Missed the point?

I respect Symtym and enjoy reading his blog. However, I suspect that he missed the point in one of my recent posts.

I was answering a question from someone who had asked a question in a comment. I was asked how an FP could work in the ER. That was it. I wasn't trying to insult or demean board certification by ABEM/ABMS or to suggest that this doesn't mean anything.

I recognize that some BCEP's (board certified emergency physicians) may be defensive about their specialty and board certification. And with good reason. There are many out there who have made it clear that they don't think there is any justification for this specialty. I agree completely with this post by MM House, MD. I also agree with most of what Symtym wrote here.

Let me comment on what Symtym wrote:

"First" Thank you. I have read enough of your site to know that I respect your opinions.

"Second" I agree. However, when you wrote, "These are always put forward..." did you mean to suggest that I was putting this forward? If so, I think you missed my point. I agree with what you wrote and do not think this is the issue.

"Third" I agree. Again, did you mean to suggest that I was complaining about the ABMS/ABEM monopoly? I support the monopoly. I am proud of my board certifications and don't want them watered down by any "mail in" boards. I wrote "This is not considered true board certification by those who believe in the monopoly of the AMBS, but allows some to claim "board certified." I think if you told a hospital credentials committee you were board certified and it turned out your board was AAPS, they might view that negatively." I don't believe that AAPS is recognized as a legitimate board and shouldn't be. I think you missed my point.

"Fourth" I agree. What did you mean by the "feign of ignorance" comment? Did something I wrote suggest to you that I was unaware that the practice track had been closed? Did you think that I was feigning ignorance of this?

"Fifth" I agree. The first three sentences are exactly what I was saying in my post. I think, however, that you are using unnecessary hyperbole at the end of this point. There is much less of a difference between FP and EM than there is between GYN/Pediatrics and Neurosurgery.

"Sixth" The way I read this, you are saying that you read my post as suggesting that I consider my board certification in FP to be valid, while at the same time saying that EM boards are not valid. Perhaps you missed my point. I think both are valid. There are a huge number of docs out there that are practicing "family medicine" who did not do residencies in FP nor are they board certified in FP. Many of them are residency trained and have been board certified in other specialties. Does this mean they are good or bad at FP? No, but without board certification, you have no measure. At least board certification is some measure. If I went to the ER and had no knowledge of the docs, I would feel more comfortable, in general, with the residency trained, board certified EM specialist.

I am making the exact same points as you! Don't be so defensive. I think you missed my point. I have a great deal of respect for the EM training programs and recognize the need for some limits on board eligibility and board certification.

FP's in ER's

SuperDuper asked this: "so if youre Board certified in FP ...HOW do you work as ER? (and why???)"

As far as the law goes, as far as I know, any doc can work in the ER. Now, the board certified, residency trained Emergency Medicine docs would argue that they are better, and it would be a good argument. However, the vast majority, and I mean the VAST majority, of all ER shifts worked in the US are not worked by EM trained/certified physicians. There just aren't enough of them. Besides, most ER's don't pay well enough to get those docs. Absolutely no offense meant, but the price they demand can't be met in most small town or rural ER's. Besides, a gung-ho EM trained/certified doc doesn't want to work the ER in a 49 bed hospital in a town of 5000 people with an annual volume of 5000. They would be bored out of their skulls and lose their skills. These shift are filled by a different type of ER doc.

So, most ER shifts are staffed by other specialties, or even docs without residency training or board certification in any specialty.

Personally, I think Family Practice is a great residency to prepare one to work in the ER. However, most FP residency programs are not very strong in EM and especially the trauma part. Besides, just managing an ER requires a very different mindset from the clinic. You have to be able to manage a dozen or so patients, all at the same time, some of whom may be very sick. It's not just the medical knowledge, which most docs can assimilate, but the skill to manage the ER that is one of the best things taught in an EM residency and not taught in any other.

You have to be able to decide: "Do I finish up with this patient or get the next one started? How long can/should that 35 year old with a cold wait while I deal with these other sicker patients? When do I take a few minutes to get him out of here? Do I get involved in this prolonged w/u in this relatively sick but stable patient, or do I see a few of these treat and street types and clear up a few rooms?"

Most docs aren't suited, by training or personality, to work in the ER.

In another life, I thought I wanted to be a surgeon. So, in medical school, I did most of my electives in surgery and did a lot of trauma call. I was on the trauma team at my university hospital, a Level I trauma center. As a surgery intern, I was again on a trauma team at a Level I trauma center, this time in downtown San Diego. As an FP resident, I did my ER rotation and an additional ER elective at Level I trauma centers. Not that I thought I was going to be doing full-time ER; at the time I expected to be doing a clinic practice, but I enjoyed it.

So, I felt well trained to go in and work the ER. I would agree that the average EM trained/certified doc is better in the ER than the average FP, but I think I am pretty good at it. We all know ER trained/certified docs who aren't very good at what they do. One of my recent co-workers just couldn't manage a full ER. We have 23 beds in our ER and sometimes you are the only doc there and the ER is full. This is quite a test. Only one of our full time docs is EM residency trained, and only two of them are EM board certed.

So that's the HOW. I will address the WHY later.

We are people, too.

I hope you saw the humor in my prior two posts. But, seriously, this is a very mild representation of some of the, well, face it, crap that an ER doc has to put up with. It is much worse at night. I guess it is because during the day you have greater resources available. You can call the primary, talk to consultants the patient has seen and you have greater access to hospital resources. At night, you can rarely get the specific doc who knows the patient and when you do, he doesn't have the chart.

ER docs have it worse than any others, I think. When you are seeing a patient in clinic and are treated poorly, or they treat your staff poorly, you can fire the patient. This, of course, may cost you this patient and a few that the angry patient may influence, but this won't even make an impact on your bottom line.

However, most hospital administrations don't want to lose a single patient. Even those who don't pay. The administrators figure that one angry patient will influence 10-15 others to avoid your ER. Good riddance, you may say, but the administrations take any patient complaint very seriously.

We have to work hard to prevent patient complaints. I used to work full time for a very large ER staffing company. The contracts they had with hospitals stated that the hospital could fire any doc at any time for any reason, without any notice. One hospital I worked in would fire a doc for ONE patient complaint, without even asking the doctor's side of the incident. The contract with the hospital was more important to the company than any of the docs, and the company had a large enough pool of docs to replace anyone quickly.

I know of more than one doc who was fired without notice at the end of a scheduling period. Imagine this: during July, you get a schedule for August and have 160 hours on it. Fine. Good for the budget. During July, the hospital tells the company they don't want you back. The company convinces the hospital to let you finish the July schedule, to prevent scheduling problems, but promises you won't be back in August.

But they don't tell you. Heck, you might just quit right away and then how would they fill the July schedule. So they let you think you are still employed and will have shifts in August. Meanwhile, they have a secret schedule that you don't know about on which they have filled your shifts with other docs.

You work the night shift of July 31. On the way home, your cell phone rings. It is the vice-president of the company. He notifies you that you are no longer employed. So, screw you, forget your mortgage, your family, anything else. You are out. Without even any notice at all to try to find another job. BOOM, gone.

This is NOT made up. This has happened to more than one doc I know that was with that company. Fired on the last day of the month without any notice and without any replacement job. How long does it take to get credentialled at another hospital. At least 60-90 days. I hope you paid attention to your savings.

So you see, ER docs have to put up with the feces served to them by the rudest of patients, day in and day out. I rarely defend myself, but have aggressively defended the nursing staff on numerous occasions.

Not asking for pity parties, just venting. Thanks.

A typical night patient in the EC, part II

Part I is here.

Doc: Help me understand how getting a CT now will prevent you from having to see the neurologist later today? Oh no. How am I going to get out of this one?

She: Well, if the CT scan is normal, I won't have to see the neurologist. I don't like him.

Doc: You've seen him before? What is going on here?

She: (angrily) Oh, yeah. Right after this started, my doctor sent me to him.

Doc: What did he think was wrong with you?

She: He doesn't know. He thought I might have multiple sclerotosis. He wanted to get an MRI, but I missed the appointment.

Doc: When was that?

She: Oh, about a year ago.

Doc: And you haven't rescheduled the MRI? Wait, a year ago? I thought this just started six months ago.

She: Well, his office never contacted me.

Doc: And how many times have you called his office? Oh, right, that would mean personal responsibility. I don't think a CT is the answer. You have a completely normal neurologic exam right now. The test I can get in the middle of the night is nowhere near as good as an MRI for looking for multiple sclerosis. Or sclerotic multiplications or whatever. By the way, did your family tree have any branches?

She: What do you mean? You have to do whatever I want.

Doc: Oh, no. Another "ER is Walmart" patient. I can't order any test just because you or I want to without a valid medical reason.

She: (Screaming now.) I CAN'T BELIEVE YOU WON'T HELP ME!

Doc: Please help me. Get me out of here. Someone call a Code Blue, please.

Nurse: DOCTOR!! WE NEED YOU IMMEDIATELY IN ROOM 5!!

Doc: Who said prayers aren't answered? I'm sorry, I have to go. I will come back and tell you the results of your flu test and the strep swab.

Nurse: I thought you needed a break. Here, have some ice water.

LATER

Doc: Nurse, please come with me. I can't go back in there by myself...Ok, your tests were negative. I think you were exactly right, you seem to have a cold.

She: But what about my CAT scan?

Doc: I'm so glad the witness, I mean, the nurse is with me. I don't have a valid reason for that test and I won't order it.

She: (Screaming again) WHY WON'T YOU DO A CBC OR A CHEST X-RAY?

Doc: What the f? Where did that come from? Why is that nurse trying to stifle a laugh? You have a normal lung exam and I don't think either of those tests will change what we are going to do. You don't have a cough or shortness of breath.

She: WHAT ABOUT THAT BROWN CRAP I'VE BEEN COUGHING UP!?!

Doc: Will this never end? When is my shift up? How many things do I have to order to be able to turn this nightmare over to my relief? I'm sorry, this is the first I've heard of this. Let me...

She: (interrupting and screaming even more loudly)

THAT'S BECAUSE YOU NEVER ASKED!!!!

Doc: I'm sorry, I can't do this right now. I'm becoming frustrated and can't talk about this right now. Give me just a minute. And shoot me if I ever have to work another night shift, please.

LATER

Doc: Nurse, please order the CXR and the CBC and come with me to let the patient know what we are going to do.

Nurse: You're going to give in to her.

Doc: Hey, gotta keep them happy to keep my job.

But, alas, the patient had left.

This scenario is fictitious, but the patient is real times infinite. This is really an amalgam of multiple visits. There is no real diagnosis, sorry anonymous. I just wanted to share some of the frustrations of the EC in the middle of the night. Thanks, folks, I feel better now.

A typical night patient in the EC

Her chief complaint was "a cold." She presented to the triage nurse at midnight and waited in the lobby until 2 am when she was shown to a room. Another 45 minutes later, enter the physician.

Doc: How can I help you this morning? Oh, My God! This woman waited 3 hours to be seen for a cold! I can't believe it.

She: Doc, I've had a cold for several weeks. It's just not getting better.

Doc: What symptoms are you having? What was so freaking emergent that you had to be seen at 3 AM for a problem you have had for several weeks?

She: I told the nurse already. Isn't it all on my chart?

Doc: This isn't going to be easy. Well, I always like to ask again, sometimes people remember extra stuff. Have you had a stuffy nose, fever, runny nose, cough, shortness of breath?

She: Well, my legs quit working all the time.

Doc: Oh, that's not good. Tell me what happens. You think THAT is due to a cold? What on earth are you talking about?

She: I have so much trouble walking. My legs just give out and I fall to the ground.

Doc: How often does that happen?

She: It has happened at least a hundred times.

Doc: Yes, but how many times a day/week/month? Jeez, don't you know what "how often" means? You answered "How many times?" See the difference?

She: Oh, all the time.

Doc: Ok, in the last week, how many times has it happened? Maybe she can't answer a two variable questions (numerator and denominator, such as 2times/week) Maybe if I define the denominator, she might accidently answer the question.

She: Every day.

Doc: So that didn't work. Try again. How many times a day does it happen?

She: All the time.

Doc: OK, I freakin' give up. Are you saying that your legs are weak all the time and that you can never walk?

She: No, doctor. You're not listening. I said that when I am walking, sometimes my legs give out on me and I fall.

Doc: I'm tired. I'm tired. I'm tired. I'm busy. I have 13 more patients waiting to be seen. OK, be nice. Don't get another patient complaint. Maybe there is actually something wrong with her. Be patient. I'm just trying to understand so I can help you. What I hear you saying Wow, I'm reflecting, just like that guy in med school told me to do. is that you are able to walk, but that, occasionally, and at least once a day, your legs suddenly become weak and you fall. Is that right?

She: That's what I've been saying. I've been waiting 6 hours and you are just repeating what I'm saying!

Doc: I'm not repeating, I'm reflecting. Anyway, you've only been here 3 hours! I'm just trying to make sure I get everything clearly. Thank you for your patience. I'm always sorry when anyone has to wait. So how long do these spells of weakness last?

She: Every day.

Doc: Wait, where's the camera? This can't be for real. Am I on ER Candid Camera? Yes, maam. It happens every day, but how long does it last when it does happen?

She: Oh, about as long as it takes my mother to drive from her house to mine.

Doc: Here in the real world we use a standardized units of time such as minutes and hours. HEY!! I DON'T KNOW WHAT WHERE YOUR MOTHER LIVES OR HOW LONG IT TAKES HER TO GET TO YOUR HOUSE!! Would you say it was just a few minutes or more, like several hours?

She: Usually just a few minutes.

Doc: OK, thank you. Finally, an answer. Have you ever been hurt as a result of any of these falls?

She: No. I just fall onto the couch.

Doc: So, do these spells only happen when you are getting up from the couch? Maybe orthostatis.

She: No, when I am walking about my house.

Doc: I don't understand. If the spells happen anywhere in your house, how come you only fall on your couch? You've never fallen on the floor?

She: No, I can make it to my couch before I fall.

Doc: No way this is real. Are the nurses playing a joke on me?

She: What?

Doc: Uh Oh. Did I say that out loud? No, it's in purple, I just thought it. You said this has been going on for several months. Have you had an opportunity to talk to your doctor about this? What does he think it is?

She: Oh, he doesn't know. He sent me to a neurologist.

Doc: And what did the neurologist say?

She: My appointment with him is at 8 this morning.

Doc: So why are you here!? And how can I help you this morning? Wait, am I repeating myself?

She: I was hoping to get a CAT scan so I wouldn't have to see the neurologist.

MORE TO FOLLOW...

WHO praises Cuban Pharmaceutical Industry

I guess the mainstream press down there is as bad as ours.

Grand Rounds XXXI

Welcome to this week's Grand Rounds. As you know, each week a different department here at the institution hosts this conference. Registration is free and attendance is not taken. This should come as a great relief to the medical students, who have learned that there is no advantage to being anywhere you don't have to be.

The conference chair this week is in the Family Medicine, Emergency Medicine, Insurance Medicine and Sports Medicine departments, so please forgive the schizophrenia seeming lack of focus.

Almost every department at the institution has contributed lecturers to make today's conference successful.

Here is the schedule for this week's conference. Please feel free to attend all of the lectures, or pick and choose. Audio recordings are not available, but transcripts are available at the lecturer's blogs.

Family Medicine

Kevin, MD, reminds us that zebras do exist. A local man dies of neuroleptic malignant syndrome at a psychiatric hospital. Kevin is more famous than most of us, just see.

In his poetically eloquent way, Dr. Charles introduces us to an interesting patient. Wow, if only I could write this well.

Emergency Medicine

How does he do it? A busy ER doc in Texas found time to submit humor and economics.

Health Business

Coming in from BeanTown, Mr. Williams, co-founder of MedPharma Partners, wishes to present on Electronic Prescribing.

Internal Medicine

DB is ranting again, this time about too many medications. Amen. Folks, we all know that complications and drug/drug interactions skyrocket the more drugs we prescribe. Try to stop one for every one you add.

Galen's Log has a very interesting post about something that, at times, can be very irritating to us, when our patients have access to information that lets them know more than we do about their problems. But, hey, what's wrong with that?

General Surgery

Everyone knows that nothing heals like cold hard steel. Never one to let a little thing like skin get between him and a diagnosis, Orac shares a tragic story.

Aggravated DocSurg (who looks suspiciously like John Belushi, I never really believed he was dead, anyway) has a patient with an interesting x-ray. In addition, he is peeved. I tried to shoot golf once. I thought I was doing well with a 68. Then they wouldn't let me play the second hole! Geez, he likes Diana Krall, so he must be a good guy, even if he is a surgeon.

Student Representatives

MudFud, who deserves special honors for being one of the first to blogroll me, has a confession to share. In addition, she is hosting Grand Rounds next week. She requests submissions by 6 PM on 5/2/02. She has a test the next day. I don't know what the deal is with midnight anyway! Send submissions to mdphdstudent AT gmail DOT com.

God Nick, who started this whole GR thing, still hasn't put me on his link list, but he did write an interesting post about Todd Krampitz, the guy who bought billboards advertising his need for a liver.

"A" is a medical student in Little City, USA. She hasn't achieved sufficient status to warrant a name, apparently. Anyway, she will speak about Vanishing Lung Syndrome. She wrote here that no one other than she reads her blog. I don't think this is an inferiority complex, as this is probably normal for a second year med student.

The Anonymous Clerk has bad news to impart.

A self professed dork, Graham interacts directly with GOD.

Ob/GYN

There are so many great MedBlogs out there, not to mention all the other blogs, that it is almost impossible to keep up with them all. But you should definitely read what Red State Moron has to say. Today he writes about elective cesarean delivery and birth defects.

Oncology

Dr. Hildreth, The Cheerful Oncologist, lectures on My Last Spring. BTW, note his new office location and update your bookmarks! Recently, St. Elsewhere tried to steal Dr. Hildreth from our staff and didn't succeed. As you browse his blog, you may note some of his comments regarding his tour of their facility.

Allergy/Immunology

Dr. Andy reflects on Living Pancreatic Islet Cell Donation. What he is running from, I will leave to your imagination.

Pediatrics and Neonatology

Dr. Suresh, from Charleston, SC, one of our new faculty, has an interest in evidence based practice, with a slant towards pediatrics and neonatology. I am not sure when he works, as his blog suggests he spends all his time downloading articles and attending journal club. (Just kidding, doc). He is just starting and didn't submit any particular link. However, because his blog is so new, read the whole thing.

"Pure" Sciences

Pharyngula (he says it is a particular stage in the development of the vertebrate embryo, but I think it is one of those dangly things, perhaps in the throat, that we studied in Gross Anatomy) wants us to think about cockroaches. Just let me get another glass of wine. Would this be red?

Healthcare Resources

Another with finely discriminating taste (read--he likes my blog), The Hospice Guy refuses to be scared or intimidated. I wish every family in the world could understand this, for hospice, general hospital care and the ER.

Dr. Emer, one of the premiere med bloggers in the Phillipines, warns us the RP is running out of doctors.

HospitalImpact wants us to imagine what it would be like if Disney ran our hospitals. Yesterday was their one month birthday!

Nephrology

Here's good info from KidneyNotes. Follow his advice and make more money!

Nursing

Mrs. Geena, RN now!! :-), wants us to spend the morning with her in the CCU.

I found this one when I was surfing GruntDoc. The nurses I work with loved it. You will too, if you have ever worked with a patient.

BioEthics

DoktorMo asks if we think the politicians should overrule science.

Other Interested Input

Interested-Participant interests us with this story about a woman who has to wait for surgery under a system of socialized medicine. I was also interested in this one. Wow, what empathy.

El Capitan had an interesting, er, urologic/gastronomic problem. Of course, if you perform this type of nighttime ablution without luminescence, you might not notice. I am always tempted to ask patients who complain of hematospermia, "How do you know?" One of my urology staff just tells them to turn the lights off.

Time Gee is a connectologist who writes about Smart IV pumps.

An engineer, Political Calculations warns us that the US Government is trying to regulate the vaccine stockpile out of existence!

Another engineer, at Power and Control, let's us know about a possible blood test for PTSD. How exciting!

Here at this institution, we recognize the value of technology in our work and play. Here, MedGadgets reports on using electricity to diagnose CIN.

I'm Not Too Sure, But I Think They Work Here

Polite Dissent, with his interesting viewpoint, let's us in on The Treatment of Pleurisy in the early 1700's. Don't try this at home, folks!

An EMT in the UK let's us in on the smelly truth of the hidden danger of drugs.

I know that Johathan, of Catallarchy, is a resident at Harvard Medical School, but I don't know in what. I do know that he posted, in a typical thought provoking way, on prenatal ultrasound.

Grand Rounds

I am soliciting faculty for presentation at Grand Rounds scheduled for 4/26/05. The conference chair is DrTony, of the FP/EM/IM/SM faculty. Any faculty or student or other interested input is appreciated. Submissions should be submitted by 6 PM for consideration. Please note the deadline, as it is slightly earlier than for other GR hosts.

Please indicate with your submission which department on the medical staff you represent.

Thanks.

UPDATE:

Oops, I should have said the deadline is 6PM 4/25/05, not today. Sorry.

Observations from the ER

I don't think it is a good thing when your patient cycles between depression and mania multiple times in one ER visit. Either their disease is bad or your turn-around-time in the ER is really bad.

It is bad to combine mania with a credit card.

The New Pope

I enjoyed this post by The Anchoress (hat tip Instapundit.) I especially found the comments interesting with some saying, "I'm a Catholic, but change this, change that," and others replying, "Hey, love it or leave it."

I don't believe you have to accept every tenant of the Catholic church to be a faithful member of the church, but it is completely unreasonable to criticize the Church for not agreeing with you. Like any organization, you will find areas of agreement and disagreement. If the areas of disagreement become more important to you than the areas of disagreement, you should probably leave.

Today's OpinionJournal had this comment:

But the Catholic Church, it is worth recalling, is not a one-man show. All the media focus on Rome when a new pope is elected distorts the nature of the church itself. The problems and opportunities facing Catholics around the world cannot be solved by papal fiat or pontifical programs. Bishops and priests can help. But what the church needs most are Catholics who want to be Catholics, who know what that means, and who seek the grace to become true disciples of Christ. That they must do themselves.

Exactly! What the church needs most are Catholics who want to be Catholics. You have to want to be a Catholic because you agree with the church and want to advance the church and reinforce your own faith. Don't expect the church to change to satisfy you. If you want a white jacket, would you check every day to see if your black jacket has become a white jacket? Or would you just return the black jacket for a white jacket? Another alternative is to be happy with the black jacket and modify your wardrobe to work with it.

The Catholic church is what it is. I joined the Catholic Church specifically because it wasn't changing to satisfy the fads of society, like my previous church. I have found great fulfillment in this. I pray that you will, also.

Another good comment, worthy of repeating, from the OpinionJournal:

The papacy changes the man as much as the man chances the papacy. Years before his election yesterday, then Cardinal Ratzinger spoke openly of wanting to retire. Now he has a job for life and seems refreshed.

We should consider Benedict's role now, as compared to Cardinal Ratzinger's job. When I was in the Navy, we recognized that the Commanding Officer of a ship was meant to be charismatic, approachable and "the good guy." However, beware the Executive Officer, the second-in-command, the enforcer. Was the XO a bad or mean guy by nature? No, that was the role in that particular job. I had one XO who was widely feared respected as a strict disciplinarian, but when he got his own ship, was a very congenial and beloved CO. Why don't we think that Cardinal Ratzinger was perceived as a doctrinal enforcer because he was supposed to be in the job that he had; now that he is Pope Benedict, he may present differently.

Elliot Spitzer

It wouldn't bother me at all if Elliot Spitzer resigned. I don't have any doubt that he is using his position to promote his candidacy (candidacies?).

Attention All Med Staff

Grand Rounds is scheduled for April 26, 2005, and will be hosted by the Family Practice/Emergency Medicine/Sports Medicine/Insurance Medicine faculty in room DrTony. Please submit all agenda items to drtonyblog at hillsides dot com by midnight on April 25,2005.

Grand Rounds

Expand your horizons and explore the medical blogosphere by attending Grand Rounds, hosted this week by GrrlScientist at Living the Scientific Life.

Is Corporate Medicine For You?

Today we interviewed a PM&R doc for a job at the insurance company where I work. It made me think about some of the concerns I had about taking a non-traditional medical job.

Would I still be a "real doctor?" What would my peers think? Would I lose my skills? Would I get bored? Would people think I was an "insurance whore?"

What would doctors think when I called them to ask about their patients? Could I stay active clinically?

I have been very satisfied with the answers to these questions.

My colleagues are actually jealous. I have the luxury of a traditional work schedule without call, without the worry of malpractice, with a salary and no collection or billing worries, no patient complaints. I remember one medical conference where I was routinely surrounded during the breaks by docs asking about the opportunities in corporate medicine.

I get to participate in corporate bonus programs and an employee stock purchase plan.

I am an employee, which means I have a 401K, employer paid (or at least subsidized) medical, dental, vision, life and disability insurance programs and paid time off.

Think about it. Do you actually get 30 days of paid vacation per year. Along with 10 days of paid CME, a CME budget, license and professional membership fees paid?

I have the luxury of taking as much time as I need to review a claim file. I have access to a well stocked medical library as well as subscription web sites with continually updated medical resources. I feel my fund of knowledge is as good as it has ever been, even when I was a resident.

I am not sure I would be able to do this job if I didn't have the opportunity to stay active clinically. I work as a hospitalist and in the ER on a regular basis. Having this variety makes all of these jobs more tolerable.

I haven't found that anyone other than the plaintiff's lawyers think of me as an "insurance whore." When I call someone on the phone and describe what restrictions and limitations I think are reasonable, the usual response is something like, "Wow, that's pretty good." I have become the specialist in disability medicine. I enjoy calling the treating physicians associated with the claims and discussing the cases with them. The docs seems to value the information I can share with them.

I definitely haven't become bored. This has actually surprised me. This is what I was most concerned about. The files do have some repetition, but the presentation is extremely varied. I asked some of the other docs at the company today and they all felt the same.

I actually feel that the ER has greater potential for boredom than the insurance job. As you have experienced, either in the ER or the office, it becomes difficult to tell the difference between one and the next URI, diabetic, hypertensive patient.

One the orthopedists with whom I work remarked that he gets to see a greater variety of orthopedic cases than he did when he was in private practice. We see the most complicated cases in a great variety of settings.

Unfortunately, we also get to see some of the worst, most substandard care dispensed in this country.

I have more time to spend in consultation with the other docs at the company. I mentioned this during the interview today and got nods and comments of agreement from the other docs present. Even in a group practice, there is so much time pressure that we don't have the luxury of leisurely consults. I have learned a great deal from my interactions with the ortho, neurology and neurosurgery specialists with whom I have daily contact.

It's certainly not for everyone. I miss the ongoing patient relationships I had when I was in private practice, but I didn't have that in the ER anyway. Of course, a lot of physicians don't have that in their specialties. I guess that's the family practitioner coming out in me. I know that my family certainly benefits from the predictable schedule associated with this type of work.

This is not meant to be a recruitment monologue, just some of my thoughts. However, if you have questions or thoughts, put them in the comments or e-mail me.

Appeals court OKs Bredesen’s TennCare cuts

A federal appellate court Tuesday ruled Gov. Phil Bredesen could move forward with plans to slash 323,000 people from the state’s troubled $8.7 billion TennCare program.

The 6th U.S. Circuit Court of Appeals ruling said U.S. District Judge William J. Haynes Jr. does not have the authority to block the state’s plans to implement the major overhaul needed to offset a $650 million shortfall in the program.

This is actually surprising, that a court is actually going to let the ELECTED LEGISLATORS do their jobs.

However, I am not surprised that the online newspaper, NashvilleCityPaper.com, characterized the plans as "slash 323,000" people. Are we really supposed to believe that the newpaper is objective with language like this? Isn't this editorializing?

Again, Grand Rounds

You should definitely read GruntDoc, and especially now that he is the host of this week's Grand Rounds. GruntDoc is a great ER blogger.

Touring the hospital

Another delightful entry on the tour track for St. Elsewhere, by the Cheerful Oncologist, at his new blog home.

Should Congress pass the president's medical malpractice proposal?

Yes, says Sally Pipes, in the Daily Herald, from Provost, Utah.

Medical malpractice lawsuits have been driving up the costs of health care for decades. In recent years, they have actually started to limit patient access to quality care.

From 1975 to 2002, malpractice insurance premiums increased at four times the rate of inflation.
By 2002, the malpractice cost to Americans was $25 billion -- or $250 per American household. That's more than half of what the average household spent on prescription drugs.

Lottery-size awards drive the problem. The average award increased from $700,000 in 1999 to more than $1 million in 2001. Seven of the top 20 lawsuit awards in 2001 and 2002 were for malpractice resulting in a combined cost of $3 billion. Up to 40 percent of the awards wind up in the pockets of lawyers.

...

Most recently, a study by health economist and former Clinton administration official Kenneth Thorpe found that premiums in states with limits on non-economic awards are 17 percent lower than in states where attorneys have free reign.

A national solution is exactly what the doctors are ordering.

The House of Representatives has twice passed legislation only to see it die in the Senate where the trial-lawyer lobby has many friends.

And, no, says Michael Saks.

The best way to prevent medical malpractice litigation is to reduce the incidence of medical errors and injuries.

So what? What does this have to do with the subject at hand, which is the ridiculous size of the jury awards?

Proponents of the legislation argue that litigation adds to health-care costs because doctors and hospitals pass those costs along to consumers. But that is exactly why health-care providers cannot complain too loudly about malpractice premiums: it is patients, not providers, who ultimately are expected to pay the bill.

Not true. Those of us who work in medicine know that we don't get to pass along our expenses. While malpractice expenses continue to go up, most of us are facing competitive pressures to decrease or maintain our charges.

Second, that litigation "surcharge" buys patients deterrence against error, harm and the resulting costs, thereby keeping the total real cost of health care lower. As the deterrence factors go down, injuries, and the total real cost of health care rise.

Wait a minute! I thought you just said the "surcharge" argument didn't apply because we just pass the costs on. Now you are arguing that this cost, which we don't actually pay because we pass it on, keeps us from making errors. Fellow physicians, you don't do good work because you are ethical, smart, hard-working or concerned about your patients! You don't have pride in a job well done! You avoid errors because you have malpractice insurance!!! The ONLY reason you try to avoid errors is to avoid a lawsuit! Betcha didn't know that. Thanks, Mike.

Come to think of it, this is very relieving. Imagine, you don't have to care whether you hurt anyone with your car, because the only reason you drive carefully is to avoid an increase in your car insurance.

A relatively few doctors cause most of the carnage. About 5 percent of doctors are the focus of half the lawsuits. Removing those doctors would reduce quite a lot of malpractice, malpractice suits and the costs of both.

So get rid of those guys. BTW, who are they anyway? I'm going to have to pay more attention at my next staff meeting. I guess 5 out of every 100 of us are real f**k ups.

When the relatively few cases that get filed reach trial, juries give doctors considerable benefit of the doubt. Of cases where insurers believed their clients committed malpractice, half of the victims lost at trial.

Really? Where did you get this kind of information? How can you know whether the insurer believes the doctor committed malpractice? I can't believe any malpractice insurer would publish this kind of data. Imagine: Boy did we get lucky. That SOB really reamed that patient, but that great jury found for us!

And those few who win usually are under-compensated. Though the law says that victims of negligent injuries should be fully compensated for their losses, research finds that only 10 to 20 cents are paid on each dollar of economic loss.

Again, I find this hard to believe. Let's see the evidence.

Proponents argue that provisions such as caps will make doctors more willing to disclose their mistakes and thereby reduce future errors. How caps can do that is a mystery. Moreover, existing federal law already protects the confidentiality of such communications.

It's a mystery only because you think we don't have empathy or a conscience. Federal law protects information released in confidential peer review situations. However, ask any physician who's been involved in peer review what lengths are observed to prevent the discovery of that information. If a physician even removes the report of a peer review from the immediate peer review environment, like to take a copy home to generate a response, it can be discovered and used against her in a malpractice case.

Tort reform

It's been said before, but I'll say it again: Why should the manufacturer of a legal product be held responsible for the illegal use of the product? Why do people think it is reasonable to sue a gun manufacturer because someone used that product to kill someone, illegally?

These people think so: Gun Opponents Speak Out Against Tort Reform Bill.

Would they argue that GM is responsible for the injuries caused by a drunk driver?

A common response to my question is that cars have a legitimate legal harmless use and that guns don't. Of course, many people, including the majority of our lawmakers, and, most importantly, the crafters of the 2nd ammendment to the US Constition, differ with that opinion.

I don't think we need to pass more laws about guns, but just enforce the laws that are already on the books. If a gunowner leaves a loaded gun where a minor can get it and, accidently or purposefully, hurt someone with it, prosecute the gunowner. Those killers at Columbine didn't have those guns legally.

Passing a law to take my guns away won't prevent any crimes.

Warn your patients!

From The Prescriber's Letter (link may require subscription:

The same brand names are used for different drugs in different countries.
A patient traveling in Serbia ran out of Dilacor XR (diltiazem). He got a refill and landed in the hospital with DIGOXIN toxicity. It turns out that Dilacor is a brand name for digoxin in Serbia.
Dilacor is also a brand name for verapamil in Brazil...and the calcium channel blocker, barnidipine, in Argentina.
Norpramin is omeprazole...not desipramine...in Spain.
Flomax is an analgesic...not tamsulosin...in Italy.
Vivelle is an oral contraceptive...not an estradiol patch... in Austria.
Cartia XT is extended-release diltiazem in the U.S. But Cartia contains aspirin in Israel, Australia, New Zealand, and Hong Kong.
Some foreign names are very similar to ours. Ambien is zolpidem in the U.S...Amyben is amiodarone in the U.K. Prolixin is the antipsychotic, fluphenazine in the U.S...Prolixan is an NSAID in many parts of Europe.
The Institute for Safe Medication Practices supplies us with this important information. Mix-ups are now a real danger as people travel more...and drugs cross borders more often.
It's especially important for people who return to their native country often...and are also treated there.
Tell patients who travel abroad to carry enough of their meds...and a list of their drugs by BOTH generic and brand name. Warn patients who are getting drugs abroad to beware.

If you don't, you should consider subscribing to the Prescriber's Letter. I learn something useful from every single issue.

Tangled Bank

The newest edition of Tangled Bank is available at Respectful Insolence. A look at science on the blogosphere. Hey, you might learn something.

Blogorrhiphic

The Carnival of the Vanities is up at Incite. A very valuable source to learn your way around the blogosphere.

And early, too!

Grand Rounds

is up at Polite Dissent, one of the wierdest most intriguing ideas in MedBlogging.

After they die

The night before last I relieved a doc at 10PM who had just concluded a code and the elderly patient was deceased. We all hate to break the news to the family, but recognize that is part of what we do. However, the family wasn't around. I had a first: my colleague signed out a dead patient to me.

When the family arrived, I was very busy. There was no way I wanted to get involved. I was aggitated and aggravated as I went to the Family Conference Room; a place, I can assure you, you never want to be taken.

The patient's wife and son were in the room. Now, every physician has a particular way to break this kind of news to the family. I tend to begin by asking what happened at home and then describing the treatment leading up to the arrival in the EC and the subsequent treatment. Then I say something like, "Everyone did everything possible and it just wasn't enough. Mr. Patient was just too sick and [pause] didn't make it."

However, in this instance, the patient's wife just kept interrupting my carefully prepared delivery. Forget that I didn't have the first clue what had happened and was just confident in my colleague's abilities, but I had something to say and she wouldn't let me! How dare her!

I fought my rising irritation at this imposition on my busy night, just getting started. I gently (maybe not so gently) interrupted and asked, "Have you been told that Mr. Patient has passed?" She replied, "Yes," and continued to tell me about him. I mean, recent and remote stuff. Not just the events of the night.

My mind was racing with the huge number of charts (note I said charts, not patients) waiting for me. Only just into my night shift and I was already tired and irritated. Why wouldn't she just shut up!!! How did I get stuck in here, anyway? What purpose could I serve here? I had real work to do!

Then I realized that this was a woman who had just lost her husband, her companion for most of her life, a big part of her. She wasn't thinking about the number of things she had to to, or the impact of this on her life right then. She was just remembering the life of a good man, a man she loved.

Jesus told us to rejoice at death. We all know about the huge parties some cultures have, like the wakes of the Irish and the parades in New Orleans.

This is what I could do. I could listen. And so I did. I just sat quietly and listened. She wasn't talking to me as much as she was talking to herself, but I listened. Man, it felt good. I relaxed and just waited.

Soon, after only a few minutes, she looked up and said, "I guess I shouldn't keep you. I'm sure you have much more important things to do than listen to an old woman ramble on about her dead husband."

But I didn't.

Alkermes submits alcoholism drug to FDA

APR. 1 11:15 A.M. ET Alkermes Inc. on Friday submitted an application to the Food and Drug Administration for marketing approval of a new drug that would treat alcohol dependence.

Vivitrex would be the first medication available for the treatment of alcohol dependence in a formulation that is administered once a month by injection. The drug is a new formulation of naltrexone, which reduces the desire for alcohol.

Two sides of the same coin?

Ranbaxy Receives FDA Approval To Market A Generic Alternative To Macrobid

Total annual market sales for Nitrofurantoin Monohydrate/Macrocrystals Capsules were $80.0 million (IMS - MAT: December 2004).

...

“We are delighted to receive approval from the U.S. FDA to market this product to add to our ever growing generic product portfolio. Our plans are to bring this product to the market as quickly as possible during the month of April,” according to Jim Meehan, Vice President of Sales and Marketing for RPI, USA.

and

Schering drug Asmanex, finally gets FDA approval

Once hailed as a billion-dollar-a-year blockbuster, the drug is now seen by analysts as a more moderate seller.

“It would have been a big deal if they would have gotten approval four years ago,” said Sena Lund, an analyst with Cathay Financial LLC. Still, Lund called the approval a “positive” for the drug maker, and forecasted peak annual sales to reach as much as $300 million.

Now, while I am not necessarily a big fan of big drug companies, this seems to be a classic case of a "blockbuster" drug that fizzled because the FDA messed around and didn't approve. Not to mention that this is 7 years of patent time that has expired without any sales. That much close to generic competition.

This is not good news

President's Proposed Remedy to Curb Medical Malpractice Lawsuits Stalls

Almost everywhere President Bush traveled on the campaign trail last year, he lashed out at plaintiffs' lawyers for filing "junk lawsuits" that he said were sending the cost of health care out of sight.

These days the president rarely mentions the topic, and the effort in Congress to rein in medical malpractice litigation has stalled, according to proponents and opponents of the bill.

The troubles faced by his "med-mal" proposal may signal a turn in Bush's fortunes on domestic policy. In the first three months of the year, he scored large and comparatively easy victories on legislation to restrain class-action lawsuits and to revamp bankruptcy laws to make it harder for consumers to wipe out their debts -- both measures that had been long sought by business interests.

But those proposals represented what a senior Democratic Senate aide called "low-hanging fruit," easily picked by a newly reelected president. The medical malpractice legislation -- a more complex and more controversial idea -- is proving to be a longer reach.

Right now, the various states are all over the map (no pun intended) with regards to MedMal reform. The only way to get a consistent playing field is for the US Congress to do something. This is looking less likely.

Polls telling stories

Remember stories of poll results during the Terri Shiavo kerfufle that reportedly showed that 80% of Americans would have preferred to have died rather than be in her situation? At the time, there was criticism that the questions were slanted for that result.

Consider this, from Zogby International:

"If a disabled person is not terminally ill, not in a coma, and not being kept alive on life support, and they have no written directive, should or should they not be denied food and water," the poll asked.

A whopping 79 percent said the patient should not have food and water taken away while just 9 percent said yes.

Hat tip: Powerline, who said:

That's obviously a fairer way of describing Terri Schiavo's situation than most polls used. The only thing that bothers me about the Zogby data is that I haven't been able to find the complete poll results anywhere; even Zogby's own site only has a "Life News" story about the poll.

Cool post, on its way to being a cool series:

You should never miss a post by The Cheerful Oncologist. As an ER doc, I encourage you, specifically, to read this one:

With time even the most timid oncologists will learn how to master the hospital routine and put a little spark in their step as they go about their rounds. There is one special place, however, that can unnerve even the most jaded practitioners - a place of unspeakable tension, where green-skinned zombies strain at the leather straps that bind them, where blood and vomit, sheets, tubes and rubber gloves amass into a tornado that sucks up nurses, doctors, even little old ladies in pink volunteer jackets into a writhing, screaming mass of chaos.

Goodness gracious - am I hallucinating? Is this a dagger which I see before me?

Of course not - I'm just describing the friendly confines of the elite suite where the injured meet - the emergency room.

This post reminded me of some thoughts I have had as I treat patients in the ER. We, the denizens of that "place of unspeakable tension," that "writhing, screaming mass of chaos" take where we work for granted, just like the guy who changes my oil at the shop. We don't see the place as a "mass of chaos," but can see the order where there seems to be none.

I frequently find myself trying to imagine what it must seem like to the unitiated. Geez, if a physician colleague sees it like this, what must it seem like to the patients? I find myself more able to calm down, slow down, sit down and just talk and be a person when I am with my patients if I can imagine the sense of unreality they must be experiencing.

I take it for granted that I can punch in a code to open a locked door, go wherever I want, get a cup of coffee from the radio room, read the board and come and go as I please. I try to remember that it isn't like this for the patients and their families.

I have found myself, lately, explaining more than just the medical issues to these people. I now explain the procedural (read administrative) elements of their trip through the emergency center. I have always recognized my responsibility and duty to explain the medical issues, but have only relatively recently understood the need to cover these other issues.

And you know what? I enjoy myself a hell of a lot more now. These are real people, confused, hurting, and in need. What a joy to be able to meet those needs; medical, psychological and just curious.

BTW, Dr. Hildreth, the worst acronym is WADAO syndrome: Weak And Dizzy All Over!

CodeBlueBlog does it again

You have to admire his confidence. Read this.