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Healthcare Updates

Links and commentary to healthcare news around the internet

Dr. WhiteCoat Goes to Washington

Sorry about the sparse posting lately – have been away in Washington at an ACEP conference Just so Matt and others don’t think that all I’m all talk and no action, I’ll let you in on some things that I did at the conference. I attended some excellent lectures about leadership. Colonel Thomas Kolditz gave a great talk about leadership in extreme circumstances. He described his interviews with many soldiers, Iraqi prisoners, sports team captains and their teammates, and various other people in leadership positions to determine what makes a good leader. Why do people follow some leaders and not others? Commitment is important. If a leader doesn’t believe in a mission, neither will the rest of the team. Effective leaders work with the team – they get down in the trenches and don’t sit on the sidelines barking orders and cheerleading. Trust is also important. If team members are worried about whether their leader might throw them under the bus, they will second-guess the leader’s intentions. The biggest factor in being an effective leader is competence. Col. Kolditz described his interview with a group of soldiers in an elite army unit. Almost all of them hated their commander. They thought he was a jerk. But every one of them said that when the rubber met the road he knew what he was doing and that there was no one else they would rather have leading them in their missions. I listened to Dr. Melissa Givens, a Lieutenant Colonel in the US Army, describe how difficult it was to manage the shootings at Fort Hood and all of the unexpected difficulties they had in trying to save the wounded soldiers. Ever wonder what it’s like to watch one of your co-workers die right in front of you? She told us how she was in the same room where the shootings took place only two days prior to when the shootings occurred. Very informative and very emotional. I watched a room full of physicians throw up their hands in frustration when a California physician showed how his group and other groups in the state are having difficulty staying solvent because California does not allow medical groups to bill patients fair prices for the care that they provide. Insurers lowball payment to the physicians and the California government made it illegal for the physicians to bill the patients for the remainder of the payments. Many physicians are considering whether or not to leave the state. California patients may soon be getting what they – or their insurers – pay for. There were other lectures about how health care reform fell short and some possible options for the future. One of the most informative lectures I attended was given by a former Congressional aide and current consultant who described his impressions about how legislators come to decisions and what does and does not influence a legislator’s decision-making. Personalized letters to legislators really do make a difference. And I went to legislators’ offices. The legislators weren’t in town when I went to visit, so I was lucky enough to get appointments with some of their staff. I discussed ideas for health reform and medical malpractice reform with one legislator’s assistant. He took my name and said that he was going to have another assistant get in touch with me to get some more ideas and input. I spent 45 minutes talking with one legislator’s assistant who is the go-to person for health care policy. I didn’t try to sell anything to him, I asked him if he had any questions that I could answer ...

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Healthcare Update – 05-18-2010

Lather, rinse, repeat. Difficulty in accessing psychiatric care and lack of follow up blamed for a mentally ill Louisiana patient stabbing her grandmother to death. Sketchy episodic care doesn’t address underlying psychiatric problems. Patients go from emergency department to psych hospital to emergency department. Because only 145 psychiatric beds are available in the entire state of Louisiana, patients who are a risk to themselves or others are sedated and wait in emergency department beds for days to weeks until inpatient beds open up. Effective July, the state is dropping funding for 35 more inpatient psychiatric beds, which will make definitive care for seriously mentally ill patients that much harder. As the emergency nurses complete the every 15 minute checks on sedated patients as required by JCAHO (and complete the requisite paperwork each 15 minutes), there will be even less care available for other patients with emergencies. What are we whining about? The best paying jobs belong to doctors. I saw a graph on a message board somewhere showing that upon graduation from college, it took doctors 19 years to catch up to the salaries made by a UPS driver. While attending physicians are paid well, don’t forget that doctors have to spend hundreds of thousands of dollars on college and medical school – while at the same time their peers are earning money working. Residency positions pay much less than attending positions while interest accrues on the educational loans. When you think about the $105/hour that surgeons are quoted as earning, take away $25/hour in taxes, then deduct $25 to $50/hour each year for medical malpractice premiums, then deduct another $15/hour for student loan payments, then factor in that few surgeons work only 40 hours per week. I’d venture a guess that an average surgeon works more like 60 hours per week. When you hear about how good all the greedy doctors have it, keep in mind that many times there’s more than meets the eye. Eat your veggies, dear, they’re good for you. Woman sentenced to 4.5 years in prison after putting foxglove plants in her husband’s salad. Foxglove is what digoxin – a heart medicine – is derived from. Oh, and if that didn’t work, she also stockpiled the poison ricin. Not sure why they needed a poll to figure this out … When you increase the number of patients with “insurance”, then decrease the number of emergency departments and decrease the number of family practitioners so that the “insured” patients can’t find routine medical care, what do you expect will happen? Emergency department visits will increase and the strain on the safety net will get worse. Hey! Who keeps messing with the nitro drip and why do the monitors keep blinking on and off? Israeli officials dig up grave site and remove Pagan bones to make way for new “fortified” emergency department. The citizens are pissed off. The graves have been desecrated. Can you say Poltergeist 4? Liar liar. Healthcare worker files complaint after waiting 8 hours with abdominal pain at LA County Hospital. She stated that her vital signs were never taken and that she was told the average wait time to be seen was 35 hours, so she left and went to another hospital. After an investigation, it was discovered that the staff took her vital signs 4 minutes after she arrived and that her name was called after only 4 hours. With patient volumes up by 15%, expect wait times at LA County/USC to increase. Do you want me to fill out the JCAHO forms before or after I write admission orders, transfer the ...

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Aging Physicians

I came across a graph in AM News depicting how the physician population is aging. Notice how the the distribution of physicians in 1970 (brown graph) was skewed toward younger physicians. By 2008 (yellow graph), the number of young physicians is significantly lower than any other demographic – including physicians 65 years old and older. The US population during that time increased from 203 million to more than 300 million. The graph demographics don’t state whether the physicians are practicing medicine or whether they still even have licenses, so it’s tough to compare whether the amount of available care per patient is changing. Oh, and for disclosure, the graph is from the AMA statistics, so according to some people that read this blog, the information is biased, comes from a shill organization organized by Phil Howard, and only represents the insurance companies, the Mafia, those Nigerian phone scam artists, and all those people who club baby seals to death. But the thing that caught my eye about the graph was that if the older physicians who are still practicing get fed up and retire, the country stands to lose a substantial proportion of its physicians. The numbers on the graph put the number of physicians 65 and older at around 200,000 and the number of physicians 55-64 at a little less than 200,000. One of the other things that bothers me is that, according to this graph, the country doesn’t seem to be replacing older physicians with younger ones. The population is growing, not shrinking. What would a decline in younger physicians mean for future generations of patients?

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Guaiac issues

JCAHO apparently requires that the doctors show nurses results of all hemoccult testing. I can’t find the actual requirement anywhere, but then again, JCAHO hides its patient safety requirements and makes anyone who wants to learn about patient safety purchase their books. In addition, whomever interprets the test must take a certifying exam every year to show that they are able to properly interpret the color change on the hemoccult card. Kind of like taking a certifying exam each year to prove that you can determine when a traffic light turns from green to red, I suppose. Apparently physicians are competent enough to manage a multi-trauma patient, intubate, insert chest tubes, and calculate the doses for vasoactive medications, but, on that same multi-trauma patient we lack the fundamental knowledge to determine whether a piece of paper impregnated with resin from the Guaiacum species of plant on a hemoccult card turns from white to blue. Did you also know that one of the other uses for the guaiacum species (pictured at right) is to create guaifenesin for cough syrup? Don’t tell JCAHO that. Otherwise we’ll have to keep the cards under lock and key in case someone with a cough decides they want to chew on the cards instead of taking cough medicine. Patient safety, you know. Oh, and then for patient safety reasons we have to log each and every test result not only on the patient’s chart, but also in a log book. No one ever says what the log book is for, and no one has ever used the log book other than to log results from the hemoccult testing that the doctors are unable to interpret — and to show JCAHO investigators that we are actually keeping the log book — but woe be to the nurse who took care of the patient where a hemoccult was done, but a result (including lot number of the card, a lot number on the bottle of developer, and respective expiration dates) was not logged. Major nursing demerits on you! That was an interesting mind melt that had nothing to do with the actual post. Getting back on track … During one recent shift, we had a run on abdominal pain patients — as in I was managing 7 patients all with some varied form of abdominal pain. Because I do a rectal exam on most patients with abdominal pain, we were going through a lot of stool guaiac cards. One nurse started giving me a hard time for doing too many rectal exams. Then she did it. She called me a “turd tickler.” Them’s fighting words. So I hatched a plan. I went into the break room, found some A1 Steak Sauce, and put a little on the edge of my gloved hand. Then I put some on the back of a hemoccult card. I walked into a room, asked the patient how she was doing, then came out of the room and handed card to nurse, telling her to make sure that she logged the results in our JCAHO-approved stool sample logging book . When she grabbed the card, she immediately felt the moisture, looked at her hand, gasped, dropped the card, and ran to the sink. She watched me as I looked at my gloved hand, made a face, and rubbed my hand on my scrub bottoms. Then I took the glove off, grabbed the next chart, and walked into the room. I heard the nurse say “eeeeeewww” as I was walking away. She was pale and had this disgusted look on her face when I walked ...

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Healthcare Update — 05-10-2010

Coming soon to a hospital near you? Overcrowding and physician shortages at Royal Columbian Hospital in British Columbia having adverse effects on patient care. Volumes are up by 20% from a few years ago and the physician groups estimate they need about 25% more physicians to handle the patients. The result is significant overcrowding. A recent report showed 34 “near misses” where wait times could have affected a patient’s safety or medical outcome – including a man who waited five hours with an intracerebral bleed. Fire marshals visited the emergency department due to a complaint about overcrowding and issued a notice of fire safety violation. As a result, ambulances are being instructed to hold patients in vehicles in the ambulance bay until there is a bed available. Apparently if you can’t see them, they’re not your problem. The docs even created a web site to notify the public about how inadequate staffing and overcrowding are limiting their ability to provide “safe and effective care to all patients in a timely and respectful manner.” In other news, hospital officials are now chastising the emergency personnel for their lower than average Press Ganey scores for the previous quarter. Should I pack lunch … or lunch and dinner? As emergency department use has increased 32% and wait times have increased 50% over the past 10 years, more emergency departments are posting wait times online. Now if we could only get someone to post wait times for specialist appointments, the Department of Motor Vehicles, and tax refunds. More on Bret Michael’s experiences in the emergency department. “Am I dying? If I’m dying, I want to see my kids, but if I have a chance, I don’t want them to see me in this condition.” Former Miami Dolphins receiver O.J. McDuffie wins $11.5 million medical malpractice award after team doctor allegedly misdiagnoses big toe injury. Parkland Memorial Hospital in Dallas is repeatedly investigated by the Centers for Medicare and Medicaid Services, yet according to this article, CMS found few violations and may have even downplayed or covered up some mistakes. Another one of those “too big to fail” scenarios? Obtaining an MRI often requires that the patient remain still for extended periods of time. Kids often don’t want to fit into that category. Pediatric emergency physicians are frequently using propofol – the same drug that allegedly killed Michael Jackson – to sedate children prior to MRIs. In a study of more than 25,000 patients, complication rates with using the drug averaged about 6 percent, with 1.4% of patients needing ventilatory support. No deaths from the drug occurred. Opting out of Medicare. “Why would you sign up for something that would guarantee to pay you less over time when you’re expected to work harder? We want to be able to spend our time caring for patients instead of assigning codes to them and filling out paperwork.” Another cardiologist whose practice is comprised of 70% Medicare is considering “opt[ing] out of America,” by moving to and practicing in another country, or retiring early. Other physicians and patients are considering the “opt out” as well, affecting patients’ access to care. This is precisely what the government wants – a slow attrition of medical providers so that patients have increasing difficulty accessing care. Those providers that stay with the system will be paid less and less for the services they perform. A win-win situation for government insurance. Pay providers less so you save money on care. Then providers drop out of the system. Patients have to wait longer and longer to access care. When patients can’t access care or ...

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Healthcare Update — 05-02-2010

Talk about drive-thru medical care … North Carolina man tries to commit suicide by crashing his truck at a high rate of speed … into the ICU entrance of a hospital. So should the pedestrians be hunted down and charged with murder? Man tries to help woman who is being beaten and becomes a victim himself. The assailant stabs him several times in the torso. He laid in a pool of his own blood while people walked around him, stopped and stared briefly before continuing on their way, or stopped and took pictures of him. Ninety minutes later, he was dead and no one had helped him. All of the passers by were caught on security camera. Where have the morals in this country gone?  This article has some answers. When something is dead and you don’t know what to do with it, bring it to pathology. When something is alive and you don’t know what to do with it, bring it to the emergency department. Canadian police are having difficulty deciding what to do with multiple intoxicated patients arrested each day. After one intoxicated patient died in a police “drunk tank,” the RCMP are now bringing 15-20 intoxicated patients per day to the hospital for “medical clearance.” In a related story, family members and several comments to the article are calling for murder charges to be filed against the police. Using Canada’s definition of homicide – “a person, by an act or omission, does any thing that results in the death of a human being, he causes the death of that human being notwithstanding that death from that cause might have been prevented by resorting to proper means” – could the family also be accused of murder by failing to help the patient get alcohol counseling? “When this ER closes everybody’s unsafe,” says one nurse as she watched St. Vincent’s Hospital in New York close its doors this week. Prior to closing, the hospital’s debt topped $1 billion due to caring for New York City’s poor and uninsured patients. Now the closest Level I trauma center in New York’s lower West side is more than 2 miles away — in NYC traffic. Oklahoma cuts state mental health budget. More and more patients with mental illness or substance abuse problems end up in the emergency departments. “We’re going to be more and more busy, and we’re going to lose opportunities and possibly lose lives. That’s a loss for society. Prevention is the way to go,” says one trauma surgeon. Oklahoma’s response? Expect 12 percent more cuts in the near future. Don’t worry, though, now everyone has insurance with the health reform bill. Problem solved. Another entry in the “you don’t appreciate it until it’s gone” category. Large water main break near Boston means that 2 million people must boil water for at least a minute before ingesting it. Restaurants stop serving water, ice, and fountain drinks. Surgeons at hospitals were ordered to use bottled water to scrub before surgeries. Scrubbing with Evian? How gauche. Bret Michaels improving? Treating physician states the Poison singer has an “unbelievable fight in him.” News conference on his condition planned for Tuesday. Keep the faith, Bret and family! Should you have to pay for “balance billing” by a physician or not? Most people commenting on this article didn’t believe so. Another wrench in the system caused by the squeeze from insurance companies. Simple solution in most circumstances: When prices for any services or medical testing are not clearly posted in advance, those services are free. Enable consumers to make a free market decision on how ...

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