Tuesday, December 29, 2009

Wenis Flytrap


I make sure the residents and students always come with me to talk with the families after surgery. I stress that the families have been there waiting, hoping and praying and are staring at the door waiting for us to come out and tell them that their loved one is ok. Long before you get to say anything, they will see you and immediately jump to conclusions based on your body language and manner of step. It is essential that you make sure your body language matches the results of surgery. If your body language does not match what you tell them, they will read your emotions and think that no matter what you say is untrue. Even though you may be tired and have a hundred things to take care of , when you meet the family, 100% of your body and mind needs to be theirs. Your body languange always tell the truth. When things are bad, you need to honestly let them know to the best of your ability. If there is a problem or there is a complication, be honest and let them know. If you are worried, let them know.

I wish politicians would talk to us like we try to talk to the families of our patients. After the recent bombing attempt of the Detroit bound flight, I saw the Homeland Security Chief come out, and try to pin her wenis to the side of the body to keep them from flapping as she said "the system worked". Clearly in panic mode, her body language showed she was in the wenis flytrap, way over her head, clueless. I'm glad that her boss got of a golf cart to tell the press that there is a systemic breakdown and he will make it a priority as he wmt back a picked up his golf club.

Friday, December 25, 2009

Constitutional Rights Obamified

The 4th Amendment gives us protection from unreasonable search and seizure and is a major part of limiting governments invasion of our privacy. Obama who taught Consitutional Law has just amended Executive Order 12425 that gives Interpol immunity in the US from the 4th amendment. This gives Interpol, an international organization, the ability to invade your home and seize your property without having a warrant or probable cause. I wonder what the next consitutional right he will waive? This is the same guy who thinks healthcare is a right, but protection from unreasonable search and seizure isnt!

http://www.whitehouse.gov/the-press-office/executive-order-amending-executive-order-12425

Freudian Slip!


It always seems that when people are tired or in crisis that their guard is let down and they tend to say what is really on their mind and what they have been trying to suppress and the truth comes out.

I guess this is why Senator Reid first voted NO on the Senate Healthcare Bill before one of his aides pointed out his error. He then claimed it was because he was too tired! Was this a sense of morality that was suddenly blinked out?

Acute Fibro!

For those who dont understand why many of us are cynical about fibromyalgia, here is a great video that pretty much sums it up!

http://www.youtube.com/watch?v=LIFc2mlSm7U

Friday, December 18, 2009

Health reform in one sentance

Medical care providers and facilities must bill and recieve payments from patients only.

There it is. Simple and to the point. Right now there is no competition. If you need a ct scan, do you call around to find the best deal? Of course not. The CT place only gets paid what your insurance company contracted them. They can try to get as many in that insurance to come there but it certainly did not affect the price. If you dont have insurance, you can call around and I think you will be suprised at the discounts you can get. Imagine if that was for everyone. I dont think the problem is that we have so many uninsured, I think the problem is that we have so many insured.

I propose that your insurance company gives you so much for routine health exams. You would then shop around and find out where you can get the best care for that amount. Doctors and hospitals would then advertise and try to entice you with low prices and better care to sway you to use their facilities. The same should be true with Medicaid and Medicare. Sure there are patients who wouldn't make the effort to get insurance but now everything would be cheaper.

I have said it again. Health insurance is like Federal Income Tax. They get the money before you see it and spend it before you know it. Dont seperate healthcare dollars from the patients, give it to them and let them decide how to spend it.

Wednesday, December 16, 2009

Frying Pan or Fire?

It is that time of year again, the time where we have to negotiate not only our contracts with health insurance companies for our reimbursement but also when we have to try to get the best insurance for our employees. In our area, there are only two insurance companies that we can get health insurance for our employees through. Blue Cross and United Health. There are some other complanies and they have better deals but they wont talk to you unless you have over 100 employees. So, we are stuck with the expensive ones. Because we have several employees with serious health problems, their extra cost is spead to the rest of our employees. We cant group ourselves with other medical practices to get a better rate or to take advantage of these other companies by law. We also cant get insurance from outside of the state or our area.

When we tried to form a supergroup, the Feds told us that since we had over 33% of the doctors our geographical area, this meant that we could be considered a monopoly and this was agaist statues.

The long and short of it. I cant get better health care insurance and cheaper insurane for my employees because of existing federal laws. Our health insurance is going up because federal law prohibits competition and better business practices. We have two choices now for health insurance for our folks, the frying pan or the fire? I think Congress should have to go out and get and pay for their own insurance as well as that of their staff in their own state. I think they would rapidly change how they want health insurance reformed.

Saturday, December 12, 2009

A Huff-ington Post

I guess it is a sign of the times when our usual cadre of drug abusers are having a hard time affording their preferred drugs and resorting to huffing paint. I asked one of them who was in the hospital for an exacerbation of another problem when I saw the gold paint on his lips. He told me that moneys tight so people are raising the price of the good stuff and he cant "ford his percs and vikes no mo" and "other shi**s spensive". I saw in his chart that the case managers are filling out all the forms so he can get Medicaid for his now chronic "paint induced pulmonary conditions" so the hospital can get paid. Once he is on Medicaid the state will try to pass the buck of to the feds to get Medicare to cover it, so if all goes well he will soon have disability and be able to use tax dollars for his "vikes and perks and the spensive sh***".

Aint no free hotel

I went to discharge a patient today. She is doing a lot better and the oral meds are doing her just fine. She doesnt want to go home. I asked her why and she said because when she gets home she will have to do a lot of cleaning to get ready for the holidays and that right now her sister is there doing it and will expect her to help. She said if she went home Monday, it would be all done. I checked her chart, sure enough she had Medicare and Medicaid, was only 31 and her disability was "fibromyalgia". (She was admitted for cellulitis). I checked with the nurse who explained that the patient was going outside to smoke which is no easy task given the size of the medical center at least every hour.

When I explained that I was discharging her, she said that it wasnt costing her anything to stay in the hospital so why cant she stay. I wanted to say that it was costing our country but fell back on the "I would hate for you to catch one of those hospital acquired infections" and signed her discharge orders.

Friday, December 11, 2009

Informed Consent

Unknown to me, the medical center apparently had some big inservice that only the clip board toting administrative non-patient caring for nurses had a chance to go to about proper informed consent. This including the use of attorney developed forms and proper statements to document that consent was obtained for a procedure and that all realistic risks, benefits and alternatives were discussed. These forms of course make sure that all outcomes are the responsibility of the physician and in no way should the medical center be held responsible for the patients misinterpetation of what was about to happen.

So here I am in the middle of the night with a patient that comes into the ED from an accident bleeding out. We are rushing into the OR and the adminoRN stops us and says that we have to have informed consent before we can procede! I look at the patient and said, "there's something bad wrong in there, we gotta open you up", he looked at me and said, "Fix me doc!" and scribbled a line of the paper. Consent obtained. As we rolled in to the OR, the patient looked at me and then looked at the consent Nazi and muttered "what a b****"!, cant she see Im dying here!"

Sunday, December 6, 2009

Galliean Peer Review



I love how the press is blowing off all this Climategate stuff by saying that all the research has passed peer review. Somewhere they dont seem to get it that your peers are quite often the ones that share your own views or share in your paycheck. Look at Gallieo. He proved that the world revolved around the sun yet his peer review was to be imprisoned because it went against the opinion of "the peers". We have a journal club were we all take recent papers in our field and have to present them. This is a great exercise for the residents. The first thing you do is look at the question the research is hoping to answer. You then check to see how they are getting the data and if analysis of the data will lead to an answer. You then check the statistics on the data. Only then can you say if the research is of merit. I stress that the comments and discussion are just that, or better expressed an editorial. It is amazing how many of the papers dont support the conclusions. I cant help but feel this way with the whole "Climategate" thing. It seems that this a classic example of having an opinion and then trying to backtrack to make the research support you and your peers opinion. This is why they destroyed the original data and only have the "corrected data". There original data did not show warming, in fact it showed the opposite which was against their "peers" in the global warming religious and grant funding movement. An essential part of research is to openly publish your research so that someone else can reproduce it an come to the same conclusions. When you cant do that you have to suspect that there is major bias in the research. Then it appears they contacted their "peers" to make sure that they too purged their data and anything that would bring to light the faults of their study. In Gallileo's time you had to publish what the church agreed to. I wonder is Gore the pope of Global warming. Oops, forgot, its snowing in Houston better call it "climae change".


Saturday, December 5, 2009

Grey Lady Down

The old Gray Lady closed it doors. It was the big charitiy hospital downtown that took care of many of the indigent and government payors. It just couldn't support itself. Its overhead kept increasing and it lost more and more of its private pay patients. I know that many would argue that this is a sign of the times but I am afraid that it is more than that. Hospitals lose money on the self insured, lose a bit less on the Medicaid and lose a bit on Medicare. They make the money to offset these losses with the private insurance. To give you an idea, if we use the Medicare reimbursement as the basis, you lose about 5% if you just have every patient in the hospital having Medicare. Medicaid pays 60% of Medicare, so you lose about 45% of cost with Medicaid. Self pay, you are lucky to collect 5%. Now these are not charges, this is the actual cost of doing business. Depending on how well you negotiated your contracts, BlueCross might pay about 115% of Medicare. So, to make it you need as many private pay patients as possible to offset the losses.

Now here is the kicker. The present debate in Congress is to have a public option that is basically an expansion of Medicaid, which again pays at a rate that causes the hospital to lose 45%. The pateints who would get this public option are those that would have otherwise had a private insurace. So, the long and short of it is the hospitals are going to fall just like the Old Gray Lady. Our other hospitals are at 90 to 100% occupancy. They have to be just to meet expenses.

The Gray Lady took care of those who were in most need, too bad no one bothered to take care of her.

Wednesday, November 25, 2009

Double the work, to increase efficiency?

Right in time for the huge increase in "I met my deductable and want my surgery now season", the medical center decided to implement a new computer charting system in the ORs to increase efficiency and decrease costs. So far it has caused every case to run late and a has caused the hospital to double the circulating nurse staffing. The system is supposed to help the OR be more efficient by not only charting but by tracking all the supplies, meds, implants etc. The only ones who can enter data in the system are the circulating nurses. So here is the problem. The circulating nurse is the one who is there to make sure the patient is safe and the surgery runs smoothly. So, now the circulating nurse has to sit infront of the computer, away from the patient and enter page after page of data. We still need a circulating nurse to do what the circulating nurse is suppose to do, so guess what? We now have to have two in each room. One to actually take care of the patient and one to take care of the computer. Thats increasing efficiency and decreasing costs!

Monday, November 23, 2009

Naval stalagtites


I know that the old story is that you should always wear clean underwear in case you get in to an accident, but we just cut those things off with big bandage scissors and toss them on the floor when you come in with a multitrauma. The real problem is when you have a patient that you have to take to the OR to do a trauma lap. You spread paint on the abdomen and right next to where you are going to make your incision is this mass of unidentified fibers, sweat and sebum full of bacteria and often the occaisional piece of gum or french fry. You grap it with sponge stick and pull and it wont come out. The patient is crashing and you just pour betadine on it and cut around it hoping that it doesnt fall out into the belly. I dont care what kind, how clean or even if you are wearing underwear, please just keep that crud out of the belly button!

Oh, wait a minute. I have got an idea. I just have to come up with a special, single use disposable naval smegma extractor. Then I write a paper in which I show a Press-Gainey study that it potentially could cause improved survival and get JACHO to mandate a three page chart document that shows who and how the goo was removed, its color, clarity, palate and aesthetic qualities making sure that it in no way is discrimatory and make a fortune. We will have to charge a lot for the extractor to cover the lawsuits where people claim loss of consortium for all the pain that they have had post lint extraction and those that claimed that we participated in a class action against all those who have navels. I wonder what portion of the population are outies vs inees?

Oh, while we are at it, could you also trim those toenails?

Sunday, November 22, 2009

BS Check!

The State of Tennessee has instituted several tort reforms in the area of medmal. The two big ones are that plaintiff attorneys must file a pre-suit notice and the have a certificate of good faith from a physician that attestst that there was a possible deviation of the standard of care (BS check!). Tennessee saw a huge rush of suits filed before the law went into effect. Since the law has been effect however, medmal suit filings have dropped 65%. John Day at Dayontorts (http://www.dayontorts.com/medical-negligence-new-medical-malpractice-case-filing-statistics.html) has a great piece on it. In my little group of docs, most of carry malpractice insurance because we want patients who are harmed because we screw up to be taken care of. What we dont want is to be dragged into court because we are seen as a cash cow for some plaintiff and their attorney who figure that all they have to do is be a big enough pain in the neck to get some money. I think it will be interesting to see what the effects are of these reforms. Will the number of judgements against physicians be the same? What will be the total defense costs? I hope that injured patients get what they deserve and frivoulous filing attorneys get what they deserve.

Friday, November 20, 2009

The Government Insured

This was a letter to the editor on August 29, 2009 in a Jackson , MS newspaper.


Dear Sirs:"During my last night's shift in the ER, I had the pleasure of evaluating a patient with a shiny new gold tooth, multiple elaborate tattoos, a very expensive brand of tennis shoes and a new cellular telephone equipped with her favorite R&B tune for a ringtone. Glancing over the chart, one could not help noticing her payer status: Medicaid. She smokes more than one costly pack of cigarettes every day and,somehow, still has money to buy beer. And our Congress expects me to pay for this woman's health care? Our nation's health care crisis is not a shortage of quality hospitals,doctors or nurses. It is a crisis of culture -- a culture in which itis perfectly acceptable to spend money on vices while refusing to takecare of one's self or, heaven forbid, purchase health insurance. A culture that thinks "I can do whatever I want to because someone else will always take care of me."Life is really not that hard. Most of us reap what we sow. Don't you agree?

Physician Name Deleted at my discretion, MD Jackson , MS

Halstead is Dead!

I was called to see a patient urgently. Of course I got there and started to take care of the emergency and once things had calmed down, I went to the chart which of course meant logging on and slowly making my way through all the HIPPA screens and then the whole thing crashed. About this time the resident of the service of whom the patient was on came in and I started asking him what her labs were and her past history. I got a shrug and he said that he would get the intern as he might know. It was all I could do to no take his head off right there. (It is the kinder more gentle era of medical education where incompetence is met with, please do better next time and I hope that your feeling were not offended!) This is the new"team" way of teaching medicine. You only have to work a certain number of hours and no one is really the boss or responsible, the patient is "the teams" not a specific doc.

I know I am dating myself but we trained under the halstead principles. We were expected to know everything about our patients and be able to recite their labs, history etc from memory. We drew their blood, we pushed them to the OR and got to know their families like they were ours. For all intents and purposes, we lived at the hospital. Everything about our pateints was our responsibility. If we failed in that responsibility, punishment was harsh and instant. We weeded out surgical residents with only a few surviving to the top of the pyramid.

Now we have a scary trend of shift workers and a mentality of not being totally invested in patients that is slowly creeping into medicine. The Halsteadian code of ethics and responsibility is being eroded by "its not my responsibility or someone else will do it". We cant reprimand or even fire bad residents because they can claim to be ethnically, sexually, intellectually discriminated against. When I am sick, I want an old school doc, not one of these time card pushing, Union docs.

Saturday, November 14, 2009

Homicidal Family Members

We review all the codes that occur in the medical center to see what happened and do determine how best to improve our responses and to prevent the events that lead to the code. One code this week involved an elderly patient who had a stroke and and as result had severe dysphagia. They had a feeding tube in place and were strickly NPO. The patient suddenly had a respiratory arrest and when the code team went to intubate they had to remove a large portion of fried chicken from the glottis. The family though that since the patient loved fried chicken, that a little bit wouldn't hurt. The second case was in one of the units. The sedation was decreased to allow the patient to start to wake up to begin a weaning trial after bypass and valve surgery. While the patient's family was visiting the nurse went to do her charting outside of the room. Appartently, the family saw the patient was starting to move his arm and decided to undo the restraints. No sooner had they started to release them than the patient reached up and pulled out the ET tube in one swift motion with the cuff up. Luckily the team was able to get the patient re-intubated before laryngeal swelling made it more difficult. The famlily immediately blamed the nurse and the hospital for "poor care" and "letting this happen" and denied that they did anything. We were fortunate that we have each ICU room on CCTV and the whole event was caught on tape. Of course I am sure that the tape is a HIPPA violation but we were able to show the family that it was their fault.

Wednesday, November 11, 2009

Thank you for your service!

You have got to love how our government shows its support for our troops. The health insurance for our soldiers and their families is called Tricare. Tricare pays on average the same amount as Medicaid, which is 60% of Medicare and comes with a lot more governmental headaches. It pays so low that our military families often have to travel out of state to find a hospital or doctor that will accept it. Tricare mandates precertified and approved appointments for all specialist care and outpatient visits. Federal Employees and Congress on the otherhand, have BCBS which pays top dollar, do not need referrals and can go wherever they want.

Welcome to the world of government dictated single payor healthcare, and the first people to get the shaft are the ones who actually are the ones fighting for out country.

Friday, November 6, 2009

Angels fly home

We lost an angel today. We watched her grow and fight infection after infection, endure numerous days in the ICUs and pic lines after hickmans. Everyone in the hospital was her friend, she was our family. The nurses were her teachers, mothers and sisters. Each infection and episode of pancreatitis brought her pain which she endured with a smile. She would joke that she like sherbet ice cream even when she could only have it through her g-tube. Her cystic fibrosis made the hospital her home and her life. She was hoping to get a lung transplant but the flu was too strong. We miss you Lindy and know that you are not in pain.

Local and Vocal

We are in a medical crisis. On top of if all there is a severe shortage of propofol. There are two companies that make it. One had a contamination problem with metal shavings and I am not sure about the other but it has been recalled. The side effect is that is is scarce. So instead of a little bump of propofol for the needle sticks and the infusion of the lidocaine, you get some versed, fentynl and a bit of "just a little poke", "stay still"! I dont know about you but I will wait until propofol is back before any colonoscopy!

Thursday, November 5, 2009

Signing out AMA

I hear that the American Medical Association claims that it represents Americas doctors but I sure cant find any in our town who believe it. From what I can tell, they may have about 13% of the physicians. Anyway, I cant figure out for the life of me why the AMA would even support Pelosi's healthcare bill. I know that many of us are scared of the SGR thing and it would decrease Medicare payments by over 20%, but man selling your soul?

The same goes for AARP. Did they even read the thing? Anyway, at least the docs I know are signing out of the AMA.

Saturday, October 31, 2009

Emergency only if it is Before 5 pm

Here in the US, one of the big things that we get cited for is too many scans. In our ER one of the major reasons we do CTs is to check for pulmonary embolism which essentially is a clot in your lungs that can kill you. This is a NHS protocol from Kings Hospital in the UK.

http://www.drasticmediaproductions.com/kings/downloads/Low%20risk%20PE%20proforma.pdf

There, if you come in with the symptoms of this life threatening condition, they will do the scan as long as it is before 5pm. That is of course after you have survived 2 hours. They also might just discharge you early to save money and just have you follow up in a few days and put you on a medication that can cause you to bleed to death in the meantime.

Friday, October 30, 2009

$7.18

Just out of curiosity, I divided my yearly malpractice premium by my yearly patient encounters. In other words, every time I see a patient, it costs me $7.18 just to cover the malpractice insurance.

Thursday, October 29, 2009

Scooter Sign

(In 2008, Medicare paid over 686 million dollars for powerchairs, it is approaching 1.3 billion this year). I was wathcing TV and on came the commercial for the Scooter Store. They basically said that if you had Medicare, they would do all the paperwork to get you a power chair at no cost to you. Of, course I know that they would only do something like that if there was money to be made and sure enough, I found that Medicare would pay $11,000 for a chair that the Scooter Store could get for $6000. Then came the commercial for diabetes testing equipment. Sure enough, if you have Medicare, they will do all the work and you dont have to pay a cent. Well it appears that durable medical goods are the fastest growing Medicare expense. Things like power chairs, hospital beds, home oxygen equipment. Its not physicains fees. In fact, inflation adjusted, physicians make less now than they did in 1984.

It cant wait until I'm old enough for Medicare so I can get me a free power chair, this walking around the hospital on rounds wears me out.

Wednesday, October 28, 2009

Obama's Katrina

The CDC reported today that Children and adults under age 25 have accounted for 53% of hospitalizations for laboratory-confirmed H1N1 and 23.6% of related deaths since Sept. 1. Flu vaccine, its production an distribution are all under strick control of the Federal government. The private market for flu vaccine vanished with lawsuits and regulation years ago. So, we now have shortages of both H1N1 and regular seasonal flu vaccine. I can help but believe if there was not the Federal involvement and trial attorneys sueing like crazy, the pharmaceutical business would have been all over the mass production of the flu vaccines. We most likely would have had so much that we were exporting it and even hiring people to help make it. Instead, the ICUs are filled with the young and dying. Got to love the Federal Government and their single payor system for flu vaccine.

Saturday, October 24, 2009

Sebelius Epidemic


(Deaths due to the appointment of a trial lawyer as Health and Human Services Secretary) I saw today that the president has decided that we are in a H1N1 emergency. Part of this emergency is that there is a huge shortage of the vaccine as well as the regular vaccine for the plain flu. The vaccine is produced under contract for the Federal Government. Most of the vaccine companies are no longer in business or able to produce vaccine because they have been sued or fear lawsuits. So here is the question, if you or a loved one wants the H1N1 vaccine but can not get it because of the governments inaction and the trial lawyers targeting of the vaccine companies and contract the flu, can you sue the government and the trial lawyers for your pain and suffering? How about wrongful death? We had plenty of companies making vaccine before all the lawsuits. We had huge delays because the Obama administration dragged their heels appointing and directing the HHS department. We have over a thousand deaths for the H1N1 already this fall. Oh, wait a minute, I understand. Obama put a trial lawyer in charge, in fact a former head of the trial lawyers, in charge of our public health!

Friday, October 23, 2009

Heathcare a RIGHT to refuse?

I was listening to someone who was arguing that healthcare was a right. I wondered if healthcare is a right, cant you refuse it. I mean, I have the right to an attorney if I am in criminal court but I can refuse one. I have the right to bear arms but I dont have to go out and buy a gun. I have the right to vote, but dont have to face fines if I dont. I cant think of other rights that are government mandates where I can be fined for not exercising them.

As far as I can tell, rights mean that you have the ability to do something if you choose, and the ability to not do them if you choose. Many of the rights that I have require me to make an effort or spend some money to exercise them, where I dont have to spend money or time to not exercise them.

Why sould heathcare be any different. Right now if I am sick, I can go to any ER and be seen an treated. If I want more than that I can pay more or get insurance. I cant be denied. I have the right to "healthcare". If I dont want to go, I dont have to.

Saturday, October 17, 2009

Newtons First Law of Medicine

I got into a discussion of healthcare policy today while watching football in the OR lounge waiting for the OR to get ready. The discussion was with one of the anesthesia folks who is a bit on the liberal side. Anyway, the discussion came to how much we could save with preventitive care. He thought that with national health insurance, everyone would be able to get the preventitive care and the savings would be huge. I thought it was ironic that we were waiting for the OR to be ready so we could operate on a patient who had Medicaid but did not want to go to the doctor for years and then comes into the ER at deaths door. From my experience, people only want to come to the doctor when they are sick or in pain, otherwise they will blow it off. Likewise, the people who are not motivated to get a job or education will tend to just collect wellfare and will not be the ones who get up and get their screening exams. Oh, for what its worth. If you have you Medicaid appointments before 11:00 am, almost none will show up.

Friday, October 16, 2009

Governmentium

I dont know where this came from, but I salute the author!


New Element Discovered
A major research institution (MRI) has recently announced the discovery of the heaviest chemical element yet known to science. The new element has been tentatively named Governmentium. Governmentium has 1 neutron, 12 assistant neutrons, 75 deputy neutrons, and 224 assistant deputy neutrons, giving it an atomic mass of 312. These 312 particles are held together by forces called morons, which are surrounded by vast quantities of lepton-like particles called peons. Since governmentium has no electrons, it is inert. However, it can be detected as it impedes every reaction with which it comes into contact. A minute amount of governmentium causes one reaction to take over four days to complete when it would normally take less than a second. Governmentium has a normal half-life of three years; it does not decay, but instead undergoes a reorganization in which a portion of the assistant neutrons and deputy neutrons exchange places. In fact, governmentium's mass will actually increase over time, since each reorganization will cause some morons to become neutrons, forming isodopes. This characteristic of moron-promotion leads some scientists to speculate that governmentium is formed whenever morons reach a certain quantity in concentration. This hypothetical quantity is referred to as Critical Morass.

Tuesday, October 13, 2009

"But, I'm not dead yet!"

I just saw today on World net Daily that one of Obama's Czars, Cass Sunstein, has written that the state controls your organs and should be able to remove them if you are dead or in a hopeless condition. Futher, he wrote that the state can remove your organs without your permission. When I heard this, I thought that someone was pulling my chain, but guess what, it is right there in his book "Nudge: Decisions about Health, Wealth and Happiness".

Where did the president find these guys and how in the world did they get to be in positions to affect policy? My father always told me that you are judged by the friends you keep.

Monday, October 12, 2009

Taking it below the dentate line

In order to help balance the budget, the lawmakers of the State of Pennsylvania have decided to raid the fund MCARE. This is a fund (100 million dollars) that Pennsylvania physicians were forced to pay in addition to their malpractice payments to cover catastrophic losses. In fact the MCARE (Medical Care Availibility and reduction of Error Fund) was just the renamed Medical Professional Liability Catastrophic Fund. Anyway, the State Legislature just decided to take it and use it for other things. I wonder why they dont make the lawyers pay into a fund and then steal it in the middle of the night?

Saturday, October 10, 2009

Ginormous Headache


The medical center gets all kinds of complaints and in almost every one the person filling the complaint threatens a lawsuit. The latest was from a patient's attorney that claimed she was discriminated against because of her disabilities and requested a cash settlement to prevent a "large lawsuit from moving forward". When I looked into the case, I found that first she was disabled. She had severe arthritis, backpain, diabetes, could not walk, in fact she could not even care for herself. She was on Medicare, Medicaid and had Social Security Disability. Secondly, I found out she was 780 pounds. I looked into the case further and found two notes from the nurse manager of the floor. The patient had filled a complaint two hours after she was admitted because she was not allowed to smoke. Since she was admitted for a respiratory condition amoung other things, the attending physician said no. She then demanded that she be allowed to smoke anyway in the room. When she was told that she could not smoke in the hospital (which is the law) she demanded to be taken outside to smoke. (It took 9 ems personell to transport her to the hospital, 7 to get her onto the "Big Boy Hospital Bed".) When her nurse said that they could not roll her bed outside for her to smoke she then demanded to be put in a wheelchair. (The max load of the Big Boy wheel chairs is 600). When the nurse said that they didn't have a wheen chair big enough, the patient went off further.


So, the long and short of it, this was an attempt to "extort by attorney" money from the medical center by a patient who is disabled because of obesity who claims she was discriminated against because other patients were allowed to go out and smoke!

Sunday, October 4, 2009

Magical Medicaid

I know that many liberals think that the answer to healthcare accesss is government plans. I actually had one in the office on Friday. He was mad that it took so long to get an appointment. As usual I claimed responsibility for the delay, said I was sorry and took care of him. He muttered that he had insurance (Medicaid) so he should have had to wait. This is what I really wanted to tell him.

All of us physicians have templates. These are the schedules that allow us to schedule patients. Right now, if a patient has Blue Cross we get paid three to four times as much as someone who has Medicaid. In fact, a patient who pays $40 out of pocket is paying us twice as much as someone who has Medicaid. If we want to maximise our payments we would see only Blue Cross, if we could not fill our schedule we would see lower reimbursed insured, we would then add self pay, and then if there are any openings left, we would see Medicaid. So, every physician has to decide if they are going to see any Medicaid at all. Since it pays worst of any other insurance if you do take it you put them to the back of the list. I hate to say it but Medicare is just infront of Medicaid. So, if you are going to take government insurance, those patients will be at the back of your waiting list. Our group has decided that it wants to help everyone as best as we can regardless, that being said, we still have to stay in business so we have placed in stone some Medicaid appointments in everyones schedule. I have to admit though, you will wait alot less if you have good insurance.

So, what is going to happen with this government option? It is going to put even more people at the bottom of the list. Face it, if you pay cash, you will get in sooner. This whole thing about preventive care? Medicaid pays $19 dollars for a 30 minute preventative care visit. Blue Cross pays five times that amount. If you are already full, why would you take less money and incur more liability to do preventative visits that aren't worth the money? Of course, there is no medical liability in the healthcare bill either!

Thursday, October 1, 2009

Giving them the middle finger of the Upper Hand

The State of Michigan has been running ads trying to get some foolish business to move into the state. The ad campaign has as it slogan, 'Michigan gives you the upper hand". Michigan is in dire straits with its huge entitlements and policy of increasing everything from the sales tax, gas tax and of course the state income tax. In reality it appears that Michigan is just giving its citizens the middle finger of the upper hand. Well, they have now decided to stick it to the physicians that have not left the state by imposing a 4% tax on all physican payments and other medical fees. By doing this they hope to decrease their multibillion dollar deficit. Since Michigan already has made sure that it has the lowest Medicaid payment rates and chased as many businesses out of the state as possible, it seems that the medical business will be the next to leave the state. On the bright side, Michigans Democratic Majority are trying to overturn what little tort reforms they had on top of all this.

Friday, September 25, 2009

Closing the Door for Taxpaying Citizens


I was up in the trauma ICU making rounds when we got the word that we were on divert for trauma due to lack of beds. Since we are the only level 1 trauma center for a huge area this is a big deal. I looked glanced at Fern the ward clerk and before I could even ask she said 18 between here and the SICU. This was the number of illegals or "undocumented" as the Feds say filling the ICUs. She then added there are 33 altogether on the trauma service. (There were three with the same name and same drivers liscence number but that is a different story.)
I would love to bring together the ACLU and our Congressmen and make them be the ones to explain to the greiving husband why his wife, mother of their three kids, school teacher and taxpaying citizen had to be sent 3 hours away while she bled to death because the Trauma Center that is payed for by her tax dollars that could have saved her life was too busy taking care of illegal immigrants. I wonder if he would feel consoled by the fact that the illeagal immigrant, drug dealing, gang banging MS13 member who took the last bed in the ICU was going to be fine as were most of the other illegals that filled the trauma service.

Thursday, September 24, 2009

Send in the JV

(Junior Varsity) Despite my best efforts, I am still on the medical center's quality review committee. At our latest meeting we discussed the problem of transfers that are coming from outlying hospitals that turn out to have a totally different diagnosis than what the transferring ED said they have. An example of this is when the outside ED calls and says they have a patient with a bad pneumonia and when they get to us we find that they are actually in cardiogenic shock from a massive MI, not pneumonia and the TPA window is passed. Our physicians are irate with these transfers but because of EMTALA they cant refuse them so they are stuck with the misdiagnoses and mismanaged train wrecks. So anyway, we looked into the issue. What we found was that these EDs have independent practicing ARNPs not docs. This was not the first time this issue has come up in the quality meeting, so the medical centers attorney was there to explain again how under EMTALA we just had to accept the patients and suck it up no matter what. Fuming at the the bad care that these patients were getting at the outside EDs I blurted out, "if we mismanaged and misdiagnosed patients like that we would get our a++ sued off!". To this the medial center's attorney explained that the ARNPs are held to a different standard. A lesser standard. I had to ask for clarification " so, if you come in to the ED and are seen by an ARNP there is a different standard than if you are seen by a MD or DO? Why isn't there just a standard for what problem that you came in to the ED with?" I didn't get an answer. I guess what I learned is that if you go to the ED with shortness of breath a DOC is held accountable for making the right diagnosis and performing the correct treatment, where a ARNP is not.

Monday, September 21, 2009

Want Ad

It seems that our rural hospitals are having a hard time finding general surgeons. I wonder why.

Wanted General Surgeon to cover small rural hospital.

Must have high school diploma, completed bachelors degree and four years of medical school followed by five to seven years of additional training. Must be able to work 50 to 80 hours a week and be on call all evenings and weekends. Must employee at least 6 others and provide malpractice insurance costing $200,ooo/yr. As a small business must also pay all self employment taxes and all retirement costs. Must be further able to support plaintiff attorneys and serve as a target for several frivoulous lawsuits/year. Must take all patients referred by the ER regardless of their ability to pay and be subject to government regulated pay, audits and fines. Pay is irrevelent to experience and consists of what is left over from all above.

Saturday, September 19, 2009

Medicolegalspeak Reports

Oh, I miss the days when you got a radiology report that said, "fracture right 3rd rib, no pneumothorax". Because of frivolous lawsuits radiologists have learned to be vague, noncommital and to pass the buck of possible litigation. So now you get a 2 page report that says "linear lucency in right 3rd rib, clinical correlation recommended, underinflated lung fields can not exclude underlying intersititial disease and or masses. CT recommended for futher evaluation, if condition warrants." along with several other paragraphs of lawyer imposed legalmedspeak. The radiologists are not the only ones who are protecting themselves from possible lawsuits. Pathology is right there. Once a lymph node biopsy they used to say "node consistent with reactive process". Now they give the ratios of the B and T cells and dont even bother to tell you what they think it is, you have to decide and therefore assume all the responsibility. Aint it great. We think we are the surgeons but the radiologists and pathologists have learned to amputate themselves from the disease of "joint and severable lawsuits".

Friday, September 18, 2009

O'bait and O'switch

I just saw that the President may be not have lied when he said that he would not give free healthcare to illegeal immigrants. It seems that he is planning to just legalize them all so not only can they get free healthcare but they will be able to get social security, wellfare, disability and every other entitlement that he can offer.

http://washingtontimes.com/news/2009/sep/18/obama-ties-immigration-to-health-care-battle/?feat=home_cube_position1

Water Glass Sign


(Some delusional patients are very prone to suggestions. The best are those in DTs. You can hand them a glass of water and ask them what color the liquid is and they will answer every color you can imagine even though they can see that it is just a glass of water.)

I had to go to the board of trustees meeting for the medical center. The trustees are an interesting group, some are local businessmen, several are in politics and one is very wealthy thanks to his inheritance. He is a proud fixture of the local democratic party and a major donor for them. I usually like to sit next to him just to see if anything is sinking in.

Anyway, the meeting's purpose was to explain why the medical center was shutting down most of its community outreach programs such as the diabetic teaching centers and local physical therapy centers as well as decreasing its overall staff. It also explained why it was shutting down two of the outside local satellite hospitals. Of course this created an uproar and the trustees wanted to know why.

Out came the numbers. Although the overall number or patients for all areas of the medical center was increasing (inpatient, outpatient and ancillaries such as diagnostic) the ratio of government insurance to private insurance was increasing. Simply put, the hospital was seeing more people with government insurance than private insurance and was therefore going broke. In fact, the center was losing money hand over fist. Even though it is seeing more patients, since they had Medicare or Medicaid it cost more to take care of them than they got from the government.

As this information was being digested by the trustees, I looked around to see the 3 Democratic politicians in the room. They were squirming a bit in their chairs. Before I could even look at Mr. Trust Fund, he spoke out and said it will "all be better with Obama's health care plan once we have a "public option". He said this after we had just seen graph after graft showing that the more goverment insurance we got, the worse we were! I wanted so hard to ask him what color the water was in his glass!!

Wednesday, September 16, 2009

Flu do, Flu dont

You have to love the government how they come through in a crisis. In our area the H1N1 is rampant. Infact, our ICUs are full of young people with flu associated pneumonia. So, in the interest of public health the government came out with several policies. First, to cut down on the spread, they announced that if you have flu symptoms to stay home, they also came out and said that if you have the flu to not go to the Health Department Clinics as the flu is self limited and this will decrease the chance of people there with other problems will get the flu. They also suggested that you avoid the hospital ers and doctors offices. So, guess what happened? If kids miss school, they have to have a doctors note. Since the flu lasts several days, the feds require FMLA paperwork from the doctors office for adults. Both of these require that the patient be seen either at the health department of a doctors office or hospital. So, they tell you not to go to the health department or doctor but demand that you do so for the paperwork. It is insane.

Saturday, September 12, 2009

I-Phone uninsured


I get a bit of time to write between cases while on call. It is often in these wee hours that I have time to ask the really hard questions that come from careful observation. Tonights is this. I have taken three patients to the OR tonight for urgent conditions. Each is uninsured, yet all three had the latest Iphones. Infact, one was looking up his condition on Google with one in pre-op. I dont have an Iphone because I thought it was too expensive and then you still had over $150 dollars/month for the sevice plan. I wonder what kind of catastophic health insurance you can get for $150/month? Anyway, it just seems obvious that no matter how cheap you make health insurance there will always be other things that people would rather spend their money on and still wont pay for it no matter how much it costs. Who knows, maybe the next big bill in Congress will allow for a government Iphone option.

Mama Bama's

(After Michelle Obama's policy where the University of Chicago hospitals dumped patients from the ED to nonexistent "community medical clinics" while she served as Executive VP and called it a "Community Outreach Program") I really hate patient dumping and this week on call is no exception. It seems that our ED becomes the one that outreach is to. As the hospitals are going broke, the dumping seems to be increasing and the hospitals are now very good at finding ways around COBRA and EMTALA just like Michelle Obama did. The result is that the patients have to go somewhere. One of the misconceptions is that these dumps are patients are the ones without insurance. Actually, they usually have insurance. It is almost always Medicaid. The hospital administrators know that the more Medicaid they get, the less likely they will be financially solvent so they have to find somewhere else for it to go and to make sure that it doesnt get into the hospital. I think it is rather funny that the President who clains that insurance companies shouldn't cherry pick their patients is married to someone who did just that. Seems she understood that hospitals cant survive on government insurance. Anyway, the game is to get the patients just enough better that they dont have to be admitted to comply with EMTALA and then tell them if they have any more problems to go to the "hospital" or "clinic" down the street!

Saturday, September 5, 2009

Draw the Rainbow


(When you dont know what is wrong with the patient, you draw every color blood tube you can find and send it to the lab for pan testing) I was supprised when on another blog a surgeon stated that he never had any problems with Medicare approving anything. I guess he either does not follow his patients in the hospital of that he has a very restricted practice because we run into it all the time. The usual situation is a patient who has sustained either a severe trauma or horrible infection that requires long term hospitalization. You get them through the acute phase but then there is the long recovery. Medicare will not cover the hospitalization after a certain peroid so then you try to get them to a "longer term rehab bed" but Medicare limits this. The patients only get so many days. So, you end up with the constant dilema. The patient is not well enough to be discharged but according to Medicare is not sick enough to be in the hospital. Before we could come up with some fuzzy diagnosis like "failure to thrive" or some such but that doesn't fly anymore. If you discharge them to a nursing home (Medicare wont pay for that either) and they come back to the hospital, Medicare counts that against you. So, what do you do? You have to come up with a diagnosis that Medicare will accept to keep the patient in the hospital that you can support with a lab or test. We use to just draw a UA or get a chest xray because we could always find an asymptomatic urinary tract infection in an elderly female patient or at least a questionable density on the chest xray to support a questionable pneumonia. But since these are now not reimbursed diagnosis by Medicare as "hospital acquired infections" they do not count. You see our goal is to keep the patients in the hospital until they are well without the patient and the hospital going broke. So, now we draw the rainbow and hope to come up with a documentable diagnosis to keep the patient in the hospital. If you draw enough blood for testing, the patient becomes anemic. Severe anemia is a Medicare approved reason for hospitalization!

Friday, September 4, 2009

Fem-pop, chop chop

I saw that in a speech in N.H. last month our President stated that physicians would rather cut off a leg than treat diabetes. He went on to say that we get paid between 30 and 50 thousand dollars for the ampututation!

Here is the problem with the whole we can save with "preventative care" debate. First, all of us are eventually going to get sick and need care. Secondly, how many of us are actually accountable enough to go and get our preventive care stuff done? United Healthcare has already figured this out. When they sell health insurance, they are sure to tell people that their preventative health checkups are covered. It is a great selling point becuase only 17% of patients that have this coverage actually go and get a single check up! People go to the doctor when they are sick, they dont like to go when they aren't. So, are we going to force them? If so how? (By the way, is not going to your preventive care checkups a pre-existing problem?)

While all this is being figured out, what should I do with the hypertensive, chain smoking, sedentary diabetic who comes in with a dead foot? One thing for sure, I wont be getting between 30 and 50 thousand dollars!

Thursday, September 3, 2009

Blue Falcon


(POTUS' unofficial Secret Service and military Call sign) Rumor has it, he accidentally overheard it ant though it meant the old cartoon superhero and his dog! (So much for a President who has never served in the Military)
I think this whole health care debate would be more entertaining to watch if it wasn't so scary. I guess the scariest thing is the rush to get something done just to take credit for something regardless of the outcome. On top of it, to then blame others for why it is not happening.
We then have ACORN and others calling us who oppose the present healthcare bills "disruptors and organized mobs"
I guesss we should call ACORN, and the other minions the Blue Falcon's Army.

Saturday, August 29, 2009

Government Mandated Phones


Sitting down in the lounge between cases, I went to dictate my op note and grabbed the phone. It was bright red and next to it on the wall was a sign that informed me that this was a phone that would still be usuable in the event of a fire or electrical failure. The sign was one of those government signs that showed that this complied with the various federal laws that require such phone. It also said that in accordance with the Federal Law, the list of phone numbers of all the Red phones in the hospital is maintained on the hospitals intranet computer system where Federal Law mandates all emergency plans be located. I tried not to look, but had to. Yep, the computer was not red. I guess if there is an electrical failure, you first have to get the power back on to use the computers! Better yet, you could just fix the phones! Dont you just love how the government works!

Friday, August 28, 2009

Kennedy/Kopechne Health Care Bill

I saw that several attempts to insert an ammendment in to Obama's healthcare bill to require members of Congress to participate in a "public option" were killed in committee. Now some of the people sponsoring the bill want to rename the bill, the Kennedy Bill. Given Senator Kennedy's approach to healthcare I think it is appropriate, but should be called the Kennedy/Kopechne Health Care Bill. This way if you are a member of the elite such as a Senator and get an incurable tumor, you can fly by private air ambulalance to a medical center in another state for an expensive surgery and chemotherapy to prolong your life. If you are an average tax paying citizen, you just get driven off a bridge, left to drown and your family notified the next day by some random civil servant.

Thursday, August 27, 2009

Emanuel's principles of triage

This was just forwarded to me. More of the wisdom from Obama's man in charge of healthcare reform.

Complete Lives System - by Dr. Ezekial J. Emanuel et al.
Dr. Ezekial Emanuel, brother of Rahm Emanuel - chief of staff to the President, writes in the Lancet that: "The death of a 20-year-old young woman is intuitively worse than that of a 2-month-old girl, even though the baby has had less life. The 20-year-old has a much more developed personality than the infant, and has drawn upon the investment of others to begin as-yet-unfulfilled projects." Lancet, Volume 373, Issue 9661, Pages 423 - 431, 31 January 20, 2009.

Source:
Principles for allocation of scarce medical interventions
The Lancet, Volume 373, Issue 9661, Pages 423 - 431, 31 January 2009
Authors: Govind Persad BS, Alan Wertheimer PhD, and Ezekiel J Emanuel MD

Tuesday, August 25, 2009

Always take the history!


I stress to my students and residents that the key to diagnosis and treatment is taking the patient's history. I then have then research what is known about the disease state and tell me what treatment options have been tried and what seems to work. I am glad that none of them are politicians as our elected officials seem to want to ignore the history. I started looking at Massachusetts attempt at mandidate insurance and found that the costs are skyrocketing, access is lower and overall it is collapsing. Even better, I found Tenncare. This was the implementation of Hillary Clintons health plan in Tennessee. It was a massive government public option that was designed to be a to compete with private insurance in the state. So what happened? First, the cost tripled and the state went bankrupted. Second, it reimbursed so low that hospitals closed and refused to see patients with the government option. It got so bad, that the state did not pay some hospitals for over 3 years. Since the Tenncare paid less than what it cost to provide care and the cost was to be made up by the privare insurance companies, they left the state. Lastly, because it was given for free, people from other states flocked to Tennessee to get free drugs and care. So in a nut shell, Tenncare bankrupted the state, decreased access and care to patients and disrupted the whole healthcare system. Now, Obama and his team want to institute Tenncare to the whole nation. What did Tennessee do? It went back to a Medicaid form of governmental medical assistance and encouraged private medical insurance providers to come into the state. It made sure that it kept taxes low to bring in industry and business and enacted tort reforms.


Tuesday, August 18, 2009

Mind the Queue


I had the chance to watch some British television last week and came accross some interesting things. First, the minister in charge of the National Health Service in the UK was responding to US criticisms. He stated that there were no waiting lists in the UK for specialist referrals or hospitalization. He was then forced to say that the official waiting lists did not start until someone had been in the referral queue for 18 weeks! Then it came out that there was at least 250,000 on the over 18 week list. There was also another story that explained because of the UKs liberal immigration policies, UK citizens between the ages of 19 to 25 have a 23% unemployment rate because all the entry level jobs are taken by immigrants. They have their own "cash for clunkers program" and the result is all the government money is being sent overseas instead of their own economy.
I wonder if we can make it possible for our voters to watch British television?

Friday, August 7, 2009

Hypocratic Oath


Zeke Emanuel who is Obama's man for healthcare said today that he thinks the oath that physicians swear is outmoded and should be eliminated. Although it is called the hippocratic oath, since the 70's this is the oath that we swear. It is the Oath of Maimonides. He swore the same oath, but I guess his idea of what swearing an oath is like saying, "well, I sort of swear unless it is politically incovienent". I guess he swore a hypocratic oath that is above all others. I wonder which parts he objects to? After all, it mentions God (bad for atheists, and which God); (It warns to resist charlatans and others who interfere with care like politicians).


"Almighty God, Thou has created the human body with infinite wisdom. Ten thousand times ten thousand organs hast Thou combined in it that act unceasingly and harmoniously to preserve the whole in all its beauty the body which is the envelope of the immortal soul. They are ever acting in perfect order, agreement and accord. Yet, when the frailty of matter or the unbridling of passions deranges this order or interrupts this accord, then forces clash and the body crumbles into the primal dust from which it came. Thou sendest to man diseases as beneficent messengers to foretell approaching danger and to urge him to avert it.
"Thou has blest Thine earth, Thy rivers and Thy mountains with healing substances; they enable Thy creatures to alleviate their sufferings and to heal their illnesses. Thou hast endowed man with the wisdom to relieve the suffering of his brother, to recognize his disorders, to extract the healing substances, to discover their powers and to prepare and to apply them to suit every ill. In Thine Eternal Providence Thou hast chosen me to watch over the life and health of Thy creatures. I am now about to apply myself to the duties of my profession. Support me, Almighty God, in these great labors that they may benefit mankind, for without Thy help not even the least thing will succeed.
"Inspire me with love for my art and for Thy creatures. Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession, for these are the enemies of truth and of love for mankind and they can lead astray in the great task of attending to the welfare of Thy creatures. Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend. In the sufferer let me see only the human being. Illumine my mind that it recognize what presents itself and that it may comprehend what is absent or hidden. Let it not fail to see what is visible, but do not permit it to arrogate to itself the power to see what cannot be seen, for delicate and indefinite are the bounds of the great art of caring for the lives and health of Thy creatures. Let me never be absent- minded. May no strange thoughts divert my attention at the bedside of the sick, or disturb my mind in its silent labors, for great and sacred are the thoughtful deliberations required to preserve the lives and health of Thy creatures.
"Grant that my patients have confidence in me and my art and follow my directions and my counsel. Remove from their midst all charlatans and the whole host of officious relatives and know-all nurses, cruel people who arrogantly frustrate the wisest purposes of our art and often lead Thy creatures to their death.
"Should those who are wiser than I wish to improve and instruct me, let my soul gratefully follow their guidance; for vast is the extent of our art. Should conceited fools, however, censure me, then let love for my profession steel me against them, so that I remain steadfast without regard for age, for reputation, or for honor, because surrender would bring to Thy creatures sickness and death.
"Imbue my soul with gentleness and calmness when older colleagues, proud of their age, wish to displace me or to scorn me or disdainfully to teach me. May even this be of advantage to me, for they know many things of which I am ignorant, but let not their arrogance give me pain. For they are old and old age is not master of the passions. I also hope to attain old age upon this earth, before Thee, Almighty God!
"Let me be contented in everything except in the great science of my profession. Never allow the thought to arise in me that I have attained to sufficient knowledge, but vouchsafe to me the strength, the leisure and the ambition ever to extend my knowledge. For art is great, but the mind of man is ever expanding.
"Almighty God! Thou hast chosen me in Thy mercy to watch over the life and death of Thy creatures. I now apply myself to my profession. Support me in this great task so that it may benefit mankind, for without Thy help not even the least thing will succeed."


I am proud of this oath, it is the oath that I swore, and where I am from, when you swear an oath, it means something. I guess for others especially in Washington, that is not so.

Party of Parasites

A host can often tolerate a few parasites without severe effects. As the load of parasites increases, the host has to expend more metabolic effort to maintain itself. Eventually, the load can increase to the point that the host begins to fail. Some parasites can modify the hosts immune defenses to protect themselves making them harder to remove. Also some hosts make it easier for other parasites to enter the host. I think this applies to Congress, the Country and the Democratic Party.

Sunday, August 2, 2009

Aerophagia


I generally do not get to ask questions to our "political elite" but happened to have one cornered in the hospital so I let them fly. I asked "If we shift our medical spending to prevention and early detection of diseases, doesn't that mean that people will still get sick and die but later and of different things? So, how does this save money?" He replied "well, we wont have the cost of chronic preventable diseases." I asked him "which ones", and "how does this make any savings", he started gulping air, so I went on. I mean, say we "prevent" cancer. People are going to get other things, like chronic renal failure, congestive heart failure, other "chronic diseases", it is not like people are not going to need medical care and just suddenly drop dead (about Medicare age). "So, are you going to stop treating these other things?" He started to have blepharospasm and I was worried that any minute he might code. He went to his fall back party line quote "most medical expenses occur in the last months of life", of course I threw back, "How does prevention change that?". I would love to have had him on telemetry to see what his st segments and t waves were doing, but then one of the residents paged with a crisis and I had to leave. I am sure that I will be in the hospital CEOs office soon, why do we have our names on our white coats.

Friday, July 31, 2009

Attorneys' Laws 1-9

I have often heard that the fist law of Attorneys is that the attorney always gets paid. Well I saw today that Nancy Pelosi and Harry Reid are hiding in the health care bill provisions that allow attorneys to deduct all expenses in contingency cases as soon as they are incurred. Their idea is that this tax break will help improve access to trial lawyers and encourage attorneys to take cases that they would otherwise turndown. Not to mention that it would make the trial lawyers wealthier. Since the second through ninth laws of being an attorney are also, "attorneys always get paid," I guess the tenth is that they dont have to pay taxes.

Well I thought of our situation in medicine. We by law can not deduct from taxes our expenses for taking care of the indigent. For the most part neither can the hospitals or other health care providers. It seems that we are the only business that can not deduct bad debt. Would allowing medical providers to deduct their expenses help with access? Tax incentives seem to have worked in other areas, why not medicine? Right now, hospitals off set the cost of taking care of the indigent and the under insured by trying to get the most from the private insured. As a result, the private insured are paying more and more. Reducing the tax load reduces the hospital overhead, the lower the overhead, the less is needed from the private insured to make the hospital run. This lets the hospital negotiate lower contracts and thus more funds are available for care.

Oh, nevermind. I just saw that they want to add tax to private insurance and to increase the tax on hospitals. Just take what I said and reverse it.

Tuesday, July 28, 2009

Obama's Sign (The Devil is in Charge of the Details)

Forwarded by a physician who was able to make it through the first 500 pages of Obamas Healthcare Bill: HR 3200

Page 22: Mandates audits of all employers that self-insure!
Page 29: Admission: your health care will be rationed!
Page 30: A government committee will decide what treatments and benefits you get (and, unlike an insurer, there will be no appeals process)
Page 42: The "Health Choices Commissioner" will decide health benefits for you. You will have no choice. None.
Page 50: All non-US citizens, illegal or not, will be provided with free healthcare services.
Page 58: Every person will be issued a National ID Healthcard.
Page 59: The federal government will have direct, real-time access to all individual bank accounts for=2 0electronic funds transfer.
Page 65: Taxpayers will subsidize all union retiree and community organizer health plans (read: SEIU, UAW and ACORN)
Page 72: All private healthcare plans must conform to government rules to participate in a Healthcare Exchange
Page 84: All private healthcare plans must participate in the Healthcare Exchange (i.e., total government control of private plans)
Page 91: Government mandates linguistic infrastructure for services; translation: illegal aliens• Page 95: The Government will pay ACORN and Americorps to sign up individuals for Government-run Health Care plan.
Page 102: Those eligible for Medicaid will be automatically enrolled: you have no choice in the matter.
Page 124: No company can sue the government for price-fixing. No "judicial review" is per mitted against the government monopoly. Put simply, private insurers will be crushed.
Page 127: The AMA sold doctors out: the government will set wages.
Page 145: An employer MUST auto-enroll employees into the government-run public plan. No alternatives.
Page 126: Employers MUST pay healthcare bills for part-time employees AND their families.• Page 149: Any employer with a payroll of $400K or more, who does not offer the public option, pays an 8% tax on payroll
Page 150: Any employer with a payroll of $250K-400K or more, who does not offer the public option, pays a 2 to 6% tax on payroll
Page 167: Any individual who doesn't' have acceptable healthcare (according to the government) will be taxed 2.5% of income
Page 170: Any NON-RESIDENT alien is exempt from individual taxes (Americans will pay for them).
Page 195: Officers and employees of Government Healthcare Bureaucracy will have access to ALL American financial and personal records.
Page 203: "The tax imposed under this section s hall not be treated as tax." Yes, it really says that.
Page 239: Bill will reduce physician services for Medicaid. Seniors and the poor most affected." Page 241: Doctors: no matter what specialty you have, you'll all be paid the same (thanks, AMA!)
Page 253: Government sets value of doctors' time, their professional judgment, etc.
Page 265: Government mandates and controls productivity for private healthcare industries.
Page 268: Government regulates rental and purchase of power-driven wheelchairs.
Page 272: Cancer patients: welcome to the wonderful world of rationing!
Page 280: Hospitals will be penalized for what the government deems preventable re-admissions.
Page 298: Doctors: if you treat a patient during an initial admission that results in a readmission, you will be penalized by the government.
Page 317: Doctors: you are now prohibited for owning and investing in healthcare companies! Page 318: Prohibition on hospital expansion. Hospitals cannot expand without government approval.
Page 321: Hospital expansion hinges on "community" input: in other words, yet another payoff for ACORN.
Page 335: Government mandates establishment of outcome-based measures: i.e., rationing.
Page 341: Government has authority to disqualify Medicare Advantage Plans, HMOs, etc.
Page 354: Government will restrict enrollment of SPECIAL NEEDS individuals.
Page 379: More bur eaucracy: Telehealth Advisory Committee (healthcare by phone).
Page 425: More bureaucracy: Advance Care Planning Consult: Senior Citizens, assisted suicide, euthanasia?
Page 425: Government will instruct and consult regarding living wills, durable powers of attorney, etc. Mandatory. Appears to lock in estate taxes ahead of time.
Page 425: Government provides approved list of end-of-life resources, guiding you in death. Page 427: Government mandates program that orders end-of-life treatment; government dictates how your life ends.
Page 429: Advance Care Planning Consult will be used to dictate treatment as patient's health deteriorates. This can include an ORDER for end-of-life plans. An ORDER from the GOVERNMENT.
Page 430: Government will decide what level of treatments you may have at end-of-life.
Page 469: Community-based Home Medical Services: more payoffs for ACORN.
Page 472: Payments to Community-based organizations: more payoffs for ACORN.
Page 489: Government will cover marriage and family therapy. Government intervenes in your marriage.
Page 494: Government will cover mental health services: defining, creating and rationing those services.

Monday, July 27, 2009

BOTAX


The House of Representatives have proposed a tax on cosmetic surgery to cover the cost of healthcare. How much do you think we can get out of Nancy Pelosi?

25 units of Botox ($400 every 4 months), endoscopic browlift ($3200-5000), Upper lids, lower transcong blephs ($1200), C02 facial ($3500), Medium flap face lift with playtsmaplasty ($7500). All prices based on Federal Congressional Insurance Maximum Allowables.

The Buck Stops Here (not!)

I just did one of my pet peeves! I consulted someone for something that I could take care of, but didn't wan the liabilty.

We call it Fleaing a patient. It is based on the fact that the dying dog gets covered by fleas as it departs the world. The hospitalist who can manage the patients blood sugar consults endocrine, because the patient has a pacer cardiology is called, the patient cant fart so Gi is called. Each time the doctor does not want to be the last standing when the patient dies and the family looks for someone to blame and finds a way to consult another doctor (flea). Attorneys always ask, did they consult a specialist? So every specialist gets called. When there isn't a local specialist, they can transfer the patient to somewhere where there is one because of EMTALA and the fleaing starts again. The buck gets passed. And so it goes. (By the way, attorneys will argue that defensive medicine does not exist). It is amazing when the local specialists will suddenly decide that although they are trained in the procedures that the patient needs, they have restricted their practice and no longer perform that procedure. (limits liability) So the patient gets transfered.

Well, here is the problem. After transfer after transfer you get to the end of the line. The problem was that it was me. I have done the procedure that the patient needs in my training and once since. I know how to do it but the outcome will not be good. I told this to my patient and his familty. They have been to 4 other hospitals so far and everyone has passed the buck. They asked me what I would do if it were me or one of my family. I told them that I would try to find someone that has done the most and has the most experience. That is what they wanted. I called in every favor and pleaded and the surgeon who trained me accepted the case. He is at another center where they are self insured and make the patients sign arbitration agreements.

Thursday, July 23, 2009

Political Nihilistic Delusions

Been spending my free time emailing, faxing and snail mailing my resignation of my AMA membership as have most of the other doctors that I know who still were members. I shouldn't have but I watched the Presidents news conference last night. There was more confabulation that I get when a gang banger is trying to explain how he got shot while minding his own business. I dont know how Congress and other politicians can say with a straight face that they are going to get down to the problems and fix health care without coming full circle and discovering that they caused all the problems! Healthcare used to be a true free market, you went to the doctor and the hospital and negotiated your price. Then in WW2 Congress set wage limits, to help get better workers, companies could not pay their people more so they started adding healthcare as a benefit. As these people got benefits and could afford more care, other got jealous and soon Congress came up with Medicare which was at first and emergency back up but soon became an entitlement. Since it looked bad for private insurance to pay for what Medicare would not, it had to compete and of course grew and grew to the monster that it is. Every year Congressmen would add new perks and new groups that are entitled to it, not to mention more and more administrators and federal employees. Congress then worked to decrease all the possible ways that services could be performed cheaper by not letting physicians collectively negotiate with insurance companies for fees and approved diagnosis and treatments. The created Stark laws that prevent single office care so you cant have a Wallmart where in one office visit you can get your xrays, labs and meds. The politicians kept the door open for every possible frivolous lawsuits which boomed defensive medicine. Congress then made sure that you cant go to an insurance company and get a huge discount because you dont smoke and are not overweight because that would be discrimatory. They made sure that if are an illeagal immigrant you can go to any hospital and get the best care possible so that the cost is passed on to those who actually have private insurance.

If Congress wants to get to the bottom of the healthcare mess, they need to be able to look in the mirror unfortunately their Nihilstic delusions wont let them see their reflections. Just like reflectionless vampires, they will go on and suck the blood out of their victims.

Monday, July 13, 2009

I dont have to think so I cant be accountable!

Beeper keeps going off. There is a new JACHO policy about pain medications, you cant write in the post op orders, Morphine Sulfate 1 to 4 mg IV q 2 hours prn pain. You must write, if pain on pain scale is 0-1 give no morphine. If pain is 1-3 give 1 mg morphine 1v. If 3-4 give 2, and so on. Gone are the days when the nurse was able to watch the patient and keep them comfortable by asking them about their pain and watching their vitals using their experience and wisdom to guide them. Now the attitude is dont let the nurse think, just let them do paperwork. If they dont have to use judgement then they dont have to be accountable.

Oh, I forgot, before the pain medication can be given, the nurse must document what pain was on the pain scale. I know that most of my patient who are waking up from surgery are in pain but can only raise one finger to show their pain scale. It is of course the middle finger which is raised when they are shook violently to wake them up so you can ask them about their pain scale.

Sunday, July 12, 2009

Cachexic Healthcare

The timing was perfect. On the way to a meeting I was listening on the radio to an Obama Administration spokesman saying that that the Administration has saved millions of jobs and made new ones and she pointed to healthcare as an example. The meeting was for the Executive Committee of the hospital which is where the clinical staff and the adminsistration try to mesh the two to provide the best care possible given the monetary situation. At the meeting, the administration dropped the bombshell. The hospital loses money on self pay, Medicare and Medicaid and makes up the difference with the private insured. Well, the number of the private insured patients has plummeted. Since the main money is made on elective procedures like total hips and knees, and people are holding off on these, the medical center is going broke. This is despite the fact that hospital is 85 to 95% full on average. A huge cut in Medicare is also coming and the Obama Administration and Congress is getting rid of the tax breaks that hospitals got to take care of the indigent. Since by law the hospital has to provide its services and it can not turn anyone away who comes to the ER the only place it can cut costs is staffing. So, as of this Monday 25% of the medical center's staff will be laid off. Four of 12 associated community hospitals will be closed and all outpatient physical therapy/occupational therapy and infustion centers will be closed.

I guess I should look on the bright side. The other medical center is cutting 30%! I guess Obama's spokesperson hasn't been to a hospital lately.

Friday, July 10, 2009

Using Restraint

One of my biggest peeves is the ever increasing paperwork load that keeps nurses from actually taking care of patients. Well, JACHO and CMS are at it again. Somebody without a clue complained that there are nursing home patients with dementia are restrained and therefore we need to completely regulate the use of restraints with tons of new paperwork. No one bothered to explain to the regulators that the nursing home patients have dementia which means that they dont remember that they cant walk so they try to stand and fall and hurt themselves. Anyway, JACHO and CMS came up with all these new regulations for the use of restraints. So, here we are in the ICU where a patients who has ODed on xanax is waking from his coma and tring to pull out his IV, endotracheal tube and ng. Since he has to be restrained for this, the nurse must document every thirty minutes the need for and the degree of restraints. To comply with JACHO and CMS this is a three page form that must be filled out either on paper or in the electronic chart. Since the nurse is the one who has to do the documentation, you either need to get another nurse to watch the combative patient and take them away from their patient or you leave someone less qualified to take care of the patient.

I wonder how many pateints will self extubate themselves and die because of these new regulations? At least they will leave behind a nice chart.

Wednesday, July 1, 2009

Least Common Denominator

I know that many people feel that defensive medicine does not exist but I did a little controlled study to see just what happens. Here is how it works. When a patient comes to the ER, they often get admitted by one of the hospitalist services. These doctors see the patient and are the general managers of their care. Because of liability reasons, if the patient has chest pain rather than work it up themselves and assume the risk, it is an immediate cardiology consult. Headaches, neurology. Diabetes, call endocrine. Pretty soon you have consultants jumping on the patient like fleas on a dog. Of course each of these consultations cost money. If the patient has insurance, each consultant charges their fee. Now here is the study. I looked at whether or not patient who were indigent had more of less consults. The answer was that they had more. The reason was simple. Indigent patients are less likely to follow up and more likely to sue. So, you consult more to make someone else responsible. As one of our ER docs put it, you are recruiting co-defendants. So, it seems that the least common denominator is not money, but liability.

Sunday, June 28, 2009

Baker Act vs Stark Law

For those outside of medicine, Democratic US Representative from California Pete Stark is the one who has added many laws to regulate medicine into other bills to hide their initial effects. Many of us consider his laws to be at the root of why their is not more competition in medicine and why it is regulated into a beurocratic mess. Anyway, if you had any doubt of Congressmans Starks sanity, here he is explaining that "the more our country is in debt, the better we are off" and many more of his great "insights"!


http://www.youtube.com/watch?v=UjbPZAMked0&eurl=http%3A%2F%2Fjs%2Dkit%2Ecom%2Fapi%2Fstatic%2Fpop%5Fcomments%3Fref%3Dhttp%253A%252F%252Fglobaleconomicanalysis%2Eblogspot%2Ecom%252F%252F%26path%3D%252F2009%252F06%252Fus%2Dsavi&feature=player_embedded

I wonder when some California physician will just use the Baker Act on him in the middle of the House of Representatives?

Sunday, June 21, 2009

Agricultural Stimulus


I got to see an old patient in follow up. I love him to death and he has been fighting different cancers for years. As I looked for another, I teased him about the smell of smoke on his clothes, by saying "Gosh, how much are those cancer sticks now with all those taxes?" His answer was priceless, "I know that you cant get around death, but the taxes are easy!" Before I went into my stop smoking talk with him for the 50th time, I had to ask him what he meant. Well, he is an old farmer and it isn't that hard to plant a half acre of tobacco for his personal use and the use of some of his friends. Infact, they have sort of a co-op. He grows it, another person cuts and drys it while another grinds it. They then roll their own. He did confide that sometimes people give him some money for it. Turns out enough to pay the rent. As to the taxes, he said "I'm 79 and I have had cancer 4 different ways and it aint licked me yet, I'm going to roll in that social security as long as I can until I break even on all the money the governement took from me!"


I wonder how many others are growing tobacco in their gardens?

COPD vs Obamanomics


In several ways patients with COPD (Emphysema) are like small business. In these patients the lungs are having a hard time getting oxygen into the blood. As a result the patients body compensates. As the lungs start to fail, the body starts shutting down all nonessential functions. The pateints lose weight, the kidneys and other organs barely function. To keep things going, the body then concentrates the blood by making sure that every cc of blood has as many red cells as it can to carry the vital oxygen to the deprived organs. The hyperconcentrated blood compensates for the lungs failure and the patients keep going. If these patients lose blood, bad stuff happens fast. Their body is already on the edge. You have to replace their blood. If you just give them fluid and dilute what blood they have bad things happen fast. In other words, you dilute the blood, they die.




Small business is very similar. As the economy decreases and people buy less, the business has to compensate. At first it can lower prices temporarily to try to keep the volume up. This is like breathing faster. Eventually however you burn up what ever profit you have and start to lose money. Because you have certain demands to stay in business (overhead) you cut where ever you can. Since the vital organs of a business are its employees, they get cut as much as possible. You then get to a point that you have cut all that you can and volume of business is low. So low that the only way you can stay in business is to increase the price of your product. This causes inflation because you had to raise the price just to compensate for the economy. This inflates the dollar because it takes more dollars to buy the same thing. So, what decreases this whole process? The answer is to decrease overhead or the stress on the system. For business, one of the big stressors is taxes! The other thing that needs to be done is to make the dollar stronger!




Instead, in Obamanomics you increases the taxes on business to further decrease their ability to stay afloat and mandate more costs per employee which speeds up and increases the cuts that have to made in the staff and lastly devalue the dollar by massive unbacked spending. So now you really have to increase the cost of your products just to stay in businees and really have to lay off as many people as possible just to stay in business. Thus raising unemploment and letting inflation run wild.


In other words, it is like a making a patient with COPD carry another patient on his back while running on a treadmill which you are making up hill while you literally suck the blood out of him.




Friday, June 19, 2009

"Not the Disabilty I was looking for!"


Saw a patient today with a plethora of complaints. She had worn her internist out with various complaints from low back pain to headaches, she had every article she could print out on the internet about fibromyalgia and after presenting these to her doc, she wanted him to back date forms so she could get both temporary and permanent disability. She was well known for hitting different ERs for narcotics and actually had been fired from her job because she had taken off for the beach when she claimed she was out sick. I ended up seeing her because in her work up he saw something. It was unrelated to any of her complaints. In fact it was asymptomatic. The problem was that it was very malignant. Melanoma is like that. The node meant that it was stage 4. The primary site can not be found. She will get her disability. It wont be some paperwork and checks from the government. It will be seizures, liver failure and death.

Wednesday, June 17, 2009

Anton-Babinski Syndrome

It is so hard to watch the politicians try to figure out the healthcare mess that for the most part they created. Rather that look at what is obvious, they turn a blind eye to the results of their meddling and continue to press on. When they are confronted with the damage that has been done by their actions, they act like the Black Night in Monte Pythons "Holy Grail".

It is all very simple, they have done to healthcare what they have done to our governmental spending. Long and short, its like the income tax. Those that support the "Fair Tax" are quick to point out that you would pay a lot more attention to what the government was spending its money on if you had to write a check out of your own pocket each month. Because they get the money before you do in the income tax, we really dont see it so they can spendit before we know it. The same is with employer paid healthcare and government healthcare. You dont feel the money coming out of your pocket so you dont care how much it is spent.

So, if you paid for healthcare out of your own pocket, you would be much more careful how you spent it! You would shop around to get the best deal. Oh, wait a minute. Congress made it so you cant shop around. They fixed the prices of all Medicare/Medicaid so there is no real competition for who can give the most for the money.

If you want to help more people get healthcare and drive down the cost, its easy. Give the people the money and let them spend it. Sure, some will decide not to spend it and pocket it. Then its their own problem. I would love to see hospitals become Wallmart and have specials and deals. I can just see it "After Thanksgiving Sale on mamograms and PSAs, we will even throw in a colonoscopy". (Of course, you cant do that because of Pete Stark).

Lets get rid of physicians having to contract with health insurance companies. Let physicians and hospitals post rates for their services and compete for patients and let patients spend their healthcare dollars as they wish. You pick if you want Hilton on Motel 6 healthcare. Get rid of insurance contracts with pharmacies. If the drug companies want to sell more meds, let them make it cost effective enough that the patient will want to pay for their drugs.

Of course none of this will happen as our elected officials turn their blind eyes to the results of their meddling in our healthcare system and ingnore the results of all the other countries who have already been done the same road.

Saturday, June 13, 2009

Auditory and Visual Hallucinations

I was flipping channels and came accross someone explaining that the price of gas is going up because of the inflation of the US dollars in overseas markets. They went on to describe how unmatched federal spending and huge US debt is causing the price of commodities to rapidly increase of which oil is one. They then had an expert come on and show how inflation causes loss of jobs, increased interest rates and overall stagnation of business. The overall message was that the "Stimulus" was causing oil to go up which will further stagnate US businesses and then the rest of inflation will cause further US economic decline.

I couldn't believe it, it was on CNN! I must have been hallucinating.

Friday, June 12, 2009

"It's the ECONObama Stupid"

Survived another meeting this morning. It was with the medical center board of directors where they explain what business decisions have been made and relate it to the department chiefs of the medical staff. The long and short of it is that as there has been such an increase in self pay and medicaid patients, the hospital is going broke. They had been waiting it out but with the prospect of the proposed healthcare changes, expected impact of the taxing healthcare benefits and it larger government re-embursement they dont think they can make it. So, they are cutting 500 jobs across the medical system. Becuase many of the jobs are mandated by various regulations, the cuts will be in the clinical/nursing staff. So essentially, there will be cuts in the people who actually take care of patients, not in the paperwork pushers. Its the ECONObama!