DB’s Medical Rants

Abraham Verghese published a curmudgeonly essay in the NEJM recently.  He bemoans information technology and champions physical diagnosis.  I thought seriously about his rant, but had not developed my own response.  Bob Wachter comes to the rescue - Can the Physical Examination Save Us From the Technology-Induced Dehumanization of Medicine?

This is where my argument diverges from Abraham’s. In my zeal to bring physicians back into the patient’s room, I’d place 20% of the emphasis on performing and interpreting a good, thorough physical examination, and 80% on teaching and promoting superb communication skills – eliciting the history, describing prognosis, discussing alternative treatments, determining the patient’s attitudes about end of life care, and apologizing for medical errors, to cite but a few examples. These are teachable skills that will never go out of style, skills whose value won’t be supplanted by PET scan results and graphs of trended ANCA levels. And, to me at least, they highlight the patient-as-person and physician-as-humanist more than sticking a tuning fork on a forehead ever could.

Bob understands. 

I have a very distinctive attending style.  We start in a room with technology available (in case we need to look at images or review labs or review old records.)  We discuss all the patients in that room.  This gives the students and residents a chance to present their opinions.  It gives me a chance to pimp behind closed doors.  It allows us to be inappropriate (sometimes patient care drives one to inappropriate comments, but behind closed doors decreases the damage).

We leave the room once we all have an idea of our plan for the day.  My job then is to go to the bedside and talk to patients, and occasionally examine patients.  Bob has the percentages correct.  I spend at least 80% of the time communicating with patients.  I retake histories, break bad news, and explain the plans for the day or for discharge.

I perform targetted physical examination.  When I find something worthwhile, I get the patient’s permission and teach the team about the abnormality.

The most important thing I teach at the bedside is patient communication.  Hopefully, I model good bedside manner.

In the hall we often dissect the interaction, pointing out my strengths and weaknesses.  I often grade myself, and I am a tough grader.  I make the team consider what I did and why I did it in the way I did.

Physical examination skills are worthwhile, but communication trumps them.

Tuesday’s WSJ has this headline which is meant to scare readers - Obama Will Ration Your Health Care

Given the opportunity, Mr. Daschle would likely charge the board with determining which treatments and drugs are cost effective and therefore permissible to use for patients covered by the government. And because the government is such a big player in the health-care market (46% of health-care spending comes from the government), the board would effectively set parameters for private insurers.

It is nearly certain that the process of determining which drugs and which treatments would be approved for use would be quickly politicized. The details of health-care policy may not be kitchen table conversation, but the fact that a Washington committee can deny grandma a hip replacement due to her age, or your sister a new and expensive drug, is. Health care is personal and voters will pressure lawmakers on access to care.

Liberal experts, Mr. Daschle included, believe that America needs to ration new technology and drugs. In his book, Mr. Daschle complains about overuse of new technology and praises the United Kingdom’s National Institute for Health and Clinical Excellence (NICE), a rationing system that controls government costs. NICE’s denial of care is legendary — from the arthritis drug Abatacept to the lung cancer drug Tarceva. These drugs are effective. It’s just that the bureaucrats don’t consider them cost effective.

We already have health care rationing.  Our current rationing system is covert - DrRich explains this concept on a regular basis, and specifically in this post - Covering "Effective" Medical Services

Please understand that DrRich is not complaining. Such a system, as odious as it sounds, is substantially better than what we have now. Today, we have a healthcare system that claims to cover “everything,” then conducts most of its rationing by coercing doctors to act against the best interests of their patients. Under the system DrRich has just described, a) at least some of the rationing decisions will be made away from the bedside, by the Fed Health, and will be less destructive of the doctor-patient relationship; b) the black and white pronouncements of the Fed Health will not go completely unchallenged, and eventually the feds will have to become more open about their rationing decisions; so c) it is possible to visualize how such a system might evolve, some day, to one where open rationing is conducted under a process of actual transparency.

But DrRich urges his Dear Reader to be less “hopeful” and more skeptical about coverage decisions. If one is mired in hope, then it will be all too easy to just accept on its face the black and white pronouncements of the Fed Health regarding which medical services are “truly effective,” and which are “useless.” Many if not most medical services fall somewhere in between these extremes. Therefore we will need to hold the feds’ feet to the fire to make them accountable for their decisions. Demanding accountability and transparency will eventually yield rationing decisions that are much less bad.

But no matter where or how you draw the line between covered and not-covered medical services, we will still be rationing. And that means that at least some beneficial medical services will always be withheld from at least some people.

For those who have read this far, let me provide the abridged version.  We currently have rationing, albeit often covert rationing.  DrRich and I both believe that open transparent rationing would provide higher quality care to more patients.

Why must we have rationing? Money, we cannot afford to provide every new technology or medicine indiscriminately.  We have actually known of this problem for over 25 years, but now the idea is getting traction.

I am a strong proponent of comparative effectiveness data.  As a physician I need to understand the relative merits of different medications, devices or diagnostic tests.  Unless we demand that appropriate studies compare effectiveness, then we remain at risk for marketing to drive our decision making. 

Too often, we have accepted new medications only to later learn that they really are not better.  We see TV ads encouraging our patients to ask for the newest (and most expensive) treatment.  But we do not really know, because as a society we have not demanded the appropriate studies.

I hope that we can have transparent medical decision making.  Transparency and data would likely lead to voluntary rationing (that and a healthier malpractice environment.)

Why not just let the market place decide?  We have not had a free market in medicine during my career.  Our current medical insurance industry runs current rationing, and patients have no real role in making informed cost-effective decisions. Currently patients want everything, even when everything causes more problems than moderation.  Patients want antibiotics for colds; they want MRIs for simple headaches; they want Nexium (when generic omeprazole is really the same drug.  We need some rationing.

The biggest advantage of a Health Board is that such a board will allow us to avoid some defensive medicine practices.  I only hope that they protect this concept with legal protections.

Oskie commented:

Your proposal rewards the lowest common denominator of physicians’ performance (primary care) and therefore will result in a lowest common denominator health care system. Primary care “medicine” should be outsourced to mid-level providers with MD/DO’s assuming more of a managerial role. Let the expert specialists practice state of the art disease management and let the medical social workers and mid-level health care providers “coordinate” care.

Fortunately, several stalwart readers have posted excellent comments.

I am frustrated, because I have spent so much time posting about primary care on this blog.  I periodically write avoid the term, just because of this misunderstanding.  In my post, I was careful to define primary care, but I guess I do not write clearly enough.

Primary care is not the lowest common denominator!  Primary care physicians have the most challenging practices, because they see undifferentiated patients.  I can list over 50 causes of chest pain.  As a generalist, we see a patient with chest pain and have to sort through all the possibilities.  By the time we send the patient to the cardiologist, we usually have a strong indication of heart disease.

Our patients have many problems.  The treatment for each problem can have an impact on the other problems.  Just now I have a patient who had a pulmonary embolus 6 days ago.  Now he has heme positive stools and a slowly decreasing hemoglobin.  So what do I do?  The pulmonologist would emphasize the importance of anticoagulation.  The gastroenterologist would emphasize the risk of anticoagulation.

"The good physician treats the disease; the great physician treats the patient who has the disease" - Sir William Osler

We have to balance the risks to make a good patient level decision.

The patient I presented last week with a sore throat had a complex problem.  Sore throat is a primary care problem, but it can turn complicated.

Patients need excellent primary care physicians.  Unless we address those issues which make that option less appealing, overall patient care will suffer.  If Oskie does not understand that, I have failed as a blogger.

A medical student recently challenged us to "quit whining" about primary care.  As I recall my postings on primary care over the past few years, I believe I have often provided potential solutions, but then I might have selective recall.

This article highlights the primary care crisis - 2 hospitals cut family practice training

The first step requires that we as a country decide that primary care has great value.  I use the term primary care with trepidation (as I have written previously.)  As you read this missive, consider the broader definition of primary care - which includes accessibility, continuity, comprehesiveness, and coordination.  High quality primary care decreases subspecialty use. 

Primary care physicians spend their time in various activities - seeing patients, reviewing records, paperwork (filling out forms), and telephone conversations.  We must pay them for all their time.  Primary care physicians have only time as a commodity.  They deserve payment for all their time.  I have previously called for a time based payment system for primary care.  This would encourage physicians to spend an appropriate amount of time with each patient.  This system would reward physicians for email and telephone consultation.  We must change our payment system to encourage physicians to join the 21st century in communications.

My payment system proposal would allow for a differential among specialties, but I would cap the multiplier at 2 or less.  Thus, if a primary care physician working 50 hours a week (a standard time allocation) would make $200,000 net, then perhaps a cardiologist would make $350,000 net.  Or a radiologist might make $300,000 net.  These differences seem large when typed, but are actually much less than current differences.

We need a national EMR.  I do understand the privacy concerns, but truly believe that the trade off makes this a necessity.  When I see a patient at the VA, I can review his (or occasionally her) records from any VA in the country.  These records improve my decision making.  There records often allow me to forego additional testing.

This EMR needs (at least) a unified problem list and medication list.  We need access to all laboratory tests and imaging studies. 

Such a system would decrease health care costs and a subset of errors.  While EMRs still have problems, the problems of paper records are much greater.  Of course in my payment proposal, physicians would be earning money while writing or dictating their notes.

Third, we must decrease the cost of medical school.  Our students have debts which influence their career decision making. 

I believe these are positive suggestions.  These are not whines, but rather the basis of a health care reform platform. 

You can imagine my excitement when I realized that the gram negative rods growing from the blood of the pharygitis patient were only growing in the anaerobic bottles. As readers guessed, Fusobacterium is a gram negative anaerobic rod.  So I obviously made the assumption that the blood cultures would reveal Fusobacterium.

We switched antibiotics to high dose clindamycin.  The patient had a slow recovery over the next 3 days.  We discharged him with a normal looking tonsil and no exudates. 

Today the laboratory confirmed Fusobacterium sp.  It will take another 3-5 days to identify the precise species.

As far as I can tell, there is only one published patient with Fusobacterium necrophorum bacteric pharyngotonsillitis.  Usually, the patients present with the flow blown Lemierre’s syndrome.  I suspect that if the walk-in clinic physician had not obtained the blood culture, the patient would have presented a couple of days later with Lemierre’s (although I cannot prove that assumption.)

The physician in the walk-in clinic obtained blood cultures because the patient had had a drenching night sweat and a temp as high as 103 (over 102 in the clinic.)  That physician started the wrong antibiotic, but the positive blood cultures allowed us to make a most unusual diagnosis.

We do plan to write the details of this case for a medical journal.

How to be a human

Too often I see or hear about physicians who do not treat others with human kindness.  Most physicians who care for patients do develop good bedside skills, but unfortunately a minority do not.  Non-physician readers can unfortunately too quickly provide examples of our failings.

Just as disturbing this occurs during clinical rotations.  How often do attendings fail to treat their students and residents as humans?  How many attendings have the false impression that the students and residents are working for them, and those workers fall into a lower caste?  I spend much time talking with students and residents.  Too often they tell me tales of rude attendings or rude residents.

Physicians should always remember that we are working for the patient.  Attending physicians should always remember that our job is to help the students and residents grow.  They are not here for our comfort, but rather we are here for them.  Afterall, the students even help pay our salaries.

Remember to treat each trainee with respect.  Learn their names (I know that sounds obvious, but you would be amazed.)  Learn something about them; found out what their life is like. 

Always remember what Hillel said:

What is hateful to you, do not do to your neighbour. This is the whole Torah; all the rest is commentary. Go and learn it.

This medical student thinks so - Enough whining about primary care

I’m not trying to present this as a comprehensive look at the data. But it is representative. I stand by my claim that the sum of the evidence favors the conclusion that medical students are largely not picking their specialty based on their debt load.

I have spent 30 years teaching medical students.  I have advised them and counseled them.  Most medical students will admit that money is a major factor in choosing a medical specialty, but not on a survey. 

But the real problem is related to money, even though our idealistic student does not completely understand.

That’s certainly true for me. I came to medical school thinking I wanted to enter a field where I could work with my hands. But any thought of primary care died when I entered my clinical years in medical school. In my experience, I met only one happy primary care physician. If I were to listen to all the primary care physicians I know, or who I read in journals and online, I would think it was the apocalypse for primary care.

You must ask why primary care physicians are unhappy with primary care.  The big problems are time and paperwork.  They do not have enough time to spend with each patient, because of the financial structure of care.  They have to spend too much time on paperwork, because of the financial structure of care.

Physicians generally like caring for patients (or they choose radiology, pathology or perhaps ER medicine.)  They do not want to shortchange the time they spend with patients.  Our financial structure has the greatest negative impact on primary care physicians.

Primary care physicians are the oppressed. 

Disclaimer: I have done primary care and now only do hospital medicine.  As I gave up my outpatient practice, the paperwork and time constraints were becoming onerous.

I teach primary care residents.  They love their patients.  They love medicine.  But I know that many of them we reassess their career, because primary care physicians cannot practice they way they should or they way they desire.

I do not think I am whining.  I look objectively at our health care system, and believe that more primary care physicians would improve the patient health.  I ask how we should modify our system to encourage the growth of primary care.  Money does matter.  To think otherwise is unfortunately wrong.

The primary care physician drew blood cultures and started moxifloxacin.  Two days later the blood cultures come back growing gram negative rods in the anaerobic bottles.  He is called back to the ER.  On exam he has a fever of 103, markedly swollen right tonsil with exudates, mild swelling of right neck, but no clear adenopathy.  He does not have a cough.

CT scan shows a huge right tonsil, but no evidence of abscess and normal patent internal jugular vein.

Now what would you do?

What do you think is wrong with this man?

A 30-year-old man comes to your office for 2 days of progressive pharyngitis.  He is unable to eat but is drinking well.  He has a temp of 103 and endorses a drenching night sweat.  He has a swollen right tonsil with marked exudates.  His right neck is slightly swollen.  You cannot feel anterior or posterior adenopathy.

His rapid strep test and flu screen are both negative.

Would you give antibiotics?

Would you get blood cultures?

I am slow updating my media recommendations.  This weekend I took some time to consider the music I am listening to, the books I have read (or listened to) and the movies I admired.

Music

1. Veneer - Jose Gonzalez
2. In our nature - Jose Gonzalez
3. Time without consequence - Alexi Murdoch
4. Narrow Stairs - Death Cab for Cutie
5. Dear Science - TV on the Radio

I am entranced by Jose Gonzalez.  His music is lovely, his guitar work sublime, his voice enchanting.

If you like Nick Drake, try out Alexi Murdoch.

Movies

1. Slumdog Millionaire
2. Milk
3. The Dark Knight
4. Burn after Reading
5. Munnabhai MBBS (a Bollywood movie from 2003)

I saw Slumdog Millionaire this weekend.  The movies combines a disturbing view of Indian poverty with a tale of love and hope.  The movie is beautifully filmed and directed. 

Milk reminds us of the political struggles of the gay movement in the 1970s.   The execution is pitch perfect.

Many readers will not like the dark Batman portrayal of the Dark Knight.  If you read comics, think Frank Miller. 

Burn after Reading represents the Coen Brothers at the top of their game (and totally different from No Country for Old Men.)  I think Brad Pitt deserves and Academy Award for best supporting actor - he is simply hilarious.

Munnabhai is a hilarious Bollywood movie with a profound message (or at least I thought so.)

Books

1. The White Tiger - Aravind Adiga
2. The Jewel Trader of Pagu - Jeffrey Hantover
3. The Yiddish Policeman’s Union - Michael Chabon
4. Exit Music - Ian Rankin
5. The Brass Verdict - Michael Connelly

I loved all these books, but recommend the first most highly.  The White Tiger won the Man Booker award this year - and I understand.  Aravind Adiga writes a story of India which starts in a poor rural village.  The story ends in Bangalore with a greatly successful entrepenuer. The story of his transformation taught me much about a culture that I want to understand.

Yesterday, I saw the classic CHF mistake.  Our patient came in volume contracted and hyperkalemic secondary to overuse of furosemide and sprinoalactone.  I see this problem so often that I feel obliged to provide a blog entry.

As I tell my residents and students, overuse of diuretics remains a major error in CHF management.  The goal of diuretic therapy is to relieve symptoms (make the patient "not wet") not to volume contact the patient (not make the patient "dry".)

We have mounting evidence that excess diuretic use correlates with increased mortality.  This article really helped me understand that issue - Relation of Loop Diuretic Dose to Mortality in Advanced Heart Failure - The American Journal of Cardiology Volume 97, Issue 12, 15 June 2006, Pages 1759-1764

Abstract: Although loop diuretics are widely used in heart failure (HF), their effect on outcomes has not been evaluated in large clinical trials. This study sought to determine the dose-dependent relation between loop diuretic use and HF prognosis. A cohort of 1,354 patients with advanced systolic HF referred to a single center was studied. Patients were divided into quartiles of equivalent total daily loop diuretic dose: 0 to 40, 41 to 80, 81 to 160, and >160 mg. The cohort was 76% male, with a mean age of 53 ± 13 years and a mean ejection fraction of 24 ± 7%. The mean diuretic dose equivalence was 107 ± 87 mg. The diuretic quartile groups were similar in terms of gender, body mass index, ischemic cause of HF, history of hypertension, and spironolactone use, but the highest quartile was associated with a smaller ejection fraction and lower serum sodium and hemoglobin levels but higher serum blood urea nitrogen and creatinine levels. There was a decrease in survival with increasing diuretic dose (83%, 81%, 68%, and 53% for quartiles 1, 2, 3, and 4, respectively). Even after extensive co-variate adjustment (age, gender, ischemic cause of HF, the ejection fraction, body mass index, pulmonary capillary wedge pressure, peak oxygen consumption, β-blocker use, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use, digoxin use, statin use, serum sodium, blood urea nitrogen, creatinine, hemoglobin, cholesterol, systolic blood pressure, and smoking history), diuretic quartile remained an independent predictor of mortality (quartile 4 vs quartile 1 hazard ratio 4.0, 95% confidence interval 1.9 to 8.4). In conclusion, in this cohort of patients with advanced HF, there was an independent, dose-dependent association between loop diuretic use and impaired survival. Higher loop diuretic dosages identify patients with HF at particularly high risk for mortality.

When discharging a patient from the hospital, I almost always arrange for "sliding scale" diuretics.  I try hard to minimize diuretic use and encourage diuretic free holidays.

Diuretics help patients feel better when they are volume overloaded, otherwise, we should withhold them.

I received this comment yesterday:

I find that many of my colleagues are not that interested in learning and do not actively attempt to become better physicians. They have not kept up as they should have. I can say confidently that they would have a difficult time explaining any medical topic in detail to a medical resident. This has been my experience. They are simply not equiped to deal with the nuances of a complicated medical patient without specialist help.

I think DB has had a different experience surrounded by residents in the VA system.

Soon thereafter I received this rebuttal:

I disagree with former internist. In this part of the country, it is the private internists who actually treat the chronic problems; the academic internists are the ones who won’t treat RA, CKD, A-fib or thyroid disease without specialists helping.

Maybe it’s different in other parts of the country; back east pts only saw a specialist once a year if their condition was stable.

Both comments reflect the availability heuristic that I discussed yesterday.  I suspect that the truth is quite different than either comment reflects.

What do I know?  Many internists (and family physicians, and radiologists and surgeons, etc) work hard to maintain their knowledge and skills.  Many internists really do care for the entire patient, and only get consultations when it will really benefit the patient.  Other internists use consultants too sparsely.  They try to care for problems outside their scope of competence.  Finally, some internists order too many consults.  Why do we have these 3 groups?

The first group represents the committed great internists.  They participate in ongoing education, and take pride in the care they give.  They worry less about the money and more about practicing the highest quality medicine.

The second group are always the most dangerous, for they do not know what they do not know, and moreover have egos which decrease the probability that they will ask someone for help.  Occasionally we see residents like this.  They scare me, because I know they will make big mistakes during their career.

The third group represents the sad unintended consequence of our payment system.  These physicians a focused on money, and thus understand that testing and consulting can shorten their visit length without decreasing their payment.  Thus, they can see more patients each day, and make more money.  Would a more intelligent payment system change them?

This third group represents the worst of medicine.  Such behavior is not restricted to generalists.  I see subspecialists who shotgun consultation and order tests like they are free.  These orders and consulters replace thinking with asking others to see their patients, and substitute a careful history and physical exam with an imaging study.

Can we fix this?  I suspect that reforming the payment system would help, but not totally solve this problem. 

Internal medicine is cognitively and emotionally challenging.  Many internists love that challenge.  Others tire of the challenge and look for an easy way out.  Internal medicine does not have an easy way out.

Now that I have finished my trip, and furthered my hate of Delta (too long and aggravating a story to recount), I have to expand my rant about the ER physician who has no respect for primary care.

He, who will go nameless here, stated:

I cannot be the only emergency physician who has treated patients referred by primary care doctors for such non-emergencies as:

▪ Asymptomatic hypertension of 190/115 mm Hg picked up in the office or at health fairs. If you told me 25 years ago that some guy out on the town for the evening would be referred to the ED by an internist to manage high blood pressure, I would have thought you were crazy.

▪ Asymptomatic hyperglycemia of 350-500 mg/dL in patients already managed by these doctors on oral agents.

▪ An asymptomatic patient with an INR of 5.

▪ An entire family of eight referred for screening for pertussis exposure, all asymptomatic.

I can instruct the patient with the INR of 5 to avoid getting hit in the head by a baseball bat for the next few days, but so can the doctor who sent him to the ED. Give primary care doctors more money? Their patients usually have the common sense to know they do not have a medical emergency when these doctors refer them in to the ED.

I have my own ideas about what primary care should accomplish, but foremost among them is to see patients in a timely way when they get sick as opposed to the dermatologist who schedules an appointment three weeks later, by which time the rash has disappeared. Or how about having the diagnostic and therapeutic skills to intervene in some way when the acutely ill patient does show up? Or caring for patients regardless of their ability to pay. After all, the people who sustain strokes, MIs, and aortic dissections because of untreated conditions of some sort (hypertension, diabetes, hyperlipidemia) are the ones most likely to benefit from preventive services.

There are so many issues here.  First, I must point out his use of the "availability heuristic".

The availability heuristic is a phenomenon (which can result in a cognitive bias) in which people base their prediction of the frequency of an event or the proportion within a population based on how easily an example can be brought to mind.

Simply stated, where an anecdote ("I know a Chinese guy who…") is used to "prove" an entire proposition or to support a bias, the availability heuristic is in play.

I know this heuristic, because I use it to criticize the ER physicians! 

The rest of his rant is so uninformed as to be laughable.  He has no idea what primary care physicians do in their offices.

I love the willingness to pay complaint - ER physicians are almost always subsidized by hospitals to care for those patients.  They have almost no overhead.  Check out the overhead for the average primary care physician.  Compare the hours worked each week.

I would love to debate this nameless one, but it would not be fair.

Still boiling in Alabama - db

Many readers know that I started blogging over 6 years ago.  Some bloggers sing praises of twitter.  I really do not know.

So I am asking you the readers - should I twitter?  If I get enough positive responses then I will twit (or whatever the verb is).

An ER doc has a piece criticizing primary care, and Bob Doherty discusses the issue - Primary care has no value?

This commentary exceed my imagination of uninformed.  And this is written by an ER doc.  We are talking about an ER doc.  (channel Allan Iverson talking about practice)

This is too ludicrous to induce my comments.  Not all physicians have common sense. Not all physicians understand health care.

Anyone who does either inpatient or outpatient care understands that the current billing model does not reflect the appropriate amount of time needed to see a patient.  For example, I can see a patient with an acute sore throat in 5-10 minutes, but how long should I spend with a 70-year-old man who has had diabetes type II for 10 years, hypertension, coronary artery disease (s/p CABG), and Class 2 CHF.  He missed his last appointment, so he has not seen me in 6 months.  His preventive screening is overdue.  He is still smoking.  How much time does he deserve?

We have the same issues on the inpatient side.  Some patients have one straightforward problem, and some patients have the intersection of multiple problems. 

Why do we not have a good database on these questions?  Why has no one provided the information we really need to understand time?

What do you think?

No, you have not stumbled onto the wrong blog.  Last night we had dinner with 2 other couples.  On the drive to the restaurant we were discussing the financial collapse.  One friend, a successful businessman, recommended this article.  I had heard of Liar’s Poker, and actually had heard of this article.  Having just read it, I highly recommend it for anyone who wants to understand.

The End of Wall Street

Then came Meredith Whitney with news. Whitney was an obscure analyst of financial firms for Oppenheimer Securities who, on October 31, 2007, ceased to be obscure. On that day, she predicted that Citigroup had so mismanaged its affairs that it would need to slash its dividend or go bust. It’s never entirely clear on any given day what causes what in the stock market, but it was pretty obvious that on October 31, Meredith Whitney caused the market in financial stocks to crash. By the end of the trading day, a woman whom basically no one had ever heard of had shaved $369 billion off the value of financial firms in the market. Four days later, Citigroup’s C.E.O., Chuck Prince, resigned. In January, Citigroup slashed its dividend.

From that moment, Whitney became E.F. Hutton: When she spoke, people listened. Her message was clear. If you want to know what these Wall Street firms are really worth, take a hard look at the crappy assets they bought with huge sums of ­borrowed money, and imagine what they’d fetch in a fire sale. The vast assemblages of highly paid people inside the firms were essentially worth nothing. For better than a year now, Whitney has responded to the claims by bankers and brokers that they had put their problems behind them with this write-down or that capital raise with a claim of her own: You’re wrong. You’re still not facing up to how badly you have mismanaged your business.

Fascinating and scary reading. 

Where Have All the Doctors Gone?

The primary care crisis raises questions not just about future access but about current morale.

“There was a tremendous amount of disenchantment, frustration, all bordering around one thing,” Tim Norbeck, the executive director of the Physicians’ Foundation, said of the survey. "Doctors feel they can’t spend enough time with their patients because of the paperwork and red tape hassles.”

Mr. Norbeck added: “Physicians went into medicine to spend more time with their patients, and that time has just been eroding. There’s serious reason to believe that there won’t be enough doctors to cover people sooner than we thought.”

Regular readers of this blog will recall how often I emphasize time.  As a physician our only currency is time.  Whenever we are not seeing patients, we are not making money.

We have the confluence of many undesirable problems.  Unfortunately, we can trace many problems back to the creation of a government bureaucracy - Medicare.

Please follow my argument before you start your commentary.  Medicare provides a wonderful benefit to patients.  Health care is expensive.  The price of health care has increased much faster than income. (Please note that I chose the word price rather than cost.) 

Because prices are increasing, Medicare has tried classic bureaucratic techniques to minimize expenses.  Our billing system requires extensive documentation.  If we do not document well, then we are not paid appropriately.

In an effort to pay physicians more appropriately, Medicare adopted RBRVS.  But then they made a huge mistake.  They let the AMA develop the RUC - The primary care reimbursement mess.  The members of that secret society include very few primary care physicians and many proceduralists.  Dr. John Goodson does a wonderful job explaining the implications of the RUC on primary care payment.

At a similar time, primary care married managed care.  During the late 1980s, primary care was all the rage.  Managed care provided better payment for primary care.  The subspecialists revolted and primary care suffered.  Managed care made primary care and subspecialty care opponents for physician payments.  Primary care has not yet recovered from losing this battle.

And managed care added another wrinkle which plagues all physicians today - prior authorization.  We have to spend our valuable time begging over the telephone so that our patient can get an imaging study or a consultation, or even a hospitalization.

The most recent actor in this play came with the adoption of hospital medicine as a career option.  Hospital medicine probably takes over 90% of internal medicine graduates who do not subspecialize, leaving very few for outpatient medicine.

So we have multiple problems for anyone wanting to do outpatient medicine.  We have other options which allow us to change to inpatient physicians.  For those who love outpatient primary care, we have the growing trend towards retainer medicine.  Retainer medicine, which has many positive features, decreases the number of patients that a physician sees.

Dr. Chen is correct.

I won’t envy Mr. Obama as he steps into the White House in January. Any attempt to make health care more accessible will be doomed to failure without an adequate number of primary care physicians and a strong primary care system. The situation in Massachusetts should be a wake-up call. Since a landmark law was enacted in 2006 requiring health insurance for nearly all residents, the state has struggled to provide primary care to the estimated 440,000 newly insured.

Mr. Obama and his team may find ways to give more Americans access to the waiting room, but what if there’s no doctor on the other side of the door? The crisis in primary care must be addressed before any real change can occur; otherwise, the flood of new patients may instead turn out to be a final strike for our ailing health care system.

And at that point for all of us, doctors and patients, the game would be over.

I hope they are reading and understanding.

‘It almost killed my daughter.’ Tracking down a rare and lethal disease

Very well written article.

Thanks to KevinMD for this link - Halt the Surgery—It’s Time for My Nap

Unfortunately, working less comes with a big price tag. Countries that have imposed shorter work hours for residents have faced steep staffing shortages as well as questions about the quality of their medical training.

New Zealand and Australia were two early adopters of shorter hours for residents, and their experiences should have warned other countries against the idea. In 1985, when New Zealand restricted residents to 72 hours of work per week, hospitals faced a sudden shortage and ended up hiring more senior doctors to fill the gap. Australia experienced a similar problem after physicians adopted a 1999 "National Code of Practice" designed to minimize the risks facing all shift workers who work extended hours. By 2004, physician shortages were common in Australia, and the state of New South Wales had 900 vacancies for residents and other doctors in training.

Other countries have seen similar snags. In Europe, where thousands of physicians were needed to fill vacancies created after residents scaled back their hours, hiring additional personnel cost an estimated 1.75 billion Euros. Exceeding the 48-hour-a-week allotment "is the rule rather than the exception" in Portugal, noted researchers in a 2004 British Medical Journal article. The United Kingdom needed an estimated 15,000 additional doctors to staff the National Health Service to comply with the Working Time Directive, which applied to junior doctors for the first time in 2000. In 2004, the BBC reported that the NHS was facing a "staffing crisis" brought on by shorter hours for residents.

We all know that every time Congress passes a bill, they create unintended consequences.  They fail to anticipate where the dominoes will fall.

I submit that the IOM and the ACGME have not considered the unintended consequences.  They are using a new treatment for a perceived disease without considering adverse effects. 

What bothers me is the total lack of understanding about the implications of changing a system that has actually worked.  I understand the desire to sleep.  I know that post-call residents are not as sharp as pre-call residents.  As an attending I have always adjusted rounds and overall patient management to work around their sleepiness. 

We need to examine the many permutations of the current 80 hour work week to understand what works and what does not work.  We need some cost-effectiveness calculations. 

A reader emailed me yesterday:

Twenty years ago, it was fair to say that residency was an apprenticeship.  You learned from the experience of your teachers.  Now that is only half true.  Now the volume of time that must be devoted to reading and learning new science is greater than ever.  And yet there is no corresponding increase in training time.  Working 30 hour shifts is great for experience.  But have you tried reading a "Clinical Implications" article from the NEJM at hour 31?  If you can do it, you are a better man than I.  Internal medicine cannot be taught in 3 years.  When you trained, it was possible.  It is not today.

But I could be wrong.  I’m very tired.

Let me address several issues.  I have never met an intern who felt that he/she read enough.  Internship is not about reading.  We have always had new science to learn, but putting new science into context requires knowing enough about patient care to have a framework.

I learned a lot of internal medicine during my residency.  I have learned much more since my residency.  You can never learn internal medicine, you only learn enough to start your path towards continuing improvement.

I remember learning that Larry Bird would work hard every summer to add new skills to his game - even after winning the NBA championship and the MVP award.  I have heard interviews with Tiger Woods in which he talks about working to get better.

Internal medicine (and every other specialty) changes steadily.  The great physicians are always improving. 

If we decrease work hours enough, then we should increase the duration of training.  We also must remember that such increases will cost someone money.

Today, when I work with senior internal medicine residents I am not worried about their training.  They are ready to work on their own.  They will grow and improve over time.

At 59-years-old, I feel that I am still improving as an internist.  I cannot explain all the newest science as it is published, but I learn what is important once it begins to impact patient care.  But I continue to improve at the bedside; I continue to improve as a diagnostician.

So please do not worry about not keeping up.  You will never be able to keep up.  But you can still become a great internist.

Last week my father asked me if he should ask his internist to change his hypertension medicine from Cozaar to a generic medication.  Being 20 years since retirement and on a fixed income, the money really matters.  Of course I encouraged him to ask, and his internist switched him to lisinopril (with my nodding silently in agreement.)  Why do we not use more generics?

Today’s NY Times has an interesting editorial - (Generic) Drug Resistance.  The article is not totally accurate, but an important point is made. 

Health care reformers have high hopes that the relentless rise in prescription drug costs can be slowed by replacing brand-name medicines with cheaper generic versions. Unfortunately, so many physicians are so captive of the drug industry that it would take a huge effort to persuade more patients and doctors to use generics.

That discouraging lesson can be drawn from a recent report by Andrew Pollack in The Times. He reviewed how a big clinical study organized by the federal government found that a generic drug costing only pennies a day lowered high blood pressure more effectively than did newer, far costlier drugs.

I do totally endorse the first paragraph.  I am known as being publicly challenging to drug reps.  I refuse to see drug reps in my office.  I am sometimes rude to them.  They have a job to do - convince me to use their drug.  I have a job to do - put my patients on the best, least expensive medication.

My blogging colleague (with who I usually agree), Dr. RW, argues in favor of drug rep access - and other disagree - Should Physicians Avoid Interaction With the Drug Industry?

The second paragraph is wrong.  The report by Pollack is wrong to this extent.  Many (including this author - just search on ALLHAT to see my previous posts) disagree with ALLHAT because of a major design flaw.

I prefer starting with an ACE inhibitor (like lisinopril above).  ACE inhibitors are generic (or as we say - Wal-Mart drugs).  Therefore, there is no cost differential.

Despite the ACCOMPLISH trial, I still use a thiazide second. 

One of my colleagues, David Calhoun, recently gave a brilliant grand rounds on resistant hypertension.  In that talk, he argues that chlorthalidone is significantly better than hctz for hypertension - probably because of the longer duration of action.  This longer duration of action also leads to more hypokalemia and probably more diabetes mellitus.  He now often adds low dose spironalactone to chlorthalidone (both generic.)

Using generics is much more complicated than the editorial suggests.  However, using generics is an admirable goal.  My experience suggests that generalists more often worry about drug costs.  Of course I might be biased.  I believe that increasing generalists through better reimbursement would save much money in drug costs.

I highly recommend that you spend the time to listen to his Grand Rounds.

Respect Your Hospitalist

Just last week I had the situation of consultants calling other consultants in the middle of the night.  The next morning I come in to see a very sick new patient with 4 consultants.  Two were necessary at that time, and two were making life more complicated.  So I spent around 15 minutes de-consulting two subspecialists.  Despite 4 consultants, no one had treated her urinary tract infection (which the next day produced positive blood cultures.)  Each consultant had focused on their organ, but the patient needed a generalist/hospitalist to consider all her problems.

I am glad to say that this very ill patient (intubated and hypotensive on pressors last week), will be leaving the hospital in good health.  We succeeded by treating the patient rather than a few diseases.  She had about 8 problems which need one group of physicians to consider and address.

The more cooks, the worse the broth tastes. 

Please heed the lessons that Happy describes.  Please minimize the use of consultants, only calling consultants when you really need them.

I too did not like staying up all night.  During my residency I became very good at getting at least 2 hours of sleep while on call.  I have always encouraged my housestaff to take naps.

I could live with 16 hour shifts, but we would need more funding from CMS.  A poorly understood provision of the IOM recommendations will have a dramatic impact on night float.  They recommend no more than 4 nights in a row, and then mandatory 2 days off. 

My biggest objection is the harsh attitude about work hours.  They include teaching conferences in work hours.  This I cannot understand.

Now I agree that tired residents should be able to go home and sleep, but why should rested residents have to leave.  We now have to tell residents to skip conferences.  How is that educational?

Residency is a time to learn.  Part of learning involves working hard.  Private physicians have no work hour restrictions.  They do the best that they can.

I would rather have a rested physician, but I would rather have a tired physician than no physician.  I have read too many comments that assume that we can easily replace a tired physician with a rested physician.  That assumption is too simplistic.

I would rather have a tired physician who knows me make a decision than a rested physician who has to read the chart and who has not ever examined me.

Work hour discussions are very difficult.  I do not regret having a difficult residency.  I learned how to care for very sick patients.  I developed clinical instincts.

I remember residency with fondness.  I was part of a large team.  In those days we had much more scut work, yet we still had esprit de corps. 

I see our residents willing to work hard, perhaps because they do have a sense of team. 

As yourself, as a patient, do you want a physician who willingly went the extra mile during residency or one who wanted to check in and out with a time card.  Medicine is not a job, it is a profession.  Sometimes professionals have to work extra hard.  Sometimes our patients need us.

Does more sleep make for better doctors?

Dr. Pauline Chen does a masterful job in discussing this controversy.  I will quote her ending, but I urge you to read the entire story.

In fact, the much-touted cap of 80 hours is hardly based on scientific evidence or extensive testing. In a letter last year to The Journal of the American Medical Association, Dr. Bertrand Bell, who was crucial in getting residency reforms passed in the 1980s, wrote, “The specific ’80-hour week’ was actually determined by a colleague on my porch and was based on the following informal reasoning….” That reasoning included, as Dr. Bell continued in the letter, the idea that “it is reasonable for residents to work a 10-hour day for 5 days a week [and] it is humane for people to work every fourth night.” After a series of mathematical calculations, his colleague came up with the now hallowed figure. And “eureka,” Dr. Bell wrote, “that equals an 80-hour week.”

The medical profession needs to address how we can create a safer environment for patients and a more humane workplace for residents. And the recent Institute of Medicine report is an important first step. But the takeaway message is not that we should proceed with costly reforms but that we desperately need more research on what changes have already been made.

Further resident duty hours reform without adequate evidence could lead to an entirely different and equally difficult set of problems for doctors and patients. It could fundamentally affect how we interact with one another. We as patients might have to work a little harder to recall the name of the doctor watching over us on the current shift. We might have to adjust our expectations of those physicians and surgeons caring for us, as the clinical experience of future doctors could be vastly different from that of the doctors we see now. And in a culture of handovers and shifts, where individuals are interchangeable, we might have to accept that each of us, doctor and patient, and our individual contributions to the doctor-patient relationship, would no longer be as unique as we might otherwise have once liked to believe.

Because even the most well intended reform efforts will not come without strings attached.

The problem with these "reforms" stems from a lack of understanding of how we learn medicine.

Now I have commenters who disagree.  One ob-gyn resident wrote a harsh rant about the lack of learning in her residency.  As I read her rant, she works in a program where little teaching occurs.  I work in two residency programs - an internal medicine residency and a family medicine residency.  In both residencies, much teaching occurs.

Obviously, I know internal medicine the best.  Our program devotes at least 4 hours each day to teaching.  We spend about 2 hours (3 hours on post call days) discussing and seeing our patients.  We have 1 hour for morning report (with hand picked clinician educators) and a daily noon conference.  Additionally, we have multiple subspecialty conferences.

The ob-gyn resident chose the wrong residency.  Changing the work hours will not improve her education.  She can only really learn from patients.  Will she see appropriate numbers of patients?

Our residents (in both programs) resist leaving until the finish caring for their patients.  I am supposed to tell them to leave (although I am not physically there), but I must admit that I have pride that they care about patient care and education. 

With the current rules, residents are supposed to forego noon conferences if they have worked the previous night.  Some will opine that 16 hour shifts will solve this problem, but they are wrong.  Once we increase shift work, we have even less residents available for conferences.

As we are experiencing these work hour reforms, we are also asked to insure the residents have a structured curriculum.  As I ponder this I feel a bit like Yosarrian. As I discussed these new recommendations with a program director yesterday, I saw great angst.  This program director has great dedication to housestaff education, and now he wonders how we can possibly provide a high quality education to our residents.

If our residents do not get adequate training; if our residents do not see enough sick patients; then their patients will suffer in the future.  We need better trained physicians more than we need well rested residents.  I know that sounds a bit cold, but I purposely chose a difficult residency so that I would become a better physician.

We should hold all residencies to high educational standards.  I emphasize with ob-gyn resident, for she describes an undesirable residency.  But her bad experience is not a reason to change a system that actually works for the public.

I agree that exhaustion is not good for residents, or for patients, and that an increased emphasis on patient safety and the importance of sleep is clearly needed in the medical profession. But I can’t help but wonder if we may also risk losing something by trying, prematurely perhaps, to fit the unpredictability of the illness experience and the individuality of human relationships into a scheduling grid that has little proven efficacy.

Amen

Thanks for all the thoughtful comments.  A couple of themes predominant.

Does family medicine training close doors?

Some argue pro and some con.  When examined objectively, family medicine opens many doors but does close some doors.  Choosing family medicine clearly leads to primary care or a closely related field.  Internal medicine still often leads to subspecialty training.  Many more internists become hospitalists than do family physicians.  I suspect that occurs due to a combination of ones preferences in selecting a specialty and the impact of the training.

Do family medicine programs vary more in rigot?

I have no data on this subject, only personal observation.  I see too many family medicine programs that underemphasize inpatient medicine.  While family medicine physicians practice predominantly in the outpatient setting, I believe that you must have adequate inpatient experience to compliment outpatient training.

Of course as an internist I am biased about the value of inpatient adult medicine education.  I believe my bias is correct, but…

I have seen family medicine programs in which the residents care for too few inpatients.  Family medicine residency has requirements for oupatients, but do they require the same rigor for inpatient training?

Once again, both choices are legitimate and desirable.  You should choose the one which fits your personality and your career goals.

From Wiktionary: tasks that are tedious and monotonous or trivial and menial, usually inherent in the operations of a larger project

Physicians in training complain about scutwork.  They use the term to describe anything that they would rather not do.  Scutwork changes over the years.  Back in the day, we complained of starting IVs, drawing blood and wheeling patients to radiology.  Most hospitals no longer have houseofficers perform these tasks.  We considered those tasks scutwork because one need not go to medical school to perform them.  I think the definition of scut has changed.  I received this comment this morning.

I am an intern. I would say 20-80% of my time day by day is spent doing paperwork and assorted scutwork. Some of it is medically useful (pt notes, informed consent, advanced directive stuff). Notes take up the majority of my time. We are not allowed to dictate inpatient notes (I have been told) at the main hospital, as it would overwhelm the transcription services, and a second training hospital offers no transcription services at all. There is plenty of room to train physicians in less hours without sacrificing medical competency.

Can anyone but a physician write progress notes or write orders?  If those tasks are scutwork, then you will be plagued by scut your entire career.  Notes are an essential part of medical care.  We must document what we plan and why.  Rarely are we the only physician caring for a patient. 

I have worked in university hospitals, VA hospitals and community hospitals.  None of the hospitals provide dictation services for daily notes.  Some provide dictation for admission notes, and almost all provide dictation for discharge notes.

Writing patient notes helps me provide better care.  As I write my note, I review all the available data and organize my thoughts.

Our intern probably spends more time writing notes because as an intern one has less experience.  Thus, notes take longer to write.  These tasks are essential in one’s development as a physician.

Now I do understand the frustration of being a December intern.  It is a difficult year.  But when July comes and you are a 2nd year resident, observe the new interns.  Then we will start to understand how much you learn during that stressful year.

As I said last week, you cannot develop expertise without enough experience - We we should not shortchange medical training

Expertise includes writing notes, talking with consultants, and even walking to radiology to review films with the radiologists.  I would not want an intern caring for me unless that intern had a resident and attending supervising them.  Few interns have enough experience.  Internship is a necessary step in the acquisition of expertise.  Most of the tasks that you label scutwork are tasks you wil perform your entire career.

One of the first hot issues on Medrants (over 6 years ago) was the change in residency work hours.  Recently the IOM has had a committee looking further at this issue.  The report is out with some surprises and some new problems.  Expert Panel Seeks Changes in Training of Medical Residents

The experts’ report, issued by the Institute of Medicine on Tuesday, focused on the grueling training of medical residents, the recent medical school graduates who care for patients under the supervision of a fully licensed physician. The medical residency, which aims to educate doctors by immersing them in a particular specialty and all aspects of patient care, is characterized by heavy workloads, 80-hour workweeks and sleep deprivation.

So the author paints residency as "grueling."  As usual they focus on sleep deprivation.  As usual they do not ask if current training produces well trained physicians.

So of course the panel has solutions to the problem they declare.

But the expert panel said those reforms were not enough. Caps on work hours are often not enforced, and many residents still do not get enough sleep, putting doctors and patients at risk for fatigue-related mistakes. While the new recommendations do not reduce overall working hours for residents, the report says no resident should work longer than a 16-hour shift, which should be followed by a mandatory five-hour nap period.

The committee also called for better supervision of the doctors-in-training; prohibitions against moonlighting, or working extra jobs; mandatory days off each month; and assigning chores like drawing blood to other hospital workers so residents have more time for patient care.

The idea of 16 hour shifts makes some sense, but it will put great strains on education.  The mandatory 4 days off each month (recommended to increase to 5 for unknown reasons) has a serious untended consequence.  When making rounds daily with a team, often I am the only person providing continuity.  When I give "chalk talks" someone is always absent. 

Now I do understand the need for days off.  I do believe in sleep.  However, we must understand that changing these rules often have negative impacts on education.  We have residents who cannot attend noon conference because their "shift" is over.  How does that help the resident? 

I suspect that many residents will balk about the moonlighting rules.  We saddle our students with unreasonable debts, and then we will handicap their ability to make some extra money during residency.  I remember the importance of moonlighting money in buying my first house and a new car.  I see residents moonlight so that they can have some semblance of a decent quality of life.

The 16 hour shift will stretch our ability to provide good education. 

On the positive side, the committee did not back off from the 80 hours.  They recommend more strenuous enforcement, and I agree with that plan.  I do hope that they do not penalize residents and programs when the infractions are totally voluntary and associated with educational desires.

More on this subject as others comment.

Doctors urge: Rescue primary care or work force shortage will mount

The lack of access to primary care doctors leads to worse health outcomes and higher costs, according to an American College of Physicians report released in November and aimed at influencing the shape of impending health system reform. As the population ages and demands on health services increase, Americans will find it more difficult to locate primary care physicians to help coordinate care in a fragmented system.

The 63-page ACP white paper reviews more than 100 studies from the last 20 years and concludes that the proportion of primary care doctors in a community is related to population health outcomes and system costs. The number of U.S. medical graduates entering residences in family medicine and internal medicine has dropped by half in the last decade as physicians pursue less time-squeezed and higher-paying specialties, the ACP report said.

The report comes amid signs from Capitol Hill that politicians are taking the work force shortage seriously.

"The timing of the paper is critical," said Robert Doherty, ACP’s senior vice president of governmental affairs and public policy. "As Congress and the administration start putting together the pieces of the reform puzzle, we want primary care to be an important piece of the puzzle."

As the white paper demonstrates, primary care does matter.

Having more primary care physicians in a community is associated with less use of acute and surgical care, according to a national study of health care utilization. Extrapolating from those data, researchers say a 15% increase in primary care doctors in a given metropolitan area would:

* Cut emergency department visits by 10.9%.
* Cut the number of surgeries by 7.2%.
* Cut inpatient admissions by 5.5%.
* Cut outpatient visits by 5.0%.
 

I have written about the importance of primary care several times.  I hope Congress and the new administration are listening.

Wikio provides rankings of all blogs, and specifically health blogs.  Last month I was ranked #10, but the new rankings are out and I am #9!

I am not sure if my success comes from the voters or the computers (note the dig at the BCS.)

Thanks to the many readers of medrants.  I hope that after 6.5 years I am still providing interesting essays.  I hope I make you think.

The Six Habits of Highly Respectful Physicians

I love this article and highly recommend it.

There is a useful analogy here to raising children. The British physician D. W. Winnicott coined the term “good enough mother” in part to help mothers who were overly anxious about their parenting skills. Rather than worry about trying to be perfect (whatever that meant), he urged them to relax, trust their intuition and realize that their children needed a mother who was caring, alert and reliable — in other words, good enough.

Similarly, when medical schools try to turn out ideal doctors, they can miss the opportunity to help them be good enough: perhaps not perfectly attuned to the patient, but at least respectful and professional. An etiquette-based approach can promote such behavior.

Etiquette-based medicine rests on the fact that patients derive comfort from specific actions — as opposed to attitudes or feelings — that are independent of the doctor’s emotional investment in the patient. My doctor may be tired, preoccupied or not that interested in me as a person; but I should still expect him or her to treat me with the kind of attentiveness and respect I recently received from a “genius” at the local Apple store.

The “genius” was skillful, efficient and professional, and solved my problem quickly without feeling my pain (which had been considerable). I don’t necessarily want or need to have an exceptional healer, but I would like to have good service. Patients should command at least the same regard from their doctors.

Please read his 6 habits.

I was asked to write an op-ed about patient satisfaction for the current issue of Virtual Mentor which focuses on Hospitalists and Patient Care.  In my op-ed I focus on the challenges and opportunities that hospitalists face - Securing Patient Satisfaction

Hospitalists have a great responsibility in health care delivery. They attend patients who are emotionally vulnerable and shepherd them through the mechanical beast that our hospitals can become. Excellent hospitalists can help patients greatly with comforting words and body language, such as explaining each day’s plans and test results—efforts that build the patient-doctor relationship. These relationships can quickly become intense and require much skill.

With its complexity and speed, hospital medicine poses great dangers and great opportunities. Properly trained hospitalists can help patients clinically and emotionally. We must learn to impart and evaluate these skills in order to secure the best hospital care for our patients.