New Years Reflections
I wrote a year ago about my reflections on the New Year 2010.
Despite ongoing change and concerns about the direction of the practice of medicine and of the country in general, I was generally
upbeat. I counted my blessings, as it were: I’m healthy, I have a good marriage and home life, I enjoy the respect and
confidence of my peers and I’m making a good living doing something that I love to do.
All those things are still true. My relationship with my wife has grown and deepened as she has come
into her own as an independent professional. I’m still carrying more debt than I like but it’s manageable and
I haven’t had to seriously curtail my lifestyle (which is modest in any event). And I’m gratified
by the continued respaect and confidence in me shown by my peers.
my mood as I start this New Year 2011 is less confident and optimistic than it was a year ago. There are great changes afoot
in my chosen profession and in the community where I practice. Change is always unsettling. Change that is totally beyond
your ability to predict or control is downright frightening. Between the restrictions and new requirements being imposed by
the government under the new Health Plan and the reaction of hospital administrations to them, the solo practitioner like
me is left with a feeling of helplessness.
There is no question
that physician reimbursements will be cut. Fair enough. Tell me what the cuts will be and where and I’ll adjust. But
wait, we don’t know where the cuts will be made or how much they will be. We don’t even know if and when they
will occur. That makes strategic planning for the year ahead very difficult. Should I hire or fire employees? Should I put
more money aside for new expenses or invest in new equipment? How much should I pay on my estimated quarterly tax? I can adjust
a lot of the financial issues on the fly as we see how this will work out. It’s the unpredictability that is hard to
More disturbing to me is the continued expansion of ‘guidelines’
on the way that I practice. This year there will be a literal doubling of so called ‘never events’. Events that
CMS, the government watchdog that runs Medicare and controls reimbursement, says should never occur. Unfortunately, a certain
number of these events are inevitable and CMS knows this. No matter how good we are, no matter how conscientiously we adhere
to good practice guidelines some of these complications will still happen. And yet CMS says we will be penalized if they do.
There is a deep cynicism in that approach. They set an impossible goal knowing that no one can meet it so that they can justify
not paying for the care patients receive if one of these events does occur.
electronic medical record is being forced on us with little evidence to support the claims that it will reduce error, streamline
care or improve outcomes. One thing it will do is cost several thousand dollars to implement in my office. Money that is an
expense for me that the government vaguely promises to reimburse, although there is no mechanism in place yet to do that.
Nor is there any standard format for the records or assurance that I won’t be required to switch to a different system
at some time in the future. But if I don’t computerize my records by the end of 2012 I will be penalized with a 5% cut
in reimbursement from Medicare, increasing to 15% by 2015. I am not a Luddite. I am not against electronic record keeping
in general. But as yet, I have not seen a medical record system that works well. They are all overly complex, cumbersome to
use and difficult to learn. And for a surgical practice, they offer little advantage. My patient encounters tend to be short
and focused. I see the average patient only once or twice in the office and then never again. I don’t need a system
that tracks multiple medical diagnoses, multiple visits and multiple medications. I can do very well with
a couple of dictated notes, processed as text documents and stored on a disc.
reality, the electronic record is not about efficient patient care. It is part of a larger effort by government, insurance
companies and regulatory agencies to gather data and track patterns of care. I believe the ultimate goal is to use that data
to compel individual physicians to practice the way the government wants us to practice using sanctions and reimbursements
to get their way.
We are already seeing this in the hospitals.
Doctors who don’t toe the line on ‘practice guidelines’ and ‘core measures’ get annoying letters
reminding them of the party line and threatening ‘credentials action’ if they don’t ‘improve
their performance’. Be good or we’ll haul you in front of the credentials committee and suspend your hospital
privileges. Never mind that the guidelines are often arbitrary and have more to do with cost savings than best practices.
So, my predictions for 2011 and beyond: More physicians of my
generation will leave the practice of medicine or stop seeing Medicare patients. Younger physicians will chose to be employed
by hospitals rather than try to make it in private practice. Those employed physicians will be less likely to work longer
hours, above and beyond the requirements of their contracts. Why should they? They won’t be paid more for it and the
demand will only increase. Patients will face longer waits for appointments and may find that some specialists won’t
see them at all if they are on Medicare or some other government administered payment scheme.
In my heart, I am a libertarian. I believe in individual freedom and individual responsibility. I believe in limited
government--severely limited government. I am not a fan of either political party in this country, but can think of no other
place on earth that combines both the protection of individual rights and political stability that this country offers.
That said, I am
tired of the exercise of freedom being a license for stupidity. Yes, you are free to drink yourself into oblivion every weekend.
But don't get behind the wheel of a car or a powerboat when you do so. Don't decide you are superman and can leap
from a roof or a cliff into shallow water. Don't get drunk with people you don't really like and decide to tell them
off. Especially if they're bigger and more sober than you. I know this is a useless appeal because you are too stupid
to understand the consequences of your actions, but I'm the guy who gets to patch you up after your adventure and am tired
of hearing the same lame story time after time.
Yes, you should be free to ride your motorcycle without a helmet. After all, freedom is what motorcycles are all
about and that sense of free flying with the wind in your hair is part of it. I know my appeal to stop a moment and think
about what happens when an unprotected head meets concrete even at low speed has no effect on you, but again I make it. In
my more cynical moments, I can support your decision if you'd guarantee that you'd become an organ donor. At least
then someone would benefit from your stupidity.
You are free to supersize your meals, buy all that wonderfully convenient fast food. I'm a big fan of Whataburger
myself. If you are unable to exercise restraint and self control you can always blame it on McDonalds. And when your diabetes
and hypertension and heart disease leave you unable to do more than sit on the couch and watch reality TV, you can always
go on disability. Healthcare is a right, right? So no matter what you do to yourself, someone else is obligated to pay for
taking care of you.
Shouldn't we pass laws requiring motorcycle helmets? Shouldn't we pass laws that forbid drinking and driving
or operating machinery? Shouldn't we forbid motorcycles entirely and unsafe at any speed? shouldn't we outlaw cigarettes
and hi fat fast foods and sugar laden sodas? Ah, there's the rub. Where do we draw the line? 'Reasonable people'
agree with drunk driving laws and motorcycle helmet laws and minimum drinking age laws. But 'reasonable people' can
also be persuaded to ban particular foods or drugs or activities as too risky. The world is full of zealous people of infinite
good will who will try to convince me that an organic bran muffin and herbal tea are just as satisfying as a Moon Pie and
an RC Cola.
know that personal freedom isn't an all or nothing absolute. And I see daily the consequences of stupidity in the exercise
of freedom, at least as far as trauma and personal health are concerned. One of the arguments for universal health care is
the cost of caring for uninsured patient who get sick from preventable illness. I don't really agree with the position,
since there is evidence that preventive care doesn't reduce costs. It improves quality of life and delays catastrophic
complications, but the actual cost of care is higher. That's an argument for another time. My point is that to affect
chronic stupidity, you need to pass laws that intervene directly in peoples personal lives and choices. Helmet laws and drunk
driving laws are reasonable and prudent, but what about smoking bans? What about limits on the fat content in foods? What
about government monitoring of a child's Body Mass Index in the school? What about required end of life discussions with
elderly patients? When do 'reasonable people' decide what you can and can't eat in the name of protecting your
The problem with freedom is that it includes the freedom to be stupid. Yes, society ends up bearing the costs of
stupidity. But there's no cure except the restriction of freedom, a step that requires more forethought and nuance that
I'm willing to trust to any government.
Some of the best advice I ever received as a medical student was from my chief resident when I was an eager young
third-year on my first trauma rotation. "Never run to a gunshot wound to the head," he said. "They'll either
survive until you get there or they won't survive no matter how fast you run." The corollary to that axiom is 'Think
donor. The life you save may not be the one in the trauma bay'.
Gunshot wounds to the head are a particularly
difficult type of trauma to deal with. When self inflicted, they automatically create a lot of ambivalence for the trauma
team. It's hard to work to save a life that the patient himself didn't think was worth living. And shooting yourself
in the head, unlike taking pills or cutting your wrists, is a statement of a fairly serious intent to end your life.
it is an act of despair, although sometimes it seems understandable. Not a choice I would make, but understandable for the
patient. I am not a psychiatrist for a reason--I have little patience with neurotics and depressed people whose only purpose
in life seems to be inflicting their own misery on everyone else around them. So depression, despair, loneliness, all the
usual reasons people cite as the cause of their suicidal motivation don't strike me as particularly valid reasons to put
a gun to your head. In those cases, it's an act of supreme selfishness.
On the other hand, a patient faced
with a long and debilitating and ultimately fatal illness may see suicide as a rational act to avoid a futile and costly struggle
that will have the same outcome in the end as a bullet in the brain. Again, not necessarily my choice, but understandable.
I'm a firm believer in property rights. The ultimate property right is the right to decide what to do with your own life.
If suicide seems a rational decision, I support your right to make that choice. Just get it right the first time and make
sure no one else is hurt in the process.
That last part is the real problem with suicide. It may seem right to you,
but even the most rational suicide harms those whom you leave behind. Death and grief go hand in hand, but sudden death leaves
little time for the survivors to prepare or accept the loss. The thought that you would deliberately choose death over staying
with people who care about you is doubly hard for the survivors to accept. It's a very personal type of rejection and
all the rational arguments about why you did it don't change that.
As a trauma surgeon, I give families
bad news on a regular basis. It isn't something that I'm particularly good at. I tend to be very clinical and although
I try to put things in terms a that are easily understood and give an honest assessment of the patients prognosis, I'm
not good at offering comforting words or expressions of sympathy. Harder still is the discussion of brain death and organ
donation. I believe in donation. I encourage everyone to become an organ donor. But I'm lousy at broaching the subject
with families, even though it's supposed to be part of my job. Thank God for the nurses at Donor Network who do that sort
of thing very well.
A Luddite Speaks Out
now four weeks into the switch to an all-electronic medical record at my primary hospital and the pain continues. Instead
of getting better at using the new record system, I think I'm just getting numb. I know I'm depressed. Depression
is redirected anger, and I know I'm angry. The problem is, there is no way to release that anger because the people responsible
for pissing me off are a nameless/faceless 'them'. 'They' are the corporate idiots who decided to buy a poorly
designed, antiquated, and cumbersome medical records program that violates every rule of human-computer interface ever devised.
Without going into exhaustive details about what's wrong
with the system, just let me say that many of the physicians I work with are much more tech savvy than I. And I have
yet to find anyone in the hospital who likes this turkey, much less has found it satifactory for his/her daily needs. The
interface is confusing and poorly organized, the navigation is counterintuitive and requires clicking though multiple screens
to perform even the most mundane tasks, and the order entry system is organized around the department receiving the orders
rather than being easily searchable by test or class of order. (For example, to order intravenous nutrition I have to
search the 'consult pharmacy' menu rather than the IV fluid menu or the nutrition menu). Conditional orders, such
as 'If xyz occurs do the following and call me' are not allowed. Instead, I have to write a 'nurse communication'
notecard and post it to the chart and then wait for the nurse to read and acknowledge it.
I am not against technology. I am also not computer-phobic. (I'm doing this
website, am I not?) But this is not progress. This is insanity. I am being turned into a ward clerk, trapped in a never ending
cascade of drop down menus and dead end order entry screens. The mantra chanted by the hospital administration is that Computer
Physician Order Entry reduces medication errors by eliminating the middle step of having a clerk send the written order to
the pharmacy. Maybe. But what I find is that if the physician clicks the wrong box and sends a mistaken order to the pharmacy,
it's filled without question. The Doctor ordered it so it must be correct, right? And when the order entry process is
so complicated that it takes six hours of training to understand how to work it, something is wrong with the system.
What they should have done, IMHO, is take a cue from Amazon.
Order entry is no different than shopping--you look for what you want and order it, one click sends it to your shopping basket
(pending order box) until you check out (electronically sign). Instead of cumbersome, complex proprietary code that only the
program vendor can understand, write the system in HTML or some other open source code so that your in-house IT people can
tweak and adapt it to local needs. Do notes in Word or RTF or some other popular document software so that it is easily edited
and can be sent in e-mails or blast faxes to doctor's offices.
This system can't talk to any other system. I can't upload my office records which are stored
as Word Document files directly to the hospital record. I have to print them out, fax them to the hospital where the paper
copy is scanned into the hospital record. Stupid! What happened to the universally accessable electronic record that was supposed
to make it simple to share information with other clinicians and eliminate duplicate efforts? Forget about it. And now I learn
that the CEO of the vendor who sells this system is on the Board of Directors of our hospital. Can you spell 'conflict
of interest' boys and girls? How come I can't get reimbursed by the hospital for free care provided to illegal immigrants
because it would violate the Stark Law (which forbids 'sweetheart' deals and kickbacks to doctors from hospitals)
but this guy can sell his product to an institution where he holds a vote on what to buy?
I have said before that surgeons by nature resist change. But I can embrace it
if I see that it benefits me or my patients. Now I'm being forced to change my practice for the benefit 'them'.
Not for me or my patients, but some corporate system that probably bought on the cheap without looking at the product through
the eyes of those who would actually use it.
Back to Reality
"Back to life, Back to reality" On my first day back to work, I was greeted by a phone call from a radiologist
who wanted to discuss the latest MRI on an old patient of mine. She'd been admitted to the hospital during my vacation
with leg and back pain. I hadn't seen her for about 18 months, but knew her symptoms meant bad news. Sure enough, the
Rad described a recurrence of her original cancer that was now eating into her spine and impinging on nerve roots. Lovely.
The next call, five minutes later, was from the patient's daughter who wanted to discuss her mother's prognosis. We
agreed that surgery wasn't an option and I said I'd call the oncologist to look at other options.
Next, I opened the mail and found a
missive from the medical staff office regarding a complaint against one of the surgeons. As department chairman, I get to
handle these and talk to my colleagues about their temper tantrums. I hate this part of the job, especially when it amounts
to a tired surgeon taking out his frustrations on a nurse who is equally tired and frustrated and decides to write him up.
Neither party is truly injured and on another day would have let the matter drop. Now it gets official notice and I have to
write a letter to the surgeon.
Then I find the certified letter. My stomach does a bit of a flip-flop. Lawyers send certified letters. I open it,
expect a notice that I'm being sued, but find a letter from the trauma center telling me (and all the other trauma surgeons)
that our contracts are being canceled in 90 days. A relief, but also a new annoyance. This is standard operating procedure
when they plan to renegotiate. They did this last time and it resulted in three months of pain and anxiety only to arrive
at a status quo agreement. Apparently they mean to try again.
The issue is both pay, the stipend we get for our 24 hour shifts, and the
'excess liability coverage' the hospital provides. Basically this is a malpractice superinsurance that covers our
liability if we lose a malpractice case for more than our personal coverage limits. Unfortunately, trauma is a high risk specialty.
Even when you do everything right, things can still go very wrong. The excess coverage provides security that makes sure you
won't lose your pension, your house and your skin if there is a huge judgment against you. One of the
sticking points in the last round of negotiations was the hospital's attempt to cancel this coverage. It
looks like they mean to try again. Last year we threatened to walk out over it. We've since lost a couple of surgeons
and have some new guys on board, so maybe the administration thinks they can slip this by. Last time, I didn't play a
very active role in the process. This time, things will be different.
I take a deep breath and think about the sea, the sun and the
fresh seafood of the past week. It helps.
The title says it all. I am wallowing
in it right now. I get like this sometimes after a week of making rounds on the trauma service and doing two or three trauma
ER shifts during the same week. I have little love or hope for humanity today. It is often said that the only two certain
things are death and taxes. To that I would add stupidity.
A few days ago I was watching a medical drama on TV. I shouldn't do
that; it either makes me laugh or ticks me off. An earnest young character on the show made the statement that trauma happens
to anyone--most trauma patients are ordinary people who get up every day and go to work and pay their bills until some random
event blindsides them. HA! Most trauma patients are at best marginal participants in society and at worst drunks and drug
addicts. Statistics bear this out. Trauma is disproportionately a problem of the marginalized segment of society. Alcohol
is involved in more that 50% of traumas. The number of trauma patients I see who are either on chronic narcotics or psychiatric
drugs approaches 80%. Trauma affects people who take risks. Not the controlled risks that skydivers and motocross racers take;
the uncontrolled risk one takes when one drives at freeway speeds with a blood alcohol three times the legal limit. Either
that or the risk inherent in doing something really stupid like jumping from a second floor balcony into a play pool with
only three feet of water in it or trying to Evel Kneivel a dirt bike from a standing start out of the back of a pickup truck.
Gravity is a bitch to those who try to cheat it.
Of the twenty plus inpatients on the trauma service today, I would classify three as 'ordinary people blindsided
by a random event'. I know that is horribly cynical of me. I like to think it doesn't affect my care of them. I sincerely
hope not. But I do know that I don't have a very good rapport with many of them, and is subtle ways I'm sure that
does affect their care. Some of them are awfully hard to love, though.
Those of you who have read my stories know that I'm
a romantic. I'm liable to cry at Hallmark commercials. And I know this cynicism is just the flip side of the same coin.
It affect many of us in this business. It goes by many names--burnout, compassion fatigue, vicarious PTSD to name a few. One
of the reasons I write fiction is to try to relieve some of the feeling of futility I get sometimes. I guess if I were a true
optimist, I'd say that it represents job security. People will always do stupid things and so trauma surgeons will always
have plenty to do. Thank God the week is almost over and I can get back to more rewarding work, like cancer surgery.
The latest cost saving move by
my main hospital is to use 'reprocessed' laparoscopic instruments. Things like clip appliers, scissors and harmonic
shears thet we use to control bleeding, cut tissue and control bleeding. The manufacturers of these instruments intend for
them to be used once and then thrown away.
are reasons for this. The instruments are made of plastic and thin steel. They are robust enough for use but not for resterilization.
The moving parts are small and have a lot of nooks and crannies that are hard to clean.
Nevertheless, there is a company that sees opportunity here. They take used instruments. disassemble
them, clean and sterilize them, replace broken parts and them sell them at half the price of new gear. This is against the
manufacturers recommandation but the company doing it claims to have reliability data that demonstrates the gear to be safe
and effective. Unfortunately, there is no FDA regulation covering this process. The FDA can't or won't certify
the safety of reprocessed gear, nor will thay restrict it.
Despite company and hospital claims, my personal experience with this stuff has not been good. At one of the hospitals
where I work, all they provide is reprocessed gear. In the course of three days I had three separate harmonic shear fail during
surgery, had a clip applier lock on a blood vessel forcing me to tear the vessel in order to remove the device,
and had a scissors fall apart during use. I know anecdotal experience is not scientific, but I personally will not use reprocessed
gear unless compelled to do so.
As yet, my main
hospital is not forcing surgeons to use this stuff, but the hospital is part of a big system and they are under pressure to
use the gear. I am currently depoartment chair and refuse to allow it. That may be an empty gesture, since I don't
control purchasing and can't really keep the gear out if the hospital forces us to use it. All I can do is resign in protest.
My problem is threefold: First, I have not seen any independent
reliability data that shows reprocessed gear is at least as safe as new. It may exist, but all I've seen is information
provided by the reprocessing company, not exactly objective. To be fair, the opposition data comes from the manufacturer
of the new gear and can't be trusted either. To date I have seen no independent assessment of the gear. Second, the reprocessing
company says they only reprocess an instrument once, not repeatedly. But they depend on the hospital to throw the item away
so it doesn't get back into the reprocess bin. There is no tag or identifying label on the instrument to make sure it
doesn't happen. If ALL your gear is reprocessed, you just throw it away at the end of the case, but if you mix new
with reprocessed there is the potential for error. As yet there is no identifier for the reprocessed gear. Finally there is
the libility issue. I'm being asked to use a device in a way that the manufacturer of that device strongly recommends
against. Who is going to indemnify me for that. I don't relish standing up in court and saying 'Yes I knew that
the manufacturer recommends against reusing this equipment, but I went ahead and did it anyway and the patient had a bad outcome
as a result'.
Like I said, I may not be able
to keep this stuff out of my operating room. but if given the chouce, I won't use it. And I'm advising the surgeons
in my department to destroy every single use instrument on their surgical fields once they are done with it.
A few month ago
one of those silly Facebook surveys asked me to name the ten most influential books in my life. One of the ten was a slim
volume by Sir Zachary Cope entitled 'Early Diagnosis of the Acute Abdomen'. It is the surgeon's Bible when it
comes to examining the abdomen. With a clear understanding of the principles outlined in the book, an astute surgeon can evaluate
a patient in a few minutes and come to a diagnosis of the cause of the patient's abdominal pain with an 70 to 85% confidence
level. Further testing can then refine that to near 100%.
A few simple questions about the patient's pain are the key. When did
it start? Was the onset sudden or gradual? Where is it located? Does it move? What is the nature of the pain? Burning? Sharp
or stabbing? Dull or aching? Cramping? What makes the pain worse or better? Associated symptoms like nausea, vomiting, diarrhea,
Simple lab and x-ray tests add more information- a Complete Blood Count, Liver function assay, and enzyme tests for
pancreatic enzymes plus a plain upright abdominal x-ray may be all that are needed.
Armed with this basic information, an experienced surgeon
can diagnose the cause of the pain 90 to 95% of the time. Fancier, more expensive studies such as CT scans, Ultrasound and
the like may occasionally be needed to nail down a diagnosis, but should not be the first tests ordered.
I think I'm going to buy a hundred
copies of the little book and distribute them to emergency rooms all over the Valley. The current diagnostic test of choice
for abdominal pain, any abdominal pain, seems to be a CT with contrast. I understand the reason. The doctor
gets immediate feedback without the need to think very hard and the patient gets the reassurance of a high tech test. That
doesn't make it right. There are cost issues and, although I tend to pooh-pooh it, issues of radiation exposure. And there's
the bigger issue of professionalism.
Maybe I'm too curmudgeonly, or just a dinosaur, but since when was an x-ray a substitute for a careful history
and physical exam? I am often called to see a patient for abdominal pain and an 'abnormal CT' only to find clear evidence
that no one has even looked at the abdomen. I would not have the temerity to compare myself to Ochsner or Halsted or Gross,
the gurus of physical diagnosis from the beginning of the last century, but I am dismayed at how far we have strayed from
their teachings. Most of my younger colleagues would have a hard time finding their ass with both hands without a CT scan.
And whatever the radiologist reports on his reading of the scan is taken as Gospel. Even if only mentioned as part of a differential
diagnosis and a simple assessment of the physical findings would rule it out.
What is lacking, and getting harder to find is the
direct bedside evaluation of the physical signs and symptoms, the hands on exam and the gestalt assessment that comes from
experience. Experience comes from doing the exam over and over and correlating it with the findings at surgery. But if you
don't do the exam in the first place and count on technology to do the work for you, you don't learn.
Well, Governor Brewer did it.
She signed the Immigation Bill that has attracted so much criticism from the left and the 'immigrant's rights'
groups. I think it was a huge tactical mistake. She could have vetoed it and it would have had the same impact, maybe more.
It was bad law, not because it tries to target people who are in this country illegally, but because it is unenforcable unless
you are going to target people because of their ethnicity. Passing laws that can't be practically enforced is stupid.
I object, however, to the knee jerk condemnation of the motives
for passing the law as 'hatred'. However much you may disagree with this law, to label it as being motivated by 'hate'
is an ad hominem attack that demonizes the legislators without addressing the problems with the law. The label is too quickly
applied by the left and the media to any attempt to restrict the flow of immigration from south of the border. Like it or
not, the current state of affairs is untenable. Arizona is the number one conduit for illegal drugs, for human trafficking
and for kidnapping in the country. The kidnapping crisis doesn't get much national play, since most of it involves human
smugglers kidnapping the families of illegal immigrants in order to extort more money from them. Funny how rounding up people
loitering on street corners gets condemned as 'hateful' and yet there is no hue and cry over the hundreds of kidnappings
each year. More people are held against their will in Arizona than anywhere else in the country. Where is the FBI? Where is
Actually, both agencies are here and work
hard to do their jobs. They are simply overwhelmed by the sheer volume. The Federal Government has failed the people of Arizona
and many people are mad. They death of an outspoken rancher near the border has galvanized many on the right and led to the
passage of this bad law.
So what is to be done?
Does anyone have the 'right' to enter this country any time they want? That seems to be the position of the most vocal
immigration advocates. Why bother with any border control at all if that is the case? How is it 'hate' to try to enforce
the existing laws that are constantly being flounted by nearly three million people every day?
I actually believe that current federal immigration law is also bad law for the
same reason: it is unenforcable. It places law enforcement in an impossible situation by demanding restrictions but doesn't
fund the necessary steps to implement those restrictions. The individual agents on the front lines are under constant threat,
either from their own government if they are too vigorous and violate the immigrant's 'rights' or from the drug
dealers and smugglers if they get in the way of their business. I had a conversation with a patient recently. He was a guard
at the Florence prison, but had been an ICE agent in Douglas, Arizona. One day a couple of well dressed men rang his doorbell
and asked politely to speak with him in private. They handed him an envelope containing ten thousand dollars in cash. It was
his, they said, if he stayed away from a certain area of his patrol territory on a certain date. More money would follow on
a regualar basis. If he refused, well they knew where he lived and they knew where his children went to school and they'd
hate to see anything bad happen to them. He took the envelope, reported it to his superiors and the family was moved to Mesa
the next day. He claims that this was not an unusual occurrence and that the government has a routine procedure to deal with
it. How are we supposed to enforce the law under these circumstances? Is it any wonder that some people forget that you can't
stop everyone who looks Hispanic and demand ID when they feel overwhelmed by events like this?
The Devaluing of Experience
One overlooked provision in the New World Order of Healthcare Reform is the change
in how consultations by specialists are coded and paid for. As of March first, the increased rate of payment for a specialist's
evaluation under Medicare is eliminated. We are paid at the same rate as the Primary Care physician for our evaluation and
opinion. We can bill for a 'comprehensive exam' if we document that we not only looked at the patient's surgical
problem but also determined when they had the chicken pox as a child and what their great aunt Hattie died from. Never mind
that the primary care doctor has already done that and the patient was referred to me for my expert opinion about his gallbladder.
Never mind that if the primary care doctor thought he was qualified to take it out, he would have. My years of extra training
and experience in the field are of no additional value. If I do a focused exam on the surgical problem and the relevant comorbidities,
I get less than the nurse practioner who does the three page history and physical exam. Now this may seem like a petty complaint.
After all, why should I get more for an evaluation that take me less that fifteen minutes? For the same reason that you expect
to pay more for a master carpenter than a construction laborer. Or for an original work of art than a print. There is an old
saying that surgical training is six years long because it takes two years to teach you how to operate and four more to teach
you when not to operate. Judgement and experience have real value in this profession, but not according to the government
bureaucrats who write the rules. To them, we are all equal, right tsovaritch?
New Year Reflections
Reflections on the occasion of the New
Year, some good, some not so, some just uncertain.
The good: I'm ending the year in the black. Despite issues with contracts, reduced payment from many insurance
plans, higher than ever expenses and some unexpected costs, I still made a very good living. I was able to pay my employees
a bonus at the end of the year, pay most of my bills and put something into the retirement fund. I'm carrying more debt
than I'd like but I'm able make my payments and I own more of my house and office than the bank does.
healthy. My wife is always looking out for me. My cholesterol tends to be a bit high, but there are good drugs for that. I
don't get as much exercise as I should but I don't do too badly. Having a big dog and a kid who likes the park help
too. I don't bounce back from long nights on call the way I used to, but I'm taking less call these days anyway.
My books are enjoying
(very) modest success. Queen Mab Courtesy has sold a few copies recently and I get the occasional e-mail telling me that someone
liked the book. The full manuscript of Thieves Profit has actually been requested by an editor at a big print publisher. That's
still a long way from publication, but it's the closest I've come yet.
I have a wonderful, smart, beautiful wife. We work
as a true partnership, in the office and at home. It's a simple formula. I'm labor, she's management. Works for
still enjoy the respect of my colleagues. I've been in this game for over twenty-five years and have managed to keep up
with what's new, remember what's old but still works, and develop a reputation for good care and good outcomes. I
continue to learn new things almost every day. Innovation is not only good for my patients, especially when it decreases disability
and length of stay, it's also good for me. It keeps me engaged and interested in an art that is the most fun anyone can
have with their clothes on.
The bad: I am the practitioner of a dying art. I've written before about the changes in surgery. I'm sure
much of what I feel is colored by age--there's always a feeling on the part of the old guard that the youngsters coming
up behind don't have the same sense of purpose that us oldsters have. But with the work week restrictions imposed on Residency
programs in the name of safety and the trend toward employed surgeon who work shifts, there's a real danger that the idea
of individual responsibility for patients will disappear. I was trained to take personal responsibility for a patient from
initial consultation to final discharge. Everything that happened to that person was my responsibility. I might work with
a 'healthcare team' but in the end, the buck stopped with me.
The current healthcare reforms working their way through
Congress are not good for the private practice of medicine. There is no way that you can expand coverage to thirty million
people and save money without cutting services or payments or both. The prospect of an across the board 24% cut in my reimbursement
scares me. It's a done deal if there is no passage of an extension of current payments by Congress. And that's not
in either of the plans currently in play. Covering all Americans is a noble goal. But the people making the laws don't
seem to have a clue about what life is like out here in the tranches. And the AMA has sold out for a handful of empty promises
and a bribe in the form of retention of CPT coding. Almost all of our specialty societies are opposing this turkey. Only the
AMA supports it. But I fear it's a done deal already.
Good nurses are disappearing at an alarming rate and their replacements
lack the critical thinking skills that I rely on to tell me what's happening with my patients. Smart, engaged nurses are
burning out and moving on to other jobs. They can be successful at anything. They stay in nursing because they love the job.
And yet hospitals and lawyers seem to have done their best to make the practice of nursing as hostile to critical thinking
as possible. Adherence to protocols and routine cookbook type 'careplans' take precedence over understanding pathophysiology
and detailed knowledge of patient needs.
Government agencies such as CMS (the outfit that oversees Medicare) are becoming more and more intrusive into the
way we as physicians do our jobs. So called 'best practice' guidelines will soon have the force of law, whether or
not they remain valid. The average lifespan of a practice guideline is fifteen months. After that, new research or new thinking
invalidates the earlier research and the guideline is changed. Already, guidelines for antibiotic usage prior to surgery,
beta blocker drugs and postoperative anticoagulation have changed. And yet CMS is still enforcing the old guidelines. So far,
this has no more effect than mild censure. But soon, reimbursement may be denied if you don't follow the directives. The
choice then will be: follow outdated guidelines and get paid or follow the latest evidence based recommendations and risk
being denies payment. I don't trust the government agencies to be nimble enough to keep up with the pace of change. Certainly
their track record up to now does not inspire confidence.
The uncertain: All the same things that afflict the rest of the country--uncertainty
about the economy, terrorism, energy, international politics, global warming. I have definite opinions about all of these
things, but in the end can do very little to affect them. So I read my Cicero (On the Good Life; proper behavior for an honorable
man in dishonorable times) and my Sun-Tsu (The Art of War) and say my prayers for myself and my family. I write, I read, I
try to engage with friends and family and take care of my own. I honor my family, my country and my mentors every day and
try to live a life that I can be proud to show to my children.
Happy New Year!