In the Clinic - Dr. Chris Simpson, MD, Discusses the ECG of a Patient with Sinus Node Dysfunction

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

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

1) Rural Doctoring (1), Cultivating Rural Doctors

2) Health Beat (2), Choosing Our Battles

3) Dr. Wes (-), The Obfuscation of Benefits

4) Musings of a Distractible Mind (3), Obvious XP

5) Respectful Insolence (4), The paradox of screening mammography and breast cancer

6) The Happy Hospitalist (-), You Are Defined By Your DRG

7) Notes from Dr. RW (-), Can we measure the value (or harm) of CME?

8) ER Stories (-), Intermittant and Chronic Appendicitis?

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.

Cutting physician payments will escalate health care costs: "If you cut payment for services as a cost control (the 10% cut), you will get more volume by the survivors doing the expensive highly profitable procedures, AND you will get declining access from the already high volume, low profit centers (primary care). In other words, you will get less primary care (the cheap stuff) and you will get more expensive proceduralization by specialists."

Grab your popcorn, because next week will be "extraordinary political theater."

And yes, this will be routine if single-payer/Medicare for all were to be enacted: "Under a 'universal health insurance system,' which is advocated by the Democrats, political fights like this would happen every year. Doctors and insurers, if they were still in business, would face payment cuts. Patients would face uncertainty about who their doctors and insurers would be. And relationships between doctors, insurers and patients would become more strained than some of them already are."

Doug Farrago responds to criticism from a recent Reader's Digest article.

Try a sympathetic approach: "Is obesity a problem? Sure it is. But we need to get off of our self-righteous pulpits. Obese people should not be made into a group of outcasts. The 'them' mentality and the finger-wagging are no more than insecure people trying to feel better by putting down others."

Related? "With specialists fleeing for the relative safety of large multi-specialty hospitals and ERs closing they are used more and more. EMTALA strikes again."

Screw the evidence, according to cardiac CT peddler cardiologist Harvey Hecht: "It’s incumbent on the community to dispense with the need for evidence-based medicine . . . Thousands of people are dying unnecessarily."

See what Dr. Wes thinks about it.

Dr. Val: "Computers will replace physicians when robots replace spouses."

Expect a wave of practices to close: "Simply put, Sroka loves what he does. But this is the last year he may be able to afford to do it.

Half of his 4,000-client practice relies on Medicare to pay their bills, and Tuesday, a 10.6 percent reduction in Medicare reimbursement rates will take effect unless Congress intervenes.

But even without the cuts, some doctors like Sroka aren't sure their practices can survive."

The answer is clear. Or is it?

The following is a reader take by an anonymous physician.

Pharmaceutical companies could use a little greening. Consider the 5 inch by 5 inch tri-fold wrapper for a 1.5 gram sachet of the latest antibiotic cream, or how about the individually wrapped pills of the latest antihistamine to go over the counter. Does a can of formula need to go into a cardboard box? How about the reprints and other drug propaganda that reps leave in our offices when they pay a visit – from plastic lung models to stuffed animals with their latest slogan? What can an office do with expired drug samples?

Hospitals are coming under increasing control of their pharmaceutical and medical waste, but what happens to our individual offices? In 1998 the American Hospital Association and The Environmental Protection Agency agreed to manage and decrease the pollution generated by healthcare facilities. The focus of the agreement mainly refers to hospitals, but the principals can also be applied to nursing homes, physicians’ offices, and retail pharmacies. Hospitals for a Healthy Environment (H2E) was born in 2006 with the goals of “minimization of use and exposure to hazardous chemicals, reduction of the quantity and toxicity of healthcare waste, virtual elimination of mercury, and reducing healthcare’s environmental footprint through resource conservation”. Individual programs in New Mexico (Green Zia) and Texas (Clean Texas, Cleaner World) have successfully reduced waste and saved money. The Green Zia program estimates a $5 million savings from 1999-2007 through implementations of waste reduction practices.

Are there some simple steps that medical offices and physicians can take to decrease our professional, environmental footprints? I believe so. We can start by refusing all drug samples and visits from pharmaceutical reps. This would be a difficult sell in my office, as we have come to rely on samples to assist our financially-strapped parents and patients. A more moderate approach would be to limit samples to the top six to ten drugs, and in my pediatric office, I would include infant formulas, too. Donating samples to local free clinics is another way to recycle drugs instead of dumping prescription drugs down the toilet or drain. Most local wastewater treatment plants are not designed to treat household and office medical waste, and we’re not talking about just anti-neoplastic agents. Medications such as epinephrine, nitroglycerin, Lindane, and warfarin fall under U.S Federal Regulation 40 C.F.R 261.33(e) and 261.33(f) as “acutely hazardous” and “hazardous” when discarded. A 2002 United States Geological Society Study of 139 streams nationwide found 80% contained common household pharmaceuticals such as antidepressants, antibiotics and hormones.

Another easy way to green our offices is to buy commonly used medications in bulk. Our pediatric office does this with acetaminophen, ibuprofen, and methlyprednisolone. Sampling of these drugs has been hit or miss, and stocking them in bulk reliably insures that we can dose patients accurately with an oral syringe. The parents are given the syringe to take home for future doses.

Some of the pharmaceutical reps that visit my office have become good sources of information. They’ve allowed me to network with other physicians such as our local allergist and ENTs. Not ready to kiss these relationships goodbye means that I probably need to have a conversation about future green practices with my reps. For instance, I would like to limit the amount of brochures and fancy interactive detail pieces that inundate my mailbox. Do I really need 300 back to school notes emblazoned with ADHD meds?

Through simple changes in our practices, we can have a large impact on the environmental legacy that we leave our children.

This anonymous physician blogs at Momwithastethoscope.

A Hail Mary over the holiday week? "It's clear that Reid believes the pressure from the powerful doctors' and senior citizens' lobby over the July 4 recess will be strong enough to convince at least one more Republican to cross over and support the legislation."

If I Had - Macular Degeneration - Dr. Joan Miller, MD

What's wrong with American healthcare in a nutshell: "How does it reflect upon American culture today when obviously affluent families try to persuade doctors to defraud Medicare? How are we going to cut costs in an era of so-called consumer-driven healthcare which implies that patients and their families are the ones directing care? It is cases such as this one that really make me angry when the public blame doctors for inflating healthcare costs. For every doctor out there who orders too many tests, there must be a dozen patients who show up in exam rooms demanding chest CTs, lumbar spine MRIs, Lyme titers--or expensive unnecessary transfers from one medical center to another. If people really want to overhaul the healthcare system, they'd better begin with their own expectations."

"Big" John Cornyn (R-Tex.) sides with Medicare Advantage plans over physicians.

A move that looks very small from this corner.

To sell pills for fibromyalgia? "What I saw were disturbing images reminiscent of battered woman syndrome. The whole thing smacked of desperation on Pfizer's part to sell more drugs and represents DTC advertising sinking to a new low in exploiting women's fears!"

See how it's disrupting hospice services: "As a hospice think about if you lost half your staff, some of your patients had to be evacuated, and you had no safe water. You can never plan for every possible problem that might come up, but it would be very helpful to talk through different disaster plans with your staff. You never realize how wonderful it is to wash your hands, brush your teeth or take a bath until you can't. I had never thought about all the things we do to care for patents that require water."

Leads to four severed fingers.

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

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

1) Rural Doctoring (1), Cultivating Rural Doctors

2) Health Beat (2), Choosing Our Battles

3) Dr. Wes (-), The Obfuscation of Benefits

4) Musings of a Distractible Mind (3), Obvious XP

5) Respectful Insolence (4), The paradox of screening mammography and breast cancer

6) The Happy Hospitalist (-), You Are Defined By Your DRG

7) Notes from Dr. RW (-), Can we measure the value (or harm) of CME?

8) ER Stories (-), Intermittant and Chronic Appendicitis?

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.

How true is this list? Pretty true, as I've heard all of them used.

Matthew Mintz takes exception to a recent MSNBC article, and goes one step further and actually asks physicians.

You only get to pick two: "When enough people pay nothing for their medical care, that’s just what they’ll get in return. Of course, you won’t be told that you’ll get nothing. You’ll just have to wait so long to get the care that either you’ll get worse to the point that you need emergency care or you’ll just die while you wait."

It doesn't look good: "The conventional wisdom is that the cuts will eventually be stayed, but once they are implemented, and become the status quo, the higher the likelihood that the remedy will not appear and we will be stuck with the lower rates, or that a fix, if it comes, may be less than initially expected."

Dr. Rob takes us behind the scenes on what some doctors are thinking.

In the Clinic - Dr. Douglas Van Nostrand, MD - Interpretation of Nuclear Medicine Scans

It's only fair: "If it’s OK for individuals to own their own grocery stores, insurance companies, real estate offices, it ought to be OK for the doctors to have an equity interest in the hospitals. You just take care of something better if you have an investment yourself."

1) A reader writes: "I guess I'm just looking for an intellectually honest assessment of what is wrong with the practice model of one or two MDs supervising several mid-levels so the MDs are free to spend more of their time on the intellectually taxing cases."

There is nothing wrong with that model. Mid-levels play a valuable role in primary care delivery, and moreso in the future, with the ranks of primary care MDs dwindling.

The problem lies with some mid-levels (unconsciously or not) attempting to replace a physician for primary care. The rigor of MD or DO training is not equaled by a physician assistant, nurse practitioner, or doctorate-level nurse.

I agree that most of primary care can be handled well by mid-level providers. Physicians are valuable in picking out those 5 to 10 percent of cases that do not present typically.

The question is, does the public value that?

2) "Private health consultants" charge $7,000 to $100,000 a year for round-the-clock email and telephone consults, and face-to-face meetings with a personal health adviser.

For that price, would a concierge physician make more sense? At least that way, you'll cut out the middle-man.

3) A number of prominent medical blogs, including Graham Walker, Panda Bear, and Surgeonsblog, recently have signed off.

It seems that the lifespan of a medical blog is shorter than those of other fields. Over the past year, we've seen far too many health care voices go silent.

Blogging and practicing medicine often don't go hand in hand. Most of the media coverage borders on negative, focusing on patient privacy issues. Hospital administrations have shut down physician blogs. Furthermore, practicing medicine is exhausting, leaving blogging at the bottom of the priority list.

We are fortunate that new voices have emerged as these blogs have closed down. That's important. Physicians are often left out of the healthcare debate, despite the fact that we will play a pivotal role in any type of reform.

Mainstream media reads what we write, and has paid attention to issues that we have blogged about - like the primary care shortage and the physician payment system.

The blogging medium is an ideal way physicians can make our voices matter. It's in our best interest to keep the medical blogging phenomenon strong.

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.

Why is HIV treated differently? We should do whatever we can, within reason, to protect the healthcare worker and prevent HIV transmission. That’s the benefit of revealing source patient information to the clinician trying to craft the best preventive strategy. This outweighs the risk to that patient (the source) for the disclosure, which should be minimal — after all, the information is being released to a clinician, who presumably understands the importance of patient confidentiality.

Profiting from obesity, it's the American way.

Whether the model works or not: "With traditional practitioners fleeing hospitals in droves, soon there will be no comparison groups against which to study the model. It’s a moot point. The model is here to stay. We don’t need these metrics to establish our value."

Just invoke death.

I like the Medical Algorithms of Reality.

(via the Placebo Journal Blog)

For a few hundred dollars off: "He hoped [the patient] would be so thrilled with her results that she would post the 10-minute video on YouTube, along with his credentials, a link to his Web site, and a rave review."

A fascinating Gawande New Yorker piece: "The doctor looked closely at the wound. She shined a light on it and in M.’s eyes. Then she walked out of the room and called an ambulance. Only in the Emergency Department at Massachusetts General Hospital, after the doctors started swarming, and one told her she needed surgery now, did M. learn what had happened. She had scratched through her skull during the night—and all the way into her brain."

How suing can destroy doctors: "It is devastating to try your best to help someone and end up hurting them instead. Doctors carry tremendous guilt and self-doubt when they make a medical mistake. A malpractice suit compounds their self-flagellation with risk of financial ruin and public humiliation, which can drag on for years. For physicians who feel unfairly blamed, the predominant emotions are often anger and fear. 'I told her to go for a colonoscopy and she didn’t go. So why is it my fault that she got cancer?!'

All physicians who have been sued are deeply, negatively affected. Some lose their passion for medicine. Some no longer trust their patients. Many fantasize about leaving medicine and opening a flower shop or a Bed and Breakfast."

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

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

1) Rural Doctoring (1), Cultivating Rural Doctors

2) Health Beat (2), Choosing Our Battles

3) Dr. Wes (-), The Obfuscation of Benefits

4) Musings of a Distractible Mind (3), Obvious XP

5) Respectful Insolence (4), The paradox of screening mammography and breast cancer

6) The Happy Hospitalist (-), You Are Defined By Your DRG

7) Notes from Dr. RW (-), Can we measure the value (or harm) of CME?

8) ER Stories (-), Intermittant and Chronic Appendicitis?

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.

By removing the market from the equation: "It is quite clear that we’re in this situation because we’ve created it by destroying the laws of economics as relates to the primary care specialty, creating an absence of incentives to enter the profession."

Specialists should shoulder some of the grunt work: "Shouldn’t specialists pay some (or all) of the administrative cost of doing those referrals since it is our referrals that make it possible for them to earn that higher income?"

Dr. Helen echoes physician frustrations: "And it is not just about money, it is the frustration of paperwork and the feeling that you can never get everything done. Many of us who are in healthcare are perfectionists or a bit compulsive. One has to be to a certain degree because people's lives and health are at stake."

Are you afflicted with a money-loser or profit-center? "If you are a pneumonia patient, you should be pissed that the hospital values the bypass surgery patient far more economically than they do you. You are simply a financial headache for them. A loss leader. But, they want your experience to be a good one, so when you must come back for your 4 vessel bypass, you will want them as much as my hospital will then want you."

Miracle or marketing hype? (via Schwitzer)

Strangely interesting idea: "Aetna is sponsoring a clinical trial of a daily low-stakes lottery to see whether it helps promote adherence among coumadin patients . . . the unusual trial design features a daily one-in-five chance to win $10 and a one-in-100 chance to win $100."

Again, the concept of good health isn't enough of an incentive for patient compliance. Cash is still king.

Why aren't AEDs more readily available? "First and foremost: is cost."

JAMA reports better blood pressure control with web and pharmacy-based support.

Leading to diaphragmatic rupture.

Health care reform will be painful for some: "The current fight to protect those profits is a microcosm of what you can expect to see if a larger effort to rein in health costs ever gets going. The defenders of the status quo won’t say that they are protecting themselves. Instead, they’ll use the same arguments that the medical equipment makers are using — that a change will destroy jobs, bankrupt small businesses and, above all, harm patients."

A patient held hostage? "A doctor and two staffers at a Gwinnett medical office held a patient prisoner because they feared the woman couldn't pay her bill."

The Gone Wild series continues.

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.

Shrink Rap hosts the weekly best of the medical blogosphere.

Paul Sax: "The sad fact (for us ID doctors, at least) is that curbside consultations don’t fit into any reimbursement model for health care. And by the way, the 'price' for a curbside consult isn’t even $6 — it’s $0."

(via Michelle Au)

Bob Wachter: "Infection Preventionists are hard at work trying to decrease infection rates through microbiologically-sensible process changes, and bless them for these efforts. The problem is that – without adequate information technology and clerical support – they are spending a huge amount of their time data-gathering, and not nearly enough in change management. It is the usual story: in every industry, management always expects workers to accomplish boatloads of today’s new work while using yesterday’s resources."

If I Had - A Child Born With Microtia - Dr. Roland Eavey, MD

All angry right-wingers? "Maybe it's an inevitable corollary: working in an ER turns people. Another possibility: people who lean loudest to the right are the ones who choose the job in the first place."

On an unrelated note, Surgeonsblog looks to be closing down soon. The medical blogosphere loses another gifted writer.

Is it worth it? "Sure, the Orthopedist will get to prominently display a signed picture in his office waiting room of Tiger shaking his hand, and he will likely benefit from the prestige of having such a high-profile patient. And I'm sure Tiger will pay his bill in full. But what is a reasonable fee for taking on the enormous liability risk of treating such a patient?"

Breast cancer screening still has a long ways to go: "The paradox of breast cancer screening is that there are indeed some tumors whose sojourn time is so long that they will never harm the patient and it is these tumors that we tend to detect more with intense screening."

Another cornerstone of the medical blogosphere shuts down. Hopefully it's only a temporary hiatus while Dr. Walker begins his residency.

Dr. RW comes to their defense: "Where did we get the mindset that educational content must be judged primarily on the basis of who paid for it?"

Dr. Crippen: "We need high circulation newspapers to popularise (I use that word deliberately) less fashionable, more unpleasant illnesses."

Guess which one lost.

Which is why any talk of comparative effective is a non-starter.

. . . a pestle, where you least expect to find it.

Except when it doesn't.

Dr. Wes: "They should really be called 'Obfuscation of Benefits' forms; at least that name would lend them a modicum of credibility."

Meet the winners.

This sounds pretty cool.

Apparently, the patient didn't want to sue for that much:

But in the end, suing for such an astronomical amount is not in his interest, he says. The lawyers jacked up the amount, because they always expect to settle for less.

"Something like this shouldn’t have a $5 million dollar price tag on it. I should have had a better look at the amount. It’s my fault."

Taking the hard line.

Not so well, in some cases: "Neither physician nor patient trust each other anymore. Owing to the intrusive effects of third-party payers, physicians are, at best, advisors; more realistically, we're waiters who take orders from patients, insurers, and administrators."

How this rural doctor manages her money. Once you have a life, you have to find ways to pay for it.

Medicine is still an inexact science: "A doctor’s care is not a protective bubble, and cardiology is not the exact science that many people wish it to be. A person’s risk of a heart attack can only be estimated, and although drugs, diet and exercise may lower that risk, they cannot eliminate it entirely. True, the death rate from heart disease has declined, but it is still the leading cause of death in the United States, killing 650,000 people a year. About 300,000 die suddenly, and about half, like Mr. Russert, have no symptoms."

The following op-ed was published on May 4th, 2008 in the Nashua Telegraph.

Communication in medicine grows worse by the day. What should be a pillar of quality health care is instead a resounding failure.

Patients are rushed through office visits and often leave without having their questions answered. Labyrinthine barriers have to be overcome before speaking with a physician. Reaching a medical provider via the Internet is an impossibly daunting task. Doctors rarely talk to each other to coordinate treatment plans.

With appointments packing schedules in 15-minute increments, physicians report there is not enough time to conduct an appropriate office visit. This is to the patient's detriment, as studies show that the public adequately understands their doctor's instructions only half of the time. In today's digital age, one should ideally be able to e-mail or instant message their providers to ask follow-up questions.

This infrequently happens, as Medicare and private insurers rarely pay for electronic communication. A physician who repeatedly handles patient requests outside of an office visit will lose money, contributing to the reluctance of the medical community to embrace the Internet.

This is unfortunate, as judiciously utilizing "virtual" Internet-based visits and secure e-mail can both increase patient satisfaction and reduce health care costs.

Communication between medical providers, or coordination of care, is similarly uncompensated and devalued. It shows.

The New England Journal of Medicine reported that specialists and primary care physicians are not satisfied with the information they send to each other. Emergency departments sometimes treat patients without accompanying medical information. The time it takes a primary care physician to receive a specialist's report can exceed a month.

It seems counterproductive that physicians have such a hard time talking to each other when the system is becoming increasingly fragmented. Consider that the average Medicare patient sees seven different doctors annually. Combined with the advent of "hospitalists," or doctors who only practice inpatient medicine, the days where a single physician who cared for a patient from the office to the hospital and back are fading.

Nashua is fortunate that both St. Joseph Hospital and Southern New Hampshire Medical Center have established hospitalist programs that communicate well with primary care physicians. This, however, goes against the national trend that finds clear and comprehensive information exchange between hospitals and outpatient medical offices to be lacking.

Universal electronic health records are an optimal solution to address these issues and have been shown to decrease the incidence of medical errors arising from miscommunication. However, the short-term costs of adopting electronic records are steep.

Physicians pay for startup costs that can exceed $20,000 per doctor and find much of the return on investment goes to the insurance companies or the government. This is a major reason why only a quarter of physicians' offices nationwide have implemented such systems.

How can we improve this glaring failure to communicate?

We must change the incentives within the health-care system. Instead of the current reimbursement system encouraging doctors to maximize the number of office visits and procedures performed, pay them for spending time with patients and coordinating care with other medical providers.

It is also imperative that electronic records be adopted, thereby reducing medical errors and facilitating the transfer of health information. The government and medical insurers need to provide the financial resources for doctors to make this critical leap forward.

As for patients, be aware of the difficulties physicians face when trying to talk to one another. Know your medications and medical history when seeing a new specialist or receiving care in the emergency room. Ensure that any new treatment recommendations are appropriately communicated with your primary care physician.

Our health care system has plenty of room for improvement. Simply making it easier for medical providers to talk to both patients and each other would represent a significant step in the right direction.

The following is a reader take by Stuart Sutton.

The U.S. Dept of Labor says that the number of people working 2nd jobs is the highest in 15 years. The motivation is, as would be expected, not just more income for enhancement of lifestyle, but a need for such to stay financially afloat.

There is often debate about whether doctors are paid a reasonable amount for their work. This is especially true with primary care, which, for many reasons has been less well reimbursed than other specialties.

But, are these claims of inadequate reimbursement legitimate? The decision by a doctor to add on hours of clinical work outside of his or her usual practice would seem a valid surrogate indicator for the adequacy of reimbursement.

In this discussion, I’m not concerned with the decisions of residents, fellows, or those who are just starting their practices when income is expected to be low and such work decisions are commonly encountered. Nor do I include the decision by a physician to simply expand their previous office hours in order to see more patients to enhance their income.

Rather, I am questioning whether the typical reimbursement for the work of a practicing primary care physician can be considered appropriate when that physician feels the need to add on work outside of regular office hours. This includes such activities as nursing home coverage, weekend hospitalist duty, or hours at an urgent care center. Such decisions equate to taking on a “second job” to make ends meet.

I could not locate any research on this issue with searches on PubMed. Anecdotally, neither I nor other moonlighting physicians to whom I spoke can recall any physician specialty participating in this activity other than primary care physicians.

Sermo, an online physician community had several prior discussions regarding moonlighting. Most of those discussions were populated by primary care physicians. A survey I conducted there confirmed that a majority of those who choose to moonlight (other than psychiatry where the activity is still psychiatric care in a non-office setting) are primary care physicians. (70% primary care with 30% divided among OB/GYN and medical & surgical sub-specialties). Although not an original query, among all the respondents, a quarter added in the answer that they “value their free time too much to moonlight.” This would seem to confirm the sense that such extra work is undesirable though sometimes necessary.

Primary care physicians may be more likely to moonlight because they, unlike other specialties, have more time available to do so. This seems unlikely, however, since adding on more office hours would be a far more efficient technique for enhancing income. Alternatively, primary care patients may only be likely to utilize the services of such physicians during limited hours of the week. This would leave other hours in which a physician could still work, but would have to seek other venues in which to earn additional income. Certainly, many moonlighting opportunities seem relatively well suited to the broad based skills of a primary care physician.

In either case, primary care physicians seem to be disproportionately in need of additional income sources. As with other workers, this need is driven by current financial stresses and not by a desire for additional lifestyle enhancement.

Ultimately, if any sympathy is elicited by tales of average Americans who have less time for their families because they need to work 2 or more jobs, then the same consideration ought to exist for moonlighting primary care physicians.

In this regard, the personal sacrifices are the same for the physician as they are for the Wal-Mart clerk.

Stuart Sutton is an Internal Medicine physician.

In the Clinic - Dr. Roberto Pineda, MD - Indications for the Excimer Laser

The following op-ed was published on March 13th, 2008 in the USA Today.

Crippling health care bills, long emergency room waits and the inability to find a primary care physician just scratch the surface of the problems that patients face daily.

Surveys suggest that health care is a top domestic priority in the presidential election, and there is no lack of ideas on how to fix our system. Republicans favor using market forces and increasing the burden of health care costs on patients. Democrats, however, focus on covering the uninsured. Sadly, the candidates are missing the bigger picture. We need to address the fundamental issue at the root of our problems: the primary care shortage.

Primary care should be the backbone of any health care system. Countries with appropriate primary care resources score highly when it comes to health outcomes and cost. The United States takes the opposite approach by emphasizing the specialist rather than the primary care physician.

A recent study from The New England Journal of Medicine analyzed the providers who treat Medicare beneficiaries. The startling finding was that the average Medicare patient saw a total of seven doctors — two primary care physicians and five specialists — in a given year. Contrary to popular belief, the more physicians taking care of you does not guarantee better care. In fact, studies show that increasing fragmentation of care results in a corresponding rise in cost and medical errors.

How did we let primary care slip so far? The key is how doctors are paid. Known as "fee for service," most physicians are paid whenever they perform a medical service. The more a physician does, regardless of quality or outcome, the better he's reimbursed. Moreover, the amount a physician receives is heavily skewed toward medical or surgical procedures. A specialist who performs a procedure in a 30-minute visit can be paid three times more than a primary care physician using that same 30 minutes to discuss a patient's hypertension, diabetes or heart disease. Combine this fact with annual government threats to indiscriminately cut reimbursements despite rising office and malpractice costs, physicians are faced with no choice but to increase quantity to maintain financial viability.

Primary care physicians who refuse to compromise quality are either driven out of business or to cash-only concierge practices, further contributing to primary care's decline.

Medical students are not blind to this scenario. They see how heavily the reimbursement deck is stacked against primary care. Whether they opt to become a specialist or a primary care physician, they graduate with the same $140,000 of medical school debt. The recent numbers show that since 1997, newly graduated U.S. medical students who choose primary care as a career have declined by 50%. This trend results in emergency rooms being overwhelmed with patients without regular doctors.

Furthermore, if the Democrats' universal health care proposals come to fruition, the primary care system will be inundated with at least 45 million newly insured patients. As Massachusetts is finding out in its pioneering attempt to provide universal coverage, our system is not ready for this burden. Universal coverage is useless without primary care access.

How do we fix this problem?

It starts with reforming the physician reimbursement system. Remove the pressure for primary care physicians to squeeze in more patients per hour, and reward them for spending time with patients, optimally managing their diseases and practicing evidence-based medicine. Make primary care more attractive to medical students by forgiving student loans for those who choose primary care as a career and reconciling the marked disparity between specialist and primary care physician salaries.

We are at a point where primary care is needed more than ever. Within a few years, the first wave of the 76 million Baby Boomers will become eligible for Medicare. Patients older than 85, who are in the most need of chronic care, will rise by 50% this decade.

Who will be there to treat them?

I'll be away until Tuesday the 24th. I'll put up a few classic posts as well as a Reader Take on Sunday. Enjoy the weekend.

6/18/2008 - 6/25/2008
Next revision: 6/25/2008

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

1) Rural Doctoring (3), Rural's Schedule: How to Have a Life

2) Health Beat (2), Do We Need to Ration End-of-Life Care? There Is a Better Way (Part I)

3) Musings of a Distractible Mind (6), Taking Risk

4) Respectful Insolence (-), Doctors avoiding their duty to terminally ill patients

5) NHS Blog Doctor (7), Looking after patients with dementia

6) Not Totally Rad (-), I'm Not a Real Patient, But I Play One on TV

7) WSJ Health Blog (1), Tim Russert: One of a Kind; One of 300,000

8) Our Own System (-), We can’t have it both ways…

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.

Rather dour day of blogging stories today. Here's a more optimistic link.