Kevin, M.D. - Medical Weblog

Testing surgeons' skills

Buckeye Surgeon: "Moving a bunch of rubber balls from one cup to another or being able to tie a knot in a piece of styrofoam does not necessarily translate into real life excellence. It's like drafting a quarterback based on how fast they can run the 40 yard dash and how many footballs they throw through a tire in a 60 second period. Surely we can do better than rubber balls and styrofoam bowels."

Posted by Kevin | link | Comments (0) |

Loan repayment

Want more primary care physicians? Repay their student loans, no strings attached. It seems to be working in Boston.

Posted by Kevin | link | Comments (0) |

A physician-congressman goes without health insurance

A stunt to be sure, and it doesn't hurt that he's a millionaire.

Posted by Kevin | link | Comments (0) |

Generalists get no respect

The Physician Executive: "Many of US doctors feel that primary care is the choice of students with no other choice. Even Canada's social conscience cannot mask the prejudice entirely. I was once recruited by a cardiovascular surgeon who said I was too good to settle for family practice. It is a nearly universal phenomenon in a world where progressively greater expertise gets more respect than being a generalist."

Posted by Kevin | link | Comments (2) |

MedBlog Power 8

5/07/2008 - 5/13/2008
Next revision: 5/13/2008



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

1) The Happy Hospitalist (2), This Deserves The Middle Finger

2) WSJ Health Blog (3), Doctors Shun Less Lucrative Specialities

3) Health Beat (5), Health Care Reformers Debate the Road to Universal Coverage, Part II

4) DB's Medical Rants (6), The waning art of history taking

5) Dr. Wes (7), Subspecialist Shortages and the EMR

6) Notes from Dr. RW (-), Unhealthy pressure to implement electronic medical records

7) Musings of a Dinosaur (-), Just (Don't) Do It

8) Street Anatomy (-), Christopher Huet: Retouching into Beauty

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 (0) |

Medical relatives

The Happy Hospitalist: "Sometimes I'm surprised, incredibly surprised, even by doctor families that are so blinded of the reality, they can't see the forest from the trees. The patients who are clearly so ill, that aggressive intervention is the worst possible course of action."

Posted by Kevin | link | Comments (0) |

When pandering to patient satisfaction can harm

Unintended consequences, indeed: "A few years ago, as we tried to improve patient satisfaction, we changed the way that patients order their hospital food. The program was called “At Your Request" and let patients call up to order their meals from a menu of options – at essentially anytime they wanted to eat. (From a practical standpoint, this works a lot like room service: you call and order your meal, and it shows up half an hour later.)

However, this turned out to be another way that patients who were at high risk for aspiration (see above) could get food that was unsafe for them to eat."

Posted by Kevin | link | Comments (1) |

Pharmacist ranting

#1 Dinosaur launches a verbal assault on pharmacists.

I'm waiting for The Angry Pharamcist to retort.

Posted by Kevin | link | Comments (0) |

Reputation and narcotics

When words gets out that a physician doesn't give out unnecessary pain medications: "My honest reaction was to swell with pride!"

Posted by Kevin | link | Comments (0) |

When too much is too little

How palliative care is not emphasized during medical education nor is valued by Medicare:

"When a three-person palliative care team made up of a doctor, a nurse and a psychologist spends 90 minutes in a meeting with a family, Medicare would probably pay $130 to $140—for all three people . . though it would be hard to say that one of us is practicing more sophisticated medicine."

Posted by Kevin | link | Comments (0) |

The Medicare cuts are looming

The chilling effect is well stated here:

The practice of medicine is a calling and as such, my colleagues and I have endured more unfair revenue cuts than most businesses would have endured. Yet, a medical practice is also a small business, and there are limits to how much we can endure. We are now at the point where further cuts are not survivable. Just like any small business, our revenue has to exceed costs in order to survive. Despite everything that I have been able to do to cut costs, the margin of profit is now thin, and the proposed greater than 10 percent cut will put us out of business. The only option will be to downsize the practice and stop seeing all Medicare patients. I would hate this, but it will be the only option I have if Congress does not reverse the proposed cuts.

Posted by Kevin | link | Comments (0) |

Nailing anatomy

Medical students have more sex.

Posted by Kevin | link | Comments (1) |

Electronic records by 2014?

There's a reason why universal electronic records are nothing but a pipe dream:

The high cost of EMRs, combined with a small return on investment, is a main reason why physicians have been slow to adopt systems . . . While some EMR functions, such as billing and transcribing notes, financially benefit physicians, most of the return on investment accrues to health plans.

Posted by Kevin | link | Comments (0) |

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.

Posted by Kevin | link |

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.

Posted by Kevin | link |

Reader take: Ganging up on primary care

The following is a reader take by an anonymous primary care physician.

I am a primary care physician who is less than a decade removed from residency, and at a recent medical staff meeting, I witnessed the beginning of the end of primary care in this rural Midwestern town.

I work in a town of about 50,000 people roughly an hour outside of a major Midwestern city. There is one hospital in the entire county of over 100,000 people, which employs the vast majority of physicians in the area. Being a Healthcare Provider Shortage Area, they are able to offer some student loan forgiveness, but the warm fuzzies end there.

Physician retention has been a chronic problem. A malignant administration reveals itself almost before the ink is dry on signed contracts. They have recently forced increased unassigned call duties upon primary care doctors with no additional compensation. To our faces, administration promised us hospitalist coverage for not only our own patients, but also for the admissions for patients without physicians (a substantial percentage of the population).

The city itself has none of the charms of a small town and all the disadvantages of one. Having practiced in many parts of the state and country, the sense of entitlement, payor mix, tobacco abuse, sedentary lifestyles and obesity rates of our current patient population are nothing less than breathtaking. At best, it is a painful population to care for.

Not surprisingly, the recruitment and retention problem hit the hospitalist program simultaneously. Three hospitalists are now expected to manage 24-hour coverage with no relief in sight. And instead of offering the degree of compensation necessary to bring more physicians on board, the administration exploited the sense of crisis to convince the medical staff to consider opening the doors to Advanced Practice Nurses. This was the only solution, we were told, to the hospitalist shortage. The only way to stop taking extra call for free.

At this meeting, 100% of the subspecialists voted for allowing APNs to practice in the hospital. 75% of the primary care physicians dissented. The vote was overwhelmingly in favor of the measure. This happened in a system where some primary care doctors are making less than they would if they took a new position in a major city, and more than a couple subspecialists make seven figures. The abandonment of the greater medical good by our specialist friends eager to expand their already-overflowing coffers has filled me with renewed vitriol.

After weathering repeated attempts to renegotiate our contracts in a blatantly deceptive fashion, our administration has dealt yet another demoralizing blow to the community's primary care physicians. Subspecialists have an enormous return on the investment of "physician extenders" and do not surrender any of their autonomy. As a result of the awesome greed and narrow-mindedness of the proceduralists, primary care physicians will now have little recourse when the hospital offers insulting compensation packages.

What will motivate the system to improve the lives of doctors who have mortgages, children in school, and contractual "gotchas" when they can threaten to replace us all on the cheap?

Submit a reader take for consideration.

Posted by Kevin | link | Comments (20) |

Mississippi: What happened after tort reform

WSJ: "Almost overnight, the flow of lawsuits began to dry up and businesses started to trickle in. Federal Express invested $1 billion in a new facility in the state. Toyota chose Mississippi over about a dozen other states for a new $1.2 billion, 2,000-worker auto plant. The auto maker has stipulated that the company would pull up stakes if the tort reforms were overturned by the legislature or activist judges.

That hasn't happened. About 60,000 new jobs have arrived in four years – not a small number in a workforce of about 1.3 million – and a sharp improvement from the 30,000 jobs lost in the four years before Mr. Barbour took office. Since the law took effect, the number of medical malpractice lawsuits has fallen by nearly 90%, which in turn has cut malpractice insurance costs by 30% to 45%, depending on the county."

Posted by Kevin | link | Comments (3) |

MedBlog Power 8

5/07/2008 - 5/13/2008
Next revision: 5/13/2008



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

1) The Happy Hospitalist (2), This Deserves The Middle Finger

2) WSJ Health Blog (3), Doctors Shun Less Lucrative Specialities

3) Health Beat (5), Health Care Reformers Debate the Road to Universal Coverage, Part II

4) DB's Medical Rants (6), The waning art of history taking

5) Dr. Wes (7), Subspecialist Shortages and the EMR

6) Notes from Dr. RW (-), Unhealthy pressure to implement electronic medical records

7) Musings of a Dinosaur (-), Just (Don't) Do It

8) Street Anatomy (-), Christopher Huet: Retouching into Beauty

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 (0) |

Withholding antibiotics and public perception

Ten out of Ten: "But the problem with too many people is if they’re not ignorant, then they just can’t see past the boundaries of their own skin to the greater good."

Posted by Kevin | link | Comments (0) |

Malpractice reform, a bad idea?

DrRich takes a contrarian view:

The threat of malpractice litigation, as wasteful and counterproductive as it is, provides at least some degree of balance in the doctor-patient encounter, and gives doctors (even those whose professional pride has been successfully eroded by all the many efforts aimed at doing just that) a good reason to always ask themselves, “Is this action I’m about to take the action that THIS patient really needs me to take?”

Posted by Kevin | link | Comments (2) |

How trial lawyers will solve the specialist shortage in the ED

"Increasing requirements for doctors to take call as a condition of practice."

Yeah, that's going to go over real well.

Posted by Kevin | link | Comments (4) |

Failing to provide futile care

It sometimes means accepting the risk of being sued. #1 Dinosaur says to deal with it.

Posted by Kevin | link | Comments (1) |

Unintended consequences of EMTALA

Edwin Leap: "EMTALA has created the very conditions it sought to avoid. Now, with specialists unavailable, hospitals full, transfers always difficult and no lack of genuinely sick and dying patients, there’s often 1) no one to care for them and 2) no place to put or send them. EMTALA, the federal mandate to save the poor from sickness has begun to crumble at its foundations, and leave untold numbers of patients, poor and paying, without care."

Posted by Kevin | link | Comments (4) |

Physician suicide

"All physicians have access to neat, clean ways to commit suicide."

Posted by Kevin | link | Comments (0) |

More medical home analysis

The Happy Hospitalist continues his excellent analysis on payment for the medical home. Is the situation as dire as he initially thought?

retired doc is still skeptical however.

Posted by Kevin | link | Comments (0) |

Want my take?

This is a periodic open thread to solicit issues people want me to blog about. Suggest topics and links in the comments of this post, or you can e-mail me.

I'll choose a few to put into my regular "My take" feature.

Posted by Kevin | link | Comments (0) |

Insidermedicine: If I Knew Then - Interviewing for residency

If I Knew Then - Dr. Clifford Saper, MD, MS, PhD discusses interviewing for residency

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.

Posted by Kevin | link | Comments (0) |

Doctors Unite

An Open Letter from America's Physicians

Dear Fellow Americans,

For decades the United States has led the world in healthcare. We have enjoyed the finest hospitals, medical schools, research, technology, and resources. Unfortunately, our healthcare system has lost focus to the point where patient wellbeing is placed after politics, profits, and special interests. Healthcare costs are on the rise and patients have lost their freedom of choice. These trends are hurting our economy and compromising the doctor-patient relationship. As a result, it has become difficult for physicians to deliver the best possible care.

Our heavily fragmented healthcare system has made it very difficult for you, the American public, to get the care you need. As your physicians, we want to partner with you to address the critical defects of the system as outlined below:

* You are paying a lot for healthcare and not receiving enough in return. Your insurance premiums continue to increase while your healthcare options are dwindling. Gatekeepers, insurance networks, and restrictive regulations limit your choice of doctors and your access to care.

* You have been made dependent on complicated and expensive health insurance plans. Employers are forced to take money out of your paycheck to purchase health coverage. If you lose your job, you are left with no safety net and the money you have paid for health coverage vanishes.

* The time you spend with your physician has become remarkably brief due to regulatory hurdles requiring doctors to spend more time on documentation than with you.

We believe the following factors have made our current healthcare system unsustainable:

* The insurance industry's undue authority and oppressive control over healthcare processes

* Excessive and misguided government regulation

* The practice of defensive medicine in response to a harmful and costly legal environment

We, the physicians of the United States, will no longer remain silent. We will not tolerate a healthcare system where those without medical expertise or genuine interest in our patients' health have absolute control. This letter is merely a summary of the most important problems in our current system. We believe that by partnering with the public we can start to demand real change and formulate practical solutions.

We invite you, our patients, friends, neighbors, and employers to unite with us at this important time in the history of healthcare in the United States. Together, we can guarantee our nation a healthier tomorrow.

Please talk to your doctor about this letter and visit Doctors Unite for more information.

Respectfully,

The Undersigned U.S. Physicians

Go and sign the letter.

Posted by Kevin | link | Comments (8) |

Meant to be broken?

Yet another example of how physicians will always find a way to capitalize on the unintended consequences set forth by Medicare's rules.

Posted by Kevin | link | Comments (0) |

Truths

Edwin Leap, in Medical Economics: "Policymakers see too few patients. It's easy to make decisions about the docs in the trenches when you're eating a catered lunch in a quiet boardroom. We have too many rules, slowing down care and making both patients and physicians unhappy and frustrated. The rulemaking has to stop before we collapse under the weight of 'good ideas.'"

Posted by Kevin | link | Comments (0) |

Breast biopsies and reality

Studies show that repeating a mammogram in 6 months is a "safe" option for benign breast findings.

In today's climate of liability and patient demand (just take a look at the comments), who will listen to that recommendation?

Posted by Kevin | link | Comments (1) |

Florida gives doctors the finger

Jack Jawitz: "Well, after all the personal sacrifice to become a doctor, and to be told of these facts by practice recruiters and hospital headhunters looking for doctors in other states, I would decide not to move to Florida."

(via WhiteCoat)

Posted by Kevin | link | Comments (0) |

"Doctoring with one hand tied behind my back"

When insurance companies handicap physicians, patients lose.

Posted by Kevin | link | Comments (0) |

MedBlog Power 8

5/07/2008 - 5/13/2008
Next revision: 5/13/2008



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

1) The Happy Hospitalist (2), This Deserves The Middle Finger

2) WSJ Health Blog (3), Doctors Shun Less Lucrative Specialities

3) Health Beat (5), Health Care Reformers Debate the Road to Universal Coverage, Part II

4) DB's Medical Rants (6), The waning art of history taking

5) Dr. Wes (7), Subspecialist Shortages and the EMR

6) Notes from Dr. RW (-), Unhealthy pressure to implement electronic medical records

7) Musings of a Dinosaur (-), Just (Don't) Do It

8) Street Anatomy (-), Christopher Huet: Retouching into Beauty

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 (0) |

The RUC, medical home and the specter of single-payer

Roy Poses: "This is a reminder of what can go wrong with a 'single-payer health care system,' which is what Medicare is. When the government sets what physicians are paid, which is what happens in Medicare . . . the government ought to provide a rational, transparent, accountable method of doing so. The current RUC based system is the opposite, irrational, opaque, and unaccountable."

I wonder if the physicians on the vocal, radical left are listening.

Posted by Kevin | link | Comments (2) |

Banning pharmaceutical gifts

Edward Craig: "To throw this away in some misguided attempt to avoid the appearance of unseemly influence of industry on physician’s decision making is a simplistic, holier-than-thou response to what is essentially in 2008 becoming a non-issue, as medical organizations, individual physicians, and industry alike respond to increasing scrutiny by the federal government by changing substantively how they relate to one another."

Posted by Kevin | link | Comments (1) |

Optimism

Robert Centor: "I do believe we will have a payment revolution within 5 to 10 years. Our current system of payment makes little sense. Many writers and influence leaders now understand the problem. More physicians are leaving insurance dependence, and I predict that this trend will only increase."

Posted by Kevin | link | Comments (2) |

At least pretend to respect your patients

A NEJM piece on the bare minimum physician etiquette standards:

“[I]t’s simpler to change behavior than attitudes,” Kahn writes. In other words, we won’t get all doctors to respect their patients, but maybe we can get them to act like they do.

Posted by Kevin | link | Comments (0) |

"Medicare should pay for DNR orders"

#1 Dinosaur: "Recognizing the sensitive, difficult and time-consuming nature of the effort required by a physician to discuss end-of-life issues with patients and families, Medicare (and by extension, all other insurers) should create and pay for a procedure code for obtaining a DNR order. This payment should be significant; I'd suggest on the order of at least a Level 4 office visit ("25 minutes face to face time") given the time usually needed for these conversations."

Posted by Kevin | link | Comments (3) |

Heal Thyself

This a video clip from Heal Thyself, an upcoming documentary from emergency physician Ryan Flesher who pulls back the curtain on our dysfunctional health care system:

Dr. Flesher, driven by the altruism that brought him into medicine, with camera in hand, will pull back the curtain. In so doing, he becomes both observer and participant in this unique exploration into the psyche of physicians today.

Using High Definition Video cameras we have captured over 200 hours of footage that has brought out from Boston to San Francisco to Denver and from Ecuador to Maine and back.

Posted by Kevin | link | Comments (2) |

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.

Posted by Kevin | link |

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.

Posted by Kevin | link |

My take: Slow medicine, destroying the medical home, animosity, patient communication

1) Dartmouth Medical School is leading the "slow medicine" movement, where the elderly are given the decision whether to pursue more intensive medical therapies.

My take: Bravo. This trend needs to be publicized and spread nationwide. Much of Medicare's spiraling costs can be attributed to unnecessary end-of-life care.

We need to communicate the acceptability of saying "no", and give patients more of a say in the treatments they undergo.

2) The RUC is responsible for coming up with a payment mechanism for the medical home.

My take: Specialists continue to hold primary care by the balls.

The RUC is dominated by specialists and sub-specialists. Until this committee is completely disbanded and reformed with a generalist majority, primary care will continue to get the payment shaft.

Go and read The Happy Hospitalist's detailed analysis for how the RUC is sinking the proposed medical home.

3) A reader writes: "Have you seen any hospitals that are able to avoid the bantering and animosity between the ED docs and the admitting docs over admissions?"

My take: I've seen both. There are cases where hospitalists are happy to take every admission, and others where there is considerable resistance.

It comes down to the degree and acceptance of defensive medicine practiced within the hospitals. Just as hospitalists occasionally order questionable tests defensively, emergency physicians admit borderline cases on cya basis.

Physicians with an understanding and acceptance of what's really going on generally avoid the animosity that is associated with questionable admissions.

4) A reader writes: "Curious as to where physicians see the dividing line between 'patient relations' and 'risk management'. At what point does a patient who has a legitimate concern he'd like to discuss stop deserving communication and start having to be treated as a potential lawsuit -- never mind that the patient has shown no sign of being interested in suing?"

My take: Patient relations and risk management go hand in hand. Studies have shown that better communication can reduce the risk of malpractice lawsuits.

Unless the patient actually sues, there should be no barrier obstructing patient communication with the physician. Sadly, this is rarely the case, as I wrote in a recent op-ed.

Posted by Kevin | link | Comments (8) |

Twitter and Facebook

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

Posted by Kevin | link |

MedBlog Power 8

5/07/2008 - 5/13/2008
Next revision: 5/13/2008



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

1) The Happy Hospitalist (2), This Deserves The Middle Finger

2) WSJ Health Blog (3), Doctors Shun Less Lucrative Specialities

3) Health Beat (5), Health Care Reformers Debate the Road to Universal Coverage, Part II

4) DB's Medical Rants (6), The waning art of history taking

5) Dr. Wes (7), Subspecialist Shortages and the EMR

6) Notes from Dr. RW (-), Unhealthy pressure to implement electronic medical records

7) Musings of a Dinosaur (-), Just (Don't) Do It

8) Street Anatomy (-), Christopher Huet: Retouching into Beauty

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 (0) |

Lady of the house

Buckeye Surgeon recounts a post-op visit with an au pair.

Posted by Kevin | link | Comments (1) |