My take: Night float, free medical school, triage and disease management

1) After the resident work-hour restrictions were implemented in 2002, there has been more supervision during night float.

My take: Good for patient safety, bad for training. Being independent on the overnight cross-coverage team provided one of the best learning opportunities during residency.

2) The Cleveland Clinic’s medical school is going tuition free.

My take: Brilliant. These students will have substantially less debt burden than the average medical student. Hopefully their choice of specialty will have less of a financial motive, increasingly the likelihood they would choose a generalist field.

If this trend spreads, top-tier students will find medical school attractive again.

3) A reader writes: “I was reading the WSJ saw a full page color ad showing a father and his 3-year-old daughter, saying something like ‘when my daughter had a fever of 103 last night, I’m glad I got to speak to nurse instead of an answering machine’ . . .

. . . These kinds of programs, along with ‘disease management’ programs for e.g. asthma and diabetes, are bunch of crap. If anything, they only serve to further fracture care . . .

. . . I think these programs are really designed to avoid trips to the ER, and ultimately save insurers money.”

My take: Couple of points here.

Not all physician offices use answering machines off-hours. Patients in my practice can reach a doctor 24 hours a day.

I agree that one goal of telephone triage is to reduce ED visits, and thus costs. Liability however, becomes an obstacle, as it is impossible to diagnose accurately over the phone. Can you be 100% sure that the child with the 103 degree fever didn’t have meningitis? If the health insurer is willing to accept all malpractice liability for their off-hours telephone triage service, I have no problems with it.

Disease management programs certainly have their place. Working in conjunction with a primary care physician, they can be helpful adjuncts to ensure that patients are up to date with lab tests and are taking their medications.

Problems arise when they intervene with therapeutic decisions independent of the physician. Having a clear, centralized decision maker is a necessity when multiple providers and nurses are caring for the patient.

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