enjoyed an enormous response to our series on social media for medicine.
Many asked questions, so I am including some more advanced feature sets from which to obtain material, organize your SM entries, to analyze your network as well as to organize it.
Forrester has released a new report, Accelerating Your Social Maturity: How To Move From Social Experimentation To Business Transformation, which you can also find as a new chapter in the newly updated paperback version of the Groundswell book.
While this report is written with the larger enterprise in mind, much of it applies to your neophyte media presence. It serves as a framework for your social media programs.
Five Stages of Social Media Maturity offers new as well as mature social media users of all sizes new ideas.
Social media is a dynamic environment, and that is one of the reasons for engagement. It seems to always announce new ideas, and trends.
Thursday, June 23, 2011
How would you like it?
Imagine if you will, a transformation of computer power and interfaces that would allow real virtualization in space transmitted by your hands, and body movements, similar to what the Wii or Kinect do with gaming.
Here is a technology looking for an application, perhaps in neurosurgery or operating in a closed body space, virtualized and harmonized with MRI and/or PET scans.
Oblong’s radically condensed G spatial operating environment. Yes Doctor, you too can be like Tom Cruise in the “Minority Report”. Try this on full screen with HD
Hollywood imitates life. And sometimes life imitates Hollywood.
John Underkoffler, who led the team that came up with the interface that Tom Cruise’s character used in the 2002 movie “Minority Report,” co-founded a company, Oblong Industries, to make the gesture-activated interface a reality.
Using special gloves, Mr. Underkoffler demonstrated the interface — called the g-speak Spatial Operating Environment at the annual TED conference in Long Beach, Calif., a series of lectures by experts across a variety of technologies.
He pushed, pulled and twisted vast troves of photos and forms that were on a screen in front of him, . He zoomed in, zoomed out and rotated the images using six degrees of control. In one part of the demonstration, he reached into a series of movies, plucked out a single character from each and placed them onto a “table” together where they continued to move.
In this conception of computing, the input and the output occupy the same space — unlike a conventional computer, in which the mouse and computer keyboard are separate from the screen, where the changes appear.
Gesture-based interfaces are among the most significant advances in computer interface design since the mid-1980s, and they are part of a trend of accelerating advances in how humans interact with computers.
Gosh, I wish I was just entering medical school.
del.icio.us Tags: oblong,virtualization,spatial operating system,minority report,Unkerkoffler,MIT media labs
Tuesday, June 21, 2011
The Individual Mandate & AMA
The American Medical Association announced yesterday that it was supporting the ‘Individual Mandate” in Obamacare.
This is puzzling, because the AMA has always defended personal liberty, freedom and the sanctity of the physician-patient relationship.
If one thing offends most healthcare providers it is this mandate, since it smacks of being unconstitutional and loss of a significant freedom. It surpasses even the internal revenue service’s income tax and the manner in which it is collected.
While the mandate is being strongly opposed by at least 30 states and awaits judicial reckoning it is even more puzzling why the AMA would come out prior to any judicial decision. Perhaps the AMA announcement is meant to sway public opinion and judicial outcomes. Perhaps this is the means for the AMA to become a public policy force. However IMHO this is misguided and will surely alienate more physicians.
This author is not against expanding healthcare to those who cannot obtain it for whatever reasons, however this mandate surpasses what government is supposed to do. It is also a financial irresponsibility to enact this part of Obamacare at a time when we are in a severe prolonged recession, and will paradoxically increase health costs and utilization at a time when the number of primary care providers is inadequate.
A novice project manager can tell you that prior to ramping up production a system has to have adequate workforce, supplies, and capital.. Our elected officials have little knowledge of micro-economics, repeatedly displayed in stimulus funding and healthcare.
Obamacare is constructed in a world of fantasy, wishful thinking, altruism, and thoughtless construct. The reality is millions of uninsured patients. A quick solution is going to disrupt things even further.
Well meaning change should be gradual, and without sweeping authority given to the head of HHS.
Part II tomorrow on Health Train Express.
Friday, June 17, 2011
21st Century Medicine, Part II
“The Revolution will Not be Televised” (Gill Scott Heron).
The Black Panther video from the late 1960s is just the opposite of what is taking place in America in the 21st Century. Although much of the proposed changes appear to be transparent, all of medicine wonders what is really happening in committees in congress, behind closed doors of insurance company lobbyists and our representative as well as hospital negotiations for CMS reimbursements. What is the AMA doing? Is what happening, The revolution will not be televised?
Over the past 20 years there have been many recommendations to alleviate the shortage of primary care physicians. The term itself is worrisome and casts a shadow which belies the nature of family practice in the present setting of medicine beginning in the last quarter of the 20th century.
The advent of managed care, HMOs has also deepened the divide on the landscape of family practice and general medicine.
There are internal factors within the educational system, and also extrinsic factors involving reimbursements, referral patterns, authorization for services,
Central to the issue is a relative shortage of “Frontline Medicine” to Consultative medicine. Frontline medicine indicates the first stop on the Health Train. This point is where the patient enters the non-system. The provider may or may not be a ‘pcp’. It may even be a specialist a pediatrician, an Ob/Gyn, a cardiologist, an ophthalmologist, a chiropractor or a nurse practitioner.
Some say that primary care is what takes place as an outpatient, or not in the hospitals. Or that only specialists should admit to hospitals. This is what is practiced in the U.K. In fact, the general practitioners are called ‘Mister’ rather than Doctor which is reserved for specialists. The GPs do not admit to hospitals.
As a matter of fact there are many hospitals that now employ “Hospitalists” who care only for inpatients, whose care is transferred to them upon admission by a GP and then returned to the GP on discharge. The practical result is that it is easier for the GP to remain in his office and work efficiently, not losing time travelling to and from hospital, and also not requiring a disruption on the office schedule. Yet there is a disruption in continuity of care, and it takes special measures to ensure communications for the transfers. Patients often feel abandoned.
Numerous plans have evolved to attempt to correct the shortage of PCP.
Preferential acceptance of students from poorer communities, and incentives for returning to those communities to practice by forgiving medical student loans. At times this is enabled by the use of the USPHS or Federal grant block funds to community clinics and Indian Affairs.
Medical schools were mandated to increase their class size, increase diversity of the incoming classes, and adding residency programs for family medicine specifically, tied to continuing federal funding, with the threat of losing federal grants if they did not do so.
Some medical colleges, such as the new University of Central Florida, have enrolled a charter class with a four year scholarship free tuition for students with limited assets. The emphasis is on multi-culturalism. Their stated goal is, “The UCF College of Medicine was established in 2006 by the Florida Legislature and the Florida Board of Governors to address the growing physician shortage nationwide and provide economic benefits to Central Florida and the state”
This in a state with a relative abundance of physicians.
The Revolution Will Not be Televised.
Wednesday, June 15, 2011
Medical Schools for the 21st Century
This is the first in a series of articles on changes in education, the physician workforce, and what is driving changes.
Many studies have been done to analyze the physician/population ratios in different areas of the United States. In addition to their being an overall shortage of physicians, there is a disparate imbalance of primary care physicians (formerly called family doctors and/or general practitioner) and specialty physicians. This general statistic does not delve into specific oversupply of specific specialties. In some cases there is a severe shortage of psychiatrists, and mental health professionals. The statistics also do not account for physicians who function in a primary care role, but are not statistically accounted for, as such. For instance, Ob/Gyn, Moonligthing resident physicians who staff ED and Urgent care centers, Pediatricians, some general internal medicine physicians who function in a dual role as a PCP and specialist. Many women use their Ob/Gyn specialist as a PCP.
In the last several decades the number of female physicians accepted into medical school has increased. Women are faced with a difficult choice, biological imperatives and the very real responsibility of medical practice. For that reason many select a specialty with controlled hours, or a hospital specialty such as radiology or anesthesiology, dermatology, not primary care. For those who do select primary care their careers are punctuated by pregnancy, family needs, and often premature retirement, or finding a non-clinical career.
Karen Sibert,M.D. (who is an anesthesiologist) writes in the New York times,
“I’m a doctor and a mother of four, and I’ve always practiced medicine full time. When I took my board exams in 1987, female doctors were still uncommon, and we were determined to work as hard as any of the men.
Today, however, increasing numbers of doctors — mostly women — decide to work part time or leave the profession. Since 2005 the part-time physician workforce has expanded by 62 percent, according to recent survey data from the American Medical Group Association, with nearly 4 in 10 female doctors between the ages of 35 and 44 reporting in 2010 that they worked part time. .
About 30 percent of doctors in the United States are female, and women received 48 percent of the medical degrees awarded in 2010. But their productivity doesn’t match that of men. In a 2006 survey by the American Medical Association and the Association of American Medical Colleges, even full-time female doctors reported working on average 4.5 fewer hours each week and seeing fewer patients than their male colleagues. The American Academy of Pediatrics estimates that 71 percent of female pediatricians take extended leave at some point — five times higher than the percentage for male pediatricians.
Today 53 percent of family practice residents, 63 percent of pediatric residents and nearly 80 percent of obstetrics and gynecology residents are female.
The uniformed medical services have PCPs that are not available to the general public unless they moonlight in an outside practice, hospital, or urgent care center. The statistics do not account for these PCPs.
Other PCPs who are not counted are optometrists, chiropractors, or nurse practitioners working in retail clinics.
Many other specialists will function as a PCP on many occasions to serve their patients for minor illnesses, such as prescription refills, outside of their specialty certification.
A contributing cause to the relative deficiency in PCP accessibility is the increasing rigidity and bureaucracy of the medical system in the United States. Certain medico-legal issues also preclude and diminish the ability to practice general medicine by a threat of litigation when practicing outside the bounds of specialty certification.
The Association of American Medical Colleges estimates that, 15 years from now, with the ranks of insured patients expanding, we will face a shortage of up to 150,000 doctors. As many doctors near retirement and aging baby boomers need more and more medical care, the shortage gets worse each year.
The short answer is yes there is a relative shortage of PCPs, however there is no shortage of specialty physicians. Perhaps there is an imbalance and availability of specialists. Many of the factors are aggravated by what happens between a medical student’s enrollment in medical school, and their graduation from school, or during the training years.
This gap is especially problematic because women are more likely to go into primary care fields — where the doctor shortage is most pronounced — than men are. Today 53 percent of family practice residents, 63 percent of pediatric residents and nearly 80 percent of obstetrics and gynecology residents are female.
Medical licensure by states offers a license to practice general medicine, and in fact does not restrict in most cases what type of medicine a physician practices. Specialty care is regulated mostly by hospital credentialing authority for procedures, and departmental classification by medical staff regulations and bylaws overseen by the hospital administration.
Recently the public’s attention has been brought to the expenses of a medical education, and the economics of 150,000 to 200,000 dollars borrowed to pay for it by a student. Some would say this is an investment in the student’s future, however there are burdens also on society. While it is an economic boon and cash cow for banks regarding interest, it produces another parasitic industry, and more bureaucracy.
Dr Sibert goes on to say,
“Medical training is not available in infinite supply, if it were there would be graduates to replace or supplement those who work part-time, however, can only afford to accept a fraction of students who apply.
An even tighter bottleneck exists at the level of residency training. Residents don’t pay tuition; they are paid to work at teaching hospitals. Their salaries are supported by Medicare, which pays teaching hospitals about $9 billion a year for resident salaries and teaching costs as well as patient care.
In 1997, Congress imposed a cap on how many medical residencies the government could subsidize as part of the Balanced Budget Act. Last year, the Senate failed to pass an amendment to the health care bill that would have created thousands of new residency positions. Even if American medical schools could double their graduating classes, there wouldn’t be additional residency positions for the new doctors. Federal and state financing to expand medical education will be hard to find in today’s economic and political climate.”
Policy makers could encourage more doctors to stay in the profession by reforming the malpractice system to protect them from frivolous lawsuits, safeguarding their pay from further Medicare cuts and lightening the burden of bureaucratic regulations and paperwork.
PCPs carry a disproportionate share of paper-work and also acting as the gatekeeper for specialty referrals, insurance company authorizations, telephone work (none of which is reimbursable, yet takes up at least 10-25% of the daily workload).
Physicians defer saving money during their early years meeting this financial obligation, at the same time deferring home ownership. Many are in their late 20s and early 30s before they have disposable income to meet loan payments. In some cases interest accrues until payments are begun. All physicians are aware of the conundrum, increasing tuition, living expenses, deferred adulthood and dependency upon parents and relatives. Few would make it through the system without family assistance in some form.
The emotional toll of these circumstances cannot be overestimated for medical students and their families. Unlike PhD candidates who receive fellowship grants medical students have far fewer institutional or federal grants, unlike NIH grants, or federal NSF grants.
The deferment of savings also has a severe effect on eventual retirement for the early years the lack of the most powerful investment tool (the compound interest curve of savings, or even other investments is negated).
Compound Interest Curve is exponential
Lack of any saving during the first ten years of adult life, between age 30 and 40 years of age will later effect a physicians life, and statistics reveal there are many physicians who cannot retire or do so in poverty, totally dependent on social security benefits.
The problems are serious, and not isolated from the many challenges of medical practice. Physicians have been left out of the planning process, most practitioners are now isolated from academic medicine and no longer are directly involved in training new physicians. Most of us receive requests from alumni organizations asking for donations, bequeaths and scholarship funding for individual medical students.
Monday, June 13, 2011
What does Bon Jovi or U2 have to do with The Health Train Express?
These images came to mind while I was reading what Brandon Betancourt (a pediatric practice administrator had to say about your staff (and you) putting on a consistent show for your patients. KevinMD in his blog shared Brandon’s take on enabling consistency in the practice on a daily basis and at moments of fatigue and near burnout periods of the day.
I can only add a small addition to Brandon’s excellent allegory about performers, stage hands, physicians and their staffs. I remember as a medical student and training asking myself how I could build my stamina and reliability for my patients. I used the same methodology of pretending I was an actor, performing for each patient encounter. I pictured myself as a third person in the room rather than myself (not unlike an out of body experience).
Unlike actors however physicians are presented with a unique situation for each patient, requiring a different role, and most of the time requiring a different act to suit the clinical objective of the day’s visit.
I always wondered how actors and performers such a Celine Dion, and some very experienced performers accomplished this necessary .
The best actors very rarely miss a beat, the process when repeated often enough becomes automatic. Surgeons have their automatic movements in the operating room, a ritual performance, like a maestro, part of, but also the leader of the team. The supporting actors (actresses) take their cue from the main character. Asking an actor,performer, dancer, musician or artist to do less is anathema. The same for a surgeon or physician. .
Medical clinicians should do the same, and act as leaders for their staff by example. I think Mr. Betancourt’s lesson by allegory is an outstanding way to teach all office and hospital allied health providers their roles in the play of medicine.
The method served me well for over 35 years, and hopefully my last ‘act; was as good or better than my first act in 1969.
del.icio.us Tags: actors,artists,musicians,performers,surgeon,physician,kevinmd,health train express NPR
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