Kevin, M.D. - Medical Weblog

Reader take: Ganging up on primary care

noreply@blogger.com (Kevin) — Sat, 10 May 2008 18:00:00 +0000

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.

Mississippi: What happened after tort reform

noreply@blogger.com (Kevin) — Sat, 10 May 2008 17:45:00 +0000

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."

MedBlog Power 8

noreply@blogger.com (Kevin) — Fri, 09 May 2008 18:00:00 +0000

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.

Withholding antibiotics and public perception

noreply@blogger.com (Kevin) — Fri, 09 May 2008 17:00:00 +0000

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."

Malpractice reform, a bad idea?

noreply@blogger.com (Kevin) — Fri, 09 May 2008 16:00:00 +0000

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?”

How trial lawyers will solve the specialist shortage in the ED

noreply@blogger.com (Kevin) — Fri, 09 May 2008 16:00:00 +0000

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

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

Failing to provide futile care

noreply@blogger.com (Kevin) — Fri, 09 May 2008 15:00:00 +0000

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

Unintended consequences of EMTALA

noreply@blogger.com (Kevin) — Fri, 09 May 2008 15:00:00 +0000

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."

Physician suicide

noreply@blogger.com (Kevin) — Fri, 09 May 2008 13:30:00 +0000

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

More medical home analysis

noreply@blogger.com (Kevin) — Fri, 09 May 2008 13:30:00 +0000

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.

Want my take?

noreply@blogger.com (Kevin) — Fri, 09 May 2008 05:30:00 +0000

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.

Insidermedicine: If I Knew Then - Interviewing for residency

noreply@blogger.com (Kevin) — Fri, 09 May 2008 05:00:00 +0000

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.

Doctors Unite

noreply@blogger.com (Kevin) — Fri, 09 May 2008 01:21:00 +0000

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.

Meant to be broken?

noreply@blogger.com (Kevin) — Thu, 08 May 2008 21:00:00 +0000

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

Truths

noreply@blogger.com (Kevin) — Thu, 08 May 2008 21:00:00 +0000

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.'"

Breast biopsies and reality

noreply@blogger.com (Kevin) — Thu, 08 May 2008 20:00:00 +0000

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?

Florida gives doctors the finger

noreply@blogger.com (Kevin) — Thu, 08 May 2008 20:00:00 +0000

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)

"Doctoring with one hand tied behind my back"

noreply@blogger.com (Kevin) — Thu, 08 May 2008 19:00:00 +0000

When insurance companies handicap physicians, patients lose.

MedBlog Power 8

noreply@blogger.com (Kevin) — Thu, 08 May 2008 18:00:00 +0000

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

noreply@blogger.com (Kevin) — Thu, 08 May 2008 16:00:00 +0000

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.

Banning pharmaceutical gifts

noreply@blogger.com (Kevin) — Thu, 08 May 2008 15:00:00 +0000

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."

Optimism

noreply@blogger.com (Kevin) — Thu, 08 May 2008 15:00:00 +0000

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."

At least pretend to respect your patients

noreply@blogger.com (Kevin) — Thu, 08 May 2008 13:30:00 +0000

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.

"Medicare should pay for DNR orders"

noreply@blogger.com (Kevin) — Thu, 08 May 2008 13:30:00 +0000

#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."

Heal Thyself

noreply@blogger.com (Kevin) — Thu, 08 May 2008 06:00:00 +0000

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.