• 45% of doctors who responded to a survey said they’ve given placebos to patients. That number certainly seems high, but sometimes patients don’t want to hear what you’re saying–namely, that no drug will help them. Giving antibiotics for a viral illness would almost count as a placebo, if they didn’t have the associated side effects and risks. I’ve certainly wanted to write for “Obecalp 1 tab PO BID” (‘placebo’ backwards) but I find it totally unethical and undermining of the doctor-patient trusting relationship. (Then again, patients don’t always seem so keen on the whole trusting relationship either, but that’s why we’re professionals.)
• Linkage shout-out to Maggie Mahar’s Health Beat Blog, which has been around for awhile but I never gave proper… props to. Maggie wrote the outstanding Money-Driven Medicine (Amazon) and has her background in business writing. (The aforementioned book provides a lot of evidence for the problems of our health care system and perverse incentives within it.) Lately she’s been investigating the ICU Checklist for Central Line Place program that was stupidly halted and providing frequent updates about what she’s learning. One of my new favorite blogs in the last six months.
• Illinois’ state-wide smoking ban seems to be going over fairly well. Being at home lately, I’m proud my own hometown finally decided to adopt a smoking ban (better late than never, OP!) and our bustling urban metropolis of Kansas City is being forced to put it on the ballot. I for one am much less likely to go out where bars allow smoking.

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Panda Bear is great writer. A great, deceptive writer, but aren’t we writers always trying to use our words to influence and convince, anyway?

Panda Bear uses great analogy and examples (usually stereotyped) to make his point. The fallacy is perhaps not his fault–we often see the best and the worst of and in people in the Emergency Department, which may explain his selection bias. Here’s the fundamental difference between us, Panda Bear, with clichés in full force: you seem to believe that one bad apple spoils the barrel, whereas I don’t believe in throwing the baby out with the bathwater.

He writes:

But that’s the problem with Social Justice, especially as it is used to justify giving everyone free health care. It makes the assumption that everyone is a victim and doesn’t allow for the possibility of the freeloader who not only exists in droves but is aggressively selected for in every nanny-state ever created. People may be lazy but they aren’t stupid and, as most people do not love their jobs, if the conditions are set to obviate the need for work many people will tend to do as little work as they possibly can.

Social justice, as I understand, it about equality. Distributing shared, scarce public resources as equitably as possible. Nothing in it speaks of victimhood. The poor (because that’s who I think we’re really talking about here) are certainly in a terrible position, and some might think of them as victims, but I wouldn’t blanket the term on like that.

Look, our society is based on equality, equal opportunity, and justice for all. While I’m certainly not idealistic naive enough to believe that this will ever be attained, I fundamentally believe it’s something we should strive for. Will there be free-loaders? Always! It’s our unfortunate human nature. I agree that “many people will tend to do as little work as they possibly can.” But I believe that for the most part, the poor and working poor do the best they can based on their circumstances. These people are not the ones that freeload in the ED. You may never see them (until their appendix bursts). Because they’re doing whatever they can to make ends meet. I believe that these people–the large majority, in my mind–should not be punished because of the inevitable freeloaders that happen to be grouped in the same income bracket. We should do our best to create policies that discourage freeloading, but not at the cost of hurting those who already have the least. (And ahem, health care is certainly not free. I know what you mean, but if liberal wackos are going to get rightly called to task for the term, I’m an equal-opportunity call-to-tasker.)

Later in Panda’s piece he sets up the anonymous straw-man “the usual suspects” who are apparently “deeply conflicted.” I’m not sure who the usual suspects are, unless they’re tree-hugging, Communist free-spirited liberals from San Francisco. (Note: Having been in the Bay Area for 5 years, one of the tree-hugging strongholds in the US, I have yet to find a serious-about-policy, educated, truly informed “usual suspect” as Panda describes. Please report them to both Panda and I immediately.)

As if we don’t have enough trouble administering real justice we now have to gear up to dispense social justice, a highly nebulous concept the implementation of which requires that grievance, race, age, social status, intelligence, and other things that Americans should ignore be worked into an arbitrary and impossible behavioral calculus to give to each according to his need and to take from each according to his abilty.

Equality, Panda, is the word you’re looking for. Highly nebulous concept that it is, I’m all for it.

I certainly by any stretch of the imagination do not believe that highly-over-educated, job-pretty-darn-secure, world-is-my-oyster physicians (including myself) can understand what it’s like to poor in today’s society. Crappy education, dangerous neighborhoods, the convenience store and fast food for your dinner options. The medblogosphere’s tune would certainly be different if most people’s parents were poor and working poor.

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Sometimes a comment is so good it deserves highlighting. This comment by Dr. Roy Poses of the Health Care Renewal blog is one such comment. His first statement is a perfect summary: “Retainer medicine is an indication of a serious problem, and an indication that people actually value primary care. It should be looked on as a symptom, not a treatment.”

It strikes me that the increasing popularity of retainer practices suggests that people highly value care given by generalist physicians who have enough time and interest to take truly comprehensive care of them. They value this care so highly they are willing to pay for it out of pocket.

It also strikes me that the main reasons such care is not available to all people are that:
1) The reimbursement given to most generalists is inadequate to pay for such care. This reimbursement has been de facto dictated by Medicare, and in turn is determined by the secretive and unrepresentative RUC (see previous posts on this blog, Health Care Renewal, http://hcrenewal.blogspot.com/, and other blogs).
2) Most physicians’ office practice costs are driven up, and time is further wasted by numerous bureaucratic requirements imposed by Medicare, managed care, regulators, accrediting agencies, etc, etc.

These conditions seem to have developed because managers and bureaucrats believed that the practicing physician, particularly the generalist, is the cause of rising medical costs. Or maybe they just thought that the generalists were an easy target for cost cutting.

Meanwhile, the costs imposed by excessive bureaucracy, overpaid management, conflicts of interest and corruption in health care organizations go on and on.

The rising popularity of retainer practices should not be blamed for the current health care mess. It is an indicator how much people value comprehensive, generalist care, the sort of care that is now being stamped out by the bureaucrats and managers who run health care, often for their own personal benefit.

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I’d like to rudely insert myself back into the Retainer Medicine foray that Dr. Centor and Bad Medicine have kept up and offer a bit of… data.

There’s a good survey/article published from the JGIM: Physicians in Retainer (“Concierge”) Practices (also has a fantastic references section on the topic) which offers a bit of information on the practice size and demographics of retainer practices (for those who responded to the survey, obviously):

As you can see, retainer practices are likely to be MUCH smaller, and have wealthier, healthier patients.

And now two bits that certainly support retainer medicine that I hadn’t considered:

1. SteveSC’s comment about a physician’s duty to his current patients, which I agree with, but doubt that all physicians would truly close their censuses.
2. Uwe Reinhardt (renowned Princeton economist and health policy wonk)’s piece in the BMJ with this damning bit (the whole thing is only a page and worth the read):
   

   I consider boutique medicine for the upper income classes a harmless, almost playful fringe phenomenon. It is practiced by a handful of physicians who, I believe, do hide behind the shield of “quality” to protect their income. Let them. Not much harm done. The boutique medicine implicit in the Medicaid program strikes me as far more harmful and, indeed, inherently fraudulent. It strikes me as fraud when federal and state legislators pay physicians and hospitals a pittance for hard work under the Medicaid program and then pretend to God and country that they have looked after the poor. After all, what is a state legislator really saying to a pediatrician when, through the legislator’s own insurance, he or she is willing to pay the physician $80 for a patient visit, all the while paying the physician only $20-$30 for the same visit accorded the child of a poor family? Economists believe that the relative prices buyers offer signal relative values. The state legislators’ relative valuation of the treatment of their own children and that of poor children is crystal clear.

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Our talks of retainer medicine became more general talks about primary care, which is a great segue. A classmate emailed me his own sentiments:

I think you’re underestimating how screwed primary care physicians are… Primary care is royally f’d, and I don’t think its fair to pretend that their problems will magically get fixed by universal heatlhcare. As a lot of primary care’s f’d-ness has come at the hand of specialists.

As others have said, priarmy care is in trouble in this country. And I agree. Some of it is due to the lack of reimbursement compared to specialists; some of it is due to the lifestyle–seeing 8 patients an hour, including documentation and all that’s required for a patient visit–and the inability to properly care for a very sick patient with multiple medical problems in 7 minutes. (I do not ever mean to give the impression that “universal healthcare” would magically fix all these problems, just that I would rather deal with the problems in a fairly logical, rational, planned-out system than the patchwork disaster we have today.)

I’m going to attempt to discuss some solutions to the problems–both for an individual physician and health care/society as a whole. (While when I’m working as a clinician, my goal is the best care for my patients, when I discuss health care reform, I think it makes no sense to ignore the ramifications of a change to society as a whole.) If you solution is “people need to take more responsibility for their health and behaviors,” that’s a sentiment I whole-heartedly support, but if you think that’s sound health policy, Do Not Pass Go, Do Not Collect $200.

1. Income. Perhaps the biggest issue for most is the lack of reimbursement when compared to other specialties. By having a system that so heavily reimburses procedures over primary care (I wish I could remember where I read about the history of the RVU, Medicare’s unit of measure for determining who gets paid what for everything they do), you by default inequalize the playing field, and Sutton’s rule applies. One decent tutorial is from The Happy Hospitalist, “That’s Less Than Burger King Pays”, minus one gaping error of ommission:
   

   Imagine for simplicity that an internist has an all Medicare practice that generates $360,000 a year in clinic revenue. Let’s imagine the overhead is 50%.

   (I assume by “overhead” HH means expenses.) Overhead is 50%? Why not try to take a piece of this pie back? Administrative costs are a fierce proportion of total health care spending, even if you don’t like the numbers proposed. You do, of course, realize that in other countries, solo physicians can literally be solo physicians because they submit one form for their services, and get paid, right? And they certainly jump through fewer hoops with HMOs getting follow-up colonoscopies approved, or writing letters to non-medically-educated administrators to get treatment approvals, right? All of those things cost money.

   So we could certainly get money back into everyone’s pockets if we simplified the billing and administrative systems in the US, but I also think the RVU system needs to reward primary care work more and reward some procedures less. This would encourage more people to go into primary care and keep more people in primary care as well.

2. Lifestyle. Two big parts to this (correct me if I’m missing more)–time and paperwork. Panda sums up the former pretty well, and how the lack of time contributes greatly to costs (although he doesn’t mention costs specifically):
   

   The typical elderly patient who needs anything more than a routine physical exam cannot have her problems addressed in a fifteen minute visit, much of which is taken up by compliance and admininistrative tasks. Consequently, there is a disturbing tendency to consult specialists for every medical problem that will take more than fifteen minutes to address (a tendency that is completely separate from the legal imperative to fend off the predatory plaintiff’s attorneys). The result of this is that you have three or four doctors doing the work that one could do with all of the lost time and inefficiency that this entails. Additionally, under the theory that to the man with a hammer everything is a nail, when you send a patient to a specialist they are going to use their signature procedures to the full extent allowed by reimbursment and ethics. In other words, the default position of a gastroenterologist is to perform the colonoscopy because short of this, he may be adding nothing of value to the patient’s care. Now, I’m not saying that there is no use for specialists, just that sending a patient to a specialist to confirm something you already know or to implement a treatment plan that you would start yourself is a waste of money…except that the economic realities of primary care make it impossible not to use them like this.

   Many specialists are used as nothing more than physician extenders, kind of like mid-level providers if you think about it, for busy primary care physicians who know what to do but don’t have the time.

   Time. I’ve commented on this before, but it seems silly to give specialists more time with patients than primary care docs. Sure, primary care-ists see more acuity and less chronic disease, but that’s becoming less and less the case. Taking a page from the retainer medicine book, what if new standards were set for a patient based on the patient’s comorbidities? The annual diabetic exam gets 30 minutes at a minimum. The seemingly-refractory hypertensive patient gets half an hour so you can figure out what’s really going on. (Probably compliance.)

   Paperwork. Documenting is important — and not just for medico-legal blah blah blah. The US health care system is confusing and complex (and could certainly be simplified by health care reforms), but say we started paying doctors for their time–all their time. And perhaps to incentivize primary care, we only pay primary care doctors for all of it. That people practicing primary care can get reimbursed for their time on the phone, the paperwork they fill out–all of that. (Yes yes, I know this would create other incentives to send more paperwork to the PMD, but I’m brainstorming here, people.) I will also quote a poll that I can’t find right now stating that two-thirds of physicians would be willing to take a 10% pay cut for a significant reduction in the amount of paperwork they have to complete.

Look, to all of those who think retainer medicine will fix primary care, think again. It will fix primary care for individual physicians, but not for society as a whole. I’ve run the numbers. We need something in-between: something that encourages providers to stay in (and go into) primary care with better lifestyle and reimbursement, but that still allows them to see more patients than in a retainer practice.

I welcome your comments and criticisms, but I’m brainstorming solutions that would help both individual physicians and society, not one or the other. Offer something constructive–it seems like most people are happy to poo-poo an idea and complain (maybe that’s what the blogosphere is good at), but not to offer up their own solutions.

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The media is starting to cover a study saying that many people don’t get defibrillated fast enough in the hospital (by docs at my hometown hospital where I worked at the Heart Institute during the summer in college!), and Dr. Wes, our medblogging cardiologist, has already responded. I of course have my own take.

I wonder how many of these cases were slow codes? And what are slow codes?

I had never heard the term until a classmate gave an ethics talk on it last month–and didn’t know they even existed. (Yay Stanford.) From a great article discussing them:

Slow codes, also known as partial, show, light blue, or Hollywood codes, are cardiopulmonary resuscitative efforts that involve a deliberate decision not to attempt aggressively to bring a patient back to life. Either because the full armamentarium of pharmacologic and mechanical interventions is not used, or because the length of the effort is shortened, a full attempt at resuscitation is not made. Unlike a true code, in which time is critical and a state of medical emergency exists, a slow code may seem to occur in slow motion, with staff members stiffly going through the motions, then breathing a collective sigh of relief when the effort is terminated.

They are often done on patients who are thought to be severely terminal, or demented, or whatever else the people running the code view the patient to be. They are anything but ethical. They give false hope to a patient and his or her loved ones that the patient can (and should) be resuscitated–if the act was futile, why would the doctors be performing it at all? They are also certainly futile interventions, and not benign interventions, either.

Why are they done? A couple good lines from the article (which you should really read, it’s quick):

A different rationale is operative when end-of-life wishes have been discussed and the patient or family has stated a wish that “everything” be done to resuscitate the patient. Instead of hearing the request that everything be done as evidence of despair on the part of a patient or family faced with imminent loss, physicians often take such a request at face value. Indeed, the physician may believe that respect for the patient’s autonomy requires an unquestioning acceptance of the patient’s stated wishes. Rather than probing the patient’s fears and concerns and providing reassurance that the patient’s suffering will be treated and that he or she will not be abandoned, a physician may see a slow code as a way out of a dilemma — as having the appearance of respecting a patient’s wishes while lessening the consequent harm.

Patients’ autonomy is frequently cited as the most compelling reason for providing treatment that offers no medical benefit. While some view autonomy in the extreme, as a pure and independent statement of the patient’s wishes, a more encompassing view holds that true autonomy exists only in the context of the physician’s commitment to help a patient achieve that which is in his or her best interest.20 There is also controversy about whether respect for autonomy necessitates the provision of futile interventions. Furthermore, the offer of futile measures can serve to undermine, rather than support, the ability of patients to act autonomously.21

The gist? “Do everything” does not mean a physician must “do everything possible even if the ‘everything’ is going to be futile.” And talk to your patients about their code status, and make sure they and their family members know the severity of their illness. “Do everything” is probably often part of the grieving process (DENIAL), too.

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• HIV and AIDS are back in the gay community my community our communities. I just. Don’t. Get it. Sex without protection, drugs, ignorance. I saw a young man in the ED awhile back with multiple risk factors who I’m almost sure had acute HIV infection syndrome even though his rapid test was negative and I just wanted to shake him and cry at the same time. I still scratch my head and wonder if there’s a way to support those with the disease without normalizing it so much that it just becomes another chronic illness and not worth protecting oneself from and educating oneself about. Sigh. A California law just went into effect yesterday (I’m told) so that written consents are no longer required for HIV testing.
• Interesting Journal Articles from Cases Blog, plus some tips on how to stay current with the journals. “How do you eat in elephant? In small bites.”

  I’ll add my own two pieces, both from The Annals of EM: Customer Satisfaction Versus Patient Safety: Have We Lost Our Way? and a really good overview of heart failure, management, and something one of my Cards fellows has ranted about for several years now–that there are diastolic failure ladies that go into pulmonary edema, and systolic failure guys that have more subacute weight gain. (Of course patients don’t read the textbooks, but the pathophys and treatment are different and are discussed well in the paper.)

• Beautiful neuron drawings from Morbid Anatomy.
• Welcome back, Kevin and goodbye, Medpundit. Like many, the latter was an inspiration to start a medical blog (since I disagreed with most of her health policy writing).

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