Kevin, M.D. - Medical Weblog

Edwin Leap: Giving back

The following is a reader take by Edwin Leap.

I have read many articles about professionals who left their career fields after many years and decided to teach. Many of them go into the public school system to share their knowledge and experience with the next generation. In fact, it sounds like a grand idea. Qualified teachers are a commodity of inestimable value.

But I have been stricken by a comment made by many of those who changed careers Almost universally, they said they ‘wanted to give something back to society’ after years in the marketplace. I was disturbed by that thought, although it is a common sentiment in America today. It disturbs me because it represents the perception that work, beyond a certain subsistence income level, is a thing of selfishness whereby we labor only for our own greed, our own power and position, and that “giving something back” must involve such avenues as charity and volunteerism.

I believe it’s important to realize that this is a false idea; a deception, because work, or rather the worker, gives something back on many levels. And it’s time we revisit the truth. Doctor or lawyer, contractor or laborer, waitress or chef, the act of work is itself ennobling and uplifting both to the one working and to the society in which he or she labors..

The worker takes responsibility for his or her well being and needs, as well as the needs of dependents. Work feeds and clothes families, pays for their transportation, entertainment, health care, and education. Work also supports government and government sponsored assistance through multiple layers of taxation on income and purchases. Work goes on to pay for voluntary charity through giving to a host of organizations and individuals, secular and religious, representing every issue and opinion imaginable. Without work, without those who get up every day and go off to produce and provide services, none of these things would occur.

Furthermore, work is a conscious effort toward independence. The person who works to provide for self and others is saying, “I don’t want anyone else to pay for me or mine. No thank you.” That’s not to say persons who work don’t sometimes need help, because they do. But by working, they are striving toward the day when they will not need the financial support of any other person, agency or government entity. This is a high and beautiful goal in an age when government assistance seems to be a Holy Grail, coveted by too many, needed by too many, and offered up by too many politicians as a means of securing their own political careers. Sadly, once a person or family attains a level of comfort, they seem to be transformed in the view of many into the burdensome middle class, the privileged or, sin of sins, the rich.

Work contributes to other work. When workers spend their income, they become part of a wonderful interdependence; an economic symbiosis far more complex than ‘trickle-down.’ Textile workers buy cars, car dealers buy groceries, grocers pay for health care, and the cycle goes on.

Unfortunately, a significant segment of society seems disinterested in the uplifting, nation - building effects of work. And their children learn the lesson adroitly. I remember a teenage boy I saw in the ER who had a history of surgery for a congenital heart defect. He had recovered fairly well over the years, and had a mind as good as anyone his age. But his mother said to him, (in reference to a discussion about how medicine had been my goal) “You can have a goal too, even though you’ll be on disability someday!” On another visit, he told me he planned to lie around and collect a check when he grew to adulthood.

He probably will. Someone will decide that the kindest act will be to put him on government sponsored disability for his entire life. In reality, with two eyes, two ears, four working limbs and a normal brain, the kindest thing anyone could do for him is make him learn a skill, or go to college, and work like a normal person. Because if he does he’ll be “giving back” to society as much as he receives, simply by taking pride in himself and his work, and by engaging in the economic give and take that is the essence of a prosperous country.

Volunteerism is a wonderful thing; so is charity. But work, the application of individual abilities and efforts for pay, does more than ‘give back.’ It gives from the very beginning.

Edwin Leap is an emergency physician and blogs at edwinleap.com.

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MedBlog Power 8

7/2/2008 - 7/9/2008
Next revision: 7/9/2008



(Key: Rank, Blog name, Last week's rank, Comment/Post of note)

1) Rural Doctoring (1): Her posts on the economic aspects of practicing medicine are a fascinating read. MEconomics, Part 5: Will You Work Until You Drop? is the latest in the series. Dr. Chan has been a excellent recent medical blog addition and has been deserving of the top Power 8 spot for last few weeks.

2) Musings of a Distractible Mind (4): I enjoy reading Dr. Rob's primary care insights and tips he shares from the examining room. Like this insightful post on treating obese patients.

3) Respectful Insolence (5): Join the eternal battle of science versus woo. Woo seems to be winning, but it's not because of Orac, who this week takes on Andrew Weil.

4) Health Beat (2): Maggie Mahar and friends continue their weekly evisceration of the health care system. She analyzes the Medicare payment debacle in her usual thorough way this week. I don't agree with some of her left-of-center solutions, but I learned a lot about health care policy from reading her posts.

5) Movin' Meat (-): As one of the (apparently) few left-wing emergency room bloggers, Shadowfax comes across as more reasonable than the typical, shrill radical-left physician. He gives fairly balanced coverage of (what else) Medicare payments.

6) Mothers in Medicine (-): A new group blog detailing the experiences of, well, physician-mothers and how they juggle their family and professional lives. A poignant post on crying seems to have hit a nerve.

7) Dr. Wes (3): No one better to analyze the NY Times' article on cardiac CT scans than this blogging-cardiologist.

8) Wachter's World (-): Bob Wachter, a recognized leader in hospitalist medicine, adds necessary gravitas to the blogosphere. So when he speaks, as he does in the recent Annals, people listen. Quality measures sound good, but done wrong, it can be dangerous to patients.

The MedBlog Power 8 is a list of medical blogs that have had an exceptional week of blogging, based purely on my subjective measures. Factors I consider are how provocative the posts are, the amount of discussion it generates, and posting frequency.

The list is revised mid-week and will be published every 1-2 days on Kevin, M.D. If you want me to consider your exceptional week of blogging, you can contact me.

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Classic post: Cut Medicare payments for doctors, you'll have fewer doctors

The following op-ed was published on August 6th, 2007 in the New Hampshire Union Leader.

Medicare is planning to cut physician payment rates by 10 percent in 2008. These reductions will continue annually, and it is predicted that the total cuts will be about 40 percent by 2016.

The topic of physician compensation generally elicits little public sympathy. After all, the average primary care physician salary in 2006 was about $150,000. Who are we to complain about reimbursement? As you will see, however, cuts in physician Medicare payments affect everyone.

Medical practices today essentially function as small businesses. Physicians are responsible for expenses like rent, payroll, employee health insurance and malpractice insurance. These costs are expected to increase 20 percent in the next nine years. During this same time, physician Medicare payments are faced with cuts of 40 percent. Already, some practices lose money every time a Medicare patient is seen. Some may find the link between medicine and money distasteful, but the hard truth is that it is impossible to practice medicine in a business model that is headed for financial disaster.

At a time when baby boomers are approaching the age of 65, some physicians attuned to this economic reality have simply stopped accepting Medicare patients. According to a recent survey by the American Medical Association, 60 percent reported that they would have to limit the number of new Medicare patients they treat due to next year's cut. Half would reduce their staff. Fourteen percent would "completely get out of patient care." Some seniors are already faced with calling 20 to 30 providers in the desperate hope that someone will accept Medicare.

It is unlikely that the primary care shortage will improve in the near future, as Medicare reimbursement rates continue to be a primary driver of physician salary. In a report by the Center for Studying Health System Change, incomes of primary care physicians fared amongst the worst in keeping pace with inflation between 1995 and 2003, while medical specialists fared the best.

Medical students, already burdened with an average debt in excess of $100,000, are clearly gravitating towards specialties where salaries have better kept pace with inflation. The report concludes that with "the diverging income trends between these specialties and primary care, the result is likely to be an imbalance in the physician workforce and perhaps a future shortage of primary care physicians."

Some may be wondering if this is just a "Medicare problem." Should you care if you have private insurance?

Absolutely. With primary care being the backbone of every health system, patients cannot have their chronic medical issues addressed in a timely fashion with a lack of primary care access. In delaying care, chronic diseases blossom into more serious conditions that are forced to be seen in already overcrowded emergency rooms.

Hospital-based care is often the most expensive and the corresponding rise in health care costs plays a major role in the increase of health insurance premiums. Unfortunately, the government responds to rising health care costs by further reducing physician payments and the cycle continues to spiral out of control.

You will hear physicians rallying against the Medicare fee reductions in the coming year. Think about how this affects you. Contact your government representative and do your part to break this vicious cycle.

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My take: Medicare, balance billing, me, op-eds

Some pre-holiday takes readers have asked me about.

Here's my take on . . .

1) . . . the Medicare cuts:
Next week is going to be an interesting week. My guess is that the Senate will hammer out something to avoid the 10% physician payment cuts. The question is, will the Republicans take money away from the Medicare Advantage plans? And will the President veto the bill? I think the answers will be yes and maybe. The Democrats have grown some balls and will play tough.

So far, the Republicans have done all they can to hurt physicians - I'm sure this debacle has caused a few to cross over party lines.

Part of me wants to see the cuts go through. With physicians dropping Medicare left and right, the AARP will go ape. It will be the closest thing we can get to a strike. Maybe then the politicians will recognize the value of physician access and do something about the payment system. Sometimes it takes a crisis to affect change.

2) . . . the lawsuit against balance billing in California:
I just received a $2,000 bill from my dentist for costs not covered by my dental insurance. There should be no reason why doctors and hospitals can't do the same.

3) . . . why I don't write more original pieces:
Time. My day consists of seeing 25+ primary care patients, sifting through 100+ blogs and newspapers for interesting links, and spending time with my family. Writing a polished op-ed takes me about 3-5 days. So, if I write more original pieces, my patients, blog, and family will suffer. Can't have everything.

I'd like nothing more than to spend more time writing, but alas, it doesn't pay the bills.

4) . . . why I didn't publish your link:
I receive about 50+ e-mails per day asking me to link, mention, or endorse a site, book, blog, or product. I link to what I think is interesting, and it's a completely subjective process. If you don't like it, well, you can start your own blog.

In general, I prefer links to pieces that are well-written, easy to read, and takes a somewhat balanced, measured tone.

I can't post everything I receive, so I apologize in advance if I can't publish your link.

5). . . how to get an op-ed published in the newspaper:
I've been fortunate to have a few printed. I learned everything I know from Googling "How to write an op-ed". Here's a handy list of contacts for the major American newspapers.

If you get rejected, don't despair. Often times it's a matter of timing. Try submitting it to another publication.

That's it for now. I'll be taking the weekend off, but there will be a Reader Take by Dr. Leap. If you're in Boston, you can catch me at Chowderfest on Sunday. Mmm . . . chowda.

Happy Fourth, and a belated happy First to my fellow Canadians.



Want my take? E-mail a topic or question you want me to blog about. Selected entries will be posted in the regular "My Takes" feature.

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Twitter

In case you're looking for other ways to keep up with Kevin, M.D., my posts are now broadcast on Twitter.

Of course, you can always subscribe using a variety of newsreaders.

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"F***ing push like you MEAN it!"

When push comes to shove, sometimes a few expletives is all that's needed to get your point across.

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The stomach of a competitive speed-eater

This can't be good for you: "Then they looked at the competitive eater. First, they noticed that his empty stomach showed virtually no peristalsis, the normal squeezing motion that helps the stomach break down food. He started eating hot dogs and his stomach got bigger and bigger. Ten minutes in, he’d eaten 36 dogs. He said he didn’t feel full, but the researchers told him they’d seen enough."

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In time for the July 4th BBQ

How about some Krispy Kreme Bacon Cheeseburgers?



Or Grilled Twinkies?



Yummy, not.

(via Instapundit)

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Mandate metastasis

Where you can't find a no-frills policy, even if you tried.

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Advice on the wards

Help make the fellow members of your team look good.

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Best wishes

To Lauren, GruntDoc's daughter, who's in the hospital right now.

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The Massachusetts' health plan

Ezra Klein with his take. Like most liberal wonks, he ignores the biggest problem with the plan - the lack of primary care access for the newly insured.

Universal coverage is useless if the primary care waiting lists are months long. Until this is rectified, calling the plan a success is wishful thinking.

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Assisted suicide

A profitable business in some European countries, who perform the act for people who fear nursing homes.

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The economy

Leading to an abortion boom?

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The mindset of a suicide jumper

The finality of the act is appealing: "When people don't have access to firearms and get it into their head that they don't think pills are going to work, they think there is something about the finality of [jumping] and think 'If I just do this it will be over.'"

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Insidermedicine

I would like to thank Insidermedicine for their continuing sponsorship at Kevin, M.D.

Insidermedicine (www.insidermedicine.com) is a physician-led news organization that allows you to keep on top of the latest medical information by watching unique videos that are created each and every weekday by Insidermedicine's team of medical experts. Their goal is to reach patients, medical doctors and students around the world to ensure that each is receiving a daily 'evidence based' health and medical update.

Given their wide and diverse audience, Insidermedicine offers health and medical content that is unique for their viewers. Here is a sample of some of their regular programs, which are also available in Chinese and Spanish.

Their videos are highly recommended, and I am excited to include them as a regular feature of this blog.

Sponsorship opportunities continue to be available. This can be via a Standard Blogad or a customized package. Please visit the advertising information page for further details.

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MedBlog Power 8

7/2/2008 - 7/9/2008
Next revision: 7/9/2008



(Key: Rank, Blog name, Last week's rank, Comment/Post of note)

1) Rural Doctoring (1): Her posts on the economic aspects of practicing medicine are a fascinating read. MEconomics, Part 5: Will You Work Until You Drop? is the latest in the series. Dr. Chan has been a excellent recent medical blog addition and has been deserving of the top Power 8 spot for last few weeks.

2) Musings of a Distractible Mind (4): I enjoy reading Dr. Rob's primary care insights and tips he shares from the examining room. Like this insightful post on treating obese patients.

3) Respectful Insolence (5): Join the eternal battle of science versus woo. Woo seems to be winning, but it's not because of Orac, who this week takes on Andrew Weil.

4) Health Beat (2): Maggie Mahar and friends continue their weekly evisceration of the health care system. She analyzes the Medicare payment debacle in her usual thorough way this week. I don't agree with some of her left-of-center solutions, but I learned a lot about health care policy from reading her posts.

5) Movin' Meat (-): As one of the (apparently) few left-wing emergency room bloggers, Shadowfax comes across as more reasonable than the typical, shrill radical-left physician. He gives fairly balanced coverage of (what else) Medicare payments.

6) Mothers in Medicine (-): A new group blog detailing the experiences of, well, physician-mothers and how they juggle their family and professional lives. A poignant post on crying seems to have hit a nerve.

7) Dr. Wes (3): No one better to analyze the NY Times' article on cardiac CT scans than this blogging-cardiologist.

8) Wachter's World (-): Bob Wachter, a recognized leader in hospitalist medicine, adds necessary gravitas to the blogosphere. So when he speaks, as he does in the recent Annals, people listen. Quality measures sound good, but done wrong, it can be dangerous to patients.

The MedBlog Power 8 is a list of medical blogs that have had an exceptional week of blogging, based purely on my subjective measures. Factors I consider are how provocative the posts are, the amount of discussion it generates, and posting frequency.

The list is revised mid-week and will be published every 1-2 days on Kevin, M.D. If you want me to consider your exceptional week of blogging, you can contact me.

Posted by Kevin | link | Comments (1) |

Reader Takes

Reader Takes is a regular feature where selected op-ed style pieces from the audience at Kevin, M.D. will be published on the blog.

Posts are between 500 and 600 words in length, and can argue any opinion related to medicine and health care.

Original articles that are provocative, well-written, free of grammatical or spelling errors, and generally follow these guidelines are preferred.

Once a reader take is published, it will remain at the top of the blog above the fold for one day. A link to the author's book, blog, or website will be included.

Kevin, M.D. receives in excess of 10,000 visits daily, and is regularly read by major media outlets.

The piece will remain exclusive to Kevin, M.D. and may not be republished elsewhere.

If you are interested in submitting a take for consideration, please contact me.

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Door-to-antibiotics time for pneumonia

Unintended consequences from a poor quality measure: "[It's] a flawed quality measure led to a lot of unnecessary antibiotic treatment (along with its accompanying risk of side effects, promotion of drug resistance, and C. diff). That’s a bad thing."

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Penis fracture

"There are certain sexual positions associated with a penile fracture . . ."

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Spotted on an Israeli medical student . . .

. . . rounding on patients with the department chair. Classy.

(via The Happy Hospitalist)

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Delta P

A better way to assess pain?

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Air ambulances

Are they really worth it? "Air ambulances cost a fortune, crash a lot, and don’t necessarily get the patient to the hospital any faster. A shocking statistic (possibly even true) is that a crew member who worked 20 hours per week for 20 years would have a 40 percent chance of being killed in a crash."

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Stomach surgery

Buckeye Surgeon: "You feel like a goddamn surgeon when you're in there doing it."

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Just do it

It can help erectile dysfunction.

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How to use an AED

Courtesy of Katie Couric and friends.

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Who details concierge physicians?

Predictably, a lot of woo-peddlers: "So what are these new products that are being peddled to concierge physicians? Designer vitamins, electronic medical records systems, nutritional programs, on-line exercise programs, antioxidant supplements - complete with a device to measure whether patients with 'disposable incomes' have reached their optimal antioxidant levels."

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The clean insurance claim: "It's like pornography"

"I don't know what it is, but I know it when I see it."

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Medicare takes

Two of my co-bloggers at MedPage Today chime in.

Shadowfax: "I find it informative regarding the relative priorities of the parties that, while both factions want to curry favor with the doctors' lobby, the Democrats' first instinct is to preserve assistance for the poor, and the Republicans' is to preserve free market reforms."

Dr. Rob: "I don't really believe Congress has what is best in mind for healthcare. I don't believe Congress has anything but the upcoming election and partisan politics in their scope. Democrat, Republican, it does not matter - both are just posturing and using my profession as a political poker chip."

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Thump

The precordial thump looks cool on TV, but does it really work?

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Does the AMA secretly want to kill primary care?

Or are they just inept? "It could be that the AMA is craven and strategic; their true goal being to prop up this specialist-heavy medical system that is overly reliant on high-tech, high-cost procedures. They may believe that primary care doctors should be replaced by lesser-trained physician’s assistants, 'doctor' nurses, and nurse practitioners, all of whom have a lower threshold to refer to specialists."

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Why did the GOP alienate doctors?

Senate GOP aide: "We’re going to get killed, and we’ll have no help from the doctors . . . Why the hell did we fight this as a party? You took a constituency that's very friendly and just flushed it down the toilet."

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Dying woman on a psych ward floor . . .

. . . with no one helping. Caught on hospital surveillance.

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It's July 1st

Good luck new residents, and be careful not to do this.

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Medicare double whammy

Medicare is holding payments as it sorts out the upcoming 10% payment cut. But if the cuts go through, doctors take it on both ends:

At some point they may just have to lift this hold, and now the 10.6% cut goes into effect, and now paying people effectively a couple weeks late . . . It has the potential to be a double whammy if things don’t go right.

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FreeMD

You get what you pay for: "Does the founder of FreeMD . . . have enough faith in his product to institute it at his own ER as its triage program of choice. Fire his triage nurse. Set up a computer in his lobby and have all prospective patients triage themselves. And if the program says you don't need to see a doctor NOW, would he feel comfortable sending that patient home from the lobby without ever seeing them? If the answer is yes, then you, the patient, should trust FreeMD. If the answer is no, then you should delete your bookmark."

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Staring

An actual patient complaint? "Maybe I should learn how to type into the computer while taking a history like some of the younger docs. It might even save a couple of minutes per patient and allow me to see a couple of extra patients per shift."

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Planning your retirement

Some doctors do a crappy job. After reading this, there is no excuse not to save for the future

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Vaccine overload?

How one doctor approaches multiple shots: "I'm well aware that my opinion is not shared by many pediatricians, who prefer to follow the letter of the recommendations and just perforate the kids at will. More power to them. For what it's worth, I prefer to be a kinder and gentler dinosaur that I hope my patients appreciate."

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"Don't EVER let them see you cry"

Mothers in Medicine: "Sorry Chief, I have let them see me cry. I'm not weak. I just still have a heart."

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Grand rounds is up

The Covert Rationing Blog hosts the July 4th edition of the weekly best of the medical blogosphere.

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Empathy

Often times, the best treatment.

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So you decided to adopt electronic records

How long to reap the rewards? About a couple of years.

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Eczema

Bathing in bleach for chronic cases? "Concerned over the rise of drug-resistant bacteria, dermatologists typically resort to antibiotics only when eczema lesions show active infection. But a cheap alternative for reducing skin microbes is a gentle bleach bath (half a cup of Clorox in a full bathtub)."

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Insidermedicine: In the Clinic - Causes and treatments of cystic fibrosis

In the Clinic - Dr. Carol Conrad, MD, discusses the causes and treatments of cystic fibrosis

Thanks to Insidermedicine for their continuing sponsorship at Kevin, M.D.

Insidermedicine (www.insidermedicine.com) is a physician-led news organization that brings daily evidence-based updates to patients, doctors and medical students. Also available in Chinese and Spanish.

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MedPage Today

I would like to thank MedPage Today for their continuing sponsorship at Kevin, M.D.

MedPage Today is the only medical news service for physicians that links consumer medical news and the professional medical analysis needed by clinicians. Through their daily coverage of breaking medical stories and topics widely reported in the consumer media, they provide clinicians with the real-time information they need to address their patients' questions and to find out how new developments might impact their clinical practice.

Co-developed by MedPage Today and The University of Pennsylvania School of Medicine, Office of Continuing Medical Education, each article alerts clinicians to breaking medical news. Physicians and other healthcare professionals may also receive Continuing Medical Education (CME) credits at no cost by completing these educational programs. CME is required of physicians in approximately 30 states and utilization of electronic CME is growing at an estimated 80% annual rate. MedPage Today meets this growing need in a unique and valuable way.

Sponsorship opportunities continue to be available. This can be via a Standard Blogad or a customized package. Please visit the advertising information page for further details.

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MedBlog Power 8

6/25/2008 - 7/2/2008
Next revision: 7/2