Press-Ganey Hell Revisited

For those of you that follow @movinmeat's blog, as well as my own (and see me on twitter @irb123), you know about my "issues" with the unfairness of the Press-Ganey system of customer service, and how I feel it is actually undermining good patient care.

Well, irony of ironies, over the last 2 months, I am...wait for it (drumroll)...#1 in my group and in the 97.5% of all (doctors in atlanta? the US? a hypothetical sample size from the imaginings of the P-G folks?) on the list.

And guess what folks? I didn't do anything different. I told that to my medical director today when he congratulated me on a job well done, bringing up my scores. His response: pretend like you did something different if someone asks.

In other words, for the P-G to be legit, one set of behavior leads to one set of scores, but another set of behavior leads to a different set of scores. But in my world, there is one type of ER practice that leads to a rollercoaster of scores from the very bottom to the very top.

Once again, the P-G fails to indicate anything meaningful for me and for my patients. Only now, I am not in the doghouse with the CEO. Maybe this is the right time to ask for that iphone I've been wanting...

Some of my fav photos

A colleague (@DrRemy on twitter) was kind enough to set some of my fav photos to music. It is about time we take a break from all the stresses going on with healthcare reform. Even now, it is hard to say what reform will look like, though I feel confident something will happen.

Enjoy your respite:

By popular request here are the photo descriptions:

  1. Alaska Mendenhall Glacier, in B&W, film, titled "Three Waters"
  2. North Carolina Mountains, the smokies
  3. Mendoza, Argentina
  4. Does this need a description? "Purple"
  5. Amazing Sulfur formation on the road between Chile and Mendoza
  6. Machu Picchu, Peru
  7. Town of Macca Church, Peru
  8. Prague in Winter
  9. Convent doorway, Arequipa, Peru
  10. Westglow Spa, N.C., Sunset (early)
  11. Westglow Spa, N.C., Sunset (late)
  12. Smokies, rays of light through the clouds
  13. Colca Canyon, Peru "Lavender Sunset"
  14. Tallulah Falls, Georgia
  15. Jewish museum, sculpture, Berlin
  16. New York City from top of Museum
  17. Holocaust Memorial, Berlin
  18. Photo by Dr.Remy

Dr.Remy linked to my video on her blog and added my poem "Dreams" below it. The poem is actually excerpted in the video at the very end. If you want to see the whole poem here is the link to her blog:

Video Interview of Me

Just a quick note and link to a video of me talking about the medical malpractice issues that come up in my upcoming book "How To Survive a Medical Malpractice Lawsuit." Please let me know what you think.

Link to

Are ERs wasteful or the epitome of healthcare efficiency?

I have seen a lot of criticism of ERs lately. The new House Bill for healthcare reform introduces ways to reduce crowding and boarding in the ERs, and better prepare them for disasters like pandemics and Katrina-type travesties. But they also put the focus on reducing ER use, as if overuse of ERs is responsible for the exhorbitant waste and cost of Healthcare.

There is waste in healthcare, and some of the patients who come to ERs are inappropriately abusing the system. But those statistics state that 10% of patients are responsible for 90% of the visits. So the waste in the ERs is largely out of control of those who run them.

This site debunks some of the myths surrounding the ER and healthcare.

I go a step further, and challenge the criticisms that the ERs are unnecessarily over testing patients:

Why do ER docs do a lot of tests?
1) Patients expect and demand it and we are at the whim of Press-Ganey for job security.

2) Consultants demand it. I cannot get a surgeon to even LOOK at my patient without a CT (cat) scan. I would get laughed at-more accurately-yelled at for diagnosing appendicitis without a CT scan at 3am and waking up the surgeon to inform them of this.

Hospitalists and attendings routinely ask for a complete workup before they will admit a patient. That means not just labs, but followups on labs. CT scans to rule out PE (pulmonary embolism) or surgical entities.

I have found that Admitting docs expect more from us than a simple Admit or Discharge. They want a diagnosis and treatment plan. This is partly because Medicare won't pay for certain diagnoses, so hospitals want to make sure that those who come in will be "paying" patients. That requires full workups to prevent admissions that don't need to be in the hospital. In the past you could admit a patient with minimal workup, and let the attendings figure out what was going on. That's not good enough for the government because Medicare will reject payment for patients if they think it is not necessary. Unfortunately, care has already occurred and money has already been spent. No "social" admits for patients who have nowhere else to go and are too sick to be home alone. No observation admits to see if something shows up. Now the patient is worked up in the ER, gets a diagnosis, and the hospital's job is to figure out how to discharge them as soon as humanly possible.

3) Pts in the ER self select as Emergencies. Therefore an Emergency must be ruled out. I can’t always rule stuff out without further testing. Abdominal pain in an office setting and abdominal pain in the ER are not the same animal. You can't just send someone home; you need to rule out deadly reasons for this pain. Nobody comes to the ER because they want to be there (okay, there are a few, but those people aren't typical). If patients thought their problem could wait until they were scheduled to see their doctor, given a bunch of tests that take a few weeks to come back, get the outpatient study they need in a month, and see the specialist when THEY can fit the patient in, then they would have done so. Instead patients who come to ERs want relief of their symptoms. They want answers and often need immediate action.

4) Sometimes patients have ambiguous symptoms that affect areas that require different types of tests. For example, A patient with abdominal pain in RUQ (right upper quadrant) needs an U/S (ultrasound) because that is more effective for picking up GB (gallbladder) disease. However, if I think the problems is in the intestines, a CT is the best choice. CTs do not do well ruling out GB disease, so on occasion you need to do both tests if the first one is negative.

5) Lots of patients without insurance come to the ER. These patients will not get tests unless done in the ER. They will fall through the cracks. If I don’t do the CT scan, nobody will. If they had insurance, sure, they could see their doctor and get an outpatient scan. But in reality, the majority of my patients are uninsured or underinsured and can’t get these tests unless they come to the ER.

For the arrogant doctors who judge the care of the ER docs, don’t throw stones when you live in a glass house. I deal with your complications everyday. I deal with the patients who can’t reach you on the phone and come in with a preventable ER visit. I deal with the undesirables you don’t want to see. And I don’t cast aspersions upon you and question your training.

ER docs now are better trained for emergencies than internists, family practioners and surgeons. We know the emergency aspects of every specialty. We see the overall picture. Do you know how many times I am the first doctor to give them nutrition and prevention advice? Why wasn’t their primary doc doing that? Why didn’t their surgeon explain to them that their surgery will drive up the patient’s blood sugar and they’ll need more insulin?

Perhaps you shouldn’t be asking what should ER docs do to change things. Perhaps you should be looking at why ERs need to be doing what they must to be the safety net that keeps the strands of healthcare from dissolving into complete chaos.

Is our method of training medical students flawed?

The majority of people who go to medical school have an idealistic idea of saving lives and helping sick people get well. Yet patients complain that doctors seem to lack caring, compassion and dedication to the profession. Is something missing from the training of a doctor that prevents them from having the characteristics patients expect? Is it the process of medical training itself that causes this? Or is it that we are simply selecting for medical school the kind of person who will be successful yet incapable of having the kind of attributes that patients want?

I am working on a book that removes the shroud of mystery that surrounds this transformative process. I can and have recounted scores of stories about my medical school training that sound ridiculous and unbelievable, but sadly were true experiences. I would like you to help me in two ways:
  1. If you are not an MD, I would like to know what is in your head when you picture what is involved in the training of a physician.

  2. If you are an MD or medical student, I would like to know what is the most cut-throat, horrible experience you've had in pre-med, medical school and/or residency training.

Please write your answer in the comments section. By writing you give consent that your comment could end up somewhere in my book. Whether you use a real name or not, if I use part of your comment, I will give you credit in my acknowledgements. And if I use any part of one of your comments, and you leave an email contact, I will send you a free book when it is published.

Thanks for your help!

I need your help if you are not an MD. What are your preconceptions as to how a doctor is trained? Any myths? Anything you've wondered about?

I am surveying non-doctors to see what they think about how a doctor is trained. Do you have any idea how that happens? What do you think happens? Have you wondered about it? Is it shrouded in mystery? Do you have extra admiration for MDs due to this process? Please make comments to let me know your opinion and you might make it into my next book.

(Disclaimer: If you make a comment, you are giving me permission to use it in a book. If you don't want me to use your comment, don't make one.)

Thanks for your help!


I've already had a few comments that didn't address my question, so I will add this: Everyone knows the kind of qualifications it requires for an MD-college degree with pre-med classes/MCAT, 4 years of med school, and minimum 3 years of residency training.

My question is, when you picture in your mind what a med student has to do to learn what is required to practice medicine, how do you see that happening? This relates to course work, learning how to examine patients, "practicing" on patients, etc...Are there any myths, pre-conceptions (i.e. doctors are all intelligent [not saying that this is true BTW, just an example of what many people assume]), movies that bias you? Have you ever wondered about the rituals that occur to create a med student? It is not straightforward like: you go to class, you learn anatomy, you learn pathology/microbiology/pharmacology, and suddenly you can be someone's doctor. Have you ever wondered what it is really like? Do you think you know what it is like bc you have a friend/relative who is an MD? If so, I want to hear what you think you know.


What I learned at ACEP (American College of Emergency Physicians) conference in Boston

I am in Boston for the ACEP conference. I know, I should be seeing the foliage but who has time? I am eating lots of great seafood. Chowda of course. And I just ate at "No name," a soup nazi type locale with great food and little ambiance. Yum.

But I have learned a lot too, and will chronicle that here:
  1. Doctors are nerds who don't care about baseball, bc nobody seems to care that I am a yankee fan wearing my yankee clothes in public.
  2. Paul Begala is freaking funny. He gives the best Bill Clinton impersonation. And he managed to calm a skeptical crowd and be informative as well. In his opinion, health care reform will happen bc if it doesn't democrats are done. Put a fork in it done. So if they want future viability something will be passed. But not when obama says so.
  3. Only 12% of patients in ERs are non-urgent. ERs area extremely efficient and relatively low cost for the service it provides. Where else can you get seen, examined, tested, diagnosed, treated & admitted or discharged in just a few hours? In the "outside world" a patient goes to Dr. A, who says wait and see. The the patient comes back and is sent for some testing. Two weeks later tests come back with no answer as to what is going on. Outpatient CT scan ordered. A few weeks later test is done. Eventually scan is read by a radiologist. A few weeks later your doctor communicates the results to you. This is beyond their capabilities so you are sent to a specialist. The specialist orders an MRI. That takes a few days. When you suddenly worsen they say go to ER. Where we get you taken care of in just a few hours.

    It may cost a lot to go to the ER, but it only costs four times as much to run an ER as to run a medical practice. We are a one-stop shop for good health care. Which is why docs in the community and patients trust us do diagnose and treat ailments that "could" be treated as an outpatient-though much slower.
  4. Universal healthcare leads to INCREASED ER visits. An average of 8% in Massachusetts.
  5. A little prevention goes a long way: A study shows that if at 15mo of age checkup, parents are educated re: auralgin topic anesthetic for ear pain in children, then when child has pain, parents treat and wait instead of rushing to ER or doctors office. 80% decrease of ER visits for otitis media as a result. And 40% decrease in pediatrician visits as well. WE SHOULD ALL BE DOING THIS
  6. Children 3-36months of age do not need blood cultures. 'nuff said.
  7. Irritable babies should get urinalysis and culture, as 10% are positive despite no fever symptoms.
  8. LPs are not needed for febrile seizures if 3-36mo of age
  9. No matter how you clip your badge to the loop that goes around your neck, it will always spontaneously flip around to the backside. Unless you want it to be on the backside, in which case it will show your name.
  10. KevinMD and Shadowfax are a nice hang, and I learned a lot from their years of blogging experience (see future blog where I will figure out how to add a pic I took of them).
  11. When doing a lecture, the audience will only remember 3-4 points. If you try 5 points, they remember nothing.
  12. You DON'T need contrast when doing a CT for appendicitis. And you CAN give them opiates for pain without altering their exam findings.
  13. And Dr. Hoffman and Dr. Bukata remind me of those muppets in the balcony.
  14. is totally classy and I am proud to be associated with them and honored to have my voice heard (and even respected!) amongst the greats in Emergency Medicine.
  15. I probably should not have had that second glass of wine...(after the 2 mojitos-yummy made by John at the Birch bar at the westin waterfront). Tylenol works better for hangovers than advil. (that's not a scientific study)
  16. My book "How to Survive a Medical Malpractice Lawsuit" has a date for release! April 2010. No cover yet. But I have an ISBN number. Very exciting. And a pretty advert they were handing out that I will scan it in and post that on the website in a few days.

Best things I learned in medical school

I'm in a contemplative mode and thinking about the lessons I learned in med school. Also, I am writing a novel that is loosely based on my med school experiences. So these kinds of things are fresh in my mind. Please feel free to add to my list.
  1. Many of the patients you "treat" will have taught more future physicians than you have seen patients. Their lessons are valuable. Treat these "frequent flyers" with respect.

  2. The most important, and hardest thing to learn is the difference between sick and not-sick. Everything else is largely irrelevant.

  3. Think of your med school friends not as fellow students but as future physician peers. In other words, be as professional in med school (and in social media such as FB and Twitter) as you would on the wards.

  4. Stress is contagious. Stay as far away from groups of med students when studying. Pick one person to study with, and avoid the library at all costs.

  5. There is always someone above you. Achieve your goals but don't lay your happiness on getting to the next level or else you will be forever unsatisfied. Because when you are a first year med student, you are at the bottom. But when you are a first year resident you are also at the bottom. When you are a fellow, the attendings are above you. And when you are a new attending, the older attendings/medical directors are above you. If you own your own group, there are bigger groups than you trying to steal your contract. Everyone has their own stresses at every level of life. Enjoy where you are now and continue to challenge yourself from within; not as a comparison with someone else.

  6. Just when you think you've seen everything, something else happens to blow your mind.

  7. Compassion is the most important quality in a physician. Anyone can memorize facts from a book. But if you don't truly care for your patients, you should go into banking or some other profession.

  8. If you feel like the walls are closing in on you, and you can't handle the stress, and that you are the only person who feels this way-take to heart the fact that you are not alone. Everyone has felt this at some point in their career. If you experience this, reach out; you will be surprised at how many others are in the same boat.

  9. Don't ever be so overconfident and think you know everything. Nobody knows everything. And if you did, it would not matter, because tomorrow everything you know will be proved wrong by a new study. Instead acknowledge that there are some things you might not know and be open to learning new things. Ask questions. Don't ever pretend or "fake it." It is okay to look up information. Even surgeons study an anatomy text just before going into a surgery. That isn't admitting a weakness. The ability to know one's limitations is actually a strength.

  10. Remember the idealistic reasons you went into medical school in the first place. Medicine can be difficult, but never lose sight on what brought you here.

The Unstable Business of Emergency Medicine - Interview Questions for New Grads of Residency

Normally I do general health care issues in my blog. However, this being the beginning of the interview season for residents looking for work when they graduate, I thought I'd dedicate this blog to that. I hope this is helpful, and for those who don't "need" this advice, I hope you find this behind-the-scenes look at Emergency Medicine insightful.

Last year, I found myself, once again, looking for a new job when my company was taken over by a previous employer of mine. This situation led to me having held jobs with six different employers over only seven years. It is not because I've been flighty; I held one job for four years before moving on to new challenges.

While in the midst of the job-hunting process, I uncovered a file I created for myself when I finished residency. It had a list of Interview Questions to ask a potential employer. Many of the questions were very good, however, now having had a chance to look at the questions through the eyes of experience, I discovered that much more information should be given so the new graduate can truly understand what they can expect from their first job.

Words in black are the original, and the comments in red are my...err...improvements:

Group Structure:
  1. What type of group? How does it work? Is this a shady partnership where everyone has equally poor reimbursement? Is this a shady partnership where only the partners make good money and nobody else can actually achieve partner? Is this a democratic group? If so, does everyone share equally? Does that mean that you don't value experience? Is this a shady corporate group where the corporation gleans large amounts of income for "administrative" expenses or for stock market productivity gains?
    How are administrative positions assigned? That is, can someone work their way up to Director? Will I be asked to serve time on one or more committees without any hope of reimbursement for my time and travel expense?
    Are there other meetings that members see each other than on shift change? Do members like seeing each other outside of chance encounters on overlapping shifts?

  2. How long has the hospital contracted with this group? When is it up for renewal? How stable is the relationship between the group and the hospital? These are great questions that mean nothing. If the hospital wants to fire the group, they can find a way, regardless of when the contract is up for renewal. Even if the group has held the contract for 25 years, there is no loyalty amongst thieves, and the hospital will think nothing of handing your contract (and your job) over to complete strangers. This happened to me on my very first job-the contract was yanked early before I worked my first shift.

  3. What is the group composition: e.g. female, male, Board certified EM MD? Are you a young group with little experience that are there because you don't know any better yet? Or are you an aging group of docs that may or may not be Emergency Medicine Residency Trained and are resistant to "new" trends such as Etomidate for RSI and use of computers/pdas. Is there an opportunity for mentoring or will I simply be thrown to the wolves? (If female): Will you freak if I get married because it means I might want to work less and have a life? (If male): Are there a lot of women in the group of prime birthing age that will make me have to work more shifts when they deliver?

  4. Staffing Patterns: Any double coverage times? 8/10/12 hour shifts? PA/NPs? Will there be too much coverage or too little coverage? Will I have to work a bunch of long painful shifts that never seem to end, or will I have to work a lot of short painful shifts where nothing much gets accomplished? Will I have to work with the physician extenders who will be paid to have me teach them how to do their job? Or will I have to work with physician extenders who have worked for decades and resent any opportunity to be taught anything? Will their salaries come out of my salary or does the group pony up the cash for them?

  5. How do you pay? Monthly? Salaried with benefits? Independent contractor? Hourly? Productivity Incentives?

  6. Do you pay malpractice with tail? *Note: this is not always advantageous as many companies will remove more from your reimbursement than your malpractice policy actually costs. Also, if they buy the policy, they control the policy and its terms. Important things you want in your policy: 2mil/4mil coverage, ability to refuse settlement, and ability to choose your own attorney. Therefore, it is more ideal to get extra money in salary, but purchase the policy on your own (using your group for risk pooling). In fact, If I were a new grad, I would make sure not to get too dazzled by groups that offer malpractice w/tail. It is not always a good thing.

Nurses and Ancillary Staff:
  1. Nursing Turnover? Can you retain nurses? How long have most of the nurses worked here?
    Ratio of nurses to patient? Are the nurses expected to see more patients than they can handle safely, with little tech support? Are the nurses expected to see new patients in addition to managing all the ED boarded patients?

  2. Relationship with MDs? Do they resent women MDs giving them orders?
    Is there a shortage of nurses in the ED? DUH! Is there a hospital that doesn't?

  3. Phlebotomists? Are there people who draw the blood for the nurses? Does that mean the patients have to wait longer for labs since the nurses won't/can't draw blood on their own?

  4. Social Services? Do you have it at night? At all?
    Grief counseling? Is there someone to call when the deceased patient's family shows up in hysterics?
    Psych? In-patient? Is there a way to get the crazy people moved out of the ED in less than 24 hours?

Clinical Practice:
  1. Do ED MDs provide code service for the whole hospital? Are ED docs the only ones who will care for the inpatients overnight? Will we be forced to abandon our own patients for someone else's and incur huge liability in the process? Will we have to run up to pronounce patients who have recently died?

  2. How fast does it take to get EKGs in the ED? Can we easily get old EKGs? Respiratory treatments/ABGs? Will the respiratory techs be dedicated to the ED or will they have to abandon the sick ICU patients for ours and vice versa?
    Is x-ray and CT in-house? Also, will the x-ray tech spend the last few hours of my night shift up on the floor and thus ignore all my emergency x-rays?
    At night? Will someone have to come from home every time I need a CT scan?
    Is there a radiologist reading x-rays 24 hours a day? From some one in India?

  3. U/S availability? Can we do our own? Will you do ours promptly? Will you have an in-house tech or will you make pregnant patients wait 1-2 hours for an ultrasound? Can I get peripheral venous doppler ultrasounds at night or do I have to just waste a bed in the hospital (and a lovenox shot) to admit them for a potential clot?
    Can I get V/Q scans 24 hours if needed? Will you be out of dye whenever I need one? *answer: yes (out of dye) as there is a current radionuclide shortage*

  4. What is the average patients seen per hour for ED physicians? Is it above or below the 2.5pph that ACEP/AAEM recommend as a max for safety reasons?
    How many beds in the ED? Critical ones? Is there a fast-track? Staffed by MDs or Midlevels? Are most beds full of boarded patients?

  5. Admission Rate? Acuity? The key question here is not how many people are very sick and need admissions. It is how many patients get admitted and occupy their room in perpetuity, thereby preventing any new patients from being seen (especially important if you work on a productivity model)
    %Trauma? Do you have an official trauma designation?
    %Pediatrics? What percentage of patients are pediatric? If it is high, are there any pediatricians who run a peds ER for certain hours of the day? Does the hospital admit pediatric patients? Up to what age? Do 17 year olds get the unfortunate designation of not being pediatric and not being adult? Can you ask our pediatricians for advice? Is there an agreement with this hospital and the nearest Children's Hospital?

  6. How is the relationship between the ED and Medical Staff? Do they hate us? Do we hate them? Are they vindictive; sending tons of our charts to QI?
    Easy to admit? Can you get a doctor on the phone in ten minutes or less? Are they agreeable about admissions? Are there hospitalists? Do you have agreements with other hospitals for admissions?
    How are admission conflicts resolved? Has it happened that you have tried to consult and can't reach anyone? Problems on Nights and Weekends? How long to get beds?

  7. What specialties are in hospital? The better question is what specialties DON'T you have in the hospital and/or on call?
    What types of patients do you transfer? How often? These are good questions since in some hospitals the bulk of your time will be spent getting your patient dispo'd (for non ER docs, that means dispositioned).

  8. What are the strength and weaknesses of this group and hospital practice?

  9. Do medical staff see their own pts in the ED? I laughed reflexively at this one...Other than hospitalists and surgeons, and sometimes not even the surgeons, you won't have too much of this no matter what they tell you.

  10. Any specific protocols for the ED? Can nurses initiate orders? How do you treat MIs-Tnkase medicine or emergency catheterization? Do you have 24 hour heart catheterization or do the patients get shipped out to one?
  11. Observation areas? Is this a separate area run by the ED? Is it properly and independently staffed? What kinds of patients can we admit to observation status?

  12. How late do you typically stay after a shift/if at all? Do you sign out? Does the doctor signing out get credit for the patient or the doctor who finishes the dispo of the patient (important for productivity models)?

  13. Type of record-keeping?
    Computer order entry? (depending on the system/MD can be cool and can be painfully slow and complicated)
    Computerized H&Ps too? (again, depending on the system and the level of physician expertise/typing ability this could be painfully slow and complicated and is hard to get a good narrative. If not careful, can be a medical liability nightmare.)
    T-sheets? (fast but illegible and bad for medical liability)
    Dictation? (double the work, good for narrative, but if you are not careful to make notes during your shift, you will often leave out important information. also, you can't draw pictures.) Will I spend all my free time dictating?

  1. Any administrative responsibilities/opportunities? (See Group Structure Q#2)

  2. How is the schedule made? Who makes it? Is it made on a hospital by hospital basis, or is it made by a group scheduler who accomodates many hospitals? Is there a defined holiday work schedule? If you want someone to fill in an open shift, do you pay extra?
    How far in advance does the schedule come out? For this you will probably have to ask one of the docs in the ER, your interviewer likely will give an idealized time frame. Can I make plans far in advance but also that prevent me from taking a trip that comes up with less than two months notice? Or do the schedules come out on the 30th (has happened to me multiple times) of the month, preventing me from making any definite plans whatsoever?
    What kind of distribution of shifts? Are weekends/nights/holidays evenly distributed? Is there a night shift differential or shift preference for all nights?

  3. Who does billing? Does the group get a monthly printout of charting and revenue? Reading over your billing is a good way to learn about the business of medicine and can make you a better biller. It is also a good way to find out if your company is down or up coding your patients. Plus, you are more likely to notice if patients are "missing" (important [and common] in productivity models).

  4. CME time? Do you pay for CME?

  5. Voting rights? What type of issues? *I've never worked anywhere where I had a vote*

  6. Hospital financial stability? Not sure if you'd get an honest answer to this one.

  7. Number of hospital beds that are useable? # of ICU/Tele beds? Do they get filled up frequently? For instance, are there mythical beds that exist but just can't be used (e.g. reserved for "private" patients)?
  1. Can I have an opportunity to shadow in the ER for a few hours to see what it is like? Good idea. This may be the only way you find out the "real deal" with the ER job.

  2. Number of positions open? And expected in the near future? Part-time opportunities? Could you find something for a nights person?

  3. What are you looking for in a candidate?

  4. When will you be making your final decision? Do you have second interviews? When will you make a decision for that?

  5. How many hours per month do you go on diversion status? What kind of diversion are you typically on most commonly? Neuro/Critical Care/ED saturation/Hospital Saturation?

  6. What is the typical waiting time in the waiting room? What is the wait time RIGHT NOW?
So that's it folks. Every question you should ask (or wish you had asked) in your quest for the perfect job. Good luck.

Health Care Reform Will Happen - And other predictions

Once Obama got elected, I knew it would happen. I knew we would get healthcare reform. This is not said out of some partisan bias. I have simply observed the last 8 years of largely republican rule where the only healthcare reform that occurred - Medicare Part D, was a confusing morass that is more a giveback to pharmaceutical companies than a benefit for seniors. It encompasses everything that is bad about government today.

While the republicans "support" tort reform, I never saw tort reform come to a vote and get signed by W. It simply wasn't a priority.

For the democrats, health care reform is a priority. And the new president is acutely aware that he will be a one-term wonder if he does not enact dramatic changes. Passing comprehensive healthcare reform-something that hasn't been able to happen for >60 years-would be change.

I have heard the naysayers amongst friends, colleagues, bloggers and twitterers. The issue is too political; too locked into lobbyists' interests and influence. The democrats are weak. They'll cave in to pressure. While these arguments aren't untrue, the cynics forget one thing. The healthcare crisis isn't about poor people anymore. When your trauma center closes down and you-a rich person-has to be sent to a facility farther away with less resources, you suffer. When you can't find a neurosurgeon to treat your aneurysm, the rich person suffers. When your ambulance is diverted from your favorite institution because of Hospital overcrowding, the rich person suffers.

And for the average joe with "good" health insurance, rates are skyrocketing, out of pocket costs are increasing, and when you get a serious illness, maximum coverages are reached quickly. Approximately 40% of insurance claims are denied. You were supposed to feel safe having insurance coverage. There is no safety.

Now that the majority of the population is facing this healthcare crisis, there is a mandate, and the president is acutely aware that his support came from people wanting change. If he doesn't get health care reform, the advantage his party has will fall to pieces just as the advantage the republicans' had did.

So my prediction:
The only two people who determine healthcare reform are Max Baucus and President Obama. There are others who might have some influence if they are acting in good faith, such as Olympia Snowe. But most other republicans are simply trying to weaken a democrat initiative so that moderate dems won't vote for it, and those republicans wouldn't vote for it anyway. If republicans won't vote for a bill for political reasons, then they won't have a vote in what it looks like.

Thus, if you want to know what healthcare reform will look like, read the BaucusFramework.pdf. In my next blog I will discuss this further, but read this, then compare it to the Baucus Whitepaper. There are some differences, such as the public option issue. However, the whitepaper is his real views. The framework is his compromise. I think Baucus is making a political move to hide his intention for a public option, and then slip it in at the last moment.

As far as tort reform, Baucus supports it, and Obama supports it as long as there are attempts to maintain quality in the system. Obama NEEDS it if he is to exact cost savings that will make it succeed. So in some manner, there will be tort reform. Maybe not along the lines of what I would like and have suggested, but something will happen on that front.

The cynics will say I'm naive and deluded. I think they aren't looking at the big picture, because if they did, they would see that this is the year. By 2010, we will have healthcare reform passed. It likely won't translate into immediate results as it will take years to enact. But it will happen.

Anything You Tweet Can and Will Be Used Against You

I wrote an article in the latest edition of with the above title:

Just as you were getting comfortable with Facebook, detailing every moment of your life through status updates and photos, Twitter came to town. If you don’t already know, Twitter is a “micro-blogging” social media site which allows users to “tweet”– or post – short status updates. Thousands of docs have signed up, raising an interesting risk management question: Can my tweets come back to bite me?
The short answer is Yes. Take the example of a personal diary that details your life experience, or a medical diary that lists the patients you’ve seen and their medical problems. These diaries are dangerous because anything that has dates can be used as evidence against you. Let’s say you log in your diary going out for drinks with friends. Then, years later you are sued, and the plaintiff’s attorney discovers your “drinking orgy” the night before you treated their client. They will use this information to paint you as a physician just steps from requiring the Talbott Recovery Campus. If you are an EP who likes to keep detailed logs of your patients, you can’t anticipate how your innocent log can be twisted out of context to hurt you.

When it comes to the Internet, everything you do is stored somewhere. In essence, the Internet is an electronic diary. Some Internet services are more private, such as email and Facebook. Others, such as blogs and twitter, are public. Anything you say publicly, whether through a comment feed or a tweet, is searchable and can theoretically be used against you in court. Also, sites like Sermo and Ozmosis are not peer-review protected (in states that have those laws) and those “innocent” evaluations of case studies could be used against you if your lawsuit happens to be on one of those topics...

For the rest of the article, click HERE.

The Risks of Defensive Medicine and Why It Isn't Going Away Anytime Soon. Even with Tort Reform

I've already had a few blogs about medical malpractice reform (Part 1 and Part 2). And if you've read them, you know I am a big supporter of completely altering how patient complaints against physicians are handled. Not just for the benefit of the doctor, but because the current system is not so great for the patient either.

No longer is a patient a sick person with a sacred relationship with their physcian. They are now "Consumers of healthcare." And fear of retribution by those consumers prevents doctors from making sound judgments on patient care. Doctors are tired of attempting to educate patients on best practice, when not getting their demand will lead to an unhappy consumer. And all doctors know that unhappy consumers like to sue if there is a bad outcome (statistically probable adverse events that are not malpractice).


I read over and over how either defensive medicine does not exist, or that it is actually a good thing (just recently saw a tweet to this effect). These are usually medical malpractice attorneys. They have convinced themselves that they are policing the bad doctors and are helping to produce more careful, compassionate, higher quality physicians.

The only part I agree with is the careful part. Docs take care to make sure every contingency is addressed. While that might sound good, it is not. Here's why:
  • In medical classes like CME, doctors are often taught the right way and the defensible way to treat a given patient. These are often very different. For instance, the right way to treat a simple ear infection, based on the latest pediatric guidelines is NOT to use antibiotics. However, an untreated infection that leads to a rare complication such as Mastoiditis could likely lead to a malpractice suit.
  • Therefore, the defensible way to treat this situation would be to give antibiotics. The implications of taking unnecessary antibiotics seem minuscule to the patient, however, it leads to grave problems in the future on a personal and societal level when those antibiotics become resistant to infections. In a word: CA-MRSA (Community Acquired Methicillin Resistant Staph Aureus) which is what causes those huge painful boils that pop up and lead to sepsis if they are not addressed.
  • If a patient wants an x-ray or a CT they don't need, they get it. Because juries don't penalizing for doing extra, but for not doing enough. However, a brand new study by the NEJM shows that those tests that we do on patients give dangerously high radiation doses. Especially bad as a cumulative effect over time. This can lead to many kinds of cancers; one study estimated 1 in 10,000 pts will get thyroid cancer from a CT scan.
  • The funny thing about tests is that many are equivocal, meaning, they didn't give a definitive answer and the recommendation is to do another test. So tests often lead to more tests. And before you know it, that innocent CT you did "just to be safe" leads to renal failure from the IV dye you received, throwing you into congestive heart failure and leading to even more problems. The book "The House of G-d" espouses less is more for healthier patients for this very reason.

While I definitely think we need tort reform for the many reasons I detailed in my last two blogs, I think it is unrealistic to assume that physician behavior will change overnight. If comprehensive tort reform that screened out frivolous cases before they even became a lawsuit were enacted tomorrow, it would be at least five years before any change in defensive medicine practices were noticed. And much of that would be because of newly graduating physicians practicing in a less litiginous environment.

Look at the poor adoption of IT by physicians. A much less controversial topic. And look at how hard it is to change the behavior of physicians who use paper and like it that way. Changing something like defensive medicine will be doubly or triply (word?) challenging.

In the course of my psychology studies, I learned about Maslow's hierarchy of needs, which explains really well the motivations of physicians and why they regress from idealistic doctors to self-doubting defensive medicine practices.

In this theory, human beings are motivated by unsatisfied needs, with the lower, more basic needs having to be satsified before the higher, more selfless needs can be actualized. The first four needs are the deficiency needs: psychological (e.g. breathing, food, water), safety (security of body, resources, employment), social (working as a team, sense of community), and esteem (confidence, respect by others). Under stressful conditions, people can regress to lower levels, and Maslow postulated that if you have significant problems somewhere along the hierarchy, you may fixate on these needs for the rest of your life.

This model explains physician behavior very well. Physicians who are sued will likely suffer a breakdown in the second stage of the need for safety and security. They will enact asset protection plans, increase their insurance limits, and suffer extreme anxiety at the thought of losing everything. They may obsess about maximizing reimbursement. At this point, the physician's priorities change to the lower needs. And as long as they continue to regress away from self-actualization, they will look at life differently than before. They will practice medicine differently than before. They will abandon their intuition and their compassion. Their altruistic practice of medicine will cease to be a motivating factor until the physician is able to reconcile these fears.

Those that manage their safety need can still be stuck in one of the next levels of motivation. It is here where the practice of defensive medicine begins to be ingrained; from either a lack of trust of their colleagues, team, or patient (social need), or from a lack of trust in their own abilities (esteem need). Regardless, once fixated on these deficiencies, it is hard to break free to advance to a point where your sole interest is in taking care of the patient.

And if you are one of the rare doctors who can overcome all of this to be a completely selfless compassionate physician, you can become extremely frustrated when forces outside of your control (e.g. administrators or HMOs) demand that you practice in a manner that conflicts with your high ideals. These excellent physicians typically retire early, or limit their practice, while those in the lower needs continue to practice in their regressive fashion.

The current system selects for those physicians who can adapt to the system, not for the physicians who can overcome it. It's all darwin. Survival of the fittest. Darwin didn't have a place for compassion.

My solution? We should have tort reform. But we have to be realistic. It will take at least five years (probably ten) after med mal reform before a significant dent in the 100-200 billion dollar a year of costs that occur from defensive medicine.

My own private Press-Ganey Hell

I have already had two posts(1) about the Press-Ganey(2). But that isn't enough. Any physician reading this likely has the same visceral hatred that bubbles up whenever these two (one w/hyphen?) words are brought up.

Again, for those who are not familiar with the term, Press-Ganey, it is a survey that administrators of hospitals use as gospel for who is the best hospital and is all about customer satisfaction.

But there are flaws in this Press-Ganey. What are the flaws? Oh, too many to list here (let me count the ways...). I'll just hit the highlights:
  1. First is that Press-Ganey has a complete monopoly. They are accountable to no one, despite their less-than-scientific method of procuring data. If I practiced medicine in the same "Evidenced Based" manner that the Press-Ganey does, I'd lose my license.
  2. While the (from now on abbreviation PG will be used) PG is supposed to take a random sample of patients a physician sees, it is biased in the sense that the surveys are voluntary and only motivated and healthy-enough to fill out a survey in the first place.
  3. Plus, take the ER for example. My "random" sample is based on patients who are discharged from the hospital only. No admitted patients fill these out. As an "Emergency" physician, the admitted patients represent the true emergencies. I'm not saying all discharged patients aren't supposed to be there, but I'd call them easily addressed "Urgencies."
  4. Worse, the odds are that the more often a patient shows up to the ER, the more likely they are to eventually get a survey. Do I need to spell out what kinds of patients show up to the ER frequently?
  5. I am graded by the patients that I had to spend the least amount of time with since I focus my attention on the true Emergencies first and foremost.
  6. And while the PG should have the same standards for every hospital - since they compare every hospital and form a grade for each hospital/provider, they don't. Each hospital interprets the selection of patients differently - I know bc in my career I've already worked at five different hospitals. One hospital excluded patients with "drug seeking behavior," whereas my current hospital does not.
  7. The grades are on a curve. In other words, hypothetically, if you think that on a five point scale 5 is excellent and 3 is average, and all doctors surveyed had an average of four, that would mean all docs are above average. But all docs don't get a PG score of above average. They can't since it is done on a curve. You could give above average care and get a score in the bottom 25% (an "F" if you were in school). WHAT??? Yes. That is true. And that is exactly what happens. Good doctors are getting penalized even when the satifaction scores are above average.
So why am I venting, again, about the PG? Here is my recent foray into PG madness:

I started a new job in January, and from the get-go had great PG scores. Of course, the sampling was low, so nothing was statistically significant. Once I got one unhappy patient, it killed my score. So 4 excellent scores and 1 bad one = Very bad PG score. But despite that, my scores were still in the top 80%. And stayed that way until June.

All of a sudden, in June my scores dropped to 1%. I naturally assumed I must have gotten a bunch of really bad reviews. Bad luck? Bad day for me? I didn't know. We have a binder that has the recent PG reviews for the department, and looking in there, all the reviews were 5's. The highest. I didn't get it.

The inevitable happened. My administrator saw my scores and insisted I be rehabilitated. My medical director had a "talk" with me. But to his credit, he promised to pull these surveys so that I could find out what was said so I might know what to improve. And he assigned someone to the four hour, painstaking task, of searching for all of the surveys and matching it up with the charts. And you know what they found (drumroll.......)?

These charts didn't belong to me! They were the PA's patient, or another physician (obvious when the pt is criticizing the tall male MD when I am a petite female doc). In fact my scores were almost exclusively 5's. Putting me at the top of the scale, not the bottom. Yet I still get that scarlet letter score pasted up all over the ED that makes me look like a mean uncaring doctor.

My director apologized to me, but it is not his fault. It is the fault of the administrators who are so desperate to have some standard with which to grade themselves, they choose not to use scientific rigor to evaluate that very imperfect standard that they use. And we doctors are the ones who suffer.

The Medical Malpractice Reform Debate Part 2

In my previous blog I discussed why our current tort system for medical malpractice is unfair to both patient and physician. And I said I had a plan for reform. Here it is:

In order to solve the problem, you have to establish what you were trying to accomplish in the first place. The reason medical malpractice exists in such prevalence today is because physicians have resisted an organized format for policing themselves. Most patients (and their attorneys) would say that they are just trying to sift out the bad doctors.

So the question we should ask is "What kind of system would truly allow errors and malpractice to be identified, fixed, with truly egregious acts punished, and allow recompense to the harmed patients?"

Some say that physicians should have immunity, like judges, prosecutors and legislators. The reason for the federal employee immunity is that is serves the public interest in enabling such officials to perform their designated functions effectively without fear that a particular decision may give rise to personal liability. The same could be said for physicians, making life altering decisions-judgments so to speak. However, complete immunity would shield those committing true malpractice, so I don't believe this is the answer.

I understand why patients hearing of medical successes every day would think that a bad outcome would be malpractice. However, suing your physician does little to correct the problem as most errors are systemic, reversible problems.

The Solution:
  1. Each Medical Specialty Board sets the standards for what kind of education a physician should obtain to be qualified to practice. Therefore, they, not layperson juries, are the only ones truly qualified to determine medical malpractice.
  2. When a patient has a complaint against a physician, before going through the state court system, the complaint is first heard by a panel of physicians of that doctor's specialty.
  3. Every Specialty Board will require service by its members on that panel that meets every month-each physician must participate once every two years. It will be local, as there are sufficient members of each specialty in every state (however, if some states have shortages of Neurosurgeons for instance, there could be a multi-state meeting).
  4. The panel will be blinded in reviewing complaints and won't know who the physician is whom they are evaluating. The panel will have an odd number of members and decision will be majority vote.
  5. The decision will be: a) Was this malpractice, bad outcome, or a systemic problem? b) If bad outcome or systemic: a separate committee will compile this data and compare it to Evidence Based Medicine and seek answers to correct future occurrences - then disseminate that information to the physicians in that specialty.
  6. If Malpractice is determined, there will be a standard penalty for offenders: e.g. first time malpractice gets automatic required CME targeted to the issues in the case and probation, second time offenders in the probationary period will get more CME, and random case review. Third time and thereafter offenders risk license suspension and even re-education in an apprenticeship/residency type situation.
  7. Also, if Malpractice is determined, the case gets put into arbitration for settlement. While the physician (or plaintiff) could still decide to press for trial, the decision of the panel will be fully admissible in all states and will be highly influential to any jury.
  8. The process will be swift, with all patient complaints getting heard by the panel within 6 months and possible settlement within a year. Since there is no costly trial, most of the award to the patient remains with the patient, and they get it quicker. Overall insurance costs go down, and therefore so do physician premiums.
  9. Bad doctors will be rooted out. Good doctors will no longer suffer from the actions of the <5%>
However, the losers in the plan are the attorneys, and the livelihood of medical malpractice attorneys like my father will be threatened as a result. They will not go down quietly.

How Medical Malpractice Reform Does or Does not Fit Into the Healthcare Reform Debate

First the disclaimer: I feel uniquely qualified in writing this as I am not only a Physician, but the daughter of a medical malpractice attorney. Helping my father on his cases while I was in high school, is, to a large extent, why I chose medicine as a profession. I was fascinated by his cases, and in particular, the medicine aspects. Also, I have written a book, "How to survive a medical malpractice lawsuit" that will be published by Wiley-Blackwell in the late fall (shameless plug).

I grew up thinking that medical malpractice litigation was a necessary evil. Since my dad was a defense attorney, I naturally thought that he was the hero, rescuing good physicians from bad situations that often had little to do with their ability as a physician. I blamed the plaintiff's attorneys for propagating cases-not for the benefit of their clients-but for their own pocketbook. Plaintiff's attorneys often made 5 to 10x what a defense attorney made in salary due to the huge payoff.

As I applied to medical school, I was careful not to mention, if possible, what my father did for a living. Once, I was asked directly what my father did, and even mentioning that he was a lawyer was enough to engender disgust. It didn't seem to help that he was a defense attorney. I didn't understand, at the time, why a physician would have such disdain for a defense attorney; he was their defender after all. I still suspect this information coming out in the interview is the true reason for my rejection letter from that particular medical school, but I'll never be able to prove it...

Now as a practicing physician, I understand that guttural reaction towards malpractice attorneys of either side. I have learned that no matter which side you're on, you depend on doctors being sued to put food on the table. This of course led to some lively conversation between my father and myself.

So here are the issues as I see it:

  • The healthcare arena is a scary place. And patients definitely need an outlet for their frustrations with the broken healthcare system we have now. Complaints often fall on deaf ears.
  • Patients feel that the system is working against them (perhaps it is) and nobody is listening...that is...until they file a lawsuit. A lawsuit gets everyone's attention, and threatening one is the surest way to get your complaint heard and addressed.
  • Currently, there are two ways to complain about your physician. A) You can issue one to the state medical board or B) You can get a lawyer to file a lawsuit. Reporting a physician to the medical board risks a physician license and therefore is investigated thoroughly and taken very seriously.
  • The down side to this system is that there is no due process for the physician. No court. No juries. However, that is also the upside. At least your fate is in the hands of others who practice(d) medicine. And if the physician actually committed true malpractice, this is the system the is likely to punish them appropriately.
  • Filing a lawsuit, however, is the most common mode of expression for patients. There are many reasons for this, one of which is the possibility of a monetary award. Some people believe that they deserve fiscal compensation for the erroneous actions of their physician.
Regardless of why patients sue, I 'd like people to answer this question honestly: Does a monetary award do anything to fix what happened and prevent that physician from doing it again and improve overall care of others in the same specialty?

I say no, it doesn't. Someone permanently disabled will still be disabled and have their costs picked up by Social Security. Someone with chronic pain will still have chronic pain. Someone with a disfiguring scar will still have a disfiguring scar. And the doctor who committed this terrible act of malpractice likely is not going to change their treatment practices because you won lots of money from the insurance company. The other doctors in that state suffer, because those large payouts increase the rates of all the other doctors who have nothing to do with this physician's malpractice.

  • One study found that only 1.53% of patients who were injured by medical error filed a claim, but on the flip side, most events for which claims were filed did not constitute negligence. Yet researchers found that most errors are system failures, rather than individual faults.
  • The medical malpractice legal system is wasteful and time consuming for both patient and doctor. Fifty-seven percent of medical malpractice premiums go toward attorney's fees, and only two-thirds of awards go to patients, who wait many years for their settlement.

Instead, it encourages physicians to engage in defensive medicine, a process that adds 210 billion dollars a year (From an April,2008 study by Price Waterhouse: "The price of excess: Identifying waste in healthcare spending") in healthcare costs. Now I know all about the quoted CBO study that says that the effect of tort reform would lower overall costs by only 0.5%. But if you read the actual words, it discusses the lowered insurance premiums as the cost savings of tort reform. It even suggests that their numbers could be off dramatically when you figure in defensive medicine ("by as much as 7%"). And if you do the math: 7% of 2.4 Trillion dollars is 168Billion. This is per year. If you do the 10 year estimates that the healthcare reform plans like to quote their cost (e.g. the "goal" is to keep the 10 year cost at 1 Trillion or 100 Billion/year) then by the CBOs own supposition, 1.7 Trillion dollars in defensive medicine costs could be saved with Tort Reform. Not an insignificant amount.

Who are the beneficiaries under this current medical malpractice system? Not the patients who lose 80% of cases that go to trial, and if they win only receive a fraction of the award many years later. Not the doctors who suffer emotional and financial distress that gets passed along to the healthcare system at great cost. Who then? Well the attorneys both plaintiff's and defendant's (Sorry Dad...) alike.

So what is the solution?

My opinion differs from many of my colleagues. I don't believe that the ultimate solution involves caps on non-economic damages, or immunity from lawsuits. For reasons I will go into later (and [warning another shameless plug] I have a whole chapter about in my book to-be-released), I don't think that altering tort provisions will provide the proper psychological relief to have a demonstrable long term effect on the practice of defensive medicine. [Did I mention I also have a degree in Psychology? I don't think it is in my bio, but is now relevant to this discussion.]

I do, however, think that tort reform helps stop the bleeding that is occurring and is an adequate short-term solution.

See Part II for my discussion on the solution to truly create a system for policing physicians that is fair and equitable to all parties, that changes the practice of defensive medicine, and leads to better quality care at lower cost to society.

Culture Shock - Why sociologists need to have a voice in healthcare reform

Cost controls are necessary to successful health care reform. Unfortunately, it is hard to implement. As the Dartmouth study showed and Atul Gawande's article in the New Yorker
highlighted (and my previous blog explained), there are dramatic regional differences in Medicare spending. And more fascinating-the areas that spend the most have lower quality than the more pecuniary areas.

Also, neighboring cities and towns will have completely different patterns in usage (as the Atul Gawande article showed with McAllen and El Paso cities in Texas). How could towns just a few miles away be so different?

We've all experienced how "the other side of the tracks" can be wholly different in regards to race, income, real estate value, and education attainment. Clearly, cultural differences from township to township, city to city, and region to region have a huge effect on health care buying patterns.

Some of those cultural differences have to do with expectations. The more successful you are, the higher your expectations. I read a blog the other day (by a @ePatientDave) that brought to my attention a blog about the lack of good customer service in healthcare. I think we in medicine do have a long way to go to make life more convenient for patients (e.g. long waits in waiting room of offices could be twittered, emailed or texted to patients so they could do something else rather than sit and waste time). However, I had a blog about the Press-Ganey and how it is taking the decision-making away from physicians and not always for the better.

For those who don't instantly know about the Press-Ganey, it is a survey that administrators of hospitals use as gospel for who is the best hospital and is all about customer satisfaction. I do want my patients to be satisfied. However, if your definition of satisfaction is getting an x-ray for your ankle that you don't need, or an MRI you don't need, than you won't be satisfied even though I might be practicing excellent medicine.

In fact, on my Facebook account someone defriended me as a result of my comments that their MD practiced good medicine in resisting their insistence of antibiotics for bronchitis. They believed (as many do) that a Z-pack cures all, and their usage won't affect antibiotic resistance for the whole population (despite the whole micro/macro effects that each person has on public health...). The problem is, they were not uneducated demanding people. They were reasonable in wanting what they perceived as the fix to their problem, despite the fact that most evidence is to the contrary, and the negative effects are far worse than they realize. Clearly, changing their behavior will not be easy and will lead to very unsatisfied patients.

Therefore, when you talk about singlepayer and how well it works in other countries (which is debatable) realize there are extreme cultural differences in regards to expectations of care. The United States has a higher desire for personalization and as a whole will not be able to embrace reform that restricts their choice, creates longer waits, and forces their physician to refuse care that patients want but might not (statistically) need.

Thus, if we want to address cost-containment in medicine, you can't just blame the physician for over-testing and over-treating. Certainly, the current reimbursement system does allow for these abuses, and some MDs abuse this more than others (and in a previous blog, I outline my proposal to change that compensation system). However, many physicians don't have the energy, or the financial strength, to withstand the demands of their patients and give in to their demands. While tort reform could help physicians withstand their patients' insistence on unnecessary care, it won't solve the core issue: patients want what they want.

So how do you change patients' wants? Ask Frank Luntz, the master of verbal manipulation. I don't know the answer to that. My guess is that sociologists should have a large role in assessing these problems and would be better able to make suggestions as to how to modify the perceived needs of patients in a way that satisfies patients and does not enrage them.

The advertising complex is somewhat to blame for this as well, and might be the solution. It seems there is a disconnect in patient thinking: they want their doctor to practice good quality Evidence Based Medicine (EBM), but not when it conflicts with what they personally want. And it puts physicians in a bad position, "Give in to the patient, and practice expensive, less-than-ideal medicine or risk a lawsuit, patient-complaint, or administration sanction from low Press-Ganey patient satisfaction scores."

Maybe we can use the advertising complex with the help of sociologists to modify this disconnect. Maybe we can't. But if it is not done, I can predict that health care reform will to some degree make people unsatisfied bc costs will escalate out of control and need painful solutions to tamp it down, or face (on some level) the feeling of a lack of personal choice - especially in the areas of the country that have higher (and at times) unreasonable expectations of what their physician and what the healthcare system should provide.

The ignored elephant in the room. What's missing from the health care reform discussion.

What do most of the health care reform bills have in common? Amongst other things, they use Medicaid as a tool for expansion of coverage. And this could be their fatal flaw, which if enacted, will cause the reformed system to come crashing down.

Don't get me wrong, I'm all for expanding coverage. Especially for the poor. Nothing frustrates me more when I have a patient in the ER who would benefit from an outpatient treatment but won't get it because they don't have money and/or insurance coverage.

First, a little history. Medicaid was passed in 1965 along with Medicare. However, Medicaid was set up in line with welfare, where there were income eligibility requirements determined by the states. Also, the federal government matched the states outlays to Medicaid as part of the funding process, leading to many of the budgetary problems the states face today.

The program was voluntary, and since states had to pay money to receive money, the poorer states had the most stringent requirements, making only the poorest of the poor eligible and leaving many poor without coverage. Worse, it incentivized people not to work, because earning even a minimal amount of money now made you ineligible for Medicaid.

The worst problem with the setup of medicaid was the lack of cost controls. It was assumed (see reference in the link above for source) that the State determined eligibility requirements and requirement for State matching would be the force to hold costs down. However, Medicaid pays for care, not for insurance. And as the program got larger, costs needed to come down somehow. Benefits were not directly cut (at first, though eventually some benefits were made more restrictive), however payments to providers of that care were.

The federal government determines what the fee schedules are to pay physicians and hospitals. Increasingly, the states are facing budget shortfalls and looking for ways to cut their part of Medicaid, and doing it by holding back payments to physicians and hospitals (usually skewed towards physicians since hospitals have more political influence), limiting access to certain medicines, and again, lowering the thresholds for eligibility.

As a result of these cuts, Medicaid pays physicians and hospitals less than the cost of providing these services. And while hospitals can only write that off, physicians who can choose their patients, choose not to take Medicaid as it is as if the patient is uninsured. Or they limit the number of Medicaid patients they will see. And specialties such as pediatrics which depend highly upon the Medicaid population for their business earn proportionately less than their internal medicine counterparts.

Despite these cost-cutting attempts, Medicaid is still a 200 billion dollars a year behemoth (approximately half of Medicare) that grows more in the lean years and shrinks somewhat during the booming years of the economy.

Getting back to the health care reform issue, one of the main tactics for insuring more people is by increasing the thresholds for eligibility for Medicaid. Yes, this will insure more people. Massachusetts proved this to be the case in their 97% universal health care plan. However, physicians and hospitals that are located in poor areas dominated by Medicaid find they are losing money.

Physicians decide not to see those patients, or give them 4 month waits for a limited number of "Medicaid" appointments, and those patients understandably end up in the ERs getting expensive care that is incompletely reimbursed, thus jeopardizing the solvency of hospitals like Boston Medical Center.

If we model our national health care reform efforts after Massachusetts then we will get the same problems magnified fifty times over: escalating costs, poor access to primary care physicians - especially for those with Medicaid/Medicare, and risk of insolvency of critical hospitals. And the states will have a harder time than they already have making their budgets work, since they will be paying out more to Medicaid than previously (which was already enough to break the budgets).

Since we have the example of Massachusetts to learn from (good aspects and bad aspects) we should learn those lessons - the chief being, MEDICAID MUST BE REFORMED BEFORE IT IS EXPANDED.

One possibility of reform is to increase payments to physicians and hospitals giving them a margin of profit, and encouraging better coordinated care to patients with multiple and/or chronic conditions requiring good primary care. While this increases costs on the front end, it decreases costs on the back end, since patients with expensive chronic conditions get better, less costly primary care, instead of more costly ER and inpatient hospital care. Of course, this implies there are sufficient primary care physicians available to give this increased care, which, if you read my previous blog, is likely not the case.

Another possibility of reform is to take Medicaid and rather than pay for services, just subsidize Medicaid patient's premiums with a private insurer in a group market/exchange system. This will undoubtedly cost more money, as Medicaid's expenditures per patient is less than private insurance (likely due to their lower payments to providers). If the market/exchange enacts good cost controls then this option could work. If not Medicaid will cost the country more than ever.

If we don't enact significant Medicaid reform, our whole country will face the problems Massachusetts' reform is only now revealing, and it could continue the downward spiral of healthcare in this country, rather than improve it.

The Primary Problem with Universal Healthcare Coverage

There is a dark side to Universal Health Insurance. And if these concerns are not dealt with first Universal Coverage could lead to disaster.

More Primary Care Physicians Are Needed.
As I mentioned in previous blogs, few people pay attention to the law of unintended consequences of legislation. The example set in Massachusetts has shown that with some success (97% coverage), there can be the beginnings of failure. In other words, when you suddenly have a large group of people who are insured and ENCOURAGED to get preventative care, where do they go? To their Primary Care Physician. The result? Very long waits to see their physician, which is measured in months, not weeks. Also, more visits to the emergency department. And this leads to increased costs. And this happens in Massachusetts which has more physicians per capita than any state in the nation.

Currently, in the U.S. we have a shortage of Primary Care Doctors (PMDs). In 2005, the Council on Graduate Medical Education released a report predicting a shortage of about 85,000 physicians by 2020 (which will be worse if the older MDs wary of healthcare reform retire as they are threatening to do).

The American Academy of Family Physicians recommended that to meet the need for primary care physicians in 2020, the United States would have to train 3,725 family physicians and 714 osteopathic physicians annually. This is just the recommended Family Practitioners and does not address other PMDs that are needed such as Internists.

In 2007, only 1107 medical students matched into Primary Care residencies. It takes 3 years to train a PMD. If this year (2009) we tripled the number of Primary Care matches, the country would still be 40,000 PMDs short.

The GAO study GAO-08-472T found that preventative care, coordinated care for the chronically ill, and continuity of care can achieve better health outcomes and cost savings. The study also found that states with more primary care physicians per capita have better health outcomes than states with fewer primary care physicians, and that states with a higher generalist-to-population ration have lower per-beneficiary Medicare expenditures.


This means we need more money for physical infrastructure in medical schools to accommodate such a large increase in students. Also, more money for residency spots (it takes approximately $100,000/year to train a physician). Finally, I highly support government subsidization of medical school tuition to minimize student debt as students with large amounts of debt tend to pick higher paying specialties (in other words, NOT primary care).

To meet the short term demand for increased primary care, a number of creative solutions must be enacted. I have a few suggestions:
1) Increase physician productivity by elimination of non-patient duties:
  • Documentation (have government subsidies for scribes)
  • Pre-approvals (hopefully patients in health markets/exchanges or Medicare will not need pre-approvals as this costs tons of money in physician productivity and unnecessary admnistrative costs)
2) Improved physician reimbursement for primary care (will lure back current primary care physicians that have shifted away to become medi-spas/hospitalists/concierge medicine will encourage more medical students to go into primary care)

3) Encourage US-Trained foreign residents to stay in the US.

4) Create a pathway for foreign-trained primary care doctors who speak good English (particularly Australia/UK/Canadian trained) to do a one year primary care appenticeship under a board-certified IM or FP physician, followed by an exam to allow them to obtain a license to practice.

5) Give tax breaks or other incentives to semi-retired/recently retired primary care physicians to bring them back into the workforce. (via L.Saldana MD)

Getting more PMDs won't be fast. And it won't be easy. But if we want USEABLE Universal Health Care, then it must be done.

The truth about the controversy surrounding taxing health care benefits and related employer issues for health care reform

Whatever side you are on about the issue of leaving health care benefits alone or repealing their tax exempt status, I will attempt to clarify some of the issues.

I don't understand the vociferous criticisms of taxing health care benefits. Here's why: The average person likely does not realize that the tax incentive for employers to offer health insurance mainly benefits high income employees. That is, because the monies given as a health insurance benefit are untaxed.

Therefore, if you don't pay much tax, you don't get much benefit. You think you are getting "free" insurance from your employer, but you are actually getting paid lower wages than you would otherwise. Thus, eliminating the untaxed healthcare insurance benefit eliminates a wealthy person giveaway. For example, if you assume the average family of four insurance cost of $12,000, a high bracket employee would save approximately $4000 in taxes. A lower income earner would not pay much tax, and therefore would not get much of a benefit. Why are we subsidizing the wealthy with our 100 billion dollars in tax breaks?

However, if you eliminate this benefit, you must compensate for it or things will be worse off than the status quo.

  1. You must require that employers still give a benefit for healthcare insurance that is equal to the amount to what they did in the previous year, or increase the salary of each employee by an amount equal to what they paid in insurance benefits the previous year. Employers must not be allowed to interpret the taxing of benefits to mean that they no longer need to offer health insurance benefits.
  2. You must replace the tax benefit with a sliding scale credit that will benefit the poorest americans.
If the above protections are not put into place, the likely result will be an eroding of the employer supported healthcare insurance base. While not perfect, the employer model of distribution of health insurance insures millions of people and undermining this would be counterproductive when the goal is to have more people insured. This potential underlies the basis for the criticisms to tax healthcare benefits.

Even with the protections, the likely result of a healthcare market/exchange combined with removal of the tax-protected status of health care benefits is that employers will no longer provide health insurance to their employees. They will provide money that will go into a health care account that is used in the market/exchange. The burden of providing healthcare insurance to their employees will be lifted. This is a good thing. For healthcare. And for the economy as a whole.

Employer mandates for coverage vs. fines for not participating
I guess this comes down to a societal moral argument: "Should employers be responsible for giving healthcare to their employees?"

Back in the day, employers covered their employees not out of obligation, but out of necessity. If your employees were healthy, they'd be more productive. Productive companies made more money. It's that simple. The irony is that what was borne out of a need to improve their profit margins and recruit superior talent, now stifles profits and drives companies to foreign countries.

If employers want to recruit top talent, I think providing a health insurance benefit would be of value, and for that reason, employers will continue to do this voluntarily. However, should they be obligated? That is a whole 'nother issue.

As I said before, to prevent significant loss of insurance coverage, companies that offer benefits should continue to offer a monetary subsidy for health care coverage. So I'm going to set aside the standard argument that we should just let unfettered capitalism determine whether companies offer coverage. Whether that is superior or not can be debated by economists. I'm dealing with the reality of trying to cover all americans in a system where corporations already pay much of the freight.

Both the House and Senate have various versions of bills that will penalizes companies that don't offer coverage. The House version penalties could be upwards of $4000 per employee, whereas the Senate version charges $750. A big problem I have with the house version is that it charges based on size of the payroll. What if the company is losing money? They still have to pay a fine? IF there is such a penalty it should have some "outs" for companies making below a certain threshold (or not making money at all). Also, the threshold for small businesses is way too low. In this economy, small businesses are already struggling, and you are going to tax their payroll? The likely result is lower payroll, and thus, slower growing companies, and slower improvement of the recession.

My problem with the Senate version is that all companies are fined exactly the same amount without regard for profitability. I don't love the idea of fining companies for not paying into the health insurance market. However, if we as a country decide that there needs to be a shared responsibility amongst various sectors of society to give all americans health care coverage, then corporations are part of this. And corporations that don't participate become a liability to getting this coverage. We just have to make sure we don't do this at the expense of corporate health.

The truth about the controversy surrounding public option for health care reform

The public option has created a ton of controversy and risks becoming the hotbutton that makes the whole health care reform movement fall apart. And yet, the arguments don't meet the facts. So I will attempt to clear up the misinformation and confusion.

What is the public option?

Many health reform proposals create a health market/exchange where people could be grouped into large balanced risk pools via either state or federal groupings (I prefer federal see previous blog, #1 for details) and have numerous health insurance companies to choose from.

The problem with this model, especially with the state market/exchange solution, is that there has been such consolidation in the health insurance market, that 94% of metropolitan markets in the U.S. have only one choice. If it were on a state by state basis, that might improve to a few choices - unless there is some agreement by insurers to maintain state monopolies to reduce competition. If it were on a federal basis, like the federal insurance plan that congress uses [not saying we should duplicate this, but there are many aspects of FEHBP that are worth emulating], there would be a large number of choices (100s).

Adding a public option to the list of choices has been suggested by many.

1) Public Option will likely cost less due to lower administrative costs. (Probably true, though less so with the state exchange model, moreso with a federal model.)
2) Public Option will be able to have protections for patients e.g. pre-existing conditions, preventative care etc...
3) Public Option will increase competition and force the private insurers to become more efficient and have added value benefits that a public option doesn't have. (Maybe yes, maybe no. See my explanation below.)

1) Public Option will steal patients away from the private insurance market. (To some degree yes. See below for further explanation.)
2) Public Option will cause insurers to make less money. (Probably so. Though they will have access to a larger market with all those newly insured patients and might be able to make up for it on volume - e.g. the Walmart model.)
3) Public Option will cause bureaucrats to be in charge of healthcare ("get between you and your doctor"). (Possibly. Some models suggest an independent federal reserve type system to oversee the public option to prevent this. But right now most people have no insurance w/ER, or underinsurance with corporation "getting between you and your doctor.")
4) Public Option will pay doctors and hospitals just as poorly as Medicare and Medicaid. (Possibly. Medicare and Medicaid pay less than cost for many doctors for many conditions [and yet perversely overpay for certain procedures] and while insurers aren't exactly generous, doctors and hospitals do better with private insurers overall.)

So do we need a public option?

  • The biggest fear amongst individuals against the public plan is that it will steal patients from private insurers and cause them to go out of business, and thereby creating a single payer model that is increasingly showing itself to be insufficient in the many countries that have one. However, I asked a number of my well-insured friends if they would choose to keep their insurer versus going to a public plan and all said they would shy away from using a public plan. Not scientific I know, but it backs up a PNHP study from FEHBP experience: that more people choose a higher out-of-pocket plan if it gives them more choice. In other words, people won't necessarily choose the cheapest one. It is possible that the public plan might even have trouble finding people to choose it in the beginning, until it proves itself to be at least equal in quality to a private insurance plan.
  • If we don't have a public option that causes insurance companies to change their practices by competition, the alternative is not having one, but increasing regulations of the insurance companies who participate in the market/exchange. I'm not a fan of increased regulations due to the law of unintended consequences. But expect this if the public plan option is not enacted.
  • The public option will allow for competition in markets where there is a monopoly. True, in our current state, but with a well-functioning market/exchange system there should be plenty of competition already, making that a less viable reason for enacting one.
  • Insurance companies will have trouble with growth and maintaining value for their shareholders. Initially, there will be plenty of growth with the many new people entering the healthcare insurance market. However, it may be that health insurance companies will have to move into a high dividend model for shareholder value, rather than a growth model. Personally, I think this is the only ethical way to run health care businesses. Insurance companies do provide a valuable service in the creation of risk pooling and redistribution of funds to allow for people to be covered for illness, and therefore do have a right to get a margin of profit on that. However, growth of profits at the expense of health care is abhorrent (as the only way to grow profits is by decreasing what you pay to providers/hospitals, decreasing coverage/denying care for patients, increasing rates, and consolidating with other companies to create monopolies).
  • The public option will force insurance companies to be more efficient/competitive and create added value. Maybe. The insurance companies might provide more services to attract new customers. Unfortunately, it is not in their best interest to do so, in that the more services you offer, you then select for people who need more services, and thus you get a sicker group of people as clients and less profits. More than likely, they won't offer more services, they'll try to compete on price and simply make less money and/or cut reimbursement rates to providers/hospitals to compensate.
The answer is No. We don't NEED a public option. We can accomplish the same goals through regulation. However the public option provides a method of getting the desired changes we need through competition, not regulation, in a more efficient manner. So while we don't need a public option, I think it is the best way to get what we want, and I don't think it will lead to a single payer system. That is, unless the public option is so superior that private insurers fail to compete on any level. Which I find highly unlikely. UPS and FedEx have found ways to compete with the USPS. Private corporations can compete successfully with government programs allowing both to healthily coexist. Thus the public option can be beneficial without being disruptive.