Sunday, April 27, 2014

Are Physicians Becoming Distracted Drivers?

He was rather tall.  Or at least he appeared so with his long erect back jutting from the bicycle seat. The cringe worthiness of his helmetless head was assuaged by the gigantic headphones covering his ears.  I figured they would provide minimal protection during a crash, but at least he would be listening to groovy tunes.

He weaved in an out of traffic on a busy two lane road.  He peddled effortlessly, bouncing to the music that undoubtedly pumped through his brain.  His arms were bent, thrust forward towards his head.  Did I mention that his hands were no where near the handle bars?  That's right, he was riding no handed.  He gyrated his torso to control the direction of forward movement.

As he passed by, I was able to divine what he clasped in both hands, and held up towards his face.  It was a book!

I was fascinated.  He was driving through busy traffic, minus a helmet, listening to music on headphones, without using his arms to steer, reading a book.  And I couldn't but help be impressed with this supreme act of concentration.  Or should I say distractedness?

If only we all could be this efficient.  If we could all multitask to such an extant, what great things we could accomplish?  But then again, maybe he was just an idiot.  Was he really gleaning all he should from that book in his hands?  Was the music moving his soul, or just background noise?  Shouldn't he have taken the most minimal of safety precautions and worn a helmet?

The problem becomes that the dilution of concentration during the performance of complex activities is nothing short of dangerous.  This is comparatively obvious when talking about bike riding or driving.  Sadly, we don't follow the same philosophy with doctoring.

We are told not to drive and text.

We obviously shouldn't ride our bike and read.

Yet no on thinks twice about evaluating sick patients, trying to meet meaningful use, following checklists, abiding by HIPAA, and filling out forms all at the same time.

To me, it sounds like a prescription for disaster.

Monday, April 21, 2014

Let's Be Real Clear About This

Are doctors being overpaid and causing the catastrophic rise in American Healthcare costs?

Let's look at internists:

Well, yes but...

how much do doctors make, physicians earnings, US doctors income
Maybe it is that we American doctors are seeing our patients too often.


Or could this be the problem?


Sunday, April 20, 2014

It Takes Something Away From You

When someone asks me about what it is like to be a doctor, a funny thing happens.  My eyes start to water and the words catch.

It's rather comical how emotional I can be.  I have been all my life.  I sometimes feel the sadness flow through me.  I am a sieve.  Whether it be a touching book or a sappy TV commercial.  I cry.  Silently.  Often missed by others in the room, the tear ducts in my eyes become overactive.  And it eventually stops.

I used to be embarrassed.  I used to cover my eyes and wipe the tears dry before anyone could see. I don't anymore.  As so often in life, I find it much more empowering to own my "weaknesses", embrace it.  This is who I am.  I'm comfortable with that.  In fact, I enjoy it.

We can fight the inevitable pain of life, or we can bask in it.  When we allow the skin to become penetrable, emotion soaks right through us, and then out.  We become free once again.

I am no stranger to the sufferings in life.  My profession, my calling, requires that I squat in the most uncomfortable climes.  I have watched hundreds die. I have walked in moments after the last breath has faded, and I have felt the spirit leave the room.  I tell people often that the end is near.

And I have done so all these years without shedding a single tear.

It is only when someone asks me about how it feels to be a doctor, that the emotion returns.  Here, away from the examining room and aseptic hospital halls, it is once again safe.  The heat rises into my chest and the throat becomes dry.  And I remember that I am neither dead on the inside nor cold, just in pain.

How ironic to describe a majestic calling from childhood in chocked and unsavory terms.  The words struggle to leave my lips in such anemic tones.

It takes something away from you.

Sunday, April 13, 2014

Attention Physicians, Your Government Just Flipped You The Bird

According to a 2012 study by Jackson Healthcare, the percentage rate of U.S. Physician compensation is among the lowest of western nations.  In 2011 physician's salaries compromised 8.6 percent of the nations total health care costs.  This is in comparison to 15 percent in Germany, 11 percent in France, and 11.6 percent in Australia.  Detractors point to the fact that although the percentages speak for themselves, if you look at the total number of dollars (Per capita health spending in the U.S. is double that of the average for the twelve other OECD countries), physicians are still compensated quite well.  Either way, in our bloated costly system, physician services are comparatively already discounted.

So it was with great pomp and circumstances, as well as consternation from various physician sources, that the government released data for all payments made by medicare to physicians in the year 2012.   Lauded as a win for transparency, the administration argued that making such information public would lead to a reduction in fraud, greater research into healthcare costs, and empower citizen investigators to crack the code of our overwrought system.

In reality, the so called "data dump" was exactly just that.  Refuse.  The information didn't account for the percentage of each physicians practice as medicare vs private insurance.  There was no recognition of pass through costs (medications, chemotherapy, etc.).  There was no adjustment for range or severity of illness of each physicians patient population.

Besides physicians, it is unclear that this information will really interest anyone.  The government and the FEDs already know who are the largest medicare billers, they were privy to the information previously.  The public is so overwhelmed with the ACA, surgical report cards, physicians rating sites, and the like, it is unclear that they will take the time or have the expertise to actually interpret the data.  Previous studies suggest that patients could give a hoot about such information.  And even if they could, finding a doctor who takes their insurance and hasn't been narrowed out of a network is hard enough.

I can assume that the only real reasoning to release such information was to send physicians a clear and unmistakable message.  We are being told not so subtly that we are being watched:

Get on board with what is happening, or there will be consequences.

That's right.  Our government just flipped us the bird.

Sunday, April 6, 2014

Why I don't Always Follow Guidelines, My Response To Barron Lerner

Barron Lerner thinks he understands doctor's motives.  In his recent article in the Atlantic he laments that physicians act on tradition and emotion over adopting new science.  In defense of his position, he sites the example of how cardiologists use angioplasty and coronary artery bypass to treat coronary disease.  He states:

cardiologists have been remarkably slow to abandon the old hypothesis, continuing to perform hundreds of thousands of bypass operations and angioplasties annually not only in the setting of heart attacks (when they are appropriate) but also to try to prevent them.

He, of course, makes this statement without acknowledging that scientific data has only become more clear on such issues in the last ten or so years.  He ignores the fact that this has been an area of great controversy in which experts and the not so scientific guidelines disagreed over decades.  In other words, it's not that greedy doctors were just breaking the rules as a ploy to make money, there were actually highly respected leaders on both sides making persuasive arguments.  And furthermore, just because a cardiac intervention isn't in the setting of an acute heart attack, doesn't mean it is not appropriate.  

Lerner then pivots to discuss the new cholesterol and hypertension guidelines.  

In the case of cholesterol, the new guidelines, promulgated by a joint American College of Cardiology-American Heart Association task force, discourage the standard practice of checking patients’ cholesterol counts and choosing among a series of medications to lower them to specific levels. Instead, the group recommends treating all patients who fall into specific risk groups with a particular agent—the statins—and not following their levels.

What he fails to mention is that these guidelines have changed over the years based not on any new evidence, but more on the whims of the so called "experts" chosen to give their opinions.  These are the same experts who told us to shoot for an ldl of 70, treat low hdl with niacin, and use non statin lipid lowering drugs like Zetia.  All of which have fallen out of favor.  These are also the same experts who often make an income consulting for pharmaceutical companies who stand to benefit from such guidelines.  

The same can be said from the hypertension guidelines.  It seems every year some group is telling us what we should be shooting for which is often a new, random number.  The data, however, most of the time is lacking.

The problem is, the latest scientific data/theory is often wrong.  Their are countless examples of this in the literature.

Many anti arrythmics killed people.
Raising HDL cholesterol did not benefit anyone.
Vitamin E is useless.
Measuring homocysteine and CRP are rarely helpful.
Vitamin D does not treat heart disease!

The job of a physician is to evaluate the data and use this information to benefit his patients.  We are not expected, or required, to blindly follow guidelines.  So you'll have to excuse me if I'm not jumping to follow the new cholesterol dictates.

I didn't when I was told to get every one's LDL down to seventy.  I didn't when I was pushed to use gemfibrozil and niacin.  And I sure as hell won't now, until the scientific data that went into such decisions makes sense.