January 25th, 2011 by DrRich in Health Policy, Opinion
1 Comment »
While DrRich is a conservative American, and has made plain the difficulties he has with the Progressive program in general and with Progressive healthcare reform in particular, at times he is forced to admit that, on occasion, the Progressive way of looking at the world has certain merits. And as DrRich contemplates a question that has been bothering him lately, a question that no doubt plagues many American physicians who (unlike DrRich) are still toiling away in the trenches, he finds that this is one such occasion.
That question is: Just who are the people writing all those clinical guidelines — the “guidelines” physicians are now expected to follow in every particular in every case, on pain of massive fines, loss of career, and/or incarceration?
DrRich is quick to say that the act of creating clinical guidelines is not inherently evil, and indeed, back in the day when guidelines were merely guidelines (instead of edicts or directives that must be obeyed to the last letter), creating clinical guidelines was a rather noble thing to do.
But today, we have physicians clamoring to become GOD (Government Operatives Deliberating) panelists. These aristocrats of medicine will render the rules by which their more inferior fellow physicians, the ones who have actual contact with patients, will live or die. Clearly positions of such authority will be very desirable, and so, as one might predict, they are being vigorously pursued. And we are seeing candidates audition for these panels with efforts ranging from amateurish to ruthless. It puts one in mind of the early-season contestants on “American Idol.” Read more »
*This blog post was originally published at The Covert Rationing Blog*
January 24th, 2011 by Davis Liu, M.D. in Better Health Network, Opinion
No Comments »
A recent post on the Health Affairs blog proclaimed “The End of Internal Medicine As We Know It.” What the post is really asking about is the future of primary care in the world of healthcare reform and the creation of accountable care organizations (ACOs). While doctors should be naturally concerned about change, I don’t completely agree with this article.
ACOs are organizations that are integrated and accountable for the health and well-being of a patient and also have joint responsibilities on how to thoughtfully use a patient’s or employer’s health insurance premium, something that is sorely lacking in the current health care structure. These were recently created and defined in the healthcare reform bill.
Yet the author seems to suggest that this is a step backwards:
Modern industry abandoned command-and-control style vertical integration decades ago in favor of flatter, more nimble institutions.
Not true. Successful organizations are ones that are tightly integrated, like Apple, FedEx, Wal-Mart, and Disney.
The author talks briefly about how Europe in general does better than the U.S. in terms of outcomes and costs and has a decentralized system. All true. However, contrasting Europe and America isn’t relevant. After all, who isn’t still using the metric system? Therefore solutions found outside the U.S. probably aren’t applicable due to a variety of reasons. Americans like to do things our way.
What I do agree on is that doctors need to be part of the solution and ensure that the disasters of decades ago — like labeling primary care doctors (internists and family physicians) as “gatekeepers” rather than what we really do — never happen. Read more »
*This blog post was originally published at Saving Money and Surviving the Healthcare Crisis*
January 24th, 2011 by Lucy Hornstein, M.D. in Better Health Network, Opinion
No Comments »
A reader requests:
Can you do a post on what procedures constitute a thorough physical, in your opinion? I haven’t had one in several years and thinking of making an appointment now. The last doctor I went to didn’t even listen to my heart or go though the motions with feeling my belly and that stuff. And of the last three doctors I went to, I realized they didn’t bring up my immunization records. Is this usually left for the patients to bring up on their own?
Good question. What exactly is a physical? Does it include blood work? What about an EKG? And a cardiac stress test? Is an “executive physical” an orgy of “more is better,” previously paid lavishly, really better than a “camp physical?”
Here’s the thing: There is no such thing as a “complete physical examination.” There are literally hundreds of different maneuvers and procedures that encompass various aspects of physical diagnosis. Performing every last one of these on even a single patient would not only take many hours, it would be a colossal waste of time.
A “physical” is a misnomer. The clinical portion of a medical workup is more correctly termed the “history and physical.” Of the two, everyone agrees that the history — information elicited from the patient, sometimes from family members or other medical records — is far more likely to yield useful information. It is the information gleaned from the history that guides the physical.
Knee pain? The history should include mechanism of injury, and physical exam should evaluate for McMurry, Lachman, and drawer signs, among other maneuvers. Bellyache? Need to know about associated symptoms such as nausea, vomiting, stool pattern, flatus, and the exam better include careful auscultation (listening) for bowel sounds and palpation (feeling) for masses, fluid, possible shifting dullness, plus eliciting any guarding or rebound, and probably a rectal exam looking for blood. It makes no sense to use a tuning fork for Rinne and Weber tests to evaluate different kinds of hearing loss on someone with heartburn. Likewise, evaluating the debilitating heel pain of plantar fasciitis does not require listening to the lungs. I trust you get the idea.
The question appears to be about the “routine physical” in the absence of any specific medical concern. A more accurate term for this is a “preventive service” visit, for which there are specific guidelines. Read more »
*This blog post was originally published at Musings of a Dinosaur*
January 24th, 2011 by Michael Kirsch, M.D. in Better Health Network, Opinion
No Comments »
Medical ethics has properly gained a foothold in the public square. There is a national conversation about euthanasia, stem cell research, fertilization and embryo implantation techniques, end-of-life care, prenatal diagnosis of serious diseases, defining death to facilitate organ donation, cloning and financial conflicts of interest. Nearly every day, we read (or click) on a headline highlighting one of these or similar ethical controversies. These great issues hover over us.
We physicians face ethical dilemmas every day in the mundane world of our medical practices. They won’t appear in your newspapers or pop up on your smartphones, but they are real and they are important. Here is a sampling from the everyday ethical smorgasbord that your doctor faces. How would you act under the following scenarios?
— A physician has one appointment slot remaining on his schedule. Two patients have called requesting this same day appointment. The first patient who called has no insurance and owes the practice money. The second patient has medical insurance coverage. Neither patient is seriously ill. Who should get the appointment?
— Two hours before a doctor is to see a patient, her husband calls to relate private information that he fears the patient will not share with the physician. Should the physician disclose this conversation to the patient? What is the risk if she discovers at a later time that a confidential conversation occurred? Read more »
*This blog post was originally published at MD Whistleblower*
January 22nd, 2011 by Bryan Vartabedian, M.D. in Health Policy, True Stories
1 Comment »
So I’m in the exam room recently with a new patient. After some initial dialog with the child and family, I launched into the business of problem solving. Ten minutes into my history the mother politely asks: “I’m sorry, and you are?…”
I hadn’t introduced myself. I had left my ID badge at my workstation, and by order of some innocent distraction with the child or family, I hadn’t identified myself immediately on entering the room. This is rare.
Sometimes I assume people will know who I am. But I don’t wear a white coat and my stethoscope is concealed. I wear clothes only good enough to sustain the barrage of regurgitation, urine, full-frontal coughs, and sloppy hugs that mark a successful clinic day. A colleague once told me I dress like an algebra teacher. I haven’t quite processed that one, but suffice it to say it’s easy to fall into a mistaken identity.
So I apologized and made a proper introduction. What’s remarkable is how far I went without the mother having any idea about my identity. I can imagine that it took a certain amount of wherewithal to interrupt the person she suspected was the doctor to ask such a basic question. Read more »
*This blog post was originally published at 33 Charts*
