August 6th, 2009 by GruntDoc in Better Health Network, Health Policy, Opinion
Tags: Cleveland Clinic, Cost of Care, Emergency Medicine, Finance, Healthcare reform, Hospitalists, Internal Medicine, Overhead, Salaried Physicians
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The Happy Hospitalist, generally an excellent blogger, wrote yesterday about how salaried docs must be delivering better care than those greedy FFS docs, because the Cleveland Clinic does a terrific job with docs on a salary. I suspect their excellent outcomes have nothing to do with reimbursement model and a lot more to do with systems and a strong gatekeeper model.
He totally missed the elephant in the room in the Big Group Clinic model: who gets the money for doing the work.
He cites as an example a GI doc who left the Clinic for independent practice and quadrupled his income. Let’s say he’s working as hard as he did in the Clinic; is he billing more than the Clinic did? I doubt the Clinic wasn’t billing the usual amount for the work, so 3/4 of this docs’ billing went where?
I suspect it went into the overhead of the Clinic. This isn’t a knock on them, it works for their group, so fine. Other groups do essentially the same thing. It’s legal and morally defensible, and some docs don’t mind being salaried.
Salaried docs in a big Multispecialty Clinic have different incomes, but not as radically disparate as the non-clinic model. As a way to somewhat equalize RVRBS issues it works (I wouldn’t want to be in the room when salaries come up, though).
What salaries do not do is get docs to work harder, see more patients. Some docs are very dedicated, motivated people who would work for rent and grocery money. Others on a salary would do the minimum: if every patient is more work and more liability without more pay, well, why work more/harder? As an incentive to produce nothing beats getting paid for it.
(This isn’t an endorsement of excessive or un-necessary procedures; there are greedy jerks in all professions).
Also, a happy side effect of getting paid for what you do rather than for having a pulse is those who work hard resent those that don’t (but who would make the same on salary) a whole lot less. Way less inter-group stress.
Salaries aren’t all bad, but they’re not the Key to Great Healthcare.
Discolsure: I’ve worked ED’s both ways, and much prefer fee for service.
*This blog post was originally published at GruntDoc*
August 6th, 2009 by RamonaBatesMD in Better Health Network, News
Tags: Nipple, Obstetrics And Gynecology, Raynaud's Phenomenon, Vasospasm
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This article would have been off my radar had it not been for the interaction on twitter.
jeffreyleow RT @paulinechen: Camera Phones [patients taking pics] helps doctor make rare diagnosis http://3.ly/CXr (via @EllenRichter)
Granted I am not generally asked about nipple pain in pregnant women. Those questions tend to go to folk like TBTAM or ER’s Mom.
The article describes a case report of a 25 yo woman in her 2nd trimester with “frequent episodes of extreme bilateral nipple pain. A typical episode lasted between 5 and 15 minutes and was so painful as to bring her to tears.”
The article discusses Raynaud’s phenomenon of the nipple and share these photos (credit) taken with a camera phone with us. The text with the photo:
Vasospasm of the arterioles manifesting as pallor (left), followed by cyanosis, and then erythema (centre). The right hand image shows the normal, asymptomatic, status.
As with Raynaud’s of the hand (which I am more familiar with), the phenomenon tends to occur when the ambient temperature drops below a certain threshold that is specific to each individual. Exposure to cold should be avoided, as is avoidance of caffeine, nasal vasoconstrictors, and tobacco.
Additional treatment for Raynaud’s of the nipple:
Women with persistent pain require immediate relief to continue breastfeeding successfully. Recommended treatment is 30 mg nifedipine of sustained-release once-daily formulation, and most women respond within two weeks.
REFERENCE
An Underdiagnosed Cause of Nipple Pain Presented on a Camera Phone; BMJ 2009;339:b2553; O L Holmen, B Backe
Vasospasm of the Nipple–a manifestation of Raynaud’s phenomenon: case reports; BMJ 1997 314: 644; Laureen Lawlor-Smith and Carolyn Lawlor-Smith
*This blog post was originally published at Suture for a Living*
August 5th, 2009 by Toni Brayer, M.D. in Better Health Network
Tags: Cancer, Oncology, Screening Tests, symptoms
1 Comment »
I sat with non-medical friends last night and the discussion turned to “health”, as it often does. One guy related the terrible story of a woman who went to her doctor with a certain pain which turned out to be cancer that had spread and she died within a week. The inevitable question; “How do you detect early cancer, so you can catch it and cure it?”
The answer I gave was less than satisfactory for my friends. In fact, they were a bit incredulous with the answer.
All cancer is genetic, in that it is caused by genes that change. Only a few types are inherited. Most cancers come from random mutations that develop in body cells during one’s lifetime – either as a mistake when cells are going through cell division or in response to injuries from environmental agents such as radiation or chemicals.
Different types of cancer show up differently in the body. We have screening tests for some types of cancer. We can detect early breast cancer with mammography. We detect early colon cancer with colonoscopy and hemocult stool tests. We do screening for cervical cancer with pap smears. Early prostate cancer can be detected with PSA, but it is not very specific. Skin cancers can be found early with visualization and biopsy.
What about brain cancer, testicular cancer, leukemia, sarcoma, lung cancer, ovarian cancer and a number of other less common malignancies? We have no screening tests for these diseases. Perhaps we will discover some gene test or imaging test or breath test in the future, but right now, a person would need to have symptoms that would point to the disease.
This is a scary thought for people…especially those who try to live healthy lives.
It is the randomness of life that has always made us feel vulnerable to things we cannot control.
*This blog post was originally published at EverythingHealth*
August 5th, 2009 by admin in Better Health Network
Tags: Eating Habits, Food and Nutrition, Pediatrics, Toddlers, TV
2 Comments »
I have not posted a blog in a week because we were on vacation and truly wanted to be on vacation and not be tied to doing any “work.”
We went to north Georgia for a few days then up to the mountains in western North Carolina. How gorgeous! It was so nice to escape the humidity of Florida for a week!
I had an observation on my vacation that I thought I would share. I have talked in previous blogs about mindless eating and how we multi-task while we are eating. When we are not conscious of what we are eating, we don’t fully enjoy it. In addition, we eat more than we realize.
I observed this phenomenon in my little boy who just turned 2 years old. We were in the car a lot for hours on end, so snacking and fast food were part of the trip. Also, because he is 2 and difficult to entertain in a car, we had the DVD player set up for him to watch his favorite Elmo, Clifford, and Thomas the Tank Engine videos.
It was quite amazing that whenever he was glued to the TV, he ate whatever snacks or meals in his carseat without even looking down. He just picked up a piece and put it in his mouth. And he would ask for more. Whenever he was not glued to the TV, he wasn’t asking for food or eating as much. Hmmm…..very interesting.
From now on I am going to be very careful about two things. First, how much TV he is watching. He normally doesn’t watch much but on this trip he got very spoiled with watching his DVD’s and I am afraid it will lead to more asking to watch now that we are home. Second, I am going to only let him snack when he is fully conscious of what he is doing. No food in front of the TV so that he can be very conscious about what and how much he is putting into his mouth.
As a fairly new (2 years) parent, I am still learning these lessons first hand on how to feed children. I just had to share my story because our children learn habits, both good and bad, at a very young age!
This post, Do 2 Year Olds Engage In Mindless Eating?, was originally published on
Healthine.com by Brian Westphal.
August 4th, 2009 by DrRich in Better Health Network, Health Policy
Tags: Capitalism, Communism, Healthcare reform, Obama, Socialism, Tonsils
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Before the election, the right-wing commentators insisted to us that Barack Obama was a closet socialist. They hounded us repeatedly with the notion that Mr. Obama hung out with the likes of Jeremiah Wright and Bill Ayers, and that in fact virtually all of his acknowledged friends and advisors were dangerous leftists. When Mr. Obama innocently told Joe the Plumber that he wanted to “spread the wealth around,” you’d have thought he’d announced his intention to replace the Constitution with the Communist Manifesto.
And the righties have been even more vociferous since President Obama took office. In high dudgeon they beseech us to notice (dear God!) that in six short months he has gathered into the grasping embrace of his government a good chunk of the American economy, from GM and Chrysler, to Fannie Mae and Freddie Mac, to the world’s largest banks and investment houses – and in short order he intends to take over the entire healthcare system, now fully 16% of our economy and growing rapidly.
At the same time (they insist) he is doing everything he possibly can to stifle American business. He is raising business taxes during a deep recession, and is pushing Cap and Trade, which will put American businesses at a huge disadvantage in the world market. They say that the massive deficits Mr. Obama is accumulating at unprecedented rates will place our economy in grave jeopardy within a decade, and that our children and grandchildren will never be able to extricate themselves from the pit of debt he will have left them. They point out that Fidel Castro and Ceasar Chavez, avowed Communists, look at Mr. Obama’s doings with great awe and respect bordering on jealousy. The right-wing commentators say lots of other stuff, too, to prove Mr. Obama is a radical lefty, but for DrRich all these allegations blend together after awhile, and it becomes difficult to recall the specifics. (One thing they hardly ever mention is that the first step in the Great Government Takeover of Everything was taken by President Bush. Mr. Obama has merely accelerated the pace down this path from a saunter to a sprint.)
DrRich must admit that, even for someone as objective and open minded as he is, it can become easy to view the incredible flurry of policy achievements Mr. Obama has pushed through so far, and his aspirations for even bigger ones still to come, and wonder whether, perhaps, this great experiment of unprecedented government spending, and huge new entitlements that will continue on down through the generations, might not be just a tad risky.
And it is even more disturbing to consider that, if one indeed wanted to bring down the American system in order to have the opportunity to remake it from scratch (this time, emphasizing equity of outcomes rather than individual freedom as a central organizing principle), then burdening the system with crushing entitlements and crushing debt would seem to be a pretty serviceable method for achieving it. And this is exactly what the right-wing commentators would have us believe is President Obama’s real aim. (Which is why, they say, they dare commit the very grave sin of publicly hoping President Obama will fail. Only Democrats, it seems, are permitted, with political correctness, to voice such hopes about opposition presidents.)
So even DrRich (a paragon of objectivity) was beginning to have his doubts about Mr. Obama’s real commitment to the American experiment.
But in his press conference last week Mr. Obama allayed all DrRich’s fears, and made him ashamed he had ever entertained such doubts. If he really meant what he said in that press conference, it is impossible for President Obama to be a radical leftist.
Recall his typically eloquent words: “You come in and you’ve got a bad sore throat, or your child has a bad sore throat or has repeated sore throats. The doctor may look at the reimbursement system and say to himself, ‘You know what? I make a lot more money if I take this kid’s tonsils out.’”
Now, don’t you feel better? DrRich certainly does.
Of course, certain short-sighted physician groups immediately and unproductively took offense at this comment. There is no reason to. After all, Hillary pronounced 16 years ago that the problem with the American healthcare system is: Too many greedy doctors using too much expensive technology. And that’s pretty much been the sum of it ever since.
So even if Mr. Obama meant to insult doctors with his comment, he was simply restating one of the chief premises dearly held by most healthcare reformers. He wasn’t breaking new ground in any way. So doctors shouldn’t be acutely insulted here. (They should be chronically insulted. )
If there’s anything to regret about Mr. Obama’s statement, it’s that it reveals a sad misunderstanding of one important aspect of how the healthcare system works. Kids with sore throats don’t go directly to the greedy otolaryngologists, the guys who get paid “a lot more money” if they take the kid’s tonsils out. Rather, they go to primary care doctors, often pediatricians, who (if anything) are punished for sending too many kids to the greedy otolaryngologists. (DrRich knows several fine pediatricians, and not one of them any longer possesses those nasty looking tonsil scoops, or whatever those dire instruments are called which are used for removing the offending glands.) So the system is actually geared toward having kids suffer with chronic sore throats until the PCP just can’t ignore the problem any more. The ones who are finally referred to the greedy specialists often really, really need to have their tonsils out. The pediatricians aren’t referring patients for tonsillectomy all willy-nilly, and the greedy otolaryngologists (even if one supposes they always rip tonsils out first and ask questions later) must find other means of paying for their speedboats. DrRich’s point being: In the real world, using the abuse of tonsils as an example of run-away healthcare spending just doesn’t work very well.
It seems a shame that Mr. Obama does not have even a basic understanding of the system of incentives that exists today within the healthcare system, especially since he aims to fundamentally change it. But then, since he allows that he hasn’t even personally read the healthcare reform bills he’s urging Congress to make into law, one cannot really expect him to have an intimate understanding of the present system, which he hopes to soon render obsolete anyway. It would be a waste of his valuable time to come entirely up to speed on a system which is apparently in its last days.
Back to the point of this post, and it’s a point that – sad to say – every other commentator seems to have missed. (Proving, once again, how lucky DrRich’s readers are to have him.)
When President Obama declared that greedy physicians will commit surgery on unsuspecting and innocent children just because the reimbursement rate is higher, nobody seems to have noticed that what he was saying was, “Doctors respond to fiscal incentives.” And since a committed egalitarian like the President would surely not believe that doctors are fundamentally different from every other type of human person, he was really saying, “People respond to fiscal incentives.”
There it is. Mr. Obama explicitly and publicly believes the one thing that no committed Communist or radical leftist is permitted to believe, namely, that people respond logically to fiscal imperatives.
Fundamentally, socialism requires people of ability to work very, very hard for the public good, to support those who cannot or will not work hard, and as a reward they can expect to receive praise from the ruling class.* Knowing their toil is for the good of everybody should suffice as incentive aplenty. This is precisely why radically left-wing social systems (which DrRich has always thought in principle to be a very nice idea) have never worked – and never will work.
For no system of societal organization can work well for long that requires, as a first premise, a fundamental change in human nature.
So right-wingers who have railed against the overt left-wing policies of Mr. Obama, and the more moderate people who have been starting to have their own doubts, should now breathe a great sigh of relief. Whatever else our President may be, he cannot be a committed leftist.
Even though the cost of learning this vital fact was another insult to the basic integrity of doctors, it was really just one more insult superimposed on a world view that defines doctors to be fundamentally greedy and inconsiderate of their patients’ actual needs. No big deal. For the cost of that small price, we now know that President Obama must be – has to be – a committed capitalist after all.
*In practice, of course, those who take risks and work hard for personal gain are never actually praised for their contributions to the public weal, even if those contributions are enormous and stifling. Rather, they need to be demonized; otherwise some would think it unfair to take their hard-won gains from them.
*This blog post was originally published at The Covert Rationing Blog*
