There is an NY Times article about how Congress in the US is trying to pass legislation to pay doctors for better care, rather than just for seeing larger numbers of patients.
This is being implemented in areas, where such issues can be addressed and quantified.
Very interesting this and a long-time coming. This is something that should have been implemented by the medical associations themselves many many years ago, setting standards and outcome criteria - we never did it ourselves and now others are foisting them on us and making sure we start complying.
People getting fired for the diabetes related issues in the US - this is the subject of an NY Times feature.
As the problem of diabetes goes out of control, this is going to be a larger and larger issue and for businesses and corporations to take the easy way out, by firing people who are diabetic, does amount to discrimination.
If the diabetes is under control and all steps are being taken to make sure that the sugar levels remain low and that there are no complications, there should be no discrimination as well.
A poignant point-of-view on how we as doctors don't seem to want to confront end-of-life issues with our patients. Many of us have a distinct inability to deal with the dying and try to avoid them and their problems, especially when we have treated them and "failed".
This attitude needs to change, simply because we can't obviously give-up on our patients.
A surgery for dissection on the person who invented the surgery.
This post from the NY Times is interesting and again shows the opportunity that exists in servicing the needs of baby boomers with bone and joint problems.
The NY Times has this interesting article about how doctors are making mega-bucks on Wall Street, by not practicing medicine. The profile is on one particular doctor, who joined a consultancy firm and eventually landed up in Merill Lynch and now makes 10 times his fellow colleagues, which they figured out during a reunion.
This is not necessarily a new phenomenon, but as medicine gets corporatized, more and more doctors are getting this opportunity. In insurance, in management and in the financial services.
The issue is that you do cease to be a doctor when you stop practicing medicine. And if the loss of that satisfaction and special standing is acceptable, then that's fine. But the relationship between mainstream doctors and those who have opted out will always be a mixed one. Admiration and envy for being able to make so much money, but a bit of condescension that he/she had to move out of medicine to do so. All doctors believe that if they were to move out of medicine, they would be able to do the same...and a lot of the doctor ego comes from the fact that a doctor can still take to most other professions, but other professionals and workers can never ever become doctors.
Obviously, there is a tremendous disconnect between doctors' perceptions and those of patients. This article in the NY Times, brings that to the fore. The perennial debate on when to stop life-support and let people go, goes on.
In India, it seems to be much simpler. I guess we are wired from birth to let go and not to make people suffer and offer collective family decisions are taken to let people in misery off the hook.
This NY Times story talks about how one single woman, now going by the name Cheryl Chase, has tried to lobby doctors, scientists and other intersex patients and their parents for changes in the way patients with "disorders of sex development" are treated.
In most situations, especially if the external organs are malformed, surgery is offered as a way to make the genitals look "normal". Ms. Chase's arguments are that most such people grow up eventually to be emotionally and psychologically scarred and it is likely that despite the malformed genitals, if the individuals are allowed to grow up with them, they may have a better life, including sexual satisfaction.
Her lobbying has had an effect, and she is part of a consensus statement on this subject as well.
This is one more example of how patients can get involved, exercise their rights, show everyone issues from their points of view and get changes made.
Obviously, intersex is associated with a large number of thorny emotional problems. Doctors land up playing God and in that setting the perspective of people who have been through these problems and solved them would help in letting care-givers know how to proceed in the future. Thus guidelines are framed not just from the practice/scientific viewpoint but also from that of the patient.
The NY Times has a story on how lung transplantation rates and results have improved. Two things have happened
1. The waiting lists are now geared towards providing transplants to those with the most need and not to those who have been waiting the most - this ensures that those who need transplants earlier get them and do not die while waiting
2. The ability to harvest lungs successfully has improved considerably
This is one more example of how success in many areas in medicine are not necessarily skill-based, but are sometimes a result of tweaking procedural or logistical issues.
In India, we still don't do lung transplants, predominantly due to the high prevalence and incidence of tuberculosis. There is however, a large number of patients, that needs this procedure and it may not be a bad idea for someone to at least start lung transplants, in this country.
This article from Health Affairs, explores the two models of teleradiology that currently exist - the Nighthawk (US trained, board-certified radiologists) vs the "Indian" model (non board-certified, lowly paid).
Obviously the majority of the article is devoted to the legal minefields associated with the Indian model, especially since the erring Indian radiologists cannot be brought to book. Having said this, I know for sure that there are very examples of the Indian model - most of this is hype related to the old Saini Saini controversy.
The Nighthawk model is followed by Arjun Kalyanpur of Teleradiology Solutions. The Indian model...show me even one company that you can find.
This article from Imaging Economics talks about the upsurgence of musculoskeletal (MSK) MRI and the lack of trained MSK radiologists. It quotes the usual cast of characters with pithy comments, but eventually the article ends with the same turf warnings that all such articles eventually end with - that orthopedists are now putting up their own MRI scanners and radiologists are wondering what to do.
I guess in India, this is not really going to be an issue, considering that even in cardiac imaging, there isn't a turf battle. Except for gynecology and interventional procedures, there really isn't any kind of ongoing turf battle. To think that orthopedic surgeons will try and put up their own CT scans and MRIs is really unimaginable - this is probably due to a combination of lack of stomach for the kind of monies involved and more importantly the fact that everyone is busy doing their own thing and there would be very little time to manage an additional multi-crore MRI. And since an MRI facility would never be able to break-even with just the orthopedist's patient load, it would involve marketing to outside referrers, etc, which would only add on to his headache.
This is the story of radiologist who threatened to blow the whistle on the issue of unreported radiographs and was subsequently suspended and now fired by the trust hospital.
This Diagnostic Imaging report gives a feeling that there is more to this. I am not sure whether have unread radiographs is a crime in itself. Especially with ER and ICU related studies, often there is no time to read these, or the referring doctors have already done the needful. There is no question that the systems should be solid enough to prevent this issue, but often radiologists just don't have the incentive to do so, especially if they are salaried.
Blowing the whistle on something like this, needs to be looked at carefully, because it may also implicate your own colleagues, if you are proven right. Given that the issue itself does not seem to have the kind of magnitude that its being given, again I wonder if censure by your own colleagues is worth all this.
Like I said...I don't think all the facts are known, so its difficult to be more definitive here.
When Scanman gets going, he really does.
I really didn't know this, but this article by Kristof Nicholas in today's NY Times, brings into focus the problems that pregnant women face in many parts of the world (the example here is a small town in Cameroon), when delivery, with an estimated mortality rate of upto 1 in 20, for e.g. in Cameroon.
India has a maternal mortality rate of approx. 540 per 100,000, which is amazingly high. This means that. The lifetime mortality risk is 1:48.
The rates are obviously higher in rural and more importantly impoverished areas and we have the highest rate in South Asia.
The NY Times has an article on how children upto the age of 30 are piggy-backing on their parents' insurance plans.
Though this doesn't really concern us in India, it is an interest comment on a trend that is occuring in a country, whose systems we are currently trying to emulate.
Jerry Avorn talks about the "Sting of Ignorance", using an encounter with a jellyfish, as an example to show the wide gap between the medical facts available and their dissemination to and knowledge of, by the laity.
This is so true and it would really be of help if there are easy methods of communication available. I don't agree entirely with the rest of the issues that Mr. Avorn talks about. Its not as if straight-forward data is easily available even to experts in their particular fields - where it is (e.g. acute trauma, emergencies), fine...but in many other chronic conditions, there are so many grey areas.
The use of the Internet has helped the lay public get access to information, but they usually have no clue of what to do what that information.
Drug-resistant tuberculosis (TB) with or without associated HIV, is making a tremendous resurgence in Africa, and Eastern Europe and Russia. These are all usually resistant to first-line medication and most are also resistant to second-line.
This is obviously a major socio-political issue, as we see in our daily practice. Not only is there an increase in the incidence of tuberculosis, the organ systems involved and the patterns of involvement have changed and become more complex. M. tuberculosus unfortunately does not read our text-books.
NY Times has done a large feature on diabetes in India, following up on their continuing features on this subject.
If 35 million people today have diabetes with a projected 75 million by 2020, that is a lot of work for a new generation of diabetologists. Each patient with diabetes does not just have to be looked after with respect to sugar control and advise, but also needs to be evaluated for possible neurologic, cardiac, renal, and peripheral vascular disease complications.
Being a diabetologist is not a bad thing in this scenario, especially since these patients are also usually affluent and can pay.
Most certainly, the insurance companies are going to shy away from reimbursing diabetes related disease, except possibly for the first episode.
This disease has been creating waves...literally. From the Indian Ocean islands to Britain. Chikungunya is currently affecting hordes of people in the interiors of Maharashtra and in Andhra Pradesh.
It is diseases such as these that keep reminding us of our inability to control the vast majority of viral diseases.
From the same author, who coauthored "Hardball: Five Killer Strategies for Trouncing the Competition", comes this article called "Curveball: Strategies to Fool the Competition". He lists four methods
1. Draw your rival out of the profit zone
2. Employ unfamiliar techniques
3. Disguise your success (looks like a Siemens versus GE story)
4. Let rivals misinterpret your success
The last one illustrates Southwest's success, which in part was due to increased asset utilization (keeping the airplanes in the sky for a longer period of time with faster turnaround times).
In medicine as well, especially in radiology, where the capital costs are high, the asset utilization should be maximised. Dr. K G Srinivasan in Madurai, has learnt this the best - keep the machines occupied at whatever price the patient is willing to pay. To maximise asset utilization (in this case the scanners), it is necessary to reduce the price - this way you can have a low margin, high volume business, which actually is a good model, especially in India, where the patient base is huge, but the paying capacity isn't.
Most hospitals follow the low volume, high margin route, which also works, especially if cutting costs is a problem. It makes no sense charging rich patients less and so poor patients are not catered to. Which is fine, if they break even.
One MRI centre in Ahmedabad, using a refurbished 0.5T MRI has also followed this principle of high volume, low margin, by pricing aggressively all MRI scans at Rs. 2500 and then doing close to 40 scans a day.
The only other problem with this strategy is the load that it places on quality. Unlike the airlines business, there is a limit to how many scans you can actually do without cutting corners and without the radiologists getting fatigued while reporting and making mistakes - so there has to be some trade-off. But if you can run the centre for 24 hours, not cut corners and generate enough revenues to have enough radiologists reporting, the system can work well.