American College of Physicians: Internal Medicine — Doctors for Adults ®

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Friday, January 29, 2010

QD: News Every Day--Liability risk leads to reduced physician hours, study says

ACP Internist's wrap-up of current events looks at medical liability risk and news on H1N1 influenza.

Health care reform
Medical malpractice caps have been one area of contention in health care reform. Now economists (the dismal science, indeed) say that a jump of 10% in expected medical liability risk makes doctors reduce their workload by 1.7 hours per week. That's like having one in 35 physicians quit entirely, or a loss of 21,800 physicians overall. (NPR)

H1N1 influenza
Although some hospitals have lifted their visitation restrictions enacted to curb the spread of H1N1, officials in Virginia have kept theirs in place at 18 area hospitals because the state is still reporting regional virus activity. Meanwhile, WHO announced today that H1N1 continues to spread in some areas of the world but that "activity in general is decreasing." (Daily Press of Newport News, Va., Reuters)

In case you missed it ...
President Obama's State of the Union address talked about jobs much more than health care reform. He may have overlooked that the issues can overlap. Doctors' offices hired 8,900 staff and hospitals added 1,400 in December 2009, according to preliminary data from the Bureau of Labor Statistics. Outpatient medical centers added 2,500 positions and home health care agencies added 8,000. (American Medical News)

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...and I Feel Fine

This post by Rob Lamberts, ACP Member, originally appeared at Musings of a Distractible Mind.


Primary care is dead. Long live primary care.

Wait a minute, I am in primary care. I am not dead. Not yet, at least.

Which reminds me of this Monty Python skit:

CART MASTER:
Bring out your dead!
[clang]
Bring out your dead!
[clang]
Bring out your dead!
[clang]

CUSTOMER:
Here's one.

CART MASTER:
Ninepence.

DEAD PERSON:
I'm not dead!

CART MASTER:
What?

CUSTOMER:
Nothing. Here's your ninepence.

DEAD PERSON:
I'm not dead!

CART MASTER:
'Ere. He says he's not dead!

CUSTOMER:
Yes, he is.

DEAD PERSON:
I'm not!

CART MASTER:
He isn't?

CUSTOMER:
Well, he will be soon. He's very ill.

DEAD PERSON:
I'm getting better!

CUSTOMER:
No, you're not. You'll be stone dead in a moment.

CART MASTER:
Oh, I can't take him like that. It's against regulations.

DEAD PERSON:
I don't want to go on the cart!

CUSTOMER:
Oh, don't be such a baby.

CART MASTER:
I can't take him.

DEAD PERSON:
I feel fine!

CUSTOMER:
Well, do us a favour.

CART MASTER:
I can't.

CUSTOMER:
Well, can you hang around a couple of minutes? He won't be long.

CART MASTER:
No, I've got to go to the Robinsons'. They've lost nine today.

CUSTOMER:
Well, when's your next round?

CART MASTER:
Thursday.

DEAD PERSON:
I think I'll go for a walk.

CUSTOMER:
You're not fooling anyone, you know. Look. Isn't there something you can do?

DEAD PERSON: [singing]
I feel happy. I feel happy.
[whop]

CUSTOMER:
Ah, thanks very much.

CART MASTER:
Not at all. See you on Thursday.

Now I would never suggest that the cart master who clubs the dead person represents, say, Medicare. It would not be in my nature to make such a suggestion.

But that is not the point of this post. While many complain of the death of primary care and declining reimbursement, some practices are experiencing quite the reverse: growth in income. I should know, because I am in such a practice.

We are not business geniuses in any stretch of the imagination, but we have been quite successful and raising our incomes substantially. Since I started 13 years ago, my income has doubled, and most of that increase has happened over the past five years, just the time that the death of primary care has been announced.

Our practice is almost totally outpatient (we still see inpatient pediatrics), and we earn very little at this point from labs and procedures. The vast majority of our income comes from regular office visits.

Here are some of the ways we have accomplished this:

We have focused on process. Using our electonic medical record, we try and find the most efficient ways to perform tasks in the office, involving the lowest possible number of staff. This has been a passion (see also: obsession) of mine.

We have focused on our patients. Our patients are our business, and so trying meet their needs (instead of the needs of the doctors) has resulted in a booming business. Here are some ways we have done this:
1. We have extended office hours. with a walk-in clinic (for acute problems only) every morning from 7:30-9:00 a.m. and every evening from 5:30-7:00 p.m. People don't get sick on a schedule and so we allow them to come in when they are sick. To do this, we had to drop most of our inpatient care (or have no life). This accounts for about 25% of our revenue that we would have otherwise lost to prompt cares or ERs.
2. We allow work-in visits. The patient likes to be able to see their doctor when they are sick (they get whoever is in clinic if they use our walk-in clinic). So even with a full schedule, I allow one "quick sick" visit every hour.
3. We do not tolerate patients being treated poorly. Doing so is considered a fireable offense. If a physician does so, they talk to the senior partner (which is me, but this really has not happened).
4. We strive for timeliness. Although we can never guarantee being on-time, we have done our best to have patients out the door within an hour of their arrival. This goal was modest enough to be possible, while allowing for the obvious emergencies.
5. We have a modified "open access" schedule. While I have too many chronic disease patients and scheduled follow-up visits to want to go completely open access, we do leave an hour of each afternoon open until the day of, so even complex patients can possibly be seen on the day they call.

We understand what is most important. While many practices focus on the complex higher-priced visits, we have understood from the start that the money we can earn per hour is much higher for ear infections and urinary infections. Plus, the majority of our patients are only going to use us episodically, so we want our office to cater to the larger population rather than the minority who are sick all of the time.

We are growing. My income went up when my share of the overhead went down. While our system worked fine for three physicians, it requires very few additional staff and space to run it with six. Adding new physicians and/or mid-levels has cut our overall overhead per provider dramatically.

We are planning. We know that pay-for-performance (P4P) and the "medical home" concept are probably going to happen. We have tried hard to keep our data good enough to be able to pounce on this once it is offered. So far, I have personally collected over $5,000 from P4P programs already, and their penetration is minimal. We know that once that wave starts, we will be in the front of it.

Quality is not compromised. We have done what we can to run the business well, but have tried not to forget that we are offering healthcare. The physicians in our practice agree to certain care standards and common practices. If we can all agree to what good quality care is, then we are far more likely to achieve it and we can engineer our process to accomplish it. For example, when National Committee on Quality Assurance certification became a means to increasing income, we were already exceeding the standards to become certified in diabetes care within a matter of weeks.

Admittedly, it has not been a smooth road to where we are now, and we are not without our problems (there is always a crisis somewhere), but from what I can tell, we have remained one of the less dysfunctional practices around. Given the unstable ground of U.S. health care, we certainly have no guarantees that this trend will continue, but I am doing my best to anticipate any trends in the system and set us up for capitalizing on this, rather than being caught off-guard.

Hopefully we are not facing any bridge of death in the near future. If we are, then perhaps we can start collecting shrubbery. I already have my electronic medical record programmed to say "Ni!"

Bonus points if you know the significance of the title. The answer is here.

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

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Patient-Driven Primary Care, A Cornerstone Of The Health & Wellness Movement?

This post by Alan Dappen, MD, originally appeared at Better Health.


Health and wellness go hand in hand; there is little question of this. I therefore ask why isn't primary care at the heart of the health and wellness movement? This, I feel, would make outstanding economic sense for all involved.

In an effort to survive these sour economic times, more and more companies are trying to stave off the escalating cost of healthcare by pushing for wellness. There is good reason for this. According to Buck Consultant's third annual global wellness survey which was cited on the Society of Human Resources Management web site those U.S. companies who measured financial outcomes of their wellness programs reported a 43% reduction in health care costs or about two to five percentage points per year.

At first 2% doesn't sound like that impressive a cost savings. Consider, however, the skyrocketing costs of healthcare and the fact that businesses often foot up to 80% of these costs, and 2% doesn't seem like such small peanuts anymore.

How would primary care and wellness programs partner to ensure the healthier wellbeing of people? Central to the concept are the delivery of services and affordability. First of all, all involved participants would have access to a primary care practitioner, round the clock, for any issue ranging run-of-the-mill primary care issues, to urgent care problems and to the management of ongoing chronic conditions, including smoking cessation, weight management, and the monitoring of diabetes.

A service like this costs our patients and corporate partners $25/month (or $300 per year) per employee, and guarantees our patients a face-to-face check and medical history and then 24/7 access to the a practitioner however the patient wants: by phone, e-mail, videoconferencing, same-day office visits and even house calls.

Imagine how much healthier corporate America would be if employers could guarantee their employees access to a doctor without the employees ever having to leave the office or waiting hours in a waiting room packed with sick people? If, when someone called her doctor, the doctor picked up the phone and talked to her directly, often times solving her problem within 10 minutes after the phone call started? Since we establish a patient-doctor relationship with a face-to-face visit first, our patients can be treated by telemedicine, and done so quickly that our malpractice insurance rates have actually gone down.

A benefit like this could easily be paid for by a company in numerous ways: by the employer either as an add-on benefit or by funding it from a health savings account. Employees, too, can pay for the benefit from their health savings account, if they have one, or from a flexible savings account as services are rendered.

If $300 per year per employee could save 5% of a company's health care costs, plus saving employees and the company hours of lost productivity and hassle--not to mention employee loyalty--isn't it worth it?

I now come full circle: Shouldn't convenient access to a primary practitioner be a core component of any health and wellness program? Wouldn't this save businesses--and all of us--millions of dollars, not to mention help to ensure our health and wellness?

This post originally appeared on Better Health , a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Thursday, January 28, 2010

QD: News Every Day--Health care reform scarce in presidential address

ACP Internist's wrap-up of current events looks at a lack of attention to health care reform in the State of the Union address. For those keeping track, President Barack Obama didn't mention health care until a half-hour into his nearly 70-minute speech. When he did, it was nine paragraphs out of 112. He vowed to keep pushing for reform, but didn't lay out any specifics. (New York Times, White House transcript, The Hill, Politico)

dentist by ^@^ina  via FlickrPrimary care shortage
Dentists want to screen their patients for cardiovascular disease and other chronic conditions. More than three-quarters of nearly 2,000 dentists surveyed thought it was important for them to screen for hypertension, cardiovascular disease, diabetes, hepatitis and HIV. Two-thirds would tell the patients the results right away and nearly all would refer for primary care treatment. (And of course, four out of five dentists still recommend a certain brand of gum.)

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Wednesday, January 27, 2010

Why Physicians Are Going To Stop Accepting Medicare

This post by Stanley Feld, MD, originally appeared at Better Health.


President Obama's health care reform bill will not work. It is based on decreases in physician reimbursement while forcing physicians to increase overhead with unaffordable electronic medical records. More and more physician groups and practices are starting to realize that they cannot make a living from the reimbursement from Medicare. They are quitting taking new Medicare patients and trying to get rid of the old ones by not taking assignment.

President Obama's idea is to force physicians to be more efficient producers. It is very difficult to force anyone to do anything they cannot afford.

Click on the "More" link to continue reading this post.

President Obama also believes that physicians over-test patients in order to make money. Wrong! Much of the over testing comes from the practice of defensive medicine. Many physicians have been sued for under testing. No one is sued for doing a test. Yet there is not a word about malpractice reform in either version of the healthcare reform bill to decrease testing by eliminating defensive medicine.

President Obama's solution is to prohibit physicians from testing in their office even though it is more convenient and efficient for patients. Ancillary services can help with overhead and does increase physicians' efficiency of care.

In fact, the fees for the ancillary services in a physicians' office are generally much less expensive than the fees for ancillary services in hospitals. President Obama ignores this fact. He believes physicians over test for profit. This might be true in some cases. However, this abuse can be discovered with the information technology system we have at present. He believes he can force physicians to tests less if it is outsourced to the hospital.

Physicians on average earn 20% to 30% less from Medicare than they do from private patients, and many are dropping out of the program.

The administration is beginning to feel the kick-back from the physician community. I think this kick-back will escalate in the coming months. It will worsen the delivery of medical care.

"President Obama last year praised the Mayo Clinic as a "classic example" of how a health-care provider can offer "better outcomes" at lower cost."

How were better outcomes determined? The question is unanswered.

"Mayo said last week it will no longer accept Medicare patients at one of its primary care clinics in Arizona. Mayo said the decision is part of a two-year pilot program to determine if it should also drop Medicare patients at other facilities in Arizona, Florida and Minnesota, which serve more than 500,000 seniors."

Mayo says it lost $840 million last year treating Medicare patients, the result of the program's low reimbursement rates.

In Arizona alone it lost $120 million dollars. The losses are usually made up by cost shifting to the private insurers and private patients. These losses are getting harder and harder to make up by cost shifting.

"Mayo Clinic loses a substantial amount of money every year due to the reimbursement schedule under Medicare," the institution said. "Decades of underfunding and paying for volume rather than value in Medicare have led us to this decision."

The media has reported that Mayo Clinic has only dropped accepting Medicare in a small clinic in Glendale, Ariz. It has been reported as an insignificant event by the traditional media. Mayo Clinic is being very civilized by not eliminating participation in Medicare in all the clinics at once. The Mayo Clinic is sending a message to President Obama and his future plans. It will also be a signal to physicians throughout the country.

Ninety-two percent of family physicians accept Medicare. Only about 73% of those are now accepting new patients. This reduction in participating physicians comes on top of a shortage of primary care physicians.

Patients struggle to find any specialist who will accept Medicare. This experience is greatest in the specialties of neurology, oncology and gynecology. Cardiology is next.

Last week cardiologists filed a lawsuit in U.S. District Court for the Southern District of Florida, charging that the government's planned cutbacks will deal a major blow to medical care in the USA.

"It will force thousands of cardiologists to shutter their offices, sell diagnostic equipment and work for hospitals, which charge more for the same procedures."

The lawsuit is an attempt by a group of medical specialists to stave off steep Medicare fee cuts for routine office-based procedures such as nuclear stress tests and echocardiograms.

"What they've done is basically killed the private practice of cardiology," says Jack Lewin, CEO of the American College of Cardiology (ACC), which represents 90% of the roughly 40,000 heart specialists in the USA."

The government's response was politeness. It will hide behind regulations made as a result of congressional mandates. The result is typical bureaucratic gobbledygook.

"Jonathan Blum, director of the government's Center for Medicare Management, says the agency is bound by law not to increase spending when making reimbursement decisions each year."

"Lewin and other heart specialists met with Sebelius on Dec. 8 and explained their concerns. "I thought she was very empathic," he says, but Sebelius has yet to take action."

Kathryn Sebelius will not take action. Neither she nor President Obama really understands the problem, much less the solutions. One cardiologist said it is an efficient way of getting rid of cardiologists and ration access to care.

"It's so absurd, it's kind of funny," he says. "I know ACC doesn't think it's funny, but I do."

It isn't funny. It is an unintended consequence of government control of healthcare. Healthcare should be consumer driven not government controlled. Government should make appropriate rules to level the playing field for all stakeholders and then get out of the way.

A cardiologist in Silver City, N.M., not far from the Mexican border, said,

"The closest cardiologist to me is 150 miles away. With all these cuts coming, it will make it impossible for me to break even seeing 40 patients a day."

Does anyone want the government and its 118 new bureaucracies to take over medical care?

What is the problem?
1. The government is broke.
2. They have to reduce expenditures.
3. Physicians are the weakest link, politically, in the healthcare system because they are ineffectively represented.
4. The government will not fight the healthcare insurance industry's lobbying.
5. The government will not fight the Plaintiff attorney's lobbying.
6. The government will continue to waste taxpayers dollars on stakeholders who add little value to the treatment of sick patients.

It is about time groups of physicians started to make some noise.

Congratulations goes to the Mayo Clinic and the American College of Cardiology.

This post originally appeared on Better Health , a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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QD: News Every Day--health care reform pauses for a gut-check

ACP Internist's wrap-up of current events looks at health care reform, and the slow process state legislators encounter when trying to solve health policy issues such as the shortage of primary care physicians.

Health care reform
Congress will pause on health care reform, at least until tonight's State of the Union address, while they search for a clear direction to proceed. Legislators say their constituents are telling them (and pollsters) that they want more focus on jobs and the economy, and less on health care. (AP/San Francisco Chronicle, AP, Wall Street Journal)

Primary care shortage
Regulatory overhaul is one way to solve the primary care shortage, but it moves sloooowly. A New Jersey task force is looking at the particulars in the Garden State--a projected 12% deficit by 2020. For primary care, that's 1,000 too few doctors. A state legislator asked the state's Board of Medical Examiners to add questions to one of its surveys to collect data that could be used to attract federal funds. No word back yet. The president of the association for teaching hospitals asked legislators to prove their interest in retaining physicians. (Courier News)

Michigan is facing a retention problem, as well. Thousands of doctors leave the state after their residencies, and an 8% cut in Medicare reimbursement may drive more away, says the state's medical society. That group is looking to drive physicians into the state's universities, where they may get better reimbursement. (South Bend Tribune)

In case you missed it ...
An internist undergoes recertification and mulls the relevance of standardized exams to her real-life practice, and to her work-life balance. (JAMA, subscription required)

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Tuesday, January 26, 2010

QD: News Every Day--Health reform reconciliation (for Democrats, anyway)

ACP Internist's wrap-up of current events looks at an agreement to try to salvage health care reform legislation.

Health care reform
Democrats will use a legislative maneuver called reconciliation to pass health care reform legislation. The procedure bypasses the Democrat's lost filibuster-proof majority in the Senate. In short, the House will modify the Senate's legislation with enough changes to try to pass it in both Chambers. Reconciliation hadn't been a popular option before today's announcement. (San Diego Union-Tribune, Politico, Boston Globe)

The White House continues to mull over what's achievable. To avoid being perceived as trying to push through health care policy, it had sought cooperation with Republicans on the low-hanging fruit--capping medical malpractice, buying insurance across state lines and tax credits for those buy their own insurance. But Republicans aren't necessarily in agreement on those very issues, which couldn't pass a Republican-controlled Senate in the 90s and 00s. (New York Daily News, NPR)

Patient-centered medical home
Carilion Clinic Family Medicine's Parkway Vinton practice describes how it implemented the patient-centered medical home. Care coordinators, a new role in the practice, track patients with chronic illnesses, ensure screening tests are up to date, answer questions and locate community support. The National Committee for Quality Assurance certified the practice its first Level-3 Patient-Centered Medical Home in the state. (Roanoke Times)

In case you missed it ...
Joseph Kim, MD, who hosts a blog on non-clinical physician careers, mulls over the options for doctors who want to pursue an MBA.

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Med students unfamiliar with electronic health records

Generation Y medical students are supposed to be the tech-savvy ones. As it turns out, they may be more familiar with Facebook than with the electronic health records they'll likely use in their medical practice. (Modern Physician, free-registration required)

Educators at the University of Illinois at Chicago College of Medicine assessed nearly 190 fourth-year medical students on their use of EHRs during a mock encounter simulating a cancer patient hospitalized with complications from chemotherapy.

Students were scored on their ability to find information crucial to the patient's case within the EHR and their ability to analyze the EHR without alienating the patient. While most couldn't access the information, they did interact with the patients face-to-face and even explained when they looked away to the computer.

Following more research, the school may incorporate class work on using EHRs.

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Monday, January 25, 2010

QD: News Every Day--Health politics becomes health policy

ACP Internist's wrap-up of current events turns its attention toward health care reform, and how health care policy translates into health care delivery.

Health care reform
Congressional legislation will move forward with the least controversial elements of health care reform: solving Medicare's pending insolvency and closing a gap in Medicare Part D coverage. But Democrats and Republicans differ on how to accomplish such goals. (Wall Street Journal)

Medicare's reimbursement system has long stuck in the craw of primary care physicians. As a result, they don't always accept such patients, so one in three Medicare enrollees had trouble finding a primary care doctor when entering the Medicare population, according to a June 2008 report by the Medicare Payment Advisory Commission. The impact is shortening an already pressed primary care system. In Arizona, only three of that state's 15 counties have the appropriate ratio of primary care doctors to the general population. (The Arizona Republic)

Physicians aren't waiting for health care reform that may never come. They continue to leave community practice and delve into concierge care, which they say allows them to practice the thorough, hands-on medicine they'd envisioned when they graduated medical school. ACP Fellow David Grulke, MD, of Norfolk, Va., converted his practice to a concierge model in 2002. He charges $660 to $1,080 annually (unlike some practices that charge thousands or more) and describes it as a service for ordinary people who want a relationship with their doctor. In the same article, Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, tells the Virginian-Pilot such arrangements are the symptom of a broken care system. (Virginian-Pilot)

Haitian relief efforts
ACP Member Myriame Casimir, MD, was raised in Haiti. Today, she returns there on a medical mission comprised of her and 20 other providers from Rush University Medical Center in Chicago. (Chicago Tribune)

Also, an aid worker used a first-aid app on his cell phone to survive 60 hours trapped in the rubble of a building. (CNN)

In case you missed it ...
ACP Fellow Turi McNamee, MD, blogs about the "weekend effect" and concludes that, on Satursdays and Sunday, it's better to be shot than have a heart attack. She covers her local hospital's shifts on weekends and wonders what the impact will be on her facility's relaxed atmosphere if more research leads to an increase in weekend staffing. (True/Slant)

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Medical News of the Obvious

As someone who is already reading a blog, you may be more likely than most to know that contemporary Americans consume a lot of media. But did you know that kids do, too?

That's the news brought to us by a new study of children's media consumption habits, reported by HealthDay. Turns out kids watch TV, listen to music, surf the net, and mess around with their cell phones a lot. The rise in kids' media consumption may even be linked to wider use of cell and smart phones.

Other not-so-surprising facts revealed by the survey:
--Fewer children are reading magazines and newspapers, but more of this reading is done online.
--Boys spend more time playing video and computer games than girls.
--Oh, and kids who spend 16 hours or more a day consuming media are more likely to get bad grades. (Just hypothesizing here, but would that perhaps relate to the fact that they don't have time to either sleep or go to school?)

More MNO comes to us from Twitter. DrRobH found this: "Pot smoking during pregnancy may stunt fetal growth." His comment: "This falls into the category of Duh?"

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Friday, January 22, 2010

What Are The Root Causes Of The Primary Care Shortage?

This post by Kevin Pho, ACP Member, aka KevinMD, appeared at Better Health.


It's no secret that without a stronger primary care foundation, the current reform efforts are unlikely to be successful. If anything, it will only delay the inevitable.

I wrote last month that one discussed solution, adding more residency slots, won't help: it would simply perpetuate the disproportionate specialist:primary care ratio.

A recent op-ed in The New York Times expands on that theme. The authors suggest that not only does primary care need to be promoted, specialist slots should be limited. Simply building more medical schools, or adding more residency slots, without such restrictions will only add to the number of specialists.

Already, many primary care residency slots go unfilled; what's the point of adding more?

You have to solve the root cause that shifts more students away from primary care: disproportionately low pay, disrespect that starts early in medical training, and poor working conditions where bureaucracy interferes with the doctor-patient relationship.

Until each of those issues are addressed, simply more spending money to produce more doctors simply isn't going to work.

This post originally appeared on Better Health , a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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QD: News Every Day--Common ground in health care reform

ACP Internist's wrap-up of current events turns its attention toward those toiling in the wake of collapse--of health care reform. Congressional aides, the folks who do all the heavy lifting for new legislation, are seeking common ground for a pared back health care reform bill. Labor groups, patient advocates and some physicians, including Nancy Nielsen, MACP, a former AMA president, are calling for health reform. While it won't be easy to find common ground, there is a short list of items in the making. (New York Times, Los Angeles Times, AP/Washington Post)

Haitian relief efforts
In a country in dire need of emergency care, internists who'd regularly traveled to the country over the years return yet again to staff clinics and hospitals. They find themselves doing pre- and post-operative care and administering what medical supplies they can muster, such as in Cite Soleil, described as one of the poorest ghettos in the Western Hemisphere. Hospitals in Les Cayes, a hundred miles away from Port-au-Prince, survived the earthquake and are performing surgery around the clock to keep up. (Verona-Cedar Grove Times, Daily Hampshire Gazette)

ACP recommends supporting Haitian relief efforts through one or more of the organizations listed here.

In case you missed it ...
A physician recounts his own experience with a rare, life-threatening illness, and notes that the patient gets lost in discussions of treatments, health care delivery and health care reform. (Philadelphia Inquirer)

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Facing the Future

This post by Rob Lamberts, ACP Member, originally appeared at Musings of a Distractible Mind.


The following is an actual fictional conversation that took place in the doctor's lounge at a local hospital.

Internist: Dang, these Medicare cuts are coming and I doubt that Congress has the wits to avoid them. I am not sure I can go on practicing if they cut them anymore.

Family Physician: Yeah, we already get paid so little by Medicaid and the private insurers, we have had to start to look for other sources of revenue.

Internist: Really? We have been looking into that as well. What are you thinking about doing?

Family Physician: We thought about doing cosmetic procedures, but we have an especially good-looking population, so we really can't make it work.

Internist: Bummer.

krispy kreme by House of Sims via FlickrFamily Physician: Yep. Instead, we have decided to open a kiosk for Krispy Kreme donuts. We figure we can make money off of the donuts, plus we can get more of our patients obese. Then we can treat worse diseases and code a higher level for each visit.

Internist: Genius. Plus, you can get all of the kids hyperactive on the sugar and treat their ADHD.

Family Physician: And the "Hot Donuts Now" sign along with the scent of fresh-baked donuts will really draw in new customers ... I mean patients.

[Click on the More link below to read the full post.)

Internist: One of the GI doctors in town is doing the same sort of thing, opening a Starbucks in his office. He figures he gets walk-ins, gets people with worse dyspepsia, and gets free WiFi to boot.

Family Physician: Brilliant. What have you been thinking of?

Internist: We have noticed the interest our patients have in holistic medicine, and thought we should capitalize on that.

Family Physician: So you are hiring a homeopath?

Internist: No, they wouldn't set foot in our office because of the "evil" immunizations we use. We tried to get all sorts of alternative providers, but they would always sneer at our practices. And so we finally opted for two things: First, we are doing aromatherapy, which has our staff so relaxed that they don't seem to have noticed that we cut their pay by 50%.

Family Physician: Great.

palm reader by markresch via FlickrInternist: Second, we have a psychic who goes around in our lobby doing palm reading and tea leaves on our patients as they wait. There are two positive outcomes from this: the patients who get bad fortunes told are so anxious that their blood pressure is up and they are ripe for anxiety treatment; the ones with good fortunes are happy enough that we can order all sorts of tests on them and they don't seem to care. There is a downside, however.

Family Physician: What's that?

Internist: My partner now thinks that we should take our entire budget for next month and invest it in Power Ball lottery tickets. He says it is a "sure thing."

Hospitalist: Hey guys, what's up?

Family Physician: We're just discussing what we are going to do to offset the impending Medicare cuts. Do you have plans?

Hospitalist: Oh yes. I don't like the idea of increasing the load to 70 admissions per day. Fifty is plenty. Instead, we are capitalizing on the fact that our patients are a "captive audience."

Internist: This I've gotta hear.

Hospitalist: We figured that we have enough turnover that some sort of direct marketing scheme to our patients could be quite lucrative. We are now certified Amway sales representatives.

Family Physician: I love it!

Hospitalist: Yep. We have these patients in a position where they can't move, and we sell them cleaning solvents, vitamins, and skin care products. Instead of taking cash, we just add it on to their hospital bill, so they usually buy a bunch.

Internist: As an added bonus, the families of your patients will be so scared that you will try to sell them Amway products, that they steer completely clear of the hospital.

Hospitalist: Bingo! It works like a charm. We got this idea from the intensivists who were holding Tupperware parties in the ICU. The patients were sedated "just enough" so that they left the hospital with all sorts of cups, jugs, and bowls.

Family Physician: Any complaints?

Hospitalist: Not yet. You figure, what we charge for the solvents is 1/4 of what the hospital charges for an aspirin. The patients really don't notice a little more charge. We have even had some insurances mistakenly pay for some of our Amway products!

Internist: You know, maybe this Medicare cut may just be a good thing. Look at how it has pushed us to open new frontiers in medicine. Our children will look back on this time as being one of the real turning-points in American healthcare.

Family Physician: Yeah, today Amway ... tomorrow ...

Hospitalist: Healthcare reform? Higher reimbursement? A fair payment model?

Family Physician: Used cars.

Internist: I am so glad I went into medicine.

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

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Thursday, January 21, 2010

QD: News Every Day--More internists arriving in Haiti

ACP Internist's wrap-up of current events follows MSNBC's chief health correspondent traveling through Haitian hospitals. He reports as they get up to speed on caring for patients in their facilities, they are also trying to coordinate care. Simple tasks, such as finding out who has space, are difficult. Relief efforts by many countries aren't fully coordinated with each other or with many of the nongovernmental efforts underway. Despite reports, logistical challenges are improving. (MSNBC, CNN)

Amid the logistics, independent medical teams are succeeding, such as a group from Christiana Care Hospital in Newark, Del. Reynold Agard, ACP Member, and Erin Meyer, ACP Associate Member, joined a team of 20 who travled to Jacmel, Haiti, a seaside town not far from the quake's epicenter, but that hadn't yet received help. Another team from Bridgeport, Conn., going to Jacmel was joined by Sangeetha Thiviyarajah, ACP Associate Member (pictured here). A team from Cooper University Hospital in Camden, NJ, has started surgical care, and physicians from Dayton, Ohio, set up a morgue, a decontamination area and showers for relief workers. And, the USNS Comfort received its first two patients by helicopter. It's now anchored off the Haitian Coast for an indefinite stay after upgrading to 1,000 hospital beds and more than 1,000 sailors. (Wilmington News-Journal, CTpost.com, Philadelphia Inquirer, Dayton Daily News, U.S. Navy)

U.S. Navy photo by Mass Communication Specialist 1st Class Troy D. Miller/Released
The USNS Comfort anchored off the coast of Haiti and began receiving patients on Jan. 20.

Health care reform
Health care reform proponents look to salvage area of health care reform that were agreed upon throughout the legislative process, such as preventing insurers from canceling policies for people who fall ill. But many aspect of health care are related to one another, so a piecemeal approach has its own problems. Drug-makers, insurers and other health-related businesses are positioning themselves in the new landscape. So are medical societies, such as ACP. (free registration required) President Joseph Stubbs, FACP, explains. (Los Angeles Times, Wall Street Journal, MedScape Today)

In case you missed it ...
An internist in California was shocked when she saw the new Medicare schedule had cut reimbursement by 20%. Her overhead costs haven't fallen, so she's contemplating giving up that block of patients, even though she loves caring for them. (Los Altos Town Crier)

Also, LiveScience.com debunks seven common medical myths that even doctors believe.

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Patient-Driven Primary Care Shouldn't be Labeled "Concierge"

This post by Alan Dappen, MD, appeared originally at Better Health.

I bristle when my patient-driven, fee-for-service primary practice, DocTalker Family Medicine, gets lumped into the "concierge" movement, as it frequently does. First, veterinarians, accountants, mechanics lawyers and all other service providers in everyday life who work directly for their clients and not as "preferred providers" for the insurance companies are not labeled "concierge." Secondly, the label "concierge" implies exclusivity, membership, high yearly retainers, and capped patient enrollment. Each of these labels we too reject.

A practice like ours out-competes the traditional model and the "concierge idea" in almost every measurable way: access, convenience, patient control, speed to treatment, quality and finally and maybe most importantly for the sake of the health care debate, price. Our boss is each patient, one at a time, and our goal is to provide the most cost effective delivery model achievable. We strive for nothing less than making primary care immediate, high quality, patient-controlled and affordable to every American. We deliver a concierge-level service at a price that is much less than even the price-fixing controlled by the insurance-driven model to date.

Click on the "More" link to continue this post.

Central to our philosophy is how we approach payment. What we sell is time; we charge purely on time-based services. Prices for materials, like supplies, vaccines, and labs are posted on the website and have little mark-up so that we can pass on the savings to our patients. Everyone who interferes with patient control, causes a conflict of interest, or increases cost has been dismissed from the relationship. This includes insurance companies, Medicare, data-miners, coders and drug reps. Our patients pay when services are rendered, just like any other services purchased in our lives.

We applaud concierge practices for providing VIP-service that all patients deserve: immediate access to a practitioner, convenience, and personalized and high quality care. We offer the same high level of service, but with key differences:

No rationing of care by price. Unlike the concierge philosophy, there is no access fee, which in many concierge practices can total $1,500 per year. We instead sell time. We charge in five-minute increments of time since it's the most transparent and policeable way of measuring our productivity. Our patients have a choice to pay-as-they-go, which means that they pay when service has been rendered, ($33.33 for five minutes) be it a phone call, 10-minute office visit, 10-minute e-mail or 10-minute videoconference, no matter what time of day or day of the year. We do offer a 25% discount to patients who put money in a pre-paid account, which means that patients can pay for service ahead of time, and will use the time when they need it. These pre-paid patients have a discounted rate of $25 for every 5 minutes. Patients can close their accounts with us at any time at no penalty.

The average person needs about an hour of care a year, meaning they have 24-7 instant access to us for $300 per year. Over 50% of interactions are solved through phones and e-mails. About 75% of the patients in our system spend less than $300 in a year. Fewer than 1% of our patients this year (out of an active patient group 3000) spent over $ 1,500 and most of these people are elderly, trapped at home with significant medical problems. We are the only medical practice left in Fairfax and Arlington County, Va. (combined population of 1.3 million) that offers house calls. This gives you an idea of the price difference that we have over the concierge and even the typical business model of care.

No exclusivity or capping of patient numbers. Our philosophy and business model is based on a volume business. We estimate that each medical provider in the practice must carry a work load of about 2,000 active patients to make a competitive living. We do not limit the number of patients we will take. When we need to add on a new primary care physician (PCP) to accommodate new patients, we do. Our satisfaction comes from the mission of providing excellent care at an excellent price and eliminating all conflicts of interest that arise between the doctor and patient that either undermine the relationship or increase the cost of the service.

Helping to solve the primary care crises. PCPs are in short supply. There are not enough of us to go around and more retiring faster than they are being made. Medical schools fail to attract primary care specialists in any large numbers since the field typically promises soul-crushing workloads and frustrations in reimbursement, which rapidly leads to high burnout. One of the directions the burned-out physician heads is towards the concierge model. By most definitions the concierge solution is a solution for the doctor.

The concierge model places a premium price on access to primary care, taking advantage of the shortage of primary care physicians. I predict this is not sustainable. The typical concierge practitioner collects $1 million in access fees from clients and takes care of 600-800 patients, which totals 25-33% of capacity in a typical practice where physicians are expected to care for 2,000 to 2,500 patients. Under the concierge banner, primary care costs three to five times more than needed; it would also require a primary care work force three times larger than it is today.

I understand that our practice seems a little radical, but some call us "the practice of the future." In truth, it's how medicine used to be practiced only a few decades ago. Likewise, or practice embodies the medical home described by many who believe in the key role primary care needs to play in our health care system. To make this happen, we've upgraded phones, emails, video, computers , the electronic medical records and direct communications between patient and doctor into the practice and linked it to time-based billing like most other sectors of the economy.
My partners and I hope that others with the same hopes and goals for primary care will consider this model or something like it soon. The future of primary care depends on it, and doctors are the solution.

This post originally appeared on Better Health , a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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Wednesday, January 20, 2010

QD: News Every Day--Haiti, U.S. Senate feel strong motions

ACP Internist's wrap-up of current events continues with a look at Haitian relief. Haiti, which felt another earthquake this morning, is home to one of the world's best rural hospitals, a model copied globally. In the face of disaster, it has been overwhelmed. While that facility was built in Haiti's Central Plateau, another hospital was founded where none had been before in Thomassique, across a major river in Haiti. Founder and internist Gilbert Irwin, MD, expects a flood of patients seeking health care after being turned away from the Dominican Republic. Doctors in the capital, Port-au-Prince, reported peaceful conditions, but internist Jonathan Crocker, MD, of Beth Israel Deaconess Medical Center reported busy conditions as medical workers ramp up their efforts. (Boston Globe, Wall Street Journal, Star-Exponent, Harvard Gazette)

Health care reform
Massachusetts voters chose their Republican candidate for the U.S. Senate, fueled by discontent with health care reform efforts so far. The swing breaks the filibuster-proof majority Democrats held while pushing legislation through, and leaves future efforts vulnerable to procedural stonewalling. Amid unpalatable options, what's left is finding a bi-partisan way to move forward. (Boston Globe, Politico, Wall Street Journal, Washington Post)

Dog is a halfway decent wet mop by Thirteen Of Clubs via FlickrIn case you missed it ...
This may come up professionally, from a patient. This may come up personally. But finally, someone has developed a decision tree whether one should eat food that's been dropped on the floor. More than the five-second rule is involved.(San Francisco Weekly)

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The doctor will see you shortly--by law

California debuted new rules that specify patients in health maintenance organizations (HMO) see a doctor within 10 days of asking for an appointment. Calls must be return within a half-hour, and health professionals must be available 24/7. Urgent care must be seen in 48 hours.

Richard Frankenstein, FACP, former president of the California Medical Association, told the Los Angeles Times that this places pressure on the HMOs to have a big enough network to deliver what they promise. Critics contend this will force doctors to rush patient care even more, or be especially damaging to rural areas already facing a shortage.

The law was passed in 2002. It took state officials seven years of negotiations with HMOs, doctors and hospitals to draft the final regulations. Now, HMOs have a year to figure out how to implement the goals, or face consumer complaints to the state and possible penalties.

Physician recruiters Merritt Hawkins & Associates found that patients in San Diego wait an average of 24 days for a routine physical and those in Los Angeles wait 59 days on average. (The results were part of a national survey for major metro areas, comparing results from 2004 to 2009.)

This might be old hat to those who've chosen to adopt the patient-centered medical home model, and can offer such care. But could you practice internal medicine through an HMO contract in California now?

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Tuesday, January 19, 2010

Pay More, Get Less - The Certain Future Of Healthcare

This blog post was originally published at Saving Money and Surviving the Health care Crisis. It appeared January 18 at Better Health.


Even with health care reform, Americans will increasingly be burdened with high deductibles, more financial responsibility, and less satisfaction with their health insurance for the foreseeable future. Why? Because the health care system is unable to transform its services in a manner that other industries have done to improve quality and service while decreasing costs. The two biggest culprits are the mentality of health care providers and the fee-for-service reimbursement system.

Doctors and patients haven't altered the way they communicate over the past hundred years. Except for the invention of the telephone, an office visit is unchanged. A doctor and patient converse as the physician scribbles notes in a paper chart. Despite the innovations of cell phones, laptop computers, and other time-saving devices, patients still get care through face-to-face contact even though banking, travel, and business collaboration can be done via the internet, webcams, and sharing of documentation. As Dr. Pauline Chen noted in a recent article, doctors are not willing to use technology to collaborate and to deliver medical care better, more quickly and efficiently. Mostly it is due to culture resistant to change. Partly it is due to lack of reimbursement. Both are unlikely to be addressed or fixed any time soon.

Yet, patients come to doctors for our medical expertise and insight in order to stay well or get better. They don't care if it is done via the web or in person. If doctors think their problems are safe to handle via technology then they are for it. If doctors feel a particular condition must be handled in the office, then they are willing to do it. After all, aren't we the ones who can make that assessment? They trust us to make the right determination. We must be willing to challenge tradition and training in the face of a rapidly evolving world.

If this country is going to make health care more affordable and more accessible, then doctors need to collaborate better. Only doctors can stop the increasing march of medical expenses.

If we as a profession are unwilling to use technology to get the information and expertise at the point of care to get people better sooner, then our country has only two options left to make health care affordable. The first is the government to force pricing down, as it is done in other countries. Based on the agenda of Medicare, the government is already squeezing costs by dictating pricing that may not be realistic. The second is to force patients to try and figure out which tests, procedures, doctors are best to help them. Research shows they don't want that responsibility and when they do have that burden they skip care. Nevertheless, employers are increasingly moving their employees to less comprehensive consumer driven health plans (CDHP) and high deductible health plans (HDHP) to save money.

It's doctors who aren't willing to do virtual visits. The public is ready and waiting. If we as a profession won't consider using the same technology we use to communicate with family and friends as well as use these very same tools to provide "second opinions" to our loved ones who value our medical expertise to our patients, then how can we say that we are committed to making health care accessible and affordable to all Americans?

While there is a small group of enthusiastic entrepreneurial doctors and leading-edge health care organizations trying to move American medicine into the 21st century, the health care system really needs Steve Jobs and Apple to transform health care. As it currently exists, the majority of doctors are either unwilling or unable to make the change.

This post originally appeared on Better Health , a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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QD: News Every Day--Haiti relief efforts struggle

ACP Internist's wrap-up of current events continues with a look at Haitian relief efforts and the internal medicine community's efforts. Domestically, a special election for Massachusetts's Senate seat could affect health care reform.

Conditions in Haiti could create a medical disaster that would complicate the earthquake's impact. Richard Wenzel, MACP, outlines the conditions in Haiti that might contribute to infectious disease outbreaks such as dengue and malaria. But diarrhea is the bigger concern. Trauma from crush injuries has its own set of sequelae that will require special management including kidney failure, worsening diabetes or asthma, post-traumatic stress disorders or permanent mental and physical impairments. Chronic conditions such as diabetes supplies still require management in the face of short supplies. (Reuters, Wall Street Journal, Newsweek, Diabetes 24/7)

Logistical challenges continue, as Doctors Without Borders planes have been diverted from Haitian airfields to the Dominican Republic. Although bottlenecks delayed many internists' privately planned medical missions or slowed ones made in the wake of the disaster, the waits will make the eventual trips more organized. Some teams are making it through, however, often bringing their own medical supplies from offices, and hospitals are not only sending teams but accepting patients. (The Daily Journal of Illinois, Crain's Detroit Business, NBC New York, CBS 3 of Philadelphia)

The Navy's top doctor predicts the USNS Comfort will be employed in the region for at least six months. For the time being, the Navy's home page is dedicated entirely to coverage of its efforts, including numerous pictures showing the vast scope of the effort.


Naval Air Crewman 2nd Class Jason Harold of Goldsboro, N.C., transfers a young Haitian earthquake victim from an SH-60B Seahawk helicopter during a medical evacuation in Port-au-Prince, Haiti. U.S. Navy photo by Mass Communication Specialist 2nd Class Candice Villarreal/Released by Lt. j.g. Erik Schneider)

Health care reform
Massachusetts, which has universal health care, now holds the key to the rest of the country getting it, too. Today's special election to elect a new Senator could swing the balance of power. Democrats tried to negotiate ahead of the election but couldn't reach a compromise. The Boston Globe is offering updates all day. If the Democrats do lose their Senate seat, there's still three ways to push the bill through in the face of likely opposition. (Wall Street Journal, Washington Post, Boston Globe, Christian Science Monitor)

H1N1 influenza
The Centers for Disease Control and Prevention estimates as many as 80 million Americans have been infected with H1N1 influenza, with 16,000 dead and 360,000 hospitalized. About one in five Americans overall have been vaccinated, but 90% of the most vulnerable people, those less than 65 with conditions that put them at risk for flu complications, aren't. Globally, the pandemic is still active. (Reuters, Los Angeles Times)

In the mean time, hospitals are lifting their visitor restrictions. (Des Moines Register)

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Monday, January 18, 2010

Medical News of the Obvious

This week's obvious news consists of findings that you might have hoped weren't true, but really you already knew they were.

First, sending your spouse off to war will make you unhappy, according to the New England Journal. "Among wives of soldiers deployed for up to 11 months, researchers found almost 3,500 more diagnoses of depression, anxiety, sleep disorders and other mental health issues than among wives who husbands stayed home," reported HealthDay. Guess these women actually liked their husbands!

Then, it turns out that diabetics should not pig out, especially on salt, according to the Archives of Opthamology via HealthDay. A study of black patients with diabetes found that those who ate more calories and more sodium were more likely to develop diabetic retinopathy. "These results suggest that low caloric and sodium intakes in African-American individuals with type 1 diabetes mellitus...might be part of dietary recommendations for this population," the authors concluded. Shoot, now we will have throw out those "hot dog a day keeps the doctor away" guidelines.

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Friday, January 15, 2010

Doctors Continue To Flee Primary Care: Pediatricians Go Part-Time

This post by Dr. Gwenn is in appeared January 14 at Better Health.

The WSJ Blog posted recently that health care job postings are up and that the health care job market is "strong."

According to the post, "The business research group said that 'advertised vacancies for healthcare practitioners or technical occupations outnumbered the unemployed looking for work in this field by almost 3 to 1,' citing November data."

While it's true that more job openings than job hunters is typically a good thing and indicates a robust job market, the WSJ Blog failed to recognize one important issue with the health care industry: in some areas of the health care sector, namely primary care, docs are leaving the field of medicine all together, and have been for at least a decade. So, it's no wonder there are so many job openings ... there's no one around to fill them!

A recent study in the journal Pediatrics, "Part-time Work Among Pediatricians Expands," gives a great over view of the pediatric work force and confirms the experience I've had in the field for the last 15-plus years.

Part-time work isn't new to pediatrics, given the amount of women in the field, but it used to be more popular as careers advanced. According to this study, however, pediatricians are now opting for part-time work right out of the gate, just after training or during, in their 30s. And, that more men are going part time as well as subspecialists along with the women and generalists that have been steady part timers for a while. All told, as of 2006, 23% of the pediatric work force was documented as part time--and growing!

Here's another tidbit for you: Buried in the data I discovered, that not only are pediatricians going part time but many are leaving the field. In fact, 12% of pediatricians are currently in nonclinical jobs.

I couldn't find any new data on how many pediatricians are leaving the field or doing what I have done and altered the career path over time to become more nonclinical at a young age, but I can tell you anecdotally it's not a small number. I know many pediatricians not working now by choice, working incredibly part time or just opting for nonclinical paths because the current clinical paths, even part-time ones, were not compatible with family life and a satisfying economic future.

Doctors leaving the field before the age of 50 is a huge red flag for any field. I hope the field of pediatrics recognizes that and seriously takes a look at not just the training but the practice of pediatrics and the current economic models being offered in all aspects of the field.

As for me, I don't regret the decisions I made. I've always enjoyed the more academic pursuits and I was going to end up in a more academic, nonclinical field regardless of any practice issue at play--the writing for that was on the wall for a very long while. I've always found volunteering at a free clinic an amazing way to "practice" pediatrics and give back to society. So, that's how I stay fresh and keep my skills up--and help people in society who otherwise wouldn't have access to a pediatrician. But, when I was a younger pediatrician and toying with options, it would have been nice had there been more that worked and I hope for future pediatricians who want to practice clinical pediatrics that the future is brighter for them in that sector. Right now, it's way too challenging and frustrating!

Are you a doc not using your stethoscope any more or using your training in a way you never predicted? Tell us about it in the comments. You are very much not alone!

This post originally appeared on Better Health , a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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QD: News Every Day--logistics stymie getting medical care into Haiti

ACP Internist's wrap-up of current events continues to follow the internal medicine community's response to the Haitian earthquake.

Overall, while needed supplies begin to reach Haiti, officials try to clear docks, roads and airports to get material into relief areas. In addition to a sizeable U.S. military presence, the U.S. Navy's hospital ship, USNS Comfort, is loading supplies and personnel and will leave this weekend. (CNN, Christian Science Monitor)


Shown is a map of the intensity of the shaking caused by the Haitian earthquake, adapted from the U.S. Geological Survey

Like other buildings, hospitals collapsed. Doctors Without Borders is struggling to manage medical care in the wake of losing its three facilities there. The group's deputy operations manager describes his group's disaster response operations. This morning, Stefano Zannini of the group updated reporters about the status of several hospitals that survived the quake and began surgeries. (New York Times, Doctors Without Borders, Wall Street Journal)

ACP members had planned medical missions for the spring, only to cancel them to make room for emergency teams. Marlo Hodnett, ACP Member from Madison, Ala., had planned a medical mission to Haiti, scheduled to depart Wednesday. The earthquake Tuesday pre-empted the group's plans. Retired internist Richard Perry, MACP, of Maryland, will put off his February medical education efforts at Hospital Sacre Coeur, 150 miles away, which survived with just a few cracks in the wall but will be repurposed as a medical and naval triage center. When contacted by phone, Dr. Perry told ACP Internist that trauma teams are more important right now--orthopedists, surgeons and their staff. Don Clark, ACP Member, of Charlottetown, Prince Edward Island, Canada, also will delay a planned medical mission, the fourth such he would have taken. Without infrastructure, there wouldn't be much he could do. Steven Williams, ACP Member, of Allegheny General Hospital in Pittsburgh, has visited Haiti for 20 years. He expects the country's already poor medical system to fare even worse under the strain. (Huntsville Times, CBC News, MedPage Today)

A physician with personal and familial connections in Haiti also spoke out about their response professionally, and the personal impact the earthquake's aftermath has had. (Boston University Today)


Editor's Note: QD: News Every Day will not be published on Jan. 18 due to the Martin Luther King Jr. holiday.

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Artificial intelligence for real diagnoses

A clogged artery landed the head of MIT's Clinical Medical Decision Making Group in the hospital, and he immediately took note that, A) he needed a bypass operation and, B) none of the machines he was hooked up to talked to one another. Scientific American profiles his experience as part of a look at how doctors might use artificial intelligence for diagnoses.

Day 9 (improved version) by j.reed via FlickrComputer programs called INTERNIST were developed in the 1980s, based upon a human internist, former ACP President and Regent Jack D. Myers, MACP. INTERNIST and other systems never caught on ("not sufficiently reliable for clinical applications" said study authors in the New England Journal of Medicine).

Today, researchers are focusing on augmenting human internists with diagnostic artificial intelligence. For example, Mayo Clinic researchers are looking at a software system that in one study would have halved the rate of invasive testing for endocarditis. That Mayo Clinic work group includes ACP Master Walter Wilson, ACP Fellows James Steckelberg and Larry Baddour, and ACP Members Daniel Uslan and David Hayes, who are continuing the work pioneered by the College's former president, who died Jan. 31, 1998.

Next, physicians want to apply AI to conditions like pneumonia, but also, they understand that the best way to roll out such a system is as an adjunct to human intelligence. Internists are the best diagnosticians, not INTERNISTs.

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Thursday, January 14, 2010

QD: News Every Day--Haiti's impact

ACP Internist's wrap-up of current events looks at the response to events in Haiti. The full scope of the disaster isn't known two days later. Physicians fear that the already fragile efforts in the country to control tropical diseases will be wiped out entirely. The facilities for Doctors Without Borders have been leveled, so they're inflating field units to help disaster relief efforts. Learn more about this method of disaster response from ACP Hospitalist. (CNN, Discovery Channel, ACP Hospitalist)
Picture courtesy of North Carolina's Emergency Response System

Health care reform
Marathon negotiations between the White House and members of Congress settled a few issues and raised a few others. Talks continue today. (Washington Post, Wall Street Journal, New York Times, AP)

Dhara by Kerala Tourism via FlickrEvidence-based medicine
Anne Nedrow, FACP, and Anastasia Rowland-Seymour, ACP Member, will travel to India to study the evidence base for introducing ayurveda, yoga and meditation into U.S. medical education and patient care. In India, such practices are mainstream medical care, not alternative medicine, and are the country has for ayurveda 150 colleges, 50 post-graduate programs and 3,000 hospitals.

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An open letter to consultants

Thank you for agreeing to see my patients. I send them to you with confidence that you can help me in the overall care for them.

Maryann Gets a Letter by feverblue via FlickrWhile I understand that you had a few extra years of training above me, and certainly have extensive knowledge in the area of your expertise (that is why I send people to you in the first place), I would like to share with you a few important points about our relationship. Understanding these things will help you better care for the patients I send your way and will greatly help me get what I want from the consultations I send to you

I am not a moron. I typically try to anticipate what you will do for the patient and order all appropriate tests before sending them to you. There are almost always has been a number of visits and several tests ordered that may greatly help you in managing the problem for which I send you the patient. When I send you a patient, I typically want a specific question answered. Please ask yourself: "What does Dr. Rob want me to answer?" and answer that question for me.

My patients are not morons. Overall, my patients are very nice and reasonable people. Even those with very strange histories are seldom coming in to simply waste their doctor's time. Rest assured that I won't send you a consult that simply gets a patient off of my hands. Please listen to what they have to say, and if you are confused as to what is expected, please call me and I will explain what I want from you.

You represent me. Please understand that when I refer a patient to you, their experience with you will reflect back on me. I sent them to you for a reason, and if they think you are incompetent or that you are a jerk, it makes me look bad.

These patients consider me as "their doctor," not you. I am the one who is ultimately responsible for their care, not you. If they are dissatisfied with you, they come to me and I will send them somewhere else. I am trying to take care of their medical care as a whole, so please communicate to me what I need to know to better their overall care. You play a very important role, but not the central role in their care. That is my job. Your job is to help me do my job to the best of my abilities

I can send my patients elsewhere. Most of my patients require a referral for them to see you. On top of that, most want to know my opinion of specialists. I essentially have complete control over whether my patients see you or not. This means that a major part of your job is to keep me satisfied. If I don't like the care you give my patients, I will send them to someone who gives me what I want. This is not a veiled threat, it is the reality of the relationship between primary care and specialty physician. I control a portion of your pipeline, so it is good business to keep me happy.

Please be brief. I really don't care about 90% of the stuff you put in your letters. Just answer my question and put it in a letter. I know you have to appease the E/M gods to get paid properly, but I really don't want to read that stuff.

Please communicate. It is useless for me to send patients to you and not get the consult note back. Make sure you get my name right (notes are often sent to the wrong office) and get it to me in a timely fashion. Like it or not, your job is to help me manage the patient, not the reverse. It is no help to have patients see you and not know what went on.

I understand that this is a somewhat odd relationship, since I am paid far less than you and yet am the central player. Truthfully, it galls me a bit that you get triple my income while I play the lead role and you support me in my job. Yet I realize that this is not your fault and that overall you value my role in the health care system. I promise to do what I can to make your job easier. Please help me in my quest to do what is best for my patients.

Sincerely,
Dr. Rob

[This post appeared in Musings of a Distractible Mind in July 2007. Since that time, my frustration with my interaction with specialists has grown, not improved. Our system seems to discourage communication when it should be promoting it.]

Rob Lamberts, ACP Member, writes the blog Musings of a Distractible Mind and is on Twitter. He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

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Wednesday, January 13, 2010

What role should a 21st century physician play?

Editor's Note: Steve Simmons, ACP Member, posted this blog entry originally at Better Health.



Some patients in the 21st century approach "modern" healthcare with the same expectations I bring into a deli for lunch: "I'd like the sinus infection with antibiotics and a note for work, please." I confess, when seeing such a patient I have occasionally acted on the impulse to ask if they would like fries with their order. Yet, these patients do have something to teach us about how to be a 21st century physician.

Eighteen years ago, while a fourth-year medical student, I registered for an elective class on the future of computer science in medicine. This was my first time to see the Internet and I was awed by the vision my instructors had for the future. They had no idea.

Today, I use a Droid or the phone uses me--the issue is still in doubt. However, during residency I put pen to paper charts and carried a pocketful of bright red metal clips to signal a STAT order on a chart. We used computers mainly for literature searches and checking lab results; palm still referred solely to the ventral side of one's hand.

But technology was invading fast. Shortly after starting my first job in 1996, computers began to be used for direct patient care and I watched two competent physicians choose early retirement over learning computer skills.

This all occurred before I had sent or received my first e-mail. The advancements over the first years of the new millennium boggle my mind as I look back over a time that saw PDAs, laptops, and cell phones ensconce us in a world colored bluetooth.

So, what role should a 21st century physician play? Since my phone doesn't have an app to tell us, I'll have to find another way to explain myself but I would suggest the answer lies, partly, in a different question.

What kind of patients do we find today? Three distinct types come to mind. The first is what I like to think of as Dr. Google, of whom I used as an example earlier. Dr. Google has searched the Internet, made his own diagnoses, and often decided on his treatment. Surprisingly, studies have shown that if the search is done right and with a lot of detail, Dr. Google can be right about half the time; sadly, that's not the worst average out there but I do aim higher for myself. Dr. Google is a challenge to care for and requires some tact (Tip: don't ask about biggie-sizing the visit).

I had the good fortune to meet the second type of patient this morning. He had used technology to inform himself and presented me with specific, pointed and difficult questions to answer. I was able to interpret for him and help him navigate towards his own goals. We forged a strong partnership in one office visit; this is my favorite type of patient.

The third type of patient can sometimes be identified by their use of a pathognomonic phrase: "You're the doctor." This was Dr. Welby's favorite kind of patient as he used a relationship based on a combination of implicit trust and deferred responsibility in decision making. Today, use of this phrase more often identifies a desire by the patient to defer responsibility than it would expose a deep faith in our profession. A 21st century physician will need to assume a leadership or shepherding type of role in helping this third type of patient navigate today's health care landscape.

Today, doctors will encounter patients armed with both good and bad information. A 21st century physician should be ready to lead, steer, interpret, teach and help when help is needed because 21st century patients need a guide, now, more than ever.

In my opinion, a modern physician working as a guide will see all of this technology for what it is--a useful tool to further the doctor-patient relationship--and when a long day leaves me feeling more like a short-order cook or paranoid lawyer than physician, I'll download a happy app.

This post originally appeared on Better Health , a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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QD: News Every Day--Medicare pay rises, cost to practice rises more

ACP Internist's wrap-up of current events looks at how primary care providers are faring in today's economic climate. (Cue the stormy background sounds.)

Primary care shortage
Primary care doctors could see a 1.1% Medicare pay increase this year, instead of a 21% cut. The bad news is the cost of practicing medicine will rise 2.5%. (American Medical News)

Thomas Bledsoe, FACP, talks to NPR in an audio report about frustrations in his practice that led him to kick a trash can across the room. Rhode Island is hoping to ease the tension by requiring insurers to invest more than a $100 million more into primary care, to fund the patient-centered medical home and electronic health records, among other goals. But frustrated physicians aren't waiting for government involvement or health care reform. Like Stephen Glasser, ACP Member, they are fleeing to concierge care. (WRNI/NPR, Washington Post)

Health care reform
Sen. Olympia Snowe, the one Republican to show any approval at all for health care reform legislation, defended her vote weeks ago to move the legislation forward (although she'd cautioned her vote was only to do that, not to approve the legislation as written.) Her constituents, including small business leaders, let her know how they felt about the impact of the bills underway in Congress. They may be comforted to know that employer insurance mandates may be dropped from the negotiations underway between the White House and both chambers of Congress. (Bangor Daily News, Boston Globe)

Mammography
In the face of strong controversy about mammography screening guidelines, Lawrence E. Feinberg, FACP, President of ACP's Colorado chapter, discusses the benefits of following U.S. Preventive Service Task Force recommendations. (Denver Post)

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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