“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Friday, April 6, 2007

If only I could hit the ball straight, I would be a great golfer ...

“If you don't know where you are going, any road will get you there.”
~Lewis Carrol

To those who read my posts, I am sorry I haven’t posted for a few days. I have been busy doing busy work. You know those pesky patients keep getting in the way of my free time. How dare they do that? I know I have residents and all. I really should have more free time. I’m told that I should be home at a reasonable time and getting plenty of rest working only 40 or so hours a week. Oh, sorry that was my dream from last night, welcome back to reality. It is summer and I am an orthopaedic surgeon, there may be a few long days.

For all those people who are commenting, I would like to thank you for you encouragement and your disagreements. It is great to get good and bad feedback. I look at this as a dialog. It is like I am welcoming you into my sometimes crazy thought process. I would like to put in a blog a comment that I thought was great. It brings up some major points related to some overall problems in medical care. To those who are residents and/or medical students, most medical educators do not teach you about the business of medicine. When you are in practice and taking care of patients, you spend about 50% of your time doing actual patient care and about 50% of your time dealing with the business of medicine.

This is a comment by Anonymous. (His comment is eerily familiar. I know this voice from somewhere in Ann Arbor.)

He (I assume) stated:

I've previously responded re: 80hr work complaints by the "old guard". I did read you reply carefully and notice you mention it in this post. The problem I have with the old guard is the mess they are leaving behind. Social Security is going to collapse. This is not an exaggeration or dramatization. The excessive medical spending of the 70-80's and the resulting sequelae will be the most important influence on how our practices are shaped financially. I can take complaints about only working 80 hours a week. I just wish I could get some answers.
This brings up great points about the old guard. You know physicians in the past lived the good life. Getting paid almost the same are what they billed. Life was good and the system may have been taken advantage of. Now we are dealing with the repercussions of the past. There is a backlash from medicare and insurance companies. Probable because we did not police our own very well, we allowed malpractice to become an issue. (This may only be part of the issue; most, I think, is a general sense that if something goes wrong, someone is going to pay for it.) Because physicians did so well financially, we did not pay attention to some of the significant changes in medicare and in other areas. We did not have a unifying voice and we allowed media to accuse us of being money hungry people. Because physicians were enjoying the good life, we fell a sleep at wheel and allowed some major things to change. Health Care Financing Administration (HCFA) came through with reforms dictating what needed to be documented to justify bills. Now, most physician practices get routinely audited (by in house people) to assure they are in compliance with HCFA. As stated above, some of these things were brought on by the “old guard” and are going to cause long term consequences, like the problems we will soon see with social security.

He also brings up issues of the stark laws (phase I and phase II).

1. Who is responsible for the offences that necessitated Stark
I&II and Antikickback legislation -the majority of which resembles and was modelled after attempts to combat organized crime?
Stark law I (1989) basically prohibited only self-interested referrals for laboratory services. This was updated in 1993, Congress broadened to Stark II which include referrals of a broad array of "designated health services” Stark I and II had changes again in 1995 and 1998.The final Stark II Regs are substantively different in a number of respects and provide physicians and other contracting parties more flexibility than originally anticipated under the Proposed Regs. Due to significant changes from the Proposed Regs, the Stark laws were issued in phases. "Phase I," which includes the Stark II Regs issued on January 4, 2001, restates or modifies definitions used throughout the Stark law. "Phase II addresses the remainder of Stark II including additional exceptions to the law, and clarifies the application of the Stark law to the Medicaid Program. These laws really affect people who are business oriented and want to expand their ability to increase revenue by investing in their own practice and ancillary services.
Anonymous also makes a statement about my beloved program and a publication that I had also had some questions about.

2. Who can explain to me pg2687 of the December JBJS-A? Plastic surgeons at a traditional "old school" program, U of M, "the U" have essentially been given distal radius fractures by orthopaedics (they put volar locked plates on 161 IN 2 YEARS and Ann Arbor isn't exactly a dangerous place). I've looked into it minimally - it came down to ortho attending level surgeons not wanting the call responsibility.

Will this be a change in thinking? Will we give up services because we don’t want to work that hard? Will residency have to suffer because we are not willing to teach? I don’t know, but it does bring into questions the heart of my fellow attending surgeons. May be we should all go home and let the patients take care of themselves. That is how some people see the future. Peer into the mind of the future.

Anonymous finally begins to discuss a topic that I have already seen to be a problem. It has been discussed on 60 minutes. Should we protect out position or should we allow other providers and countries do what we could do better? Or may be we can’t do better so they are better off going to Podiatrists and to India to have their total knee arthroplasty.

3. Why has industry in recent years so readily embraced overseas providers and non-physician providers? The most common response is physicians pricing themselves out of the market. A recent AMA newsletter detailed non-physician providers gaining authority to offer services through THEIR OWN BOARDS. Of course the podiatry board will be willing to certify their members for knee arthroscopy and pilon reconstruction. In many states it is becoming a legislative issue. Who let this get away? Why is there another report every month about elective hip and knee arthroplasties in India and China? The common response by American surgeons: well we'll band together not to take care of their complications when they are back in the US. It won't be a problem, it will probably be cheaper to keep flying the patients back and forth. None of these employers or benefit plan administrators will even have a list of local providers around the office - nor will they miss it. Non-physicians and their boards Why doesn't the public care?"
In the times where money was plentiful, we opened “specialty hospitals.” It increased our bottom line and lined our pockets. But, it is now catching up with use. There is a moratorium on building specialty hospitals. And larger hospitals are complaining that the specialty hospitals are cherry picking cases, bringing there financial practices under review.

Some Hospitals Call 911 to Save Their Patients" is the title of a 4/2/07 NY Times article detailing a mortality in a surgeon owned specialty hospital. This topic is on its way to legislation (AMA News 3/26/07) NY TimesAMA about specialty hospitals. They are given plenty of reason not to trust us.
Whenever I hear about the "old guard" commenting on something such as the 80hr wk I wish they would just ask them how their generation is leaving the world of medicine? I wish everyone who came out of medical school with less than $100k of debt would take one step back. The time of a national plan is coming it will be generations before "pay for performance" critereon are reasonable and actually based on meaningful medical performance measures - no one reading this in 2007 will see that day. The old guard lived fat off the system. They'll never admit it but SSA isn't going to collapse because they worked a few extra hours a week during residency and that extra work cost Medicare. We're going to be at the mercy of the system that results while they are retired in some house on some beach I'll never see. I just wish instead of the grief, they'd just say "sorry for the mess," and leave us to see what we can sort out.
Anonymous was exactly right in stating that medicine is not what it was in the past. We will never be rich. We will live relatively well. I do see in the future that our practices will be driven by hospitals and insurance companies. This is already occurring. Insurances are telling you that test is not indicated based on a list of criteria that they have on some piece of paper. Hospitals are telling you what implants you can and can’t use based on contract that you have had no say in negotiating. Malpractice companies raise your rates with no provocation and you have no way of changing because the other company is even worse. Patients don’t appreciate the all the hard work you just put into their case; they just want their pain medication and their FMLA form filled out.

Medicine is not what it was. The great physician is now a paper pushing mule. The glory days are over. We are basic blue collar shift workers. It really isn’t about patient care; it is about what I can get from the system. Since the system is not going to provide me with adequate reimbursement, screw the patient.

I am an optimist and I will continue to try an inspire people who are training under me to do the “next right thing.” Many of the things I do, there is no financial benefit. I still love medicine and the smiling face on the patients that to appreciate what you do for them. I guess it is like when I playing golf. Most of the time my shot is 50 yards off to the right, and if that was always the case, I would never go back; but every once in a while I hit the sweet spot and it reminds me why I keep coming back for more.

“A dreamer is one who can only find his way by moonlight, and his punishment is that he sees the dawn before the rest of the world.”

~ Oscar Wilde


Anonymous said...

I would first like to say "hello" to my friend and comment that I am continually amazed at your diverse talents. Second, I would like to respond to this blog which comments on the current state of medicine.
If I described a profession in the following way to a high school or college student, do you think they would be eager to sign up? In the profession of which I speak, you must train at least 7 years past college - most people train for longer. At each step in this path, you must be in the elite of your class in order to have the priviledge to proceed to the next level. When you finish with this training, you will likely be in debt anywhere from 100-250 thousand dollars. During your life after training, each service you provide could result in serious harm or death to another individual. Heaven help you if you do have a bad outcome because the judicial system is waiting to pounce, making your life pretty miserable in the meantime. These facts are in addition to an attitude found in the people you serve that your work and their outcome must be near perfect or someone must pay. You also participate in a profession which charges a fee for a service but receives a much lesser compensation. Not only do we receive a lesser compensation, but we expect it and are thankful because of that pesky training debt which must be paid. In addition, our collegues are generally disgruntled and ask young people like us why in the world we ever would choose this field. Many days we leave our best at the office and our family gets what is left over. As a profession we are generally fatigued, stressed, worried, fearful, angry, and resentful of the profession we freely chose a few or many years ago. I could go on, but I think you get my drift.
The fact is, that many aspects of medicine suck. I personally have never known a different system. This is a good thing because I have no idea how good the old guard had it and I quite honestly do not care. There are lots of things in my profession I do not like and when given the opportunity, I try to participate in changing them. But the fact is that my student loans will eventually be paid just as sure as I will eventually be sued multiple times. My patients will likely not appreciate the efforts I make for them and the time I spend away from my family. There is no rule that says they have to. No one said this was going to be easy and I can tell you for a fact that life could be alot worse. Some may think this attitude is similar to "giving in" or "settling for less." I disagree. My advice to potential or current residents is this: Chuck "the Iceman" Liddell loved mixed martial arts before he was ever on TV or made any real money. He enjoyed knocking people out when he drove a Ford Ranger just as much as now when he drives a Ferrari. He is passionate about what he does. In the medical field there are enough negatives to destroy your spirit if you are not at least somewhat passionate about what you do. If you are in this for other reasons, my suggestion would be to stop now while you are ahead. Find another way to spend your days. But if despite all the negatives you can still find that passion, if that one straight 300 yard drive still lights your fire like it does mine, then put on your gloves and step in that cage - Let's get it on!
Thanks for reading my ramble.
Taylor's Dad

Anonymous said...

A growing sentiment

I appreciate your reply to my comments.

The above link should be added to my list of issues. There is a growing voice knocking the quality of US medical care. Like all things, there are elements of truth and elements of opportunity.

Clearly, there are medical errors that cost patients health, life, quality of life, etc. They also cost money. I do not trust any quantification. During my residency it became beneficial to meticulously document every "complication" on d/c summaries for the sake of DRG compensation. So everyone d/c'd in '02 with the dx of "failed total hip" was d/c'd in '06 with "failed total hip", acute blood loss anemia, acute hypokalemia, some form of respiratory distress to describe atelectasis, gait dysfunction... I think you get my point. Nothing really changed other than the documentation.

Second, perks that GM offered (i.e. legacy funds) are more costly than they know what to do with. A national plan could save them I can only assume billions. The same is true as the election approaches and candidates look to distinguish themselves with issues over than the war.

Knocking the quality of care in the current system is a great way to gain public support for a large overhaul in the system. It is a sort of bait and switch since the overhaul will really be meant to control how health care is made available and paid for - not quality. Truth is, we really don't have great quality markers. "Pay for performance" measures such as everyone off abx 23hr after elective surgery is probably not the greatest measure of actual quality of care yet those types of benchmarks are likely going to be more common than how many hips are put in varus or dislocate 3 times in the first year.

I anticipate hearing a lot about the 747 jet worth of patients who die daily b/c medical errors over the next 5-10 years.

I could not find a good single link, but googling "medical errors" and "bill bradley" will return a fair amount of hits that describe some of sentiment growing among lawmakers.

Stories like the one about the specialty hospital calling 911 are great fuel to this fire. But that's the thing about fuel. Its great because it burns for anyone who uses it to build their argument. We may not like that physicians all get tagged as greedy because of those investing in specialty hospitals, but it doesn't change the validity of that story and the factors that went in to allowing that to happen.

Despite my reservations about why and how this topic gets attention doesn't change that it deserves attention on our part. The most common explanations discuss how no one error is accountable and that there are larger system problems. I really do not understand that in concrete terms i.e. how to build solutions. I hope someone does because taking the steps control iatrogenic morbidity is our responsiblity.

Anonymous said...

I've seen a lot of speeches over the years. By far the best was by a medical school dean at an academic center on the west coast. It was his retirement party, and he tearfully apologized to all the younger physicians, nurses, and even healthcare administrators for what his generation was leaving behind. It was the most honest speech I've ever seen, it came straight from the heart. He didn't blame anyone in particular, but definitely blamed his generation as a whole.

As I embark on this new career, I face the extremely challenging decision between the path of least resistance (decent hours, decent salary, home life, and time) and that which would consume my entire being with trying to improve the way in which we provide healthcare. Only time will tell if there are enough of us willing to make that sacrifice.