Dr. Wes

Spending More, Paying More and Getting Less

wes@medtees.com (Westby G. Fisher, MD) — Mon, 06 Jul 2009 04:09:23 PDT

As spending accelerates to "stimulate" health care reform, hospitals are taking steps to cut back to promote "efficiency" while limiting patient access. Meanwhile, the "bluest" of Democratic states look like they'll be funding more of the health care tab through higher-than average tax increases.

Illinois ranks among the top 10 states with residents most likely to pay more in taxes if deductions were limited, with 1.7 percent of taxpayers possibly vulnerable to higher taxes, Citizens for Tax Justice data show.

The state also ranks above the national average in the cost of its employer-provided health care plans. Nearly 47 percent of people with family plans would face taxes under an Economic Policy Institute study, compared to 41 percent in the nation overall.

So Illinois residents as a whole might be expected to pay more in taxes under a Democratic health-care plan. About 13.7 percent of Illinois residents lack health insurance, compared to 15.3 percent nationally, according to data compiled by the Henry J. Kaiser Family Foundation, which studies health insurance trends.

Me thinks the divide in the Democratic Congress is about to grow more contentious.

-Wes

Happy Fourth of July

wes@medtees.com (Westby G. Fisher, MD) — Sat, 04 Jul 2009 14:16:47 PDT

Yep, the kids are alright:

... and apparently enjoying a nice glass of wine.

More from AwkwardFamilyPhotos.com.

Happy Fourth!

-Wes

The Medicare Hatchet Begins

wes@medtees.com (Westby G. Fisher, MD) — Thu, 02 Jul 2009 07:20:07 PDT

How's an 11% cut in a single year for cardiovascular services grab ya?

From CMS:

CMS is also proposing to stop making payment for consultation codes, which are typically billed by specialists and are paid at a higher rate than equivalent evaluation and management (E/M) services. Practitioners will use existing E/M service codes when providing these services instead. Resulting savings would be redistributed to increase payments for the existing E/M services.

And that's just the start.

-Wes

Reference: CMS Press Release.

More from BNET Healthcare.

President Obama Talks About Pacemakers

wes@medtees.com (Westby G. Fisher, MD) — Wed, 01 Jul 2009 12:54:32 PDT

I was one of those who missed the "town hall" meeting aired by ABC on the 24th of June, but was nicely pointed to this video where President Obama speaks about placing pacemakers in 100-year olds by a loyal follower:

The video is remarkable on several fronts.

First, I was impressed with the remarkable footage that suddenly appears of the caretaker with her mother, demonstrating the staged nature of this "spontaneous" town-hall interview. No doubt, this question was asked to reassure our seniors about the choices that will soon be made by Washington.

Second, the number of times the elder woman presented to the Emergency Room for care. We are left wondering, did she have a primary care doctor? What were the other discussions that took place before?

Third, the issue of placing pacers in 100-year olds and the new, proposed reliance on bureaucratic "experts" in Washington that will tell the local doctors what the best course of therapy should be based on "research" (a reference to the 1 billion dollar research boondoggle that is comparative effectiveness research). To think that any research will occur on patients of this age is ridiculous. (I'll let others decide what this means for our elderly).

But this is not to say that we should not make choices in this instance. The issue of "cognitive ability" of the elderly, however, was conveniently dodged, and there ever discussion about the centurion woman paying for her own pacemaker (seems in this case it would be less than a new car).

But whatever you think, these are choices doctors and patients will have to make head-on in the days of increased pressure on Washington to cut costs. The thought of unknown and poorly-defined "experts" (MedPAC?) making these decisions based on non-existent data, rather than the frank discussions between the doctor and their patients and their families, is what really concerns me.

-Wes

Goodbye Northwestern. Hello University of Chicago

wes@medtees.com (Westby G. Fisher, MD) — Wed, 01 Jul 2009 06:19:57 PDT

Today's the day I magically lose my appointment at Northwestern University and transition to the University of Chicago's Pritzker School of Medicine. As of 1 July 2009, NorthShore University HealthSystem changes it's medical school affiliation, so I changed the "About Me" section on my sidebar.

For patients and collegues alike, I really don't expect much change, except for the logos worn by the medical students and residents.

But as we change affiliations, I'd like to thank all the residents from Northwestern with whom I have had the pleasure to work with and learn from over the years. I wish you all the best as you transition to the real world.

Now, Univeristy of Chicago, it's your turn.... (heh, heh).

-Wes

On Health Care Rationing

wes@medtees.com (Westby G. Fisher, MD) — Tue, 30 Jun 2009 04:59:34 PDT

From Michael Kinsey at the Washington Post:

I suspect that what a billion-plus dollars' worth of (comparative effectiveness) research will find is that perhaps 30 percent of what we spend on health care is almost entirely worthless, or just barely better than a much cheaper alternative. Or it might be better and no one knows for sure. Denying someone these treatments or tests is rationing.

Similarly, when fear of malpractice lawsuits leads doctors to practice "defensive medicine" -- a legitimate complaint about current arrangements -- it doesn't mean that they order worthless tests. It means they order tests with only a very long-shot chance of finding something wrong.

Here is a handy-dandy way to determine whether the failure to order some exam or treatment constitutes rationing: If the patient were the president, would he get it? If he'd get it and you wouldn't, it's rationing.

I think he gets it.

-Wes

Is Scientific Publishing About to Be Disrupted?

wes@medtees.com (Westby G. Fisher, MD) — Tue, 30 Jun 2009 03:56:16 PDT

A remarkable and thought-provoking essay by Michael Nielson. Read the whole thing.

-Wes

Grand Rounds: Advice to Residents

wes@medtees.com (Westby G. Fisher, MD) — Tue, 30 Jun 2009 03:37:13 PDT

And it's a good one over at Edwin Leap on advice to residents:

1) It’s going to be hard. Deal with it. The less you whine, the more you will be loved and trusted. Learn to be strong, learn to power through your fatigue. And remember that it often takes more energy to avoid work than to just do it.

2) Do the right thing. Ethically, professionally, morally. Be the one everyone can count on to do the right thing; however hard it may be.

3) Humans, to paraphrase Blaise Pascal, are glorious and wretched. Capable of nearly angelic goodness and demonic evil, they will both thrill and disappoint you. Be neither too judgmental nor too naive. And remember that you, dear ones, are human as well.

Nice.

-Wes

Virtual Consultations

wes@medtees.com (Westby G. Fisher, MD) — Tue, 30 Jun 2009 03:00:46 PDT

"I'll be damned."

They were the first words I heard after I was called to the Emergency Room to see this older woman in complete heart block with a wide-complex escape rhythm at 33 beats per minute.

"Could this be why I've been so exhausted any time I try to do anything?"

Her disbelief continued.

I turned to the medical record to document my findings, notify the personnel to stick around for another pacemaker, only to find that another cardiologist had been notified of the patient's admission, written a note, and made an assessment - all electronically.

No detailed history. No exam. No review of labs.

Just this praphrased note on the chart from a doctor at another facility:

"3 weeks of fatigue. EKG demonstrates complete heart block. Pacer to be placed in AM by Doctor Frigamafratz."

A virtual consultation from another hospital, courtesy of the Electronic Medical Record.

"I'll be damned," I echoed.

-Wes

Twittering Your Heart Rate

wes@medtees.com (Westby G. Fisher, MD) — Mon, 29 Jun 2009 13:16:45 PDT

Developed by Japanese geek forum Koress Project, the Akiduki Pulse box does this by autonomously posting your heartbeat to Twitter. Once there, friends, family and enemies can all watch as your natural rhythms play out on the world stage in real time.

Although it might sound like a good idea at first, your relatives might become a bit upset when Twitter crashes.

-Wes

Having Some Technical Difficulties

wes@medtees.com (Westby G. Fisher, MD) — Mon, 29 Jun 2009 11:04:03 PDT

It seems my e-mail provider decided to "upgrade" their service over the weekend. This "upgrade" (I say that with a few expletives under my breath) has resulted in my inability to receive messages on my mobile phone and greatly complicated my ability to retrieve my e-mail at work due to our workplace firewall. As a result, comment moderation and responses to posts my be delayed as I attempt to rectify the situation.

Thanks for your patience.

-Wes

Biasing the Argument Against Specialists

wes@medtees.com (Westby G. Fisher, MD) — Mon, 29 Jun 2009 04:53:03 PDT

In an article originally published in the Washington Post on 20 Jun 2009 and republished in the Chicago Tribune today, the national shortage of primary care physicians is highlighted and serves as a significant problem for health care reform efforts underway. The systematic devaluation of primary care relative to "procedural-based" medicine is again addressed:

The disparity results from Medicare-driven compensation that pays more to doctors who do procedures than to those who diagnose illness and dispense prescriptions. In 2005, for example, Medicare paid $89.64 for a half-hour visit to a primary-care doctor in Chicago, according to a Government Accountability Office report. It paid $422.90 to a gastroenterologist who spent about the same amount of time performing a colonoscopy in a private office. The colonoscopy, specialists point out, requires more equipment, specialized skills and higher malpractice premiums.

But, as mentioned previously, we should realize that Congress made attempts to correct this disparity though "fudge factors" to the RVU payment formula before:

In 1993, Congress declared a redistribution of funds from proceduralists to primary care physicians. Initially there were 2 conversion factors—1 for medicine and 1 for surgery. The conversion factor, ie, the multiple of the RVU for payment, had the added advantage of demonstrating where costs were increasing. The 2 conversion factors demonstrated conclusively that surgeons did not increase their utilization when reimbursement decreased (because, for example, patients have only 1 gallbladder, and the indications for its removal remain constant). Other specialties increased their utilization, a process that continues to this day. In a refining effort to shift money to primary care, a third and separate conversion factor was developed in 1995. By 1997, it was clear that separate conversion factors were not controlling utilization of primary care and medicine services, causing these 2 conversion factors to decrease. The 3 separate conversion factors were eliminated in 1998, resulting in a decrease for surgery and an increase for medicine and primary care. In addition, more surgeons' practice expense reimbursements are included under the indirect category, now reimbursed at 35% of cost; internists and primary care physicians have a higher percentage included as direct expenses, which are reimbursed at 66%.

But few mention these facts. Further, when payment differentials are cited between primary care and specialists (whom have been conveniently reduced to "proceduralists"), the 90-day global period (the surgery and all care related to the procedure for 90-days afterward) is rarely, if ever, mentioned in the discussion. Follow-up visits, dressing changes, wound checks, and management of complications - all conveniently ~~ignored~~ pre-paid for three months.

Without a clear understanding of all of the issues related to physician compensation and the problems with government's prior attempts at meddling with the system to correct the disparity between primary care physicians and specialists, we should understand that simply cutting specialists' fees in favor of primary care physicians might lead to not only additional primary care shortages, but an even more acute shortage of specialists as well.

-Wes

Our Pill Culture

wes@medtees.com (Westby G. Fisher, MD) — Mon, 29 Jun 2009 03:52:53 PDT

She sat at the dining room table, counting.

"Let's see, a pink one, the tiny one, a big blue one, another one of those other white ones, the yellow one... oh, I don't take THAT white one until noon ... then one of those and one of those. There. I think I've got it."

She scraped then all in a little pile on the table, then swept them in her hand and tossed to pill pile into her mouth as she chased them all down with a slosh of water, looking a bit like a pelican downing an oversized fish.

"Ahhhh," she said. "Now, how about breakfast?"

I sat in amazement as I looked at my mother-in-law's pill pile. It really wasn't anything over the top: the usual medications for coronary disease, hypertension, adult-onset diabetes - all things I've prescribed a thousand times. But I could not help but wonder how our patients keep all this stuff straight.

Most doctors don't think twice about adding another drug here and there. After all, we always seem to have such a good grasp of pharmacology that we're absolutely convinced, I mean CONVINCED, that our new drug is important for our patient's management. But recently in the hospital I've noticed a problem that seems to be becoming more common: drug-drug interactions, or more accurately: drug-drug-drug-drug-drug interactions that can lead to unintended or unsuspected side effects, especially (in my case) cardiac arrhythmias.

These interactions are becoming tougher to identify as polypharmacy increases in America. Which drug causes what effect can be particularly challenging when people take plenty of different medicines. Nowhere is this more common than with psychotropic medications, especially tricyclic and tetracyclic antidepresants which might be coupled with analgesics, antibiotics, antifungal agents or sleeping medications and the like. Often, these make the perfect cocktail for cardiac catastrophe. We see this on the ward (if we're lucky) as polymorphic ventricular tachycardia or "torsades de pointes" (so-called "twisting around the points") - a malignant heart rhythm disorder caused by excessive prolongation of a resetting current for cardiac contraction called "repolarization." With the right circumstances and when it occurs at the correct time, a single skipped heart beat can cause the heart rhythm to lose all coordination and just quiver, effectively stopping the flow of blood to the brain. Also, sedatives can exacerbate sleep apnea and its resultant hypoxia (low oxygen level). Hypoxia, if significant enough, can cause significant cardiac slowing or even complete heart block.

I wonder, in all the sadness and turmoil surrounding Michael Jackson's recent death, if this same problem might have led to this popular pop icons' demise as well. By now, we have "heard" that Mr. Jackson was given an injection of Demerol (~~propoxyphene~~ meperidene) shortly before his death. If so, demerol is usually given intramuscularly. But it would not be too inconceivable that one shot might have accidentally been injected into the vascular system, causing rapid sedation and overwhelming his drive to breathe. Follow this respiratory suppression with a few other psychotropic, analgesic medications, antibiotics or sleep aides, and not only might additional sedation occur, but a lethal cardiac arrhythmia as well, even in someone with totally normal coronary arteries.

To me, this scenario seems a much more plausible cause for Mr. Jackson's death rather than a massive heart attack, but then, since I do not have the benefit of reviewing his autopsy results, my thoughts are really nothing more than an educated guess.

No doubt by now there are a multitude of other guesses out there, a million opinions, and even more possibilities regarding the cause of Mr. Jackson's death. Everyone wants and, probably, needs an answer. Unexpected death is like that. But whether a definitive answer is ever found or whether the world will be permitted to learn the true answer is unknown at this point. Family takes precedence, in my view. But maybe there's some other take-home messages we can gain from this sad circumstance.

For one, we have become a pill culture, reaching for pills to cure almost anything and everything. We gobble them down often with barely a thought about their side effects as we eagerly seek a simple fix for what is often very difficult problems. Certainly, there there are scores of miraculous agents out there that have improved the quality and quantity of life for millions of us. (I am not advocating anyone stop any meds as a result of this blog post!) But I have become jaded about psychotropic and sedative medications because of my vocation as a heart rhythm specialist, especially when they are used in combination with other medications that can potentiate their effects or alter cardiac activity. Although drug companies have excellent testing to assure new drugs' safety, they simply cannot test the multiple permutations and combinations of medications on the market with their drug. New interactions are found all the time. It is a little known fact that many of the drug combinations we use today have never been tested in man. Further, patients might not disclose the use of psychiatric medications because of social biases toward psychiatric illness, or physicians, in their hurry to complete their 7-minute office visit, might fail to ask about psychiatric problems and medications.

Secondly, doctors have become pill-obsessed, too. All too often we don't take the time to refer our patients to qualified psychiatric or psychologic specialists. Instead, we try to add these drugs ourselves in the genuine hope of helping our patients with a "quick fix," perhaps not realizing all the consequences of our choice.

So maybe, just maybe, each of us can take a lesson from Michael Jackson, his "cardiologist" doctor, and others in a similar circumstance (Anna Nicole Smith or Elvis Presley comes to mind). First, patients must disclose all of their medications to their doctors. Second, doctors need to exercise caution when any medication, especially psychotropic or sedative ones, are are added to our poly-pill-laden patients and consider the cardiovascular effects that could arise.

Doctors and patients who would like to know many of the medications suspected of causing cardiac arrhythmias, a relatively well-maintained list can be found from the University of Arizona at qtdrugs.org.

-Wes

What Does America Think About Health Care?

wes@medtees.com (Westby G. Fisher, MD) — Fri, 26 Jun 2009 06:10:33 PDT

A new survey (pdf) from the Economist.com with the full data here (pdf). Regretably, I was unable to find the methodology for the poll other than "1000 General Population" respondents.

Another poll with lots of numbers that mean what ever you want them to mean.

-Wes

h/t: The Happy Hospitalist.

How to Fund Your Cardiovascular Company

wes@medtees.com (Westby G. Fisher, MD) — Thu, 25 Jun 2009 15:31:23 PDT

... have a Texas governor pass a bill mandating insurers pay for cardiovascular screening. The conflicts of interests involved, as I've reviewed earlier here and here, are staggering, but hey, it's all about making sure more people are considered sick so we can make them better, right?

-Wes

h/t: Schwitzer Health News blog.

Michael Jackson Found Down

wes@medtees.com (Westby G. Fisher, MD) — Thu, 25 Jun 2009 14:39:28 PDT

He's currently in a LA hospital.

-Wes

The $400 Billion Dollar Question

wes@medtees.com (Westby G. Fisher, MD) — Wed, 24 Jun 2009 06:45:19 PDT

Max Baucus (D., Mont.), chairman of the Senate Finance Committee, said after meeting with top Republicans on the panel that "the mood and tone is positive" among those trying to forge a bipartisan deal. "Nobody said...I'm outta here," he said. "We're going to have a bipartisan bill."

In another sign of progress, Senate aides said the committee has managed to cut $400 billion from the estimated cost of the 10-year measure, bringing it to $1.2 trillion.

"Obama Open to Health Overhaul Without Public Plan", Wall Street Journal, 24 Jun 2009

In policy, it's the story behind the story that matters.

About a week or so ago, the Congressional Budget Office came out with their projections for the cost of health care reform, and tabbed the bill somewhere close to $1.6 trillion dollars. Congress gasped. The price tag was so steep that even more conservative Democrats took pause.

And so, the "Senate aides" went back to work and sharpened their pencils. Magically, in the space of about a week, $400 billion in "savings" were realized. The proposal is now "on track" again.

But what, exactly, was cut?

Was it the pharmaceutical profits? Probably not, since they've already "come to the table" with price concessions.

Was it fees to hospitals? Probably not, they're already struggling to stay afloat.

Was it concessions from the unions? Probably not, after all, cost-of-living increases need to continue.

Was it the health information technology budget? No, we need that to save money, and to collect co-pays.

Was it quality assurance budgets? Not sure. But wouldn't a cut there potentially harm patients?

Was it legal costs? No way. Who will write the legislation and draft the bills that go before the House and Senate and assure the rights of all Americans?

Was it the doctors' salaries? Probably not significantly. The policy pundits understand that someone has to deliver the care.

No doubt there are many others at the policy "table" that had their say.

But in the end, the one person not at the "table" are patients. Eventually, every dollar cut from the budget will be one less to trickle down to the people receiving the care.

This is no surprise to me, but we must realize that everyone of us are having compromises to care imposed upon us when the pencil sharpeners come out and $400 billion are magically shaved from the health care delivery budget.

Putting this in perspective, yesterday a well-done study came called MADIT-CRT demonstrated that the addition of biventricular pacing to a defibrillator significantly reduces the complication of heart failure to asymptomatic or event minimally symptomatic patients with heart failure. Such a device costs about $30,000. Admittedly, heart failure is an immensely expensive complication of weak heart muscles because of recurrent admissions to hospitals, need for frequent doctor evaluations, expensive implanted devices, ongoing testing, and the like. As a doctor, it's hard to argue that patients' lives will benefit from this technology.

Now to digress a moment, when I was in the US Navy many years ago, we had a $1.2 million-dollar a year budget for our cath lab. We struggled to stay within that budget as we treated our active duty servicemen and women, their dependents, and often retirees. As defibrillators came on the scene, it became abundantly apparent that they would completely disrupt our budget. But there was no denying the benefit that these devices provided to our personnel.

So what did we do when we overran our budget? Well, first we "borrowed" from other budgets. After all, our devices saved lives, plain and simple. But expenses quarter to quarter kept growing. Sometimes, we also found that we did not have the latest technologies for our active duty personnel and we always happy to farm them out to the local private heart center since those expenses didn't come out of our budget - it was Tricare's problem then. And so it went.

Now getting back to the present discussion, we have to ask ourselves what will be our fiscal pop-off valve as new technologies are invented and lives prolonged in our health care system going forward? In the case of heart failure, will the government limit the number of defibrillators available for us to implant, or will they not, in favor of "permitting" budget overruns in one area and take from some other less-apparent part of the health care system? Should America understand precisely what is being cut when we see $400 billion suddenly disappear from the health care reform budget?

I would argue we must know.

After all, it's we the patients who are not at the policy table, and you can bet that it's the patients who will untimately be paying the tab, be it directly through health care premiums, or indirectly by taxation or deficit spending.

-Wes

A Candid Discussion of End-of-Life Decisions

wes@medtees.com (Westby G. Fisher, MD) — Tue, 23 Jun 2009 11:46:11 PDT

... show-cased vividly by Richard Knox at NPR:

If any situation kindles the impulse to be heroic, it's the threatened death of one's father, mother, spouse or child. The feeling is so primal that we are regularly warned against medical heroism these days, when every community hospital has its intensive care unit and somebody else is paying the bill. Don't, ethicists caution, yield to the temptation to keep your loved one alive beyond any rational purpose.

Among medical personnel the practice is called "flogging," as in, "Don't flog a dead horse."

Who can disagree? Apparently a shrinking American minority. A plethora of polls in recent years consistently shows that more than 4 out of 5 people approve of terminating "extraordinary" life-support measures if the patient has no hope of recovery. Recently the consensus seems to be broadening to not-so-extraordinary measures, such as "tube" feeding and intravenous fluids.

Most of these polls are couched in terms of life support for terminally ill patients. But a 1988 poll of Ohio residents found 88 percent would not want to be "kept alive by extraordinary means if there were only a small chance of living a normal life."

All well and good, but when it's your father-mother-wife-child, the question is no longer academic. Suddenly you need facts and explanations. What's wrong? Can it be treated? If he survives, will he be the same as before? Will he be normal?

I know from 20 years of writing about medicine that even the best physicians often can offer no immediate answers to questions like these. I also know that doctors and nurses vary enormously in their ability and willingness to communicate medical information.

But the next two weeks will teach me anew how hard it is to extract and assimilate the data families need to answer the awful question: "Do you want heroic measures?" I will also learn firsthand that the question is often far from cut-and-dried, as many thoughtful people imagine when they fill out living wills or declare, "I never want to be maintained on a machine."

Well done. Read the whole thing.

-Wes

MADIT-CRT Meets Primary Endpoint

wes@medtees.com (Westby G. Fisher, MD) — Tue, 23 Jun 2009 08:07:41 PDT

From a press release, just released:

Boston Scientific Corporation (NYSE: BSX) and the University of Rochester Medical Center today announced that the landmark MADIT-CRT trial has met its primary endpoint. Preliminary results show Boston Scientific cardiac resynchronization therapy defibrillators (CRT-Ds) to be associated with a significant 29 percent reduction (p=0.003) in death or heart failure interventions when compared to traditional implantable cardioverter defibrillators (ICDs). High risk(1), asymptomatic or mildly symptomatic, New York Heart Association (NYHA) Class I and II(2) patients were enrolled in MADIT-CRT. The MADIT-CRT Executive Committee expects to present and publish the trial's full results later this year.

MADIT-CRT, sponsored exclusively by Boston Scientific, demonstrates that early intervention with cardiac resynchronization therapy can slow the progression of heart failure. It is the world's largest randomized NYHA Class I/II CRT-D trial, with more than 1,800 patients enrolled at 110 centers in 14 countries. The trial is being conducted under the leadership of Principal Investigator Arthur J. Moss, M.D., Professor of Medicine at the University of Rochester Medical Center.

The MADIT-CRT trial was designed to determine if combined implantable cardiac defibrillator (ICD)-cardiac resynchronization therapy (CRT-D) would reduce the risk of mortality and heart failure (HF) events by approximately 25%, in subjects who were in New York Heart Association (NYHA) functional Class II with non-ischemic or ischemic cardiomyopathy and subjects who are in NYHA functional Class I with ischemic cardiomyopathy, left ventricular dysfunction (ejection fraction [EF] < or = 0.30), and prolonged intraventricular conduction (QRS duration > or = 130 ms). 60% of patients were randomized to CRT-D and 40% to ICD only.

This news could not come sooner to the medical device industry, but the fiscal realities before us make me wonder if soon we will dealing with medical device benefits managers, just like we're dealing with pharmaceutical benefits managers.

-Wes

Leading By Example

wes@medtees.com (Westby G. Fisher, MD) — Tue, 23 Jun 2009 04:19:27 PDT

While I support the President at signing tough new no-smoking legislation, shouldn't he lead by example?

There are fewer touchier questions inside the White House than this: Is Mr. Obama still smoking? One administration official declined to answer on Monday, but pointed out that the president spoke in the present tense, “I know how difficult it can be to break this habit,” as opposed to, “I know how difficult it was to break this habit.”

If we're going to make the case repeatedly for "prevention" as a cornerstone of health care reform (and supposed health care "savings"), I would suggest he practice what he preaches.

-Wes

Killing Me Softly

wes@medtees.com (Westby G. Fisher, MD) — Tue, 23 Jun 2009 03:59:50 PDT

I filter through progress notes looking for the few sentences different from the day before, only to find them sandwiching pages and pages of electronically-produced babble dutifully and automatically mass-reproduced in every note. I wonder, has anyone ever looked retrospectively at the mess created by this process developed to assure doctors were doing what they said they were doing? Ironically, I find we're rarely reading most of what we re-create each day.

But we're sure good at following the rules.

Next.

I now see prescription refills for each and every bottle of prescriptions ever filled by a patient, the date a patient filled it, and how many pills they received with each prescription. I’m not sure why. I sat awestruck in clinic yesterday when the list extended 94 pages, double-spaced, since January, 2009. No one, and I mean no one, filled that many prescriptions, did they? Or did they? Am I supposed to correct that list? Oh, by the way dear referring doctor, my note’s at the bottom of that listing.

Next.

I get pre-surgical notifications, even though I was the one to notify everyone else about the need for admission, just so I can click on the patient’s name again, lest it not appear I’m not doing enough, I guess.

Next.

I get EKG results forwarded for me to sign electronically, even though I’ve already read them, and signed them, by hand, on the EKG. I get notified again that the order I entered for that EKG now has a result, and I have to click on that to tell the computer, “I know.” But that, you see, is not enough. I must also log in, review, and sign off on my EKG’s on the EKG server, too. After all, I’m responsible, and it’s all about quality.

Quality three times over.

Now, multiply that same process for each and every other test I have ordered.

Next.

I see orders for things I’m not sure I ordered, just to be sure I’m responsible, and watching, literally hundreds of times per day.

Next.

I get e-mails and electronic notifications, and electronic communications, as if I know the difference.

Next.

I bypass nursing notes that are mere QA checklists and say nothing about the patient, except that a nurse was there last night.

Next.

I feel guilty entering data as I talk to my patient while serving my electronic master. Yet I find the stakes are high to assure accuracy and timeliness in ~~clinical~~ electronic reporting. After all, you never hear the bullet that hits you.

Next.

I go home on call, am paged, and reprimanded by a patient who wonders why I can't look up their medication list on-line, even though I'm standing in the grocery store.

Next.

Worst of all, I find myself sending myself messages, just to make sure I do something tomorrow that I could not get done today.

Killing me softly …

… with information overload.

-Wes

The World's Smallest Pacemaker Recipient

wes@medtees.com (Westby G. Fisher, MD) — Mon, 22 Jun 2009 18:49:54 PDT

Pretty amazing:

When she was fitted with the (external, temporary) pacemaker, nine hours after her premature birth three weeks ago, Taylor weighed only 541g and is believed to be the smallest baby to undergo such an operation. She is now a healthier 720 grams (19oz), but is still so small that the grey and green heart regulator appears bigger than she is.

The pacemaker is an external one for now and will be replaced by a much smaller internal device, once the the baby grows sufficiently.

-Wes

Picture reference: David Caird, Herald Sun.

Medicine: Too Big to Fail?

wes@medtees.com (Westby G. Fisher, MD) — Mon, 22 Jun 2009 07:10:38 PDT

After reading this piece in the New York Times, we have to wonder if the health care will be the next Hindenburg to fail:

I think Abraham Verghese, MD said (subscription) it best this weekend in the Wall Street Journal:

My wife tried to tell me the other day that she had just ‘saved’ us money by buying on sale a couple of things for which we have no earthly use. She then proceeded to tote up all our ‘savings’ from said purchases and gave me a figure that represented the money we had generated, which we could now spend . . .she had me going for a minute.

I mention this because I have similar problems with the way President Obama hopes to pay for the huge and costly health reform package he has in mind that will cover all Americans; he is counting on the “savings” that will come as a result of investing in preventive care and investing in the electronic medical record among other things. It’s a dangerous and probably an incorrect projection.

Dangerous and probably incorrect, indeed.

-Wes

How A Lawyer Would Save Health Care Costs

wes@medtees.com (Westby G. Fisher, MD) — Fri, 19 Jun 2009 05:12:44 PDT

A lawyer, of all things, at Supremacy Claus shares ideas to shave health care costs by getting rid of the "pestiliential land pirate."

-Wes

How Clever Are You?

wes@medtees.com (Westby G. Fisher, MD) — Thu, 18 Jun 2009 04:28:37 PDT

Okay, medical blog-o-sphere, opportunities like this don't come along often:

LOS ANGELES - Reese Witherspoon is going into the pharmaceutical business with Universal Pictures.

The studio is developing "Pharm Girl," an aspirational comedy centering on one woman's odyssey through the drug industry.

...

The project concerns a woman who gets a job at a pharmaceutical powerhouse and begins to see the underbelly of the industry as she rises through the company's ranks.

Anyone up for writing the trailer for the movie?

-Wes