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Physician Specialty Silos Can Cause Friendly Fire Casualties

It’s no secret that medicine has become a highly specialized business. While generalists used to be in charge of most patient care 50 years ago, we have now splintered into extraordinarily granular specialties. Each organ system has its own specialty (e.g. gastroenterology, cardiology), and now parts of systems have their own experts (hepatologists, cardiac electrophysiologists)  Even ophthalmologists have subspecialized into groups based on the part of the eye that they treat (retina specialists, neuro-ophthalmologists)!

This all comes as a response to the exponential increase in information and technology, making it impossible to truly master the diagnosis and treatment of all diseases and conditions. A narrowed scope allows for deeper expertise. But unfortunately, some of us forget to pull back from the minutiae to respect and appreciate what our peers are doing.

This became crystal clear to me when I read an interview with a cardiologist on the NPR blog. Dr. Eric Topol was making some enthusiastically sweeping statements about how technology would allow most medical care to take place in patient’s homes. He says,

“The hospital is an edifice we don’t need except for intensive care units and the operating room. [Everything else] can be done more safely, more conveniently, more economically in the patient’s bedroom.”

So with a casual wave of the hand, this physician thought leader has described a world without my specialty (Physical Medicine & Rehabilitation) – and all the good that we do to help patients who are devastated by sudden illness and trauma. I can’t imagine a patient with a high level spinal cord injury being sent from the ER to his bedroom to enjoy all the wonderful smartphone apps “…you can get for $35 now from China.” No, he needs ventilator care and weaning, careful monitoring for life-threatening autonomic dysreflexia, skin breakdown, bowel and bladder management, psychological treatment, and training in the use of all manner of assistive devices, including electronic wheelchairs adapted for movement with a sip and puff drive.

I’m sure that Dr. Topol would blush if he were questioned more closely about his statement regarding the lack of need for hospital-based care outside of the OR, ER and ICU. Surely he didn’t mean to say that inpatient rehab could be accomplished in a patient’s bedroom. That people could simply learn how to walk and talk again after a devastating stroke with the aid of a $35 smartphone?

But the problem is that policy wonks listen to statements like his and adopt the same attitude. It informs their approach to budget cuts and makes it ten times harder for rehab physicians to protect their facilities from financial ruin when the prevailing perception is that they’re a waste of resources because they’re not an ICU. Time and again research has shown that aggressive inpatient rehab programs can reduce hospital readmission rates, decrease the burden of care, improve functional independence and long term quality of life. But that evidence isn’t heeded because perception is nine tenths of reality, and CMS continues to add onerous admissions restrictions and layers of justification documentation for the purpose of decreasing its spend on inpatient rehab, regardless of patient benefit or long term cost savings.

Physician specialists operate in silos. Many are as far removed from the day-to-day work of their peers as are the policy wonks who decide the fate of specialty practices. Physicians who have an influential voice in healthcare must take that honor seriously, and stop causing friendly fire casualties. Because in this day and age of social media where hard news has given way to a cult of personality, an offhanded statement can color the opinion of those who hold the legislative pen. I certainly hope that cuts in hospital budgets will not land me in my bedroom one day, struggling to move and breathe without the hands-on care of hospitalists, nurses, therapists, and physiatrists – but with a very nice, insurance-provided Chinese smartphone.

Dosing Exercise: Choosing What’s Right For You

It is risky.

Stay fresh. Avoid repeating yourself. Don’t rant. Never preach. These would be the ‘rules’ of supposedly good blogs.

And, of course, doctors that dare to take a stance on health issues risk being perceived as pretentious. I get this.

So it is with trepidation that I write a follow-up to last week’s CW post about right ventricular damage immediately after an extreme race effort. Notwithstanding the pompousness concern, I also wish to avoid being labeled anti-exercise. Few believe more strongly in the healing powers of exercise.

But last Wednesday’s comments (both on the blog, Facebook and here on Dr. Val Jones’ BetterHealth blog) were just too good to let rest.

On the assessment of studies: Read more »

*This blog post was originally published at Dr John M*

Study Suggests The Importance Of Maintaining A Low Resting Heart Rate

When you sit quietly, your heart slips into the slower, steady pace known as your resting heart rate. A new study suggests that an increase in this rate over time may be a signal of heart trouble ahead.

Your heart rate changes from minute to minute. It depends on whether you are standing up or lying down, moving around or sitting still, stressed or relaxed. Your resting heart rate, though, tends to be stable from day to day. The usual range for resting heart rate is anywhere between 60 and 90 beats per minute. Above 90 is considered high.

Many factors influence resting heart rate. Genes play a role. Aging tends to speed it up. Regular exercise tends to slow it down. (In his prime, champion cyclist Lance Armstrong had a resting heart rate of just 32 beats per minute.) Stress, medications, and medical conditions also influence the heart rate.

In today’s Journal of the American Medical Association, researchers from Norway report Read more »

*This blog post was originally published at Harvard Health Blog*

Abiomed Announces An Upgrade Of Their Current LVAD

Impella-cVAD-small

Abiomed‘s Impella left ventricular assist device, an endovascular percutaneously-delivered LVAD, will soon be getting a more powerful new model. The current model is capable of delivering an augmentation of cardiac output by up to 2.5 liters a minute, but the new Impella cVAD should do around 3.5 L/m, and possibly up to 4 L/m in the not too distant future.

The new device, and above numbers, were announced at Abiomed’s investor day conference and the company hopes to have the device available to clinicians by the Summer of 2012.

Here are the bullet points about Impella cVAD that were provided to us by Abiomed: Read more »

*This blog post was originally published at Medgadget*

Dealing With The Problem Of Hospital Readmissions For Heart Failure

“How are you feeling, Ms. Jones?”

“Fine.”

“Have you been more short of breath lately?”

“Not really, just when I exercise.”

“How much exercise?”

“I dunno. But after I go to the mailbox and walk back up to the house, I’ve got to stop now where before I didn’t.”

Exertional dyspnea. It conjures up a large differential of potential cardiovascular or pulmonary causes. And as the above commonly-encountered doctor-patient conversation demonstrates, the problem is a dynamic one: at rest things are often fine, on exertion or with recumbency less so.

Now imagine that the doctor then sees elevated neck veins, hears rales in the lower lung fields, and sees swollen ankles on their patient. Heart failure, right? Read more »

*This blog post was originally published at Dr. Wes*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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