Former President George W. Bush answered that question by saying they can always go to the ER. Federal law, the Emergency Medical Treatment and Labor Act (EMTALA), guarantees that. But what about primary care, which for many health care needs is what patients should be getting? (That's why it's called primary care.)
The feds have decided to spend nearly $350,000 to conduct a survey to answer the question, according to an article just published in the New York Times. The Times describes it as a "stealth survey," nice wording for a headline but inappropriately pejorative. The government's contracted surveyors will pretend to be patients calling to get appointments with primary care doctors and will see what responses they get and whether those responses vary with whether patients have private insurance, Medicare (the federal program for the elderly), Medicaid (for the poor), or no insurance at all. They will also call and identify themselves as performing a government survey, asking whether doctors accept new patients with public insurance or no insurance, and see how those answers compare with the ones given to the "mystery shopper" patients.
As reported by the Times, doctors expressed dismay that Uncle Sam is doing a "mystery shopper" survey to find out what's going on with access to care. They don't like the idea that the government is "spying" on them. That baffles me. We (physicians, especially in emergency medicine) have been telling the government for years that Medicare and Medicaid pay doctors too little, compromising patients' access to primary care and leaving many with nowhere to go but the ER when they get sick. They haven't been listening. Maybe after gathering their own data, they will "get it."
Also interesting were some of the comments on another blog that reported this story. Some of the comments were from people who thought doctors should be required to accept Medicare and Medicaid, and some clearly thought they already were and that physicians revealed by the survey not to be doing so should face heavy penalties. In other words, they think the federal mandate under which emergency physicians practice should apply to all doctors. We often refer to this as an unfunded mandate because it requires us to care for all patients without regard for the ability to pay, including those with no insurance.
What those commenters don't know - and, in fact, many physicians don't know, either - is that there is a provision in the federal Medicaid program intended to assure equal access.
Medicaid is a joint federal-state program, in that there are two sources of funding. The proportion of the Medicaid dollar varies, with a larger share coming from Washington for the poorer states. But what the Medicaid program pays doctors is supposed to be enough to assure that patients on Medicaid can find doctors to care for them. If rates (set by the states) are so low that too few doctors accept Medicaid patients, that violates the "equal access" provision of the law. Unfortunately, the federal government, which has the power to enforce that provision through the Department of Health and Human Services, has shown no interest in doing so.
Perhaps this new survey will define the problem of unequal access so clearly that the feds will realize they must address inadequate reimbursement. The Patient Protection and Affordable Care Act (often called Obamacare for short) proposes to change the status of many Americans from uninsured to insured, and much of that will be accomplished by adding tens of millions to the Medicaid rolls by expanding eligibility. How about fixing the access problem Medicaid patients face at the same time? We've been singing this song for years: coverage does not equal access.
Update, 6-29-11:
The Times now reports that the Department of Health and Human Services has responded to criticism (from doctors and Republican lawmakers) of the planned survey by doing an about-face and shelving plans to conduct it. Illinois Republican Senator Mark Kirk is quoted as saying other "reputable studies" have already shown "many patients on Medicare and Medicaid cannot find a doctor to see them." The question remains whether the people who hold the purse strings have any intention of trying to solve that problem.
Monday, June 27, 2011
Saturday, June 25, 2011
This is NOT the Founding Fathers' First Amendment
In an earlier posting (4-29-11) I wrote about the Supreme Court challenge to the Vermont law banning the sale of physician prescribing data to pharmaceutical companies. Now the Supreme Court has issued a 6-3 decision that is clearly incorrect.
[In case you didn't know, the Supreme Court has the authority to issue the ultimate interpretation of the US Constitution and the laws of this nation. I, however, retain the final authority to declare the high court's opinions to be in error. If this surprises you, note the name of the blog.]
On December 15, 1791 the Bill of Rights was ratified by Virginia, and the first ten amendments formally became part of the US Constitution. December 15 is my birthday (no, not in 1791), and each year I have thought of the Bill of Rights as an extra birthday present. Now the US Supreme Court has ruined than annual celebration for me.
What does the First Amendment say, exactly? "Congress shall make no law ... abridging the freedom of speech...." Our Founding Fathers included those words in the First Amendment to protect political speech, and especially political speech that is unpopular or that the government might find objectionable.
If you have not been spending your life hiding under a rock, you know the Supreme Court has found the First Amendment to protect other kinds of speech, including those that might be offensive by virtue of being obscene, and the Court has established a variety of "tests" that can be applied to determine whether speech is protected. So one cannot yell "Fire!" in a crowded theatre (unless there really is a fire), and there are restrictions on advocating the forcible overthrow of the government, and communities may ban material of a sexual nature that is obscene by community standards and lacks serious literary, artistic, political, or scientific value.
What about commercial speech? Yes, First Amendment protections have been extended here, as well, and so commercial enterprises have wide latitude in advertising, so long as they don't cross over into that which is false, misleading, or fraudulent.
In Sorrell vs IMS Health the Court said the Vermont law unconstitutionally interfered with commercial speech. As previously noted here, however, Vermont did no such thing. Rather than interfering with the pharmaceutical firms' right to commercial expression, the law prevented data mining companies from purchasing information from pharmacies about doctors' prescribing, packaging the data (with patient identification removed), and selling it to drug companies to be used to make their marketing efforts maximally efficient in targeting physicians.
This is Big Pharma as Big Brother, aided and abetted by the Supremes. Physicians should be outraged.
If you share my sense of outrage, I have three recommendations:
1. Never meet with drug company marketing representatives. This one is easy. If you don't want to waste your time being handed marketing materials, time that you could be spending reading readily available sources of unbiased information about pharmacotherapeutics, you already follow this advice.
2. Never prescribe a brand-name drug if there is a generic that will do the job satisfactorily. There are so many reasons to follow this one that I think I need not elaborate.
3. This is one we should work on collectively: let us find out which pharmaceutical companies buy the data about our prescribing practices and assiduously avoid prescribing their products whenever possible.
This commercial enterprise is invasive of privacy and intrusive upon the doctor-patient relationship. The government requires pharmacies to collect and maintain a database of who is prescribing what for whom. The existence of that database can serve a variety of public interests. It is astonishing that the Supreme Court should find exploitation of that database for commercial purposes to be protected by the First Amendment. Astonishing, misguided, inexcusable ... and stupid. It is time for individual physicians and medical professional organizations to stand up to Big Pharma and say no.
[In case you didn't know, the Supreme Court has the authority to issue the ultimate interpretation of the US Constitution and the laws of this nation. I, however, retain the final authority to declare the high court's opinions to be in error. If this surprises you, note the name of the blog.]
On December 15, 1791 the Bill of Rights was ratified by Virginia, and the first ten amendments formally became part of the US Constitution. December 15 is my birthday (no, not in 1791), and each year I have thought of the Bill of Rights as an extra birthday present. Now the US Supreme Court has ruined than annual celebration for me.
What does the First Amendment say, exactly? "Congress shall make no law ... abridging the freedom of speech...." Our Founding Fathers included those words in the First Amendment to protect political speech, and especially political speech that is unpopular or that the government might find objectionable.
If you have not been spending your life hiding under a rock, you know the Supreme Court has found the First Amendment to protect other kinds of speech, including those that might be offensive by virtue of being obscene, and the Court has established a variety of "tests" that can be applied to determine whether speech is protected. So one cannot yell "Fire!" in a crowded theatre (unless there really is a fire), and there are restrictions on advocating the forcible overthrow of the government, and communities may ban material of a sexual nature that is obscene by community standards and lacks serious literary, artistic, political, or scientific value.
What about commercial speech? Yes, First Amendment protections have been extended here, as well, and so commercial enterprises have wide latitude in advertising, so long as they don't cross over into that which is false, misleading, or fraudulent.
In Sorrell vs IMS Health the Court said the Vermont law unconstitutionally interfered with commercial speech. As previously noted here, however, Vermont did no such thing. Rather than interfering with the pharmaceutical firms' right to commercial expression, the law prevented data mining companies from purchasing information from pharmacies about doctors' prescribing, packaging the data (with patient identification removed), and selling it to drug companies to be used to make their marketing efforts maximally efficient in targeting physicians.
This is Big Pharma as Big Brother, aided and abetted by the Supremes. Physicians should be outraged.
If you share my sense of outrage, I have three recommendations:
1. Never meet with drug company marketing representatives. This one is easy. If you don't want to waste your time being handed marketing materials, time that you could be spending reading readily available sources of unbiased information about pharmacotherapeutics, you already follow this advice.
2. Never prescribe a brand-name drug if there is a generic that will do the job satisfactorily. There are so many reasons to follow this one that I think I need not elaborate.
3. This is one we should work on collectively: let us find out which pharmaceutical companies buy the data about our prescribing practices and assiduously avoid prescribing their products whenever possible.
This commercial enterprise is invasive of privacy and intrusive upon the doctor-patient relationship. The government requires pharmacies to collect and maintain a database of who is prescribing what for whom. The existence of that database can serve a variety of public interests. It is astonishing that the Supreme Court should find exploitation of that database for commercial purposes to be protected by the First Amendment. Astonishing, misguided, inexcusable ... and stupid. It is time for individual physicians and medical professional organizations to stand up to Big Pharma and say no.
Monday, June 20, 2011
Anthony Weiner and Mary Martin
Yes, that title is an oblique way of getting at the theme, and yes, it is intended to appeal to readers who can make the connection. Maybe everyone else will read it just to find out what the title means.
Mary Martin was the actress who played Peter Pan in the 1954 Broadway production. She is the actress with whom I will always associate that role. If you're younger, you might be thinking instead of Sandy Duncan (1979) or Cathy Rigby (1990 and later productions).
Anthony Weiner suffers from the Peter Pan Syndrome.
The original Latin phrase is puer aeternus, which means eternal boy. In 1983 Dan Kiley wrote a book titled The Peter Pan Syndrome: Men Who Have Never Grown Up. In the story of Peter Pan, of course, the title character wanted never to grow up, and that is the theme of one of the play's more memorable songs. This syndrome is not formally recognized as a psychiatric diagnosis, but we've all known men who continue throughout their lives - or at least into middle age - to act like children or adolescents.
That seems to be the story of Anthony Weiner. How else can we explain the behavior of a 47-year-old man who has chosen a life in the public eye but who cannot refrain from engaging in such adolescent behavior as texting racy photos of himself to much younger women? The psychology of the character, as set forth by Carl Jung (and later described in a helpful lexicon by Sharp), is such that he covets independence and freedom, chafes at boundaries and limits, and tends to find any restriction intolerable.
The fall from grace of Representative Weiner raises so many questions, and the psychological ones are probably not the most important. It is intriguing to wonder why a grown man would engage in such adolescent behavior for so long, apparently without regard for the consequences of being discovered and having his behavior made the subject of public ridicule. One might think his courtship and marriage would have redirected his fantasy life.
The question that I have the most trouble answering, however, is the one that naturally comes to mind when one considers the immediate application to this scandal of the moniker "Weinergate." Since the scandal that brought down the Nixon administration after the burglary of Democratic party offices in the Watergate Hotel, the suffix "gate" has been added to so many misadventures that, upon discovery, quickly evolved into maelstroms that destroyed public careers. The suffix seems particularly apt in this case because it mirrors the central lesson of Watergate: it's not the crime; it's the cover-up.
If Nixon had admitted from the start that the bungled break-in was the work of some low-level operatives in his campaign, apologized to his political opponents and to the nation, taken some measure of responsibility, and vowed to see that the fools who planned and executed the operation would be punished, that story might well have played out quite differently. Instead he masterminded an elaborate cover-up, and the central theme of the subsequent investigation, both in the media and in Congress, was, "What did the president know, and when did he know it?"
Had Weiner gone public with the truth from the start, and admitted - with an appropriate sense of shame - that he had been engaged in erotic online communications with a number of much younger women, he would not have incurred the wrath of the news media, which are full of reporters who love to ferret out the truth and destroy those who try to hide it. And he certainly would have been forgiven by his constituents, the majority of whom didn't want him to resign even after the scandal unfolded in the worst possible way. Even House Republicans would likely have left him alone, except for making endless jokes at his expense.
We hold elected officials to standards of conduct that seem to be ever higher, even in their private lives (because nothing, it seems, stays private any more). But we are willing to forgive a wide range of behavior that violates sociocultural norms and broadly held moral values, so long as public figures 'fess up and appear genuinely contrite.
Those of us who are parents - oh, and a belated Happy Father's Day to those who celebrated yesterday - teach our children the importance of truthfulness and emphasize that when they have done something wrong, honesty is the best policy and will keep the consequences from getting far worse.
Anthony Weiner is widely regarded as an effective and outspoken advocate for Democratic ideals, and his departure from Congress is surely a loss for the New York delegation in the House. And it's all because he never learned the central lesson of Watergate. Foolish arrogance knows no party boundaries.
Perhaps now Mr. Weiner will focus on his personal life, repair the damage done to his marriage, forget about Peter Pan, and - at last - grow up.
Mary Martin was the actress who played Peter Pan in the 1954 Broadway production. She is the actress with whom I will always associate that role. If you're younger, you might be thinking instead of Sandy Duncan (1979) or Cathy Rigby (1990 and later productions).
Anthony Weiner suffers from the Peter Pan Syndrome.
The original Latin phrase is puer aeternus, which means eternal boy. In 1983 Dan Kiley wrote a book titled The Peter Pan Syndrome: Men Who Have Never Grown Up. In the story of Peter Pan, of course, the title character wanted never to grow up, and that is the theme of one of the play's more memorable songs. This syndrome is not formally recognized as a psychiatric diagnosis, but we've all known men who continue throughout their lives - or at least into middle age - to act like children or adolescents.
That seems to be the story of Anthony Weiner. How else can we explain the behavior of a 47-year-old man who has chosen a life in the public eye but who cannot refrain from engaging in such adolescent behavior as texting racy photos of himself to much younger women? The psychology of the character, as set forth by Carl Jung (and later described in a helpful lexicon by Sharp), is such that he covets independence and freedom, chafes at boundaries and limits, and tends to find any restriction intolerable.
The fall from grace of Representative Weiner raises so many questions, and the psychological ones are probably not the most important. It is intriguing to wonder why a grown man would engage in such adolescent behavior for so long, apparently without regard for the consequences of being discovered and having his behavior made the subject of public ridicule. One might think his courtship and marriage would have redirected his fantasy life.
The question that I have the most trouble answering, however, is the one that naturally comes to mind when one considers the immediate application to this scandal of the moniker "Weinergate." Since the scandal that brought down the Nixon administration after the burglary of Democratic party offices in the Watergate Hotel, the suffix "gate" has been added to so many misadventures that, upon discovery, quickly evolved into maelstroms that destroyed public careers. The suffix seems particularly apt in this case because it mirrors the central lesson of Watergate: it's not the crime; it's the cover-up.
If Nixon had admitted from the start that the bungled break-in was the work of some low-level operatives in his campaign, apologized to his political opponents and to the nation, taken some measure of responsibility, and vowed to see that the fools who planned and executed the operation would be punished, that story might well have played out quite differently. Instead he masterminded an elaborate cover-up, and the central theme of the subsequent investigation, both in the media and in Congress, was, "What did the president know, and when did he know it?"
Had Weiner gone public with the truth from the start, and admitted - with an appropriate sense of shame - that he had been engaged in erotic online communications with a number of much younger women, he would not have incurred the wrath of the news media, which are full of reporters who love to ferret out the truth and destroy those who try to hide it. And he certainly would have been forgiven by his constituents, the majority of whom didn't want him to resign even after the scandal unfolded in the worst possible way. Even House Republicans would likely have left him alone, except for making endless jokes at his expense.
We hold elected officials to standards of conduct that seem to be ever higher, even in their private lives (because nothing, it seems, stays private any more). But we are willing to forgive a wide range of behavior that violates sociocultural norms and broadly held moral values, so long as public figures 'fess up and appear genuinely contrite.
Those of us who are parents - oh, and a belated Happy Father's Day to those who celebrated yesterday - teach our children the importance of truthfulness and emphasize that when they have done something wrong, honesty is the best policy and will keep the consequences from getting far worse.
Anthony Weiner is widely regarded as an effective and outspoken advocate for Democratic ideals, and his departure from Congress is surely a loss for the New York delegation in the House. And it's all because he never learned the central lesson of Watergate. Foolish arrogance knows no party boundaries.
Perhaps now Mr. Weiner will focus on his personal life, repair the damage done to his marriage, forget about Peter Pan, and - at last - grow up.
Tuesday, June 14, 2011
King James?
Every once in a while I have to write about something that is entirely unrelated to health care. If you read the piece on Mother's Day, or Star Wars, or Osama bin Laden, you know this. Today the subject is LeBron James. King James? Not so much.
I have been a basketball fan for four decades, which is plenty of time to form quite a large number of opinions. I have watched too many games to count - not literally, perhaps, but no one was counting - on both the collegiate and professional levels. I have seen some great players. I even got to talk to one live on the radio once. Do you know what a triple double is? It means a player gets at least ten (double digits) points, assists, and rebounds in a game. There are two other categories (steals and blocked shots), but it is much more difficult to reach double digits in those in a game. If you are a true fan of the game, you already know the player to whom I am referring. Oscar Robertson holds the all-time NBA record for triple doubles (181 in his career). He is the only player to average a triple double for a full season. He also averaged a triple double over his first five seasons in the NBA taken together. He was once a guest on a call-in radio show, and I got to talk to him about why the CBS affiliate in Pittsburgh refused to carry "The NBA on CBS" on Sunday afternoons, instead showing old movies.
In the 80s and 90s I had the pleasure of watching the magnificence that was the NBA career of Michael Jordan. I freely admit I didn't see Jordan coming. When he played for North Carolina, sports commentator Dick Vitale said Jordan was the greatest player ever to come out of the Atlantic Coast Conference, and I thought Vitale was spouting the sort of hyperbole in which he could occasionally indulge. But he was right, and I was obtuse.
In the 90s I watched Jordan lead the Chicago Bulls to six NBA championships. (I think it would have been eight if not for his ill-advised detour into baseball.) Of course he didn't do it alone, and his "supporting cast" included players who were superb in their own right, most notably Scottie Pippen. But Jordan proved time and again that he knew how to win the big games. If you have any doubts, look up the "Flu Game," the astonishing nature of which I will not recount here. Even better, the next time you're feeling just a bit under the weather and thinking about calling off work, read about the "Flu Game" and ask yourself if perhaps you're just being a wooss.
But aside from all the remarkable numbers - scoring titles, times being named defensive player of the year, NBA championships - Jordan had something no one else ever had, and perhaps no one else ever will. There were so many times I watched him do something on the court and thought, "I have learned physics, and I'm fairly certain what I just saw him do is not actually possible."
So what about LeBron? No NBA titles yet. A talented player, to be sure. Fun to watch. Makes big plays on offense and defense. But he definitely lacks the consistency Jordan showed.
And he lacks something else, as demonstrated by the way he left Cleveland and the way he has talked about other players and about fans this season. If I had to pick a single word, it might be "class." There are nuances and subtleties that word may not capture. But LeBron doesn't have it, and Michael did. Maybe it's not all LeBron's fault. I'm a big believer in character development. LeBron went to the NBA from high school. Jordan went to UNC, where he was coached by Dean Smith. Anyone who could spend three years being coached by Dean Smith and not leave UNC a gentleman might qualify as a hard-core sociopath.
Even after his lackluster performance in this year's NBA Finals against the Dallas Mavericks, and especially the way he didn't "show up" in the fourth quarter, there are some who will continue to think LeBron James will ultimately prove to be the best player ever to step onto the hardwood. But I (and, I suspect, Dick Vitale) will always say that title will forever belong to Michael Jordan.
I have been a basketball fan for four decades, which is plenty of time to form quite a large number of opinions. I have watched too many games to count - not literally, perhaps, but no one was counting - on both the collegiate and professional levels. I have seen some great players. I even got to talk to one live on the radio once. Do you know what a triple double is? It means a player gets at least ten (double digits) points, assists, and rebounds in a game. There are two other categories (steals and blocked shots), but it is much more difficult to reach double digits in those in a game. If you are a true fan of the game, you already know the player to whom I am referring. Oscar Robertson holds the all-time NBA record for triple doubles (181 in his career). He is the only player to average a triple double for a full season. He also averaged a triple double over his first five seasons in the NBA taken together. He was once a guest on a call-in radio show, and I got to talk to him about why the CBS affiliate in Pittsburgh refused to carry "The NBA on CBS" on Sunday afternoons, instead showing old movies.
In the 80s and 90s I had the pleasure of watching the magnificence that was the NBA career of Michael Jordan. I freely admit I didn't see Jordan coming. When he played for North Carolina, sports commentator Dick Vitale said Jordan was the greatest player ever to come out of the Atlantic Coast Conference, and I thought Vitale was spouting the sort of hyperbole in which he could occasionally indulge. But he was right, and I was obtuse.
In the 90s I watched Jordan lead the Chicago Bulls to six NBA championships. (I think it would have been eight if not for his ill-advised detour into baseball.) Of course he didn't do it alone, and his "supporting cast" included players who were superb in their own right, most notably Scottie Pippen. But Jordan proved time and again that he knew how to win the big games. If you have any doubts, look up the "Flu Game," the astonishing nature of which I will not recount here. Even better, the next time you're feeling just a bit under the weather and thinking about calling off work, read about the "Flu Game" and ask yourself if perhaps you're just being a wooss.
But aside from all the remarkable numbers - scoring titles, times being named defensive player of the year, NBA championships - Jordan had something no one else ever had, and perhaps no one else ever will. There were so many times I watched him do something on the court and thought, "I have learned physics, and I'm fairly certain what I just saw him do is not actually possible."
So what about LeBron? No NBA titles yet. A talented player, to be sure. Fun to watch. Makes big plays on offense and defense. But he definitely lacks the consistency Jordan showed.
And he lacks something else, as demonstrated by the way he left Cleveland and the way he has talked about other players and about fans this season. If I had to pick a single word, it might be "class." There are nuances and subtleties that word may not capture. But LeBron doesn't have it, and Michael did. Maybe it's not all LeBron's fault. I'm a big believer in character development. LeBron went to the NBA from high school. Jordan went to UNC, where he was coached by Dean Smith. Anyone who could spend three years being coached by Dean Smith and not leave UNC a gentleman might qualify as a hard-core sociopath.
Even after his lackluster performance in this year's NBA Finals against the Dallas Mavericks, and especially the way he didn't "show up" in the fourth quarter, there are some who will continue to think LeBron James will ultimately prove to be the best player ever to step onto the hardwood. But I (and, I suspect, Dick Vitale) will always say that title will forever belong to Michael Jordan.
Saturday, June 11, 2011
Defensive Medicine: Do You Know What It Is?
The enactment last year of the Patient Protection and Affordable Care Act (PPACA) has brought to the fore many topics for discussion in the realm of national health policy. As I have noted in earlier entries in this blog, much of this talk is focused on ways to control costs.
Any wide-ranging discussion of cost containment in US health care eventually touches on the subject of "defensive medicine." Most legislators and regulators think they know what it is, but there is quite a diversity of opinion about what it costs and what to do about it.
The common definition of defensive medicine is simple: doctors order or recommend tests (especially) and treatments not because they think they are really necessary but because they are worried about the possibility of being sued if a patient suffers a bad outcome and there is some question about whether the doctor was sufficiently diligent, leaving no stone unturned in the pursuit of the correct diagnosis and omitting no possibly beneficial treatment.
As you might surmise, this way of practicing medicine can be quite a bit more expensive than would be a "less-is-more" approach. Remember that for every diagnostic or therapeutic intervention a doctor might suggest or offer, there is a risk-benefit analysis to be considered.
Let me offer an example. Suppose you are in a car accident. You don't appear to have any serious injuries, but you have some soreness in your neck, and you decide to go to the hospital emergency department to get checked out and make sure you're OK. What do you want the doctor to do? Well, if you've taken my advice from earlier writings, you want the doctor to evaluate you and render an opinion as to your condition. What you should not do is embark upon this visit to the hospital with preconceived expectations, such as that the doctor will order x-rays of your neck. Why not? Because of the risk-benefit analysis.
You see, it is entirely possible - in fact, probable - that the doctor can determine from an evaluation at the bedside that it is extremely unlikely that you have a serious injury to your neck. Adding x-rays to that evaluation will lower the statistical likelihood further by such a slight degree, if they are negative, that you should wonder if there is any risk associated with pursuing a tiny incremental increase in diagnostic certainty. And, indeed, there is. You have a gland in your neck called the thyroid that is quite sensitive to radiation. When you get x-rays of your neck - or worse, and increasingly common, a CAT scan - the radiation exposure carries with it a risk of later development of thyroid cancer. So what is the trade-off?
That is a question to which you should expect your doctor to know the answer. If the emergency physician knows the scientific evidence, the answer will be that the risk of thyroid cancer from getting the x-rays may well be greater than the risk of missing a significant injury by not getting the test.
So why do doctors almost always order the x-rays? Because they are afraid of missing something serious. They know that an undiagnosed injury to the cervical spine that subsequently causes a spinal cord injury and permanent disability will be blamed on the doctor. The bedside evaluation may be very reliable in predicting a likelihood of such an injury that is a tiny fraction of 1%, but would that sway a jury convinced that the doctor was wrong and the patient suffered harm because of physician error?
I believe this qualifies as "defensive medicine." The doctor orders a test mostly out of fear of being sued if there is a bad outcome and the failure to order a test is perceived as evidence that the doctor was less than thorough in evaluating the patient. And the consequence is not only the higher cost associated with unnecessary testing, but also the overlooked and under-appreciated potential harm.
There are many nuances to the discussion of defensive medicine, including what other factors influence doctors to order tests and treatments that aren't really necessary, and how much money could be saved if we could figure out how to change this behavior. Stay tuned to this blog for more of the story.
Saturday, June 4, 2011
Is This Lawsuit Frivolous? I'm Just Askin' a Question
In his State of the Union address this past January, President Obama said he was "willing to look at other ways to bring down [health care] costs, including ... medical malpractice reform to rein in frivolous lawsuits." There are frivolous lawsuits in many areas of life. Professional liability cases utterly lacking in merit are the ones that vex doctors, but we are not alone.
The other day the Associated Press reported a lawsuit filed by a woman in Philadelphia. She ordered coffee in a Dunkin' Donuts store. She claims the server put sugar in the coffee instead of artificial sweetener, causing her to go into "diabetic shock." Her lawyer reportedly said she didn't even finish the coffee before being overcome by symptoms of illness, resulting in a trip to a hospital emergency department.
If you are a doctor or a nurse, especially one who works in an emergency department, you know how preposterous this claim is. If you aren't, I'll just tell you: consuming the amount of sugar that one might add to a cup of coffee (and by this account, less than that) does not cause "diabetic shock."
This happened in Philadelphia, and Philadelphia lawyers are notorious for ... well, let's just say that anyone who ever has reason to worry about the risk of becoming a defendant in a civil liability case would prefer not to be anywhere near Philadelphia.
So, is this frivolous just because the claim is preposterous? A plaintiff's attorney would say no. The idea is that the plaintiff's allegation is a matter of fact to be determined by a jury. It would be frivolous if the woman claimed she went into "diabetic shock" because she walked past a Dunkin' Donuts store and smelled the donuts baking. But the lawyer would say this case should be allowed to proceed, and if expert witnesses convince the jury the woman's claim cannot be supported, the jury will return a verdict in favor of Dunkin' Donuts, and justice will have been properly served.
But maybe Dunkin' Donuts will regard this as a nuisance lawsuit that would be needlessly costly to defend and will give the woman money to settle the case and cut their losses. That would be a shame, but it's the sort of thing that happens all the time, and it encourages plaintiffs and lawyers to file claims of dubious merit.
Maybe there is more to this story than reported by AP. Maybe if I had the opportunity to read the action as filed I would think, "Well, I suppose there could be something to this." But I really doubt it. A judge should be able to consult an expert (or panel of experts) serving the court - not either side in the case - who could advise the judge that the allegation is certainly baseless, and the case should be dismissed before it goes any further.
Maybe you have no sympathy for Dunkin' Donuts because it's a big company with lots of money. But the company - and every other company doing business in this litigious environment - has to buy liability insurance to protect itself from losses that might be incurred in the course of doing business. Cases lacking in merit drive up the cost of that insurance. That adds to the company's cost of doing business, and those costs are passed along to the consumer. Part of the price of your coffee and your donuts goes to paying for this. Is it worth it?
The other day the Associated Press reported a lawsuit filed by a woman in Philadelphia. She ordered coffee in a Dunkin' Donuts store. She claims the server put sugar in the coffee instead of artificial sweetener, causing her to go into "diabetic shock." Her lawyer reportedly said she didn't even finish the coffee before being overcome by symptoms of illness, resulting in a trip to a hospital emergency department.
If you are a doctor or a nurse, especially one who works in an emergency department, you know how preposterous this claim is. If you aren't, I'll just tell you: consuming the amount of sugar that one might add to a cup of coffee (and by this account, less than that) does not cause "diabetic shock."
This happened in Philadelphia, and Philadelphia lawyers are notorious for ... well, let's just say that anyone who ever has reason to worry about the risk of becoming a defendant in a civil liability case would prefer not to be anywhere near Philadelphia.
So, is this frivolous just because the claim is preposterous? A plaintiff's attorney would say no. The idea is that the plaintiff's allegation is a matter of fact to be determined by a jury. It would be frivolous if the woman claimed she went into "diabetic shock" because she walked past a Dunkin' Donuts store and smelled the donuts baking. But the lawyer would say this case should be allowed to proceed, and if expert witnesses convince the jury the woman's claim cannot be supported, the jury will return a verdict in favor of Dunkin' Donuts, and justice will have been properly served.
But maybe Dunkin' Donuts will regard this as a nuisance lawsuit that would be needlessly costly to defend and will give the woman money to settle the case and cut their losses. That would be a shame, but it's the sort of thing that happens all the time, and it encourages plaintiffs and lawyers to file claims of dubious merit.
Maybe there is more to this story than reported by AP. Maybe if I had the opportunity to read the action as filed I would think, "Well, I suppose there could be something to this." But I really doubt it. A judge should be able to consult an expert (or panel of experts) serving the court - not either side in the case - who could advise the judge that the allegation is certainly baseless, and the case should be dismissed before it goes any further.
Maybe you have no sympathy for Dunkin' Donuts because it's a big company with lots of money. But the company - and every other company doing business in this litigious environment - has to buy liability insurance to protect itself from losses that might be incurred in the course of doing business. Cases lacking in merit drive up the cost of that insurance. That adds to the company's cost of doing business, and those costs are passed along to the consumer. Part of the price of your coffee and your donuts goes to paying for this. Is it worth it?
Thursday, June 2, 2011
The Roar of the Crowd
Boston - No, it was not a Red Sox game. It was a conference sponsored by the journal Academic Emergency Medicine, and the subject was providing high-quality care in the crowded emergency department.
If you've been healthy and careful, you may not know that emergency departments are often crowded. Good for you. If you have been less fortunate, you may be all too keenly aware of how crowded they often are and how challenging the doctors and nurses find it to provide the best possible patient care under those conditions.
The causes of crowding are obvious to those who spend their working lives in the ED. But to everyone else, maybe less so.
So here is a primer. Crowding means the number of patients is high relative to the available resources (especially physical space) to care for them. That can happen because of (1) inflow; (2) how long it takes to evaluate and treat a patient; and (3) outflow.
The first factor is straightforward. When many patients arrive, we may quickly run out of places to put them. There are emergency departments that simply don't have enough space for the number of patients seeking care, often because that number has risen quickly over a relatively short time and the hospital has been unable to adapt. But any ED can get crowded because of high inflow as a short-term problem during periods of peak demand, such as a difficult flu season.
The second factor is commonly referred to in the industry as "throughput." Some patients require evaluation and treatment that is time-consuming. And some processes consume more time than others. Certain diagnostic tests can take hours, although there is often room to improve "turnaround time" for some of them.
The third factor, one that accounts for a large part of crowding, is an outflow problem. This used to be an important factor mostly at large, urban hospitals, but it has become more widespread in the last ten years. When it is determined that a patient requires hospitalization, the patient is supposed to go upstairs. But suppose there are no beds available upstairs? The patient is "stuck" in the ED - for hours, or even days. This is called "boarding." When admitted patients board in the ED, that occupies beds. Not necessarily rooms, but beds. You see, boarded patients sometimes get moved into any available space, including hallways. There are EDs in which this is an everyday situation, and the number of patients lying on gurneys in hallways waiting for inpatient beds exceeds the number of ED patients undergoing their initial evaluation and treatment.
You can easily imagine how being a boarder is a bad thing. You are competing for nursing attention with the new patients. The doctors are busy evaluating and treating the new patients and may think of you as being no longer their responsibility, as if you were upstairs even though you aren't. The nurses taking care of you are accustomed to taking care of ED patients, not inpatients, and so your needs are not part of their usual scope of practice. The growing scientific literature on this subject in the emergency medicine journals tells us that boarded patients have worse outcomes: there are more errors in their treatment, including serious ones, their total length of stay in the hospital is longer, and they are more likely to wind up in a nursing home after hospitalization. They are also more likely to die.
If you are a patient in an ED with boarding but you are not one of those unfortunate boarders, you are still in a bad place, so to speak, because the staff attending to your needs may be overwhelmed by the additional demands being placed upon them.
The American College of Emergency Physicians has published the report of a task force that details high-impact, low-cost solutions: things hospital managers can do to improve the efficiency of utilization of existing institutional resources to make inpatient beds available to ED patients in a more timely manner. Ultimately, however, we must face a simple fact: our population is getting older and acquiring more medical problems, and it will take more resources to care for them. There is a shortage of nurses, doctors, and hospital beds. At a time when the number of ED visits has been rising steadily, year after year, the number of hospitals is declining, and the number of EDs is declining even more sharply.
And the people inside the beltway (that's I-495, which approximately makes a circle around Washington, DC) seem to have turned a blind eye and a deaf ear toward this problem. This will get worse before it gets better. If you like to talk to your Member of Congress, make this a topic of conversation.
If you've been healthy and careful, you may not know that emergency departments are often crowded. Good for you. If you have been less fortunate, you may be all too keenly aware of how crowded they often are and how challenging the doctors and nurses find it to provide the best possible patient care under those conditions.
The causes of crowding are obvious to those who spend their working lives in the ED. But to everyone else, maybe less so.
So here is a primer. Crowding means the number of patients is high relative to the available resources (especially physical space) to care for them. That can happen because of (1) inflow; (2) how long it takes to evaluate and treat a patient; and (3) outflow.
The first factor is straightforward. When many patients arrive, we may quickly run out of places to put them. There are emergency departments that simply don't have enough space for the number of patients seeking care, often because that number has risen quickly over a relatively short time and the hospital has been unable to adapt. But any ED can get crowded because of high inflow as a short-term problem during periods of peak demand, such as a difficult flu season.
The second factor is commonly referred to in the industry as "throughput." Some patients require evaluation and treatment that is time-consuming. And some processes consume more time than others. Certain diagnostic tests can take hours, although there is often room to improve "turnaround time" for some of them.
The third factor, one that accounts for a large part of crowding, is an outflow problem. This used to be an important factor mostly at large, urban hospitals, but it has become more widespread in the last ten years. When it is determined that a patient requires hospitalization, the patient is supposed to go upstairs. But suppose there are no beds available upstairs? The patient is "stuck" in the ED - for hours, or even days. This is called "boarding." When admitted patients board in the ED, that occupies beds. Not necessarily rooms, but beds. You see, boarded patients sometimes get moved into any available space, including hallways. There are EDs in which this is an everyday situation, and the number of patients lying on gurneys in hallways waiting for inpatient beds exceeds the number of ED patients undergoing their initial evaluation and treatment.
You can easily imagine how being a boarder is a bad thing. You are competing for nursing attention with the new patients. The doctors are busy evaluating and treating the new patients and may think of you as being no longer their responsibility, as if you were upstairs even though you aren't. The nurses taking care of you are accustomed to taking care of ED patients, not inpatients, and so your needs are not part of their usual scope of practice. The growing scientific literature on this subject in the emergency medicine journals tells us that boarded patients have worse outcomes: there are more errors in their treatment, including serious ones, their total length of stay in the hospital is longer, and they are more likely to wind up in a nursing home after hospitalization. They are also more likely to die.
If you are a patient in an ED with boarding but you are not one of those unfortunate boarders, you are still in a bad place, so to speak, because the staff attending to your needs may be overwhelmed by the additional demands being placed upon them.
The American College of Emergency Physicians has published the report of a task force that details high-impact, low-cost solutions: things hospital managers can do to improve the efficiency of utilization of existing institutional resources to make inpatient beds available to ED patients in a more timely manner. Ultimately, however, we must face a simple fact: our population is getting older and acquiring more medical problems, and it will take more resources to care for them. There is a shortage of nurses, doctors, and hospital beds. At a time when the number of ED visits has been rising steadily, year after year, the number of hospitals is declining, and the number of EDs is declining even more sharply.
And the people inside the beltway (that's I-495, which approximately makes a circle around Washington, DC) seem to have turned a blind eye and a deaf ear toward this problem. This will get worse before it gets better. If you like to talk to your Member of Congress, make this a topic of conversation.
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