A political/medical care observation for the New Year


donald-trumpIt is after all Sunday and this is a bit more of a time for a “Village Green” observation by your FL, for what it might be worth. What I’m about to say involves an obligatory observation on National politics because it impacts what’s happening in medicine today and in the near future. My observations are NOT so much for public debate here as they are simply pointing out facts, as they are readily apparent. Please just reflect on this, not start arguments. Med-Events does that very nicely. If you want to argue about politics, join Events.

A paper came across my desk (enclosed) suggesting that the potential for health care providers’ autonomy is under assault and eventually will all but disappear. I think there are clear reasons for this. The demand for medical care continues to increase but the supply remains relatively static. All kinds of schemes have been developed though the years do decrease the demand (cutting the price). Denying service for pre-existing conditions, “managed care”, “rationing by inconvenience” and yet the cost of health care continues to increase yearly.

The “Affordable Care Act of 2008” (Obamacare) hoped to put a dent in that by spreading the cost out over a very large population, some sick, some well, and of course, “opt-outs” wouldn’t be allowed, as they would eventually turn up in emergency rooms demanding care even though they hadn’t paid the premium. Part of this plan would have been the “public option” to take care of outliers.

There isn’t really much argument that this plan would have worked pretty well, allowing for adjustments, had it been implemented as formulated. Not perfect but a very good start to get people covered for their health care affordably. What happened was a bit unexpected. We didn’t realize at the time that opponents of the President became the “party of no” vociferously obstructing, delaying and destroying everything and anything that came out of that White House. The ACA then became a political issue and was widely advertised by the Party of No as something it wasn’t. Then the Public Option was killed, removing much of the efficiency of the entire program, followed by allowing healthy people to opt out of the program leaving a large population of sick ones.

Of course, as a natural consequence of supply and demand, the price per individual rose, as it would have (and did) for any kind of health care indemnification. Blamed on the program, of course. I had lunch with a very intelligent, perceptive friend (not the only one I have that supports repeal of the ACA) who solemnly advised me that she couldn’t wait to see the ACA repealed because middle class people couldn’t afford it and it was literally bringing the economy down. Never mind that any- and every health care indemnification program in the country was similarly raising their rates, including mine.

Enter the stimulus for all this, the current President-Elect of the USA, Mr. Trump, and his new best friends, ultra-conservative Republicans now in control of congress and soon to be also in control of the Judiciary. Mr. Trump, a very talented and experienced huckster knows nothing about any of it, but his new friends do and they’re now after many years of trying, in place to do damage to health care and a great many other things in our lives.

As is widely observed, the election of Mr. Trump caught virtually every observer by surprise, but not me. They that Pennsylvania is a state with two cities on either end (Pittsburgh & Philadelphia) with Alabama between, and that turned out to be true last Nov 8). I saw it coming as I rode bikes around the rural center of Pennsylvania, spotting Trump signs on virtually every home or business in small towns and country areas. I knew all these people would vote and they intended to “shake up” the establishment that no longer worked for them (not suspecting they had the potential to destroy it).

So now, before the new President-Elect actually takes power, we’re already getting a view of how it’s going to be.

  1. The institution of a Presidential Cabinet full of officers dedicated to untried and unlikely theoretical political ideals, not necessarily the benefit of the population.
  1. The dissolution of a health care system that currently serves about (said to be) twenty million should to one degree of another with the promise of something to replace it someday.
  1. A President-Elect that has publically disputed the opinion of every single individual in every single intelligence and law enforcement office regarding the illegal and intrusive activities of Russia in our political-social system. “The difference between skepticism and disparagement”
  1. As of Friday, the funding of a wall separating the USA from Mexico asked to be funded by congress with a bill to be sent to the other side with no mechanism to collect it. Estimated cost ~ 25 billion $ and estimated by most experts to be worthless.
  1. Active plans to decrease any and all funding for the poor and disadvantaged, active plans to decrease taxes for the well-off, active plans to get more guns on the street and eliminate “Planned Parenthood”, a service that benefits many women.

All this even before January 20.

Now, again, I ask not for argument. The above remarks are above argument, they simply exist and can be substantiated anywhere. It’s just my humble personal observation and it all matters in our health care future, which is why I bring them up.

Our current health care situation is quickly falling apart for at least two reasons (I’ll omit my scathing remarks on what’s going on in medical education).

1. I honestly believe that there is about a 50-50% chance that Mr. Trump’s coalition will collapse completely within 30 days of Jan 20. He has no clue about the delicate realities of global politics and his Cabinet members have no real experience in any other than “business” and that isn’t the way any of it works. Any number of other countries in the world could hurt us more than we could hurt them if they took a mind. Mr. Trump’s coalition fully intends to create a society built on unlikely or untried theoretical political conditions as a practical matter. It is absolutely not out of the question that the fabric of our society could be ripped apart into chaos and very quickly.

It’s already started. An increasing number of Republicans, his own party, have figured out he has no firm foundation for any of his Tweeted opinions, all capricious ramblings of what he happens to think at the moment. They’re making it known they’re re-thinking their support for him. This brings up another potential reality, that Mr. Trump et al will become very quickly bogged down in a system of government meant for- and created for bipartisan cooperation to get things done. If Mr. Trump’s coalition descends into the same kind of stubborn non-participation that has marked the past eight years, then nothing (again) will go forward and our system of government will descend into vicious and bitter fighting, wasting time and money in a very dangerous world. So much for “fixing” broken government. I do NOT see Mr. Trump actually achieving many if any of the advertised platform (such as it was) that elected him.

2. If any of that hat happens, our currently fragile health care provision system will collapse, if for no other reason than our current strategy to cope with administrative rationing will fail with it. Insurance and government strategy is to make reimbursement increasingly complicated so that those unwilling or unable to comply don’t get paid. What we’re doing now is allowing “middle management” and “financial specialists” to deal with the increasing complexities of reimbursement.  There are now an entire hall full of administrators and financial people where a lot of doctors used to be (including me). These guys peck at computers all day long all getting excellent salaries and benefits.

Now, at this point, everyone on this List should download and read every word of the following Time Magazine site (let me know if it doesn’t open for some reason).


Pay particular attention to the justifications given for incredibly outrageous charges by an automated service “Chargemaster” for patient caught in the middle- too young for Medicare and too many resources for Medicaid. Both Medicare and Medicaid pay providers only a small fraction of “Chargemaster” bills and they’re accepted. Also pay attention to the salaries for middle managers, CEOs, COOs and the like. You’ll note somewhere in the middle that the CEO of the University of Pittsburgh Medical Center’s salary (before bonuses) was close to 6 million $ per year. The same guy that mandates draconian budget cuts for the clinical departments, including mine every year.

e as providers are losing the battle of self-determination. We are losing that battle because we’re handing middle managers and financial officers the authority to order health care in an administrative system that considers us irrelevant. It considers us providers that create demand and they want to limit demand. They formulate policy and let us know how we fit into it, which is why the majority of us are not “hospital employees”. We can be controlled.

This is the state-of-the-art now for providing medical care for our population and I can assure you that if the administration, such as it is, of Mr. Trump collapses, this will all collapse with it. If Mr. Trump’s administration becomes embroiled in an endless fight with everyone creating chaos and stasis, this system will follow suit. If Mr. Trump is successful in killing the ACA, there will be a lot of people left wondering what and when their promises will be kept, even if it could be financed which is unlikely if he spends 25 billion on a useless wall. It took Obama two years to formulate the ACA and it wasn’t perfect. We’ll see what Republicans dedicated to “conservative principles” can come up with and when they can come up with it.

To end this diatribe as I sit here “retired” with a cup of coffee and my trusty iMac, I am very, very fearful for the future of the country, the health care system or the world for that matter and I’m not by nature a terribly pessimistic person. I am now an observer. We’ll all observe in time.



Some comments on where critical care medicine is headed in the next ten years


Recall several months ago I wrote some editorial opinions on where IIF thought critical care was headed, some of them not too kind. I foresaw a critical care world full of Physicians Assistants (PA) and Nurse Practitioners (CRNP) doing patient care and critical care physicians as their handlers in executive roles. The actual experience and training of the critical care fellows to do that more and more attenuated as they eschew night call and direct patient care the PAs and CRNPs are more than happy to provide.

I see it already in the surgical specialties. I saw the guy that fixed my ruptured Achilles Tendon once, the day of surgery. Everything thereafter was handled by his PA. No way to contact him even if I wanted to. I saw the guy that fixed my femur fracture once, the day of surgery. The followup visit three weeks later was handled by his PA.

I was told a while back by the head of our Department who happens to be a long time personal friend that my weakness was that I wasn’t into teaching the fellows the algorithms and protocols that are ruling critical care, and that direct patient care is becoming overrated as it really won’t be done by physicians much anymore. It will be “directed”. the critical care physicians job will be to know every possible parcel of literature and to be involved in some form of research, because that’s where the institutional prestige (and probably money) is.

My response to that was that the directorial critical care physician will be more of a figurehead as he or she gets less and less hands-on experience, especially at night when all disasters happen. That’s, of course, not to say that these people won’t do an outstanding job. It is to say that either you’re a physician and trained as such or you’re not. That distinction is becoming more and more blurred.

So, as I go down the road, predictably this Paradigm is bearing very visible fruit in my case. First time ever, my “faculty reviews” broke the bottom end of 4 (5 being the highest possible). 3.8 for this partial year (this year has been tough for me). That means bottom end of “Very Good” because of a number of “satisfactory” marks given me (3.0).

Now, you have to understand that this is a lot like “Officer Efficiency Reports” in the Army. If a guy gets a completely fair report, his career is over. The only acceptable report is hugely inflated, and mostly bullshit. Pretty much the same here. The report detailing the statistics for all clinical attending here glows for anything over 4.25 and anything under 4.0 is mentioned only as an anchor dragging the Department down.

So, if you examine my strength and weakness numbers, you see that my highest numbers are involved with the issues of (quotes) “Faculty should promote patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health”. “Faculty should promote knowledge of established and evolving biomedical, clinical, epidemiological, and social behavioral sciences, as well as the application of this knowledge to patient care”. Faculty should demonstrates respect, compassion, integrity, and altruism in the maintenance of professional relationships with patients, families, and colleagues. Meets all professional responsibilities with regard to patient care. Highest score: Faculty explains the ethical, economic, and legal aspects of Critical Care Medicine as well as the psychosocial and emotional effects of critical illness on patients and family”. Creates an appropriately relaxed, cordial, positive, and stimulating learning environment. Briefly reviews expectations of the fellow at the beginning of the rotation or at the start of time on service.

Lowest scores: “Faculty should promote the ability of trainees to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence.” These scores were low enough to bring my average down below 4, first time ever. A fairly dramatic change from years past.

I’ve cherry picked here as much of this is much more complex but I give you the skinny. What’s happening is that the CCM Fellows are being told what is important. What is important is less hands on direct medical care and more ability to honcho others to do it based on current literature cites and research data. If they don’t feel they are getting what’s important, they downgrade those they don’t think are giving it to them.

So, I think it is happening and it’s happening fast. My fear is we are graduating more intelligent, intuitive doctors that have less and less experience in dealing with direct patient care and more experience bringing forth the latest cite on any subject. Direct patient care will more and more be done by non-physicians. . Unclear where it ends and what the sudden, unexpected aftermath will be. Maybe it will work out fine. If so, the curricula of medical college will begin to approximate that of PhD programs.

Comment:  Much of what has happened is a result of supply, demand and market forces here in the south. Few intensivists, fewer who will choose to be up all night, and relatively plentiful NP/PA who value training and practice in critical care.

This has been a steady process of deterioration here for the past few years and fighting it is impossible since prospective fellows can choose to enter a “Pulmonary, Allergy and Critical Care” fellowship that has NO night call and get jobs identical to those coming out of multi-disciplinary fellowships that demand night call as a learning experience. We actually started seeing a deterioration in qualifications in our applicants until we cut back on night call. I think currently they have to do one night a week and at the rate we are adding PAs/CRNPs, most of that is just hanging out watching other people work.

Comment:  Our challenge becomes finding an effective and efficient strategy to train up those physicians who are willing to work hard to an ever higher standard. My bias–and this is a personal, not corporate bias–is that we need to get to progressively more realistic simulations that expose trainees to more problems and issues in 4 hours than we ever encountered in a fortnight.

I think the pool of those would-be physician trainees is dwindling and dwindling fast. In fact, physician trainees willing to deal with the hassles of direct patient care is dwindling. Why should they. Nuclear medicine and radiology specialists are well paid and they all go home at five. Physical Medicine and Rehabilitation. Rheumatology. Sleep medicine. Hematology. Physician trainees are choosing specialties that come with a built in barrier to being bothered after hours.

So we are building a full compliment of clinical intellectuals who know everything there is to know about subjects that fully insulate them from after hour disasters. Who’s there in the middle of the night when the dying happens. Emergency Physicians, but they are normally not credentialed for in-house care. Hospitalists? Jury out. It will be PAs and CRNPS because it seems they are more affordable. The legacy of affordability has yet to be confirmed but I see the hazy vision as it forms.

Comment:  One view is that the technology to achieve this is “too expensive”. Another view is that whoever pulls it off could create a national sim center that operates around the clock for primary and recurrent training.

This is another factor I’m seeing come to fruit here. My medical students all look at their watches mid-morning during or after rounds and decry they are late to the “sim-center” where presumably they spend the rest of their day. I am on record that if the day ever comes and it might, that students get most if not all their time dealing with clinical emergencies via simulators, we are all in deep, deep trouble indeed. The worst possible place to end up would be a hospital where providers translate virtual reality to real reality.

I landed in a hospital in the middle of the night with a femur cracked from stem to stern, a hematocrit dropped to 26 and hypotensive. Even as a long term attending physician at this institution I took pot luck when it came to a provider that knew how to deal with this issue. When Dr. X cruised into my room, had a look at me and the films and told me he’d take care of this I could have kissed him. By the time I got to the operating room it was something like 4 am and he’d been operating all day. The conversation in pre-op went like this : “Him (Putting his initials on the skin of my leg): “you up for this?”. Me: “better question- YOU up for this?” Him: “(stretching)…..You bet. Lets get this done”. Four hour procedure started at 0400 hrs, masterfully done.

Young guy seven years out of his fellowship in trauma and orthopedics. Literally putting my life and my future ability to ambulate in the hands of someone I don’t know. Trusting him with my life and livelihood? How long do you think we’re going to have these spirited guys willing to beat themselves to death for the benefit of people they never saw before. I genuinely fear we are not headed for more of them.

Comment:  I do not think there’s much point in bemoaning the new division of labor. We need to consider how to concentrate training and broaden experience at the same time. At risk of sounding like a “broken record ” (for the younger list members, please Google this archaic expression), aviation figured out the importance of high-fidelity simulators a while ago.

Dealing with the infinite clinical nightmares all conspiring at the same time is NOT like high resolution avionic training. I genuinely fear for sick people in ten years. Hospitals may or may not have the ability to care for them. I am not optimistic, Tim. Making the best of an inherently bad situation for the worst possible of reasons (diminishing funds) isn’t the same as streamlining provision logically and intuitively.

Here’s what I see happening to critical care in the next ten years.

  1. Insurers will become more and more tight with funds as they discover the multitude of patients transferred to ICUs simply to die after a massive wallet biopsy to chronicle their impending demise. But politically, it’s impossible to “say no” to it so they will find other ways co cut funds for “critical care” that can’t be traced back to bean counters. As a result, the time and energy needed to prove admissions are deserving of “critical care” will become progressively ponderous and difficult. Critical Care physicians will become experts in reimbursement policy and will spend most of their time doing it.
  1. Most if not all of the clinical catering will be accomplished by mid-level providers, PAs and CRNPs, and they will all do a great job because if for no other reason most of the day-to-day patient care isn’t all that intuitive. Busy work looking after numbers, cultures, vitals and so on. Acute decompensation in the middle of the night will be addressed mainly to keep the patient alive until morning when higher levels of expertise will come to bear.
  1. I have always said that the day will come when I can tap into a huge global multi-million patient data base, punch in my patient’s particulars and show the family what the real mortality will be and when it will occur no matter what treatment is afforded. I think that day is close. Similarly, that same data base could be used to create algorithms and protocols showing the best possible outcome according to how those millions in the data base did with any treatment scheme.
  1. Accordingly, morning rounds will consist of input from executive levels of critical care physicians who will select the proper clinical protocol for the patient to be on. Protocols based on “evidence based medicine” (consensus of journal articles on the subject), and there will be one for every possible disorder. Respiratory, cardiac, gastrointestinal, neuro and do on. Of course there will be a trailer at the end of each suggesting that they may be modified by “clinical judgment”, but since the critical care attending has long since lost any experience in clinical judgment, that won’t matter. Variations of response to protocols will be met by more protocols, and if the patient dies, it will be because he had no ability to respond to good, standardized care.

As medicine becomes more complex and the information base has increased beyond the ability of individuals to contain it, we go more to the tender mercies of collective clinical judgement (from the literature). Individual clinical judgment is not amenable to control or standardization which is a situation that can’t be condoned.

When I walk into a patients room, the entire ambiance of illness and infirmity flows into my own personal database. I see and feel things that only someone who has spent 35 years at the bedside sees & feels and I intuitively know a lot of things that I don’t need to test against a computer database of the literature to see if it’s valid for THAT patient.

However, I might be wrong because I also have human frailties. And if I am wrong, then my wrongness will be measured by the database of “evidence based” literature which will always be right, especially since it didn’t need to be consulted for THAT patient.

So, current thought is that in the end, everything will be measured by “evidence based” data. The BEST chance for success is to plug everything into a protocol that reflects “evidence”. Although sometimes brilliant, individual care plans suffer from poor quality assurance. Sometimes they can be lousy and there isn’t sufficient ability to separate the two.

So, the whole point of a protocol is that’s it’s uniformly followed to the letter. Deviations result in uncertainty which cannot be condoned. It’s like letters from the Internal Revenue Service. A half page informing you that money is owed and you have been identified as the person owing it, then five pages of what they’re going to do if you don’t pay up.

Protocols are not for thinking processes of whether they should be followed. Protocols are to be followed or those refusing will die the death of 1000 meetings to explain why to stern faced administrators.

Are protocols a good thing that will improve patient care. Unknown. Will be eventually seen. My personal brand of clinical intuition is clearly dead and if I last the next couple of years before forced retirement, I’ll be lucky.

I am the last of my kind.

  1. There will be no place for medical education as we understand it in this scheme. There will be no point in medical students dealing with these patients because they are cut out of the protocol loop. Medical students will spend 90% of their time on simulators watching the numbers fly by and the robot twitch. Any direct patient care performed by resident staff or medical students will be for routine hospital care. Anything resembling an emergency for a hospital patient will be dealt with by mobile emergency response teams who will arrive at the bedside to usurp the continuity of the previous trainees who will observe the goings-on from the back of the pack.

That this will occur (and is occurring now) is a lead pipe cinch guarantee unless……………..

The big joker in this deck is now political. (FL now suspends previous prohibition against political diatribe temporarily because it is integral to this discussion).

As the cost of health care continues to escalate and the reimbursers continue to find novel and bulletproof ways to cut funding for it, the “real” predictions of how this will all go are just that. The scenario I presented above is what’s happening right now and what will progress all other factors remaining equal, but other factors will not remain equal. Everything is now changed as of the mid-term elections where we now have a radically different power structure and a VERY unclear picture of what the Presidential situation will be in 2016.

The Affordable Health Care Act of 2008 was created to do several important things including to make health care portable and affordable by spreading the cost over all those involved. This became a political football and as of today survived those who would destroy it. However, the barbarians previously at the gate are now in charge and so it is now very unclear whether the AHCA will survive. If it doesn’t, and it may not, then we will drop back to our previous system of “private” insurance for those not eligible for Government health insurance. That insurance has been in the process of escalating the cost of indemnification yearly to as much as 50% a year and will continue to do so as long as demand exceeds supply until it collapses under it’s own weight. When it does, there is nothing else in sight for non-Medicare and Medicaid patients other than “self pay” which guarantees instant lifetime financial insolvency for a routine illness requiring hospitalization or surgery.

I also believe then that if the AHCA fails, the next step is European style National Health Service, which is the ultimate affordable system. It gets X amount of $$ and that’s it. Use it wisely. If and when that occurs, my previous predictions above are dashed on the rocks and we will be sailing through completely uncharted waters.


Some acerbic notes on the new generation of physicians


“My impression is that the older ones found work-life integration while the younger ones are focused on work-life balance. There’s not a lot of balance when up at 3 am with a sick patient or 5. And the a common refrain is “I don’t want to work weekends “

Crippen: When I was a medical student on clinical rotations in the early 70s, I was expected to be the first to arrive and the last to leave. I “took” patients and was responsible to the resident for reporting on morning rounds everything going on. I did procedures under guidance and I got chewed out or my ass kicked when I didn’t perform up to expectations. I was expected to have no other obligations during that rotation and it NEVER crossed my mind to complain that I was overworked. Had I done so, that revelation would have been greeted with dropped jaw astonishment and an admonition to get with the program or take my mangy ass elsewhere.

When I was a resident at Bellevue, there were about 100 patients on the general surgery service and ten in the surgical ICU. There were two first year residents on the service and every-other-night call. Do the math. Similarly, there was no excuse for not getting the work load done. One learned to prioritize to get the important stuff done and suck up the hassles on the rest. Complaints of overwork were nonexistent. Not conceived of.

And yes, I did walk to work 20 miles one way on crutches in waist deep snow fighting off alligators and snakes along the entire course.

Then in the new millennium, Libby Zion came along and the path of least resistance led to the proposition that residents were overworked and too sleepy to function so they had to be given a break. That evolved to a situation where medical students and residents became entitled. No more of this “service” stuff, it has to be all book learning education. Complaints of “I’m overworked” are forwarded to the RRC (Residency something Committee) a body that immediately investigates all such complaints and the burden is on the teaching program that they’re not overburdening the poor babies with a work load that they can’t handle. As a result, that work load gets smaller every year.

This is an honest to God true anecdote told to me by the Chair of one of our clinical departments here. He was teaching a session for medical students on some subject he felt was important and after a while one of the students raised her hand. She told him maybe he had spent enough time on this subject and maybe he should move on. Astonished, he told her he wasn’t finished yet, whereupon she picked up her books and walked out.

Medical Emergency Teams (MET) appear in at least some, not all, data to be doing a good job in interdicting acute deterioration episodes for hospital inpatients. As they evolve, however, the propensity for nurses to call for the MET instead of the responsible resident evolves with it, for a number of complex reasons. Then the responsible resident stands at the back of a crowd of people watching as their patient is taken care of by someone else. The issue as far as the hospital is concerned is that patient safety trumps medical education, and that may be. But in the immortal words of Bill Gates:

“We always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next ten”

And that’s exactly what’s happening with medical education. We’ve entered a realm where the “education” portion has exceeded the “experience” portion. We’re teaching them all the contents of the Textbook of Medicine and then sending them out into a world where the translation of education into experience is required to survive, and it isn’t there. They were standing in the back of the crowd that day, and every day they survive the mix is a day that their minuscule experience base fails them. To be exceeded only by the next wave of graduates.

Similarly, critical care fellows have complained about night and weekends now for the 28 years I have been involved with the UPMC system and they are following the lead of the rest of them. When I was a fellow in 1986, I was on call every third night and every other night when someone one went on vacation or got sick. Now the fellows are on call one night a week and the night calls are progressively being taken over by Certified Nurse Practitioners and Physicians Assistants. The fellows want to think of themselves as executives now, in a teaching and mentoring mode for the night and weekend crews. How they are getting that knowledge base now is with books and simulators.

I hasten to add that there is nothing intrinsically wrong with the CRNP and PA mode of direct patient call after hours. I have some in the NICU and they are REALLY great in every respect. They do EXCELLENT patient care and they know when to call for the executive modulators, which consist of the Resource Intensivists covering the house at night.

The problem with this model is that since every critical care fellow has the same training as most other residents in their specialty, they are at risk for the same dumbing-down (not always). As the syndrome as Med Student/resident Entitlement continues, will the fellows not bear fruit from the poisoned tree? Unclear at this point. We shall see.

There has been a lot of hand wringing about the poor overworked physician trainees that I am not particularly impressed with. I went through all that and not only did I survive, it made me a provider that is never surprised at ANY clinical situation because I’ve seen them all, and there aren’t many physicians that have had a fuller personal life than me (trust me on this).

Hand wringers lament that overwork and overstress creates drop outs, landing in psychiatrists office, going through ten divorces or killing themselves from what amounts to PTSD related disorders. Sorry, I can’t fix those that sink into PTSD. I wish there was a better way to sort those with a tendency for PTSD out before they get into medical school (unlikely as long as grades move all). I went through all that in Vietnam and I just worked it out and went on. I know Viet vets that thrived on it and wish they could go back and do more of it. PTSD is just luck of the draw.

I don’t know what the fix is for PTSD. I think arbitrarily decreasing work loads may solve some of it but invokes the Great Principle of Unintended Consequences (GPUC), we’re seeing it now and we will continue to see it in the future. Well rested physicians aren’t necessarily the ones you want to look up and see during a disaster in the middle of the night. But then at the rate things are going, no one may ever see one after 5 pm anyway.

I am the last of my kind.

A few notes on State of Pennsylvania health care politics


This missive is an abstract of two letters to a friend asking me to sign a petition urging current Pennsylvania Governor to “do the right thing” and expand Medicaid benefits in our State. Sadly, I think the fate of that issue is not amenable to public or provider opinion, for the reasons outlined below.


In order for this petition to have any impact, two variables must be expressed positively.

  1. Tom Corbett must care about the welfare of those that will lack meaningful health care if Medicaid expansion doesn’t occur. There is little evidence that he does. Mr. Corbett is a Republican, which means by political inclination he has little interest in the financial woes of those impacted by Medicaid and has continued to support other Republicans efforts to cut even more of their resources.
  1. Tom Corbett must be amenable to changing his lifelong political inclination on the basis of rational pleas from providers. This would be a lot like pleading with God to cure your brain tumor. If the tumor spontaneously regresses, it’s the work of God. If it doesn’t, it’s still the work of God but we just don’t understand the celestial logic.

Mr. Corbett is also very likely to be elected out of office soon, to be replaced by an increasingly popular Democratic candidate. You can be sure that Mr. Corbett will do everything in his power to hobble or incapacitate that person who will follow him. Not only is Mr. Corbett insulated from rational persuasion, you can be sure that this decision has already been made and the only issue left is how to present it to the public to minimize the political damage to Mr. Corbett and blame subsequent problems on his successor.

As a Republican Governor, Mr. Corbett’s only interest in Medicaid is cutting it, and since his money connection is the same as all of them, extreme right wing factions, he’s very unlikely to do anything not in the best interest of his political future.

So, unfortunately, we will have to live with the Medicaid issue, or hope an incoming Democratic Governor can cobble together something from the ashes.


Sure. Be happy to sign the petition, but you must keep in mind that this is a political issue not amenable to coercion from special interests (health care providers) for  lot of reasons.  This decision and many others like it were made long ago. The only residual is how to assure political opponents get the blame for unpopularity with those affected after they’re implemented.

Again, Corbett is a more or less as it suits him “conservative” Republican which means among other thing (1) he’s committed to insure the rich get richer on the backs of the disadvantaged and (2) he lays awake every night praying and dreaming of how to get rid of the Affordable Care Act of 2008 (see #1).  So, Corbett has already decided that the only way he will approve any help for the poor is if he can make them pay more or work for their pittance. Yes….sickly single mothers of three and chronically ill old people up every morning to report to a WPA-like assignment.  Why not whips and chains.

The only public coercion that would move Corbett is if he figured some of it might hurt him politically. Unlikely for at least two reasons:

  1. Corbett is a lead pipe cinch to be dumped in 2016 and replaced by a popular Democrat (Wolf), so the opinions of those affected by his decisions always quickly transfer their ire to the most proximal victim, not the one that made the decisions (Obama in 2010).
  1. Paradoxically, although Republicans are quick to defend richer citizens (doctors), they (we) have managed to get bad enough press that it puts us into a different category- need to cut expenses to show fiscal responsibility. So as the media portray us as greedy abusers of Medicare (millions made ramming patients through “clinics” illegally, we become ripe targets to cut fat from a system with little fat to be cut elsewhere. Besides, Doctors complain a lot but they don’t strike so they’re paper tigers and can be effectively ignored, unlike Teamsters.

This is why since 1997, there has been no permanent fix of Medicare reimbursement policies, instead trying to find a way to tie cuts to the desired demise of the ACA of 2008.  And by the way, all of it is said to be financed by cuts to providers.  By rejecting joint/federal Medicaid expansion under the ACA, Corbett becomes the 11th Republican governor to stiff poor recipients of these funds in a hope of somehow dismantling the ACA.


Corbett would cheerfully toss two-bits at a homeless guy and snarl: “get a job”.  His path to do similarly to Medicaid recipients is pretty clear as well. He’s happy to humbly accept petitions for anything and might even actually have one of his flunkies read and summarize them before they’re trashed. Like Nixon’s response to 200,000 Vietnam vets demonstrating under his window on April 24, 1971 (I was there).


Stress, physicians and age


Physician “burnout” is defined as loss of enthusiasm for work, feelings of cynicism, low sense of personal accomplishment.

I think the factors involved are infinitely complex. I will also hazard a guess that the issue of burnout builds on two fronts:  Stress and Age, and the nomenclature for each is radically different.

Front 1– The peak “burnout” in the age group of 36-45 comes on two groups:

Group 1.  Doctors that emerge from the long training grind to find out they’ve bitten off more than they can chew and are having trouble digesting it. Too many responsibilities, too much work load combined with the era of mortgages, spouses, kids and mounting expenses acquiring the creature comforts lacking in the austere training days.

Group 2.  Doctors that emerge from the grind to find out that their reward was a false promise and they really don’t like living with the end product. The difference between training for a career and the nuts/bolts of the career don’t match and they’re miserable locked into the saddle with no escape.

The salvation of group 1 is usually that the personality type that thrives in this environment is selected out during the gauntlet. Those that can’t hack it fall by the wayside during training, like Navy Seals in boot camp that ring the bell when they’ve had enough. I think this is an unusual burnout group.

I think group 2 is much more common and not necessarily amenable to filtering by the gauntlet. By and large, there is a big qualitative difference between trainees and attendings, and the realities of that difference are not necessarily apparent before the fact. Some seemingly high quality trainees go bust quickly in the clinch and vice versa, and as far as I can tell, it’s very difficult to discern which is which before the saddle is cinched.

I’d hazard a guess that this group is at highest risk for becoming functionally incapacitated, call it what you will, and also I might add a risk for suicide if there is no escape valve.

All complain about the following factors, but most realistic physicians understand these factors are identical to working for any major corporation in any career position.

Bureaucratic tasks, Too many hours, Compassion fatigue, Difficult employer, Difficult colleagues, The Affordable Care Act of 20008

I don’t think I have ever met a doctor that burst into tears at the thought of onerous paperwork. I do know some however that started drinking heavily at the thought of the Affordable Health Care Act of 2008. The stark reality is that all these things are the price of admission to medicine highly unlikely to cause significant lack of professional fulfillment for no other reason than they are ubiquitous to nature.

Front 2-  aging physicians are a much more convoluted and textured phenomenon- physicians who have successfully run the gauntlets to arrive at a place of relative safety only to discover seniority is a new liability. Inevitable physical limitations and the duty and obligation to make way for others climbing up the same ladder behind them. A different and much more subtle order of “burnout” from the rest.

The limitations and hassles of old age are not linear. They escalate rapidly after a variable certain age”. At 65 I was doing four night calls a month and bounced back easily. I was racing motorcycles and doing high-speed track days at 66. I thought of myself as limitless.

Then I slowly discovered my concentration on the track at 120 mph was fading and I started crashing, once twice in the same corner. I quit at age 66+ before I hurt myself or someone else. Night call quickly became difficult to maintain concentration and the day-after became more difficult to bounce back. I still had the same knowledge base but not as much concentration ability to apply it under stress.

At age 70, I have the exact same drive and passion to be the best I can as when I was at the top of my game at 36.  The only limiting factor is my physical ability to bring it all to bear as effectively and efficiently in a world of emerging young people with the same fire in their bellies. Thereby burns the age related “burnout” flame- the fear of becoming irrelevant. An absolutely terrifying, life threatening burden.

That will be the burnout issue that I think will require some creative thought on how to rectify, if it’s even possible.

Epitaph on my headstone:

“This is my generation…..

Hope I die before I get old”

Pete Townshend, 1965. (BTW, Pete is 71 this year)



The “new brain death” in 2014



We now have a completely different complexion on the brain death = death issue.

Back in antiquity (1968) brain death was defined objectively as death so we could get dead people off ventilators. Organ issues came later.  But 1968 was a different world of “life support” than it is now and many of the fine points were unknown then. We can now maintain “lifelike” cadavers indefinitely.

Brain death = death has never rested on structurally firm ethical ground. Brain death persons maintain some bodily integration and have been maintained for months so they could deliver healthy babies. We just drew a line in the sand and made objective criteria for brain dysfunction as a practical matter. Not every cell in the brain stone dead. Brain dead persons were simply “dead enough”.

We also now live in the age of surrogates that don’t want their relatives to die and we accommodate them by maintaining warm cadavers in a lifelike appearance on “life support”. Increasingly they’re demanding their relatives stay that way because if they give the appearance of life, there is always a possibility of unexpected reanimation.

Getting surrogates to accept the concept of brain death = death has never been easy in the best of worlds. A cadaver in the morgue looks decidedly dead. A brain dead cadaver on a ventilator looks decidedly comfortable, even animated. The only reason we’ve gotten away with selling brain death so far is the preponderance of multidisciplinary certitude to families.

The number of surrogates who demand futile care for near-dead persons is increasing anyway. Because of “life support”, they simply don’t believe our prognostications of doom and gloom. Their eyes and emotions tell them differently. With this case, it’s now escalated to brain dead persons, and this has the potential to change the complexion of organ donation.

Surrogates have figured out that they don’t have to accept medical prognostication they never fully believed anyway, and now enforce it legally. The groundswell for maintaining this warm cadaver is astounding.  An Internet site to raise money for her “life support” maintenance containing at last count US$28,000, all from the grass roots. Pastors of local churches imploring the court to “save this poor innocent’s life”, 60’s style marches chanting “Don’t kill Jahi!”. The child’s uncle declaring on NBC Nightly News that the child’s mother is certain she responds to her.

This is not a fluctuation in the ether. This is a gift that will keep on giving and will grow like a sunflower seed in the noon day sun. An increasing number of surrogates have now figured out they can get their way, any way they want, simply by calling a lawyer. Once it gets into court, the justice system always errs on the side of “life” as the court understands it. Sustenance of vital signs.

This is now a totally new paradigm in organ donation. It’s been a long time coming and it’s now here.


CCM-L Member Response: An element that you don’t discuss below is the question of reimbursement. According to news reports, her family’s insurance continues to cover her care while hospitalized. If this becomes more of a trend, I suspect that the carriers will quickly stop that sort of “flexibility” around reimbursement.

I say;  Health care insurers understand the reality that hospitals must continue to care for patients whether they get paid or not. So they routinely get away with rationing and conserving at the provider level, not at the level of their insured. They cut payments to providers retrospectively on the basis of paperwork while assuring their clients they are fully insured. This is a political reality.

The truly significant part of this travesty is the groundswell at the grass roots level. People contributing to the on-line fund. The 60’s, Berkeley style marchers carrying placards, just like “End the Vietnam War”. The public media revelation that the mother “feels like the child responds to her”.

All that means that the groundswell here is NOT limited to this particular family as outliers. It’s broken into the mainstream now, and you can bet your sweet bippy it will “go viral” like a youtube video of Britney Spears naked.

As of now, the “law” pertaining to death by neurologic criteria is moot. Anyone that simply doesn’t believe in death by neurologic criteria can trump it quickly and efficiently by getting a lawyer and petitioning the court. Hungry lawyers looking for work will fall all over this. The precedent is set and a significant portion of the public seems to support it. Do you see marchers today with “This is ridiculous” placards?

This has MASSIVE implications for organ donorship.

CCM-L Member Response: Not intending to make a political statement, but I suspect even more strongly that someone covered by Obamacare will find that reimbursement stop even more quickly.

I say: There is no currently convincing evidence that the Affordable Care Act of 2008 will act any differently than any other “private” company, equally as reluctant to face the political firestorm of “saying no” to their insured. Tradition has it that “saying no” to providers is the path of least resistance.


Update:  (1/1/2014)

The family’s court filings said New Beginnings Community Center in Medford N.Y., is willing to take Jahi and provide 24-hour medical care. The center was founded by a former hair stylist whose father suffered traumatic brain injury after a 2007 motorcycle crash. New Beginnings founder and owner Allyson Scerri shared a statement on her Facebook page Tuesday explaining how her facility “is about preserving life and treating brain-injured patients with care and dignity.” “We do encourage every citizen to take the time to educate themselves more clearly on the issues of what brain death is and what it is not,” the New Beginnings statement read. “This child has been defined as a deceased person, yet she has all the functional attributes of a living person despite her brain injury.”

(Did I mention radical right-to-lifers…….)

On Tuesday, the Terri Schiavo Foundation, named for the Florida woman who provoked a national debate about end-of-life-issues when she was diagnosed as being in a persistent vegetative state, said it had been helping Jahi’s family find a facility that would take the girl.

Some thoughts on mandatory influenza prophylaxis


This month marks a year since I got a demyelinating spinal cord disorder a week after getting the same flu shot I had received every year for at least 20 years. This one happened to be the one that liked me spinal cord better than the virus. It is very slowly improving but definitely still there.

Both of my lower legs are on fire 24 hours a day. Just like both legs immersed in a bath of hot water. Both hands are the same. It appears to be completely sensory in nature but now maybe not. My personal gym trainer noticed that all my muscle groups are consistently tight, then nagged me for months to have a massage therapist check it out. So I finally relented and had one bend my bones for an hour, She said every muscle group was tighter than a turkey’s ass, especially the muscles of my feet and lower legs and that was unusual. So there may be some long-term motor stuff as well.

Neurologist says it might go as long as two years but if it goes longer; I’m probably stuck with it. I’ve learned to live with it and it rarely interferes with my daily life.

I DO believe in immunizations, especially as it pertains to children. I fervently believe Jenny McCarthy, who made a career as a dumb blond really is one as it pertains to children’s immunization and she has all the credibility of Sarah Palin.

And that said, I hope the efficacy of flu immunizations are at least better than chance for adults. If so,then complications such as mine for a few are collateral damage that must be accepted to gain the benefit of many. But there are some problems as it pertains to mandatory injections for all health care workers.

First, I would like to see more convincing evidence that the flu shot actually works. People get the shot every year and are relived that they didn’t get the flu. I have elephant repellant in my back yard and I’ve never seen an elephant back there. Does that mean the repellant works? What if they do get the flu after accepting the shot? Is it the old Christian paradox, if you have good luck, its God’s working in your life. If you have bad luck, it’s still good, you just don’t understand the big picture of God’s will. If I am to accept the bad luck component for me, I’d like a little more evidence that the flu shot has a better than chance potential for mass benefit.

Second is the consent issue. I can assure you after going through this that there is NO informed consent involving potential complications of the flu shot. Anyone who asks is told that the occasional complication may occur but it’s minuscule compared to the benefit for all so don’t worry abut it. If asked specifically about the potential for Guillian-Barre, they are told this possibility is shown in the literature to be about the same as chance. BTW, this year I had a woman with Guillian-Barre that developed a week after her flu shot in my ICU. That’s two cases in this hospital this year.

So, everyone lining up for the shots are overwhelmed by good news and any potential for bad news buried. Fine. But we are a society that runs on informed consent, so much so that it frequently gets ridiculous. So should everyone in line be told that there have been two potentially serious complications of the flu shot this year in this hospital (that we know of).

But that implies they have the option to decline the shot, an option that is rapidly disappearing. The crushing wave of optimism for an injection containing various iterations of virus has now reached the point where the issue of informed consent is crushed with it. The prevailing opinion that darts thrown at a list of a thousand potential damaging viruses will hit the right ones has obliterated the issue of options.

In New York, a law is being considered, and will probably pass, that will create incentive for getting the flu shot by punitive measures. If anyone opts out, they must wear a “surgical mask” everywhere in the hospital. Now the wave of optimism for flu shots turns into a gun to the head.

This is straight up coercion with an empty gesture. There is NO evidence in any world literature that suggests ANY efficacy for surgical masks preventing spread of virus or anything else. When the ‘bird flu” came along a few years ago, I attended a mandatory lecture and fitting of a “real” effective mask we would be wearing. It was bulky, heavy and incredibly uncomfortable. The audience was told in no uncertain terms that surgical masks were worthless and no one would be wearing one.

So the mandatory wearing of a surgical mask to prevent spread of virus is not to prevent spread of virus. It’s to provide an incentive to avoid having to wear a mask everywhere. We’ve now entered theater of the bizarre.

I continue to be conflicted. On one end, I do believe in immunizations and I support them, even accepting the occasional complication. On the other end, I’m not so sure about FORCING health care workers to line up and get with the program in the face of weak evidence and known life threatening complications, however rare.

Patients, prospective or otherwise, are said to have a right to determine medical treatment on the basis of informed consent. Every other hospitalized patient can, and frequently does refuse treatment even when informed the benefit greatly exceeds the marginal risk. And they do so with total impunity. Are we now suspending that societal maxim for the flu shots because our optimism exceeds theirs?

So, I will be watching all this unfold from the sofa of fraternity rejects of “Animal House”.

How to deal with psychiatrists


tumblr_lv6alyj3O71qz9ffqPsychiatry is a different world, a different universe. So when some medical guy in a white coat, lots of badges and a stethoscope in the pocket goes over there, it’s a big entertainment deal, like half of LA showing up when U2 plays “Street with no name” on the top of a building. They come from all over and hang from the rafters.

So, the most effective way to deal with Psychiatry is to walk in there with a totally authoritative air….fix them all with a withering sneer and…..of course……sing a bar of “Alice’s restaurant”.

(in A minor) “So I wanted to look like the all American kid from New York City.
I wanted to BE the all American kid from New York City,
So I walked in, sat down, I was hung down, brung down, hung up, and all
kinds o’ nasty ugly things. And I walked in and sat down and they gave
me a piece of paper, said, “Kid, see the pyschiatrist, room 604.”

So I went up there, sat down and I said, “Shrink, I want to kill.
I mean, I wanna, I wanna kill. Kill.
I wanna, I wanna…….. I wanna see blood and gore and guts and veins in my teeth.
Eat dead burnt bodies. I mean kill, Kill, KILL, KILL.”
And I started jumpin up and down yelling, “KILL, KILL, KILL” and
he started jumpin up and down with me and we was both jumping up and down
yelling, “KILL, KILL KILL.” And the sargeant came over, pinned a medal on me,
sent me down the hall, said, “You’re our boy.”

Then of course, nail down the group experience:

…….the only reason I’m singin’ you this song now is cause
you may know somebody in a similar situation, or you may be in a
similar situation, and if your in a situation like that there’s only
one thing you can do and that’s walk into the shrink wherever
you are ,just walk in say “Shrink,
You can get anything you want, at Alice’s restaurant.”. And walk out.

You know, if one person, just one person does it they may think he’s really sick and
they won’t take him. And if two people, two people do it, in harmony,
they may think they’re both gay and they won’t take either of ’em.
And three people do it, three, can you imagine, three people walking in
singin a bar of Alice’s Restaurant and walking out. They may think it’s an
organization. And can you, can you imagine fifty people a day, I said
fifty people a day walking in singin’ a bar of Alice’s Restaurant and
walking out. And friends they may thinks it’s a movement.
And that’s what it is , the Alice’s Restaurant Anti-Massacre Movement,
and all you got to do to join is sing it the next time it come’s around on the
guitar. (With feeling).

So we’ll wait for it to come around on the guitar, here and
sing it when it does. Here it comes-

“You can get anything you want, at Alice’s Restaurant
You can get anything you want, at Alice’s Restaurant
(patient chimes in “excepting Alice”)
Walk right in it’s around the back
Just a half a mile from the railroad track
You can get anything you want, at Alice’s Restaurant

Some late breaking comments on medical politics (from Med-Events)


>The system in US is now designed

>to fail. The AHCA of 2008 will destroy

>American Healthcare as we know it.

>It is all over. “The government is here

>and they are here to help”.

Crippen:  The above cluster of sour grapes is political in nature and ordinarily, I would scotch it immediately but I can’t let you get away with it as a stand-alone without an alternative view.

In 1965, the medical establishment, including the AMA and my father the surgeon loudly exclaimed that Medicare and Medicaid would “destroy American health care as we know it”.  In fact, those services made my father’s generation of physicians rich and created the Medical-Industrial Complex which has now grown to the point where it threatens to “destroy American health care as we know it” by it’s sheer volume and weight. The Affordable Health Care Act of 2008 is not needed to hasten that eventuality.

The bill for a typical 6-day hospital stay for childbirth in 1951 was $85—well within the out of pocket range of most families. A 6-day hospitalization for cardiac workup at a large urban hospital in 2010 has recently been calculated to be $19,254; the facility lost $2,695 of that amount after reimbursement.

This cost situation arose in part because physicians in such a system have little motivation to reduce costs, given that the care is paid for by a third party relatively unable to process the value of need versus desire. Similarly, consumers of health care are not the purchasers thereof and so have little motivation to assess cost versus value. More is always better, especially when it is free.

Virtually every other civilized country in the global village has evolved to lowest common denominator of health care for ALL of their citizens, and that is single payer, government sponsored health care indemnification. The price paid for that is enforced prioritization of entry and “saying no” to expensive treatment that has a dismal benefit at great cost. It isn’t perfect, but in the end, everyone is covered and it’s more or less affordable. America runs on a consumer satisfaction mode, a situation that everyone agrees is unsustainable even if it were not for the global recession of 2008.

In 2009, the USA spent (all told) twenty five trillion dollars on health care but only indemnified about 40% of its population (some are underinsured). That’s US$8,000 per person, 17.3% of the GDP and increasing about 6% annually.  The USA ranks below Portugal in preventable mortality.  California increased its cost of health insurance 20% this year and there is no end in sight. As the price of health care goes up, fewer businesses can afford health care for their employees.  62% of all personal bankruptcies involve medical bills in 2010.

So, the AHCA of 2008 is not anywhere on this screen. We’re on our way to insolvency all by ourselves right now, and we’re still only covering a small portion of our population doing it, expensively and inefficiently.

The AHCA of 2008 purports rectify three glaring omissions we don’t have now. It effectively ends insurance payment discrimination, adds an estimated 31 million needy potential patients to an already overloaded system and it’s portable. These are all GOOD things, and I might add GOOD things that most if not all of the other civilized countries in the global village provide for their citizens.

The argument against the AHCA of 2008 is twofold:  a) Straight up political partisanship. ANYTHING that comes out of this sitting President is spawn of the devil, and: b) It will be expensive.  However, complaining that the AHCA is going to break the bank implies that the bank would remain solvent without it. Nothing could be further than the truth. The bank is hemorrhaging right out into the street and is reliably headed for insolvency all on it’s own. The worst that can be said about the AHCA is it will hasten the process. Maybe.

So if you ignore the political aspects, which you definitely should, what remains is how to finance it. Of course the best way is to mandate everyone buy into it to keep the cost of participating down. If anyone is allowed to opt out, our culture mandates we still have to treat them anyway. So if opt-out is allowed, it will collapse instantly. We’ll see how that works out.

Otherwise, there is another reality that must be faced. There is NO possibility of a system that creates demand and then supplies it in a customer satisfaction mode can remain solvent. So, if the whole system is swirling around the bowl, which it is, there are several options available, two of which are painful prescriptions for providers.

1.    Allocate resources toward health care and away from other previous priorities such as entitlement programs, military security, and bureaucratic priorities.

2.    Pay providers less for the same (or increased) workload.

3.    Reorganize health care spending so that more money is spent on some services and less or nothing is spent on others; essentially, say no more often.

History suggests that it is unlikely any modern society can or will decrease support of entitlements such as social welfare, unemployment insurance, social security benefits, or retirement benefits that citizens depend on and have paid into during their working careers. Cutting military security funding is equally unlikely. Most if not all national budgets include little else that can be reallocated in any meaningful amount. That leaves options 2 and 3. It is virtually certain that providers will have to reorganize their priorities one way or the other, and accept less remuneration in the process.

So denigrating the AHCA because it will break the bank is (I think) a “straw man” argument. We’re pointing our finger at something that hasn’t even happened yet as we descend into the depths. We can continue on the path we’re on into insolvency while indemnifying only a portion of our patients at huge expense and great inefficiency, or we can continue toward insolvency indemnifying 96% of our patients more efficiently avoiding personal bankruptcies, asking our providers to work harder for less pay. Then we can just pay for it and get over it.

If we decide not to just pay for it and get over it, we’re going to crash, and when we do, we’ll discover the reason why most of the other civilized countries of the global village have evolved to single payer system, prioritization, saying no and standing in line.

BTW, the government is indeed here and it’s helping. MOST health care in this country is government funded. All care for Washington politicians, military, VA system, Medicare, Medicai

>In critical care, the trend is to use Nurse

>Practitioners and Physicians

>Assistance to do the grunt work,

>especially at night, with the physicians

>evolving to executive managers.

Crippen:  The problem of course is the eventuality of all chiefs and no Indians. Critical Care fellows are clearly showing signs of wanting to get away from clinical responders to become managers. So the practical problem then becomes who will do the grunt work to be managed by suits. I see the model as the rise of NPs to fill the available niche field where doctors once grazed.

I would be surprised if Physicians Assistants moved much into that niche, not because they are any less competent than NPs but simply because the NPs have more experience in ICU patients care. Most of them, including ours are former ICU nurses. That’s just my initial thought, and again, I hasten to add that I know PAs here and elsewhere and I would NOT disparage them, all other factors remaining equal. It’s a matter of local experience in the field where they work.

The issue of ICU (in my case, NICU) nurses taking orders from NPs is going to be interesting to sort out. In my case, the NCU nurses feel a bond with Danielle because she is one of them, and also of course, that she knows how to generate confidence and when to call me to get involved when needed. So they feel comfortable with her because they trust her nursing judgment that has come u a level and they know she knows when to call, and if she doesn’t, they know they can call me anytime. This issue has not expressed itself with Danielle, but it might in the future with others. I might add that I am also impressed with the NP over in the neuro-trauma unit next door to me and she has similar trust and acceptance from their nurses. I think this issue will sort itself out in time for no other reason than if an individual is found wanting, they won’t be working here.

I am very concerned that doctors are abdicating direct patient care because it’s too time and energy consuming and there are too many hassles.  OK, here comes the “I slogged to school in three feet of snow” speech.  When my ilk and I were residents, we were expected to have a head of steam because that was how the game was played, and the rules had been established long before us.  Our job was to deal with ALL the patient care issues, and do them well or we would be fired. Every buck stopped with us. If any of us couldn’t take it, there were lots of other things to drop out into, like dermatology and ophthalmology.

The upscale of that, especially in surgery and critical care is that helpless, defenseless people had at least a shot at reversal of a death spiral, especially after hours when it was inconvenient and everyone was tired. Maybe not perfect, but at shot at it.  Once “intermediate” providers replace that ethos, then the disasters in the middle of the night will have a shot, but that shot will be holding on till the suit arrives. Better deal? More cost effective? Depends on which side of the bed you’re on.

Will NPs eventually evolve to the former expertise and experience of doctors, rendering them moot?  It’s possible. Is that a good thing?  I don’t know. Remains to be seen. Will NPs be more “cost effective”?  Not as they increase in expertise and experience. They’ll unionize and get into collective bargaining. (Unless they live in Wisconsin).

I lament the hard working, chronically tired resident that held the seams of the hospital together.

I am the last of my kind.

>WASHINGTON – The Obama administration

>said Monday that states could cut

>Medicaid payments to many doctors

>and other health care providers to hold

>down costs in the program, which insures

>60 million low-income people and

>will soon cover many more under the new health >care law.

Crippen:  You and I and everyone else knew this was coming.  If you’re a conservative Republican you lay it all at the feet of ANY Democratic President, but it goes infinitely deeper than that, deeper than even the Prince of Darkness himself (Bush).

The fact is that all of it has been going bust for a very long time. Long enough for each political party in turn to blame the other for having to do what it takes to control it. The fact also is that there is no inherent limit to the expenses of government funded health care programs because they are consumer satisfaction driven. There is no upper limit of expense and no one can “say no”.  This in the face of a virtually unlimited demand.

It’s political malfeasance to tell consumers in this kind of market that you’re “limiting” their care, especially if it in evolved saving YOU money. They don’t care about YOUR money. They go on TV talk shows and whine about how the “government” is trying to kill them to save a buck or two. Anyone that advocates limiting anything it immediately voted out of office with a strong odor of tar & feathers in the air.

So you can bet your sweet bippy no one on the reimbursement side is going to the demand side talking resource allocation. They have NO choice but to go to the supply side because that’s the only side there is.

Go to providers and ask that they voluntarily become more efficient (saving money).  Ha. When was the last time you saw that happen? Providers make their living by doing as much as they possibly can, and in the process expending other people’s resources. In an ICU, an empty bed is a loss so it’s filled with whatever comes down the line. An ED bed that isn’t filled is a money loss.  So, if the reimbursers don’t do SOMETHING, they will quickly go broke in a scheme of maximum demand and providers happy to fill it.

In the past they have tried limiting access to the system by the Clinton Plan (refuse to let them in on pre-determined algorithms). That resulted in anger and retribution that waxed political. Then they tried rationing by inconvenience (didn’t pay for paperwork omissions). Providers became expert paper shufflers. Then they devised DRGs, but followed quickly by endless outliers that still paid.  Providers are like terrorists. They’re always one step ahead of any attempt to limit them. The American way of resourcefulness.

So now that everything else has been tried, there are only two ploys to avoid going broke left.

1.  Simply pay providers less and let a bunch of them go out of business or quit.

2.  Bundle everything and don’t pay a cent for anything extra.

For # 1, the long-term detriment will be some hospitals will go belly up and some providers will quit in fits of pique.  The reimbursers don’t care, and the big hospital systems that can negotiate sweetheart deals don’t care either. You hear all the time doctors loudly claiming “I’ll quit if they do X…Y  or Z”.  Trust me, they won’t. They all have mortgages, kids in private school, Jaguars and high maintenance females on the side (for the males. Maybe for some females too). Remember back in the 70s on Saturday Night Live, the gaggle of adolescent girls at a slumber party discussing what it might feel like (to them) to have sex?  They all said “Ewwwwwww  I’d never do that!!!.  All but one in the back who quietly opined: “Well….I might”.  That’s the way it will go. It doesn’t matter how much of a cutback, there will always be those that will work. The “best and the brightest”?  Maybe not, but the establishment doesn’t care.

#2 is the almost perfect relief. A patient comes in for treatment or hospitalization and the reimbursement is what it is. No more. Just like DRGs except ironclad and no “DRG creep”.  The fallout will fall out on providers and institutions, neither of who will have any wiggle room because the patient anger and frustration will fall on them, not the reimbursers.

So the hospitals will admit a 90 year old with unresponsive Grade 5 subarachnoid hemorrhage and maintain them in an ICU as long as the family wants, but only at a flat rate. The hospital and/or provider get to decide whether to tell the unrealistic family “no more”.  The reimbursers say: “not our problem, you’re (patient) “insured” as we promised, work out the details with those other guys”.

Hospitals going belly up rather than offend patients and their families?  Providers quitting in fits of pique?  So much the better. The point was to limit demand and also limit the supply induced by it.

>The issue of providers as popularity

>contest- about an ER doc who was

>called in to the admin office for making

>the highest score on a patient survey.

>He made the first 100% ever and

>everyone was so impressed.

>They were all showering him with praise…..

Crippen:  It should be well understood that no hospital administration anywhere cares even a little bit about who’s naughty or nice in terms of direct patient care. It’s straight up marketing.

Previously they did more or less “anonymous” polls, then they advertise to the public that they have “nice” doctors (ergo, they must be “good” doctors as well) so prospective visitors to an ED should take this information into account.

Shortly before the late St. Francis Medical Center went under, the administration allotted a bunch of money to advertise their ED. The gist was to get more ED admissions by advertising convenience and rapidity of service. I told them they would lose money, but they, being the power players, disagreed, and so several weeks thereafter, several big billboards went up in the area featuring the then head of the ED sitting on his bed putting on a pair of running shoes.

The blurb went something like: “Dr. X X is getting ready for his day serving you and he will be running all day doing it”, or some such. So of course, months later, the statistics showed a decrease in hospital revenue (but an increase in the revenue of the private group running the ED. Convenience clinic patients that liked fast service increased, but none of them were admitted, most had trivial complaints that didn’t bring in any billing and many of them were not insured.

To a hospital, EDs are all about getting their clutches on patients that need to be admitted. That’s where they make their money. Admissions occurred when family practice and Internist types admitted patients from their office or electively.

No now a new tack of actually identifying specific doctors that are naughty, not nice. Everyone knows good” providers are nice. This is now a ploy for identifying individuals that can be moved to lower reimbursement because if they’re not nice, they must be poor quality providers.

And what does “nice” entail?  Do they give out clear, understandable information? Do they pay any attention to the patient? Did the patient get better?

Maybe.  Or does the patient feel like his or her “customer satisfaction” needs are met irrespective of how realistic or how stupid they are? Do you think an “administration” is capable of sorting out these concepts on the basis of a poll?

>”Welcome back my friends to the

>show that never ends

>We’re so glad you could attend

>Come inside! Come inside”!

ELP from Brain Salad Surgery (1973)

>Medicine keeps getting harder.

>And fewer and fewer folks are doing it.

>America has no idea that the weight of

>it all is falling on the shoulders of the

>emergency physicians and hospitalists

>who lurk inside the trauma rooms and

> inpatient floors, the fast tracks and

>ICUs of their community and university

> hospitals.

>The pasty-pale, coffee-sucking,

>junk-food-eating Spartans of health

>care who will bear the full assault

>of health care reform when there

>aren’t enough primary care doctors

>to manage an AARP convention,

>much less all of America.

Edwin Leap, Emergency

Medicine News,

January 2013.

Crippen:  Maybe not much longer. I continue in touch with a congressional committee on some of these things (as a resource for my last book), and it is clear that the government has the above issue in its cross hairs. It takes the government a while to sort these things out but when they finally do, they’re pretty ruthless and efficient in fixing it. And by fixing, I mean fixing by two means:

1.  Insuring it’s someone else’s problem

2.  Not suffering any liability for cost

There are numerous literature cites stating that the number of patients entering an overheated (ED) provision system could be reduced safely and effectively by simply identifying those that don’t need urgent care and referring them elsewhere. This would, of course, go a long way in solving the overcrowding problem. It would also deep six the need for building and staffing more EDs to handle the load, so ACEP has reliably come out against it much like the NRA reliably comes out against gun control. Lobbyists are as lobbyists do.

It has been the thesis of ACEP that a runny nose only a runny nose until meningitis is ruled out (by an emergency physician) and that since Americans have zero tolerance for mistakes, these patients must be seen anytime they feel like it and someone must pay for it. I think as I sit here the current charge for actually walking into an ED and sitting down breathing room air is somewhere in the range of US$300.00. That’s before anything else is done. Most folks get a few tests. EGKs and CXRs are read (and billed for) by ED physicians and cardiologists and radiologists later.  It isn’t uncommon to ring up a bill for US$1000.00 to evaluate a common cold. After all, pneumonia and early system sepsis must be ruled out, after all:” can be sued if I’m wrong and I don’t do enough tests”. And so it goes.

Some (not all) insurance grudgingly pays for that, but as I remark freely, the bottom of the barrel is slowly coming into view. So now as the worm slowly turns, we are hearing the President of the United States decry overcrowding in EDs and people using EDs as primary care facilities. This was a good selling point for expanding health care benefits via the Affordable Health Care Act of 2008. But not so fast…..Expanding health care benefits and paying for it by blank checks are two different things. It’s possible, even likely that expanding health care benefits may also come to pass by directing patients to the “right” venue (cost effective) instead of allowing them to go where it’s most convenient.

Now, I hasten to add that this was tried under Clinton and was an abysmal failure. But remember that the government is slow to learn from its mistakes but they eventually get around to it. Denying admission to an ED at the door for a seemingly bullshit complaint historically doesn’t work, but actually screening a patient (EMTALA style) and THEN referring them elsewhere is a different breed of cat.  Patients MUST be admitted to an ED on demand (EMTALA) but after screening, they don’t necessarily have to stay there.

So I’m told by somewhat occult sources, the government is considering a new reimbursement deal where it will pay (presumably doctors or even NPs) not to evaluate and treat in the ED, but to screen for need to be in an ED. Naturally, that reimbursement will be dramatically less than an on-site E & M. If no emergent issue found, they will be referred out.  The ACEP lobbyists will squeal like pigs in hot oil, but anymore, those holding the purse strings define the rules of the game. ED’s refuse to screen?  The President of the United States then decries the Medical Industrial Complex holding up fiscal responsibility progress for their own pocketbooks. Here we have a way of saving money and increasing efficiency of medical care. Why are these guys dragging their feet?

Next problem is where are all those ragged unwashed found wanting for ED care going to go?  Unclear how that will work, as it is as unclear how the AHCA of 2008 will work. Probably make a lot of it up as it goes along.

The point is that using EDs for convenience care at exorbitant prices enriches individuals (ED provider groups.  Remember “Coastal”?  These guys operate to their own benefit and to the detriment of the whole system.  They bill differently than hospitals and they have no incentive to conserve anything. Those paying for health care have an intense incentive to bring providers’ incentives into line with global conservation. That fact has been identified and will be fixed. As I have mentioned before, I think my bias is that Private Practice is going the way of the funny looking animals in Stephen Streat’s back yard.  Any “independent” provider has a much stronger incentive to enrich him or herself at the expenses of the system and must be controlled by the system. There is no guarantee it will be fixed efficiently or even effectively, but it will definitely be fixed.

Pin me to a guess after marinating in hospital/ED soup for 30 years, I look down the road and I see three species of “Emergency’ Services”. Joe Lex’s mileage will probably vary.

1.  Straight up convenience clinics, staffed by NPS, reasonable out of pocket fees. No insurance.

2.  Screening centers. Authentic “urgencies” identified?  Transfer to a mother ship by ambulance or private car if the relatives are willing and it’s deemed relatively safe. Insurance will pay for this service, but not anywhere near what an ED bills for an ED evaluation.

3.  A genuine “Emergency Center”. No walk-ins. Only referrals. Insurance will pay for all of it.

Will that “solve” the problem of inappropriate ED admissions and people using EDs as convenience/primary care centers? Will it save money? Maybe, maybe not, but it will definitely invoke the Principle of Unintended Consequences that will then guide future evolution.

Withdrawing life support after severe brain injury (complicated post)


Is Life Support Being Withdrawn Too Soon After ICH?
Medscape Medical News, 2013-02-13

Claude Hemphill et al have written about this concept for years.  Claude’s enormous heart is in the right place. He and everyone else for that matter desires to do the right thing in terms of maximizing treatment to get the best outcome possible.  However, the author here is preaching to the wrong choir. This is not an article per se, but a review of a concept by “Medscape”, the “People Magazine” of medical information.  The information therein is just vague enough to potentially suggest to family practitioners and patient surrogates that read Medscape that the “more is better” theory is synonymous with “if more is better than more than that might be better yet.”

The issue of prospective living wills and powers of attorney for health care delivery is not mentioned, so one might get the impression that a good course might be to suggest that an incompetent patient who has previously opted out for extended ICU care on “life support” might have made a “better” decision on the basis of this data. If that’s the case, then as the French say: “Ze worm….. it is out of ze can” as it pertains to other prospective wish issues.

This article opines:  “Those outcomes in these patients may not still be true today with our sophisticated medical care”.  There is no convincing data to suggest this is true in many, many ICU treatments, many of which convert death to life-in-death ensconced in skilled nursing facilities. The “we can do so much more than we used to” argument is directly responsible for many surrogate demands for open-ended ICU care. The mortality and morbidity statistics for ICU care have changed little in the past 20 years, and recent evidence of an intensive four year study by Levy and Chalfin et al rather convincingly suggest that the odds of hospital mortality were higher for patients managed by ICU physicians than not *.

3.  The article does not mention any limits as to how much longer an ICU admission will take to generate how much improvement in a patient to break the threshold of “acceptable quality of life”.  So, which scenario do you believe according to the ongoing clinical evidence, not the prospective optimism:

A. Each additional day of ICU care has
increasing potential to generate a viable
patient and each additional treatment
has more potential to improve outcome?

B.  Each additional day of ICU care
Does not show any improvement and each additional
therapeutic treatment has more potential
to prolong length of stay?

If you take the position that each additional day of ICU care has diminishing potential to generate a viable patient, but each additional therapeutic treatment has more potential to increase length of stay based on “hope”, then you have elevated “hope” to a self fulfilling prophesy. Your responsibility to your resource allocation system is to give up.  It isn’t a “right thing to do” anymore. It becomes practical economics. There IS a limit and you’ve reached it.

If, however, you take the position that each additional day of ICU care has increasing potential to generate a viable patient, and each additional treatment has more potential to improve quality of life than the one before it, then you will be asked to support that position not as the “right thing to do” in a perfect world but in terms of cost/benefit. When is it a straight up money issue.

In 2009, the USA spent (all told) twenty five trillion dollars on health care. That’s US$8,000 per person, 17.3% of the GDP and increasing about 6% annually. But we only fully indemnify about ~ 60% of our population and the USA ranks below Portugal in preventable mortality. California increased its cost of health insurance 20% this year and there is no end in sight. As the price of health care goes up, fewer businesses can afford health care for their employees. 62% of all personal bankruptcies involve medical bills in 2010. The whole system is swirling around the bowl and the advent of the AHCA of 2008 (fully implemented in early 2014), will radically change the whole concept of health care indemnification.

There are several fixation options available, two of which will painful prescriptions for providers.

1.      Allocate resources toward health care and away from other previous priorities such as entitlement programs, military security, and bureaucratic priorities.

2.      Pay providers less for the same (or increased) workload.

3.      Reorganize health care spending so that more money is spent on some services and less or nothing is spent on others; essentially, say no more often.

History suggests that it is unlikely any modern society can or will decrease support of entitlements such as social welfare, unemployment insurance, social security benefits, or retirement benefits that citizens depend on and have paid into during their working careers. Cutting military security funding is equally unlikely. Most if not all national budgets include little else that can be reallocated in any meaningful amount. That leaves options 2 and 3. It is virtually certain that providers will have to reorganize their priorities one way or the other, and accept less remuneration in the process.’’

That said, if the patient is not better in a week, then how long are you wiling to wait on hope-based criteria?  Two weeks?  Six weeks? Indefinitely?   UPMC bills NICU care (full support) at around US$12,000 per day of which it collects about a third from most indemnifiers. I figure the real cost of an ICU day to the hospital is about break even, maybe slightly below. When will the moneymen find a break point instead of you? None of them have arrived in your (or my) office yet, but that day is coming, and when it does, defense of your resource allocation decisions will not be credible if it’s anecdotal. Providers will squeal like pigs in hot oil to be greeted by the stone faces of suits

“All the voyeurs and the lawyers
who can pull a fountain pen,
And put you where they choose,
With the language that they use,
And enslave you till you
work your youth away”

Don McLean (Bronco Bill’s Lament, 1970)

*  http://www.biomedcentral.com/content/pdf/cc8910.pdf

(Sorry- Typos are routine for me. I never proofread. Write it once and never read it again)