Friday, April 29, 2005

Murder-suicide leads to suicidal response

A distraught and depressed lady in Colorado Springs shot her two sons and then turned the gun on herself a few days ago. There were many factors involved, to be sure, including job loss, husband having to work out of state, bipolar disorder, etc. The details can be seen in this Rocky Mountain News article.

So, what does this have to do with a medical blog? Well, it turns out that this unfortunate lady had been taken to a Colorado Springs hospital the previous day for threatening suicide; she was seen, evaluated, and released. Subsequently, the now typical vicious finger-pointing has started, with blame for this tragedy being assigned to the hospital and its staff. What irks me, however, is the irresponsible nature of the remarks made by the pastor of the church that this lady and her family attended. Without a good understanding of how psychiatric patients are evaluated in emergency rooms, he publicly launched into a tirade against the treating facility:

"What were they thinking?" Haggard said. "She's bipolar, she's under pressure. She's ADD, she's on medication and she's distraught, and they send her home? They might as well have sent her to Kmart. She would have gotten better care there."
That's not they type of compassionate, introspective thought I would have expected from the leader of a 12,000 member church. Mental health problems abound in this country, and their treatment is a very inexact science. It is also profoundly underfunded. With incidents such as this, there is always a (natural) response of regret --- often, the signs of depression are there, but it is hard to grasp how serious the situation is until it is too late. This post is not designed to criticize Rev. Haggard's theology and approach to religion. However, a pastor, of all people, regardless of denomination, must be sensitive to the difficulties associated with dealing with depression.

Indeed, the signs of depression were there, and their import was missed. A neighbor remarked:
"I knew she was depressed. Everyone in the neighborhood knew she was depressed, but not to that point."
Even the pastor had noted changes. Their children had gone to the same school until recently, and the family had attended his church, but:

Haggard said he hadn't seen Julie Rifkin for nine months.

"Most of the years I knew her, her husband was gainfully employed and she was around with her boys," Haggard said.

"The past year or year and a half of pressure has been incredible on them."

Perhaps, rather than publicly chastising the hospital, a more appropriate response would have been to privately express concerns to the hospital, hold a meeting with the administration, and help work towards a system that might prevent incidents like this in the future. Perhaps as the leader of such a large congregation Rev. Haggard could seize this opportunity to educate his flock to the signs and symptoms of depression; establish an early intervention program; work with the local hospitals to start a volunteer system that checks on patients seen and discharged from the emergency department; do something other than try to assign blame. Finger-pointing and back-biting are not going to bring this lady and her two sons back to life. If the people that knew this lady the best (church members that had not seen her in 9 months, neighbors, etc.) were unable to prevent this tragedy, it is hard to point fingers at an overtaxed emergency room that sees more patients than any other in the state (I don't work there; the statistics are published yearly). I am not blaming Rev. Haggard for his feelings; this is a very difficult and emotional issue to tackle. I just wish he would find a more constructive outlet for them.

As a physician, this issue hits close to home. I have missed diagnoses. I have sometimes made the wrong decision in the course of a patient's care. There is no worse feeling in the world, but fortunately in my field these are rarely irreparable mistakes. But, I guess that in the mind of
Rev. Haggard, that makes me equivalent to a K-Mart stock boy when it comes to my ability to care for patients.

As a physician, this issue cuts deep. I care for trauma patients, and often see patients who have attempted, or are successful with, suicide. Many, like this lady, have no good option for mental health care, as they are uninsured or have Medicaid --- and there simply is no funding for these patients to be seen or hospitalized. It is frustrating to have a patient attempt suicide, be treated for their injuries, spend a paltry few nights on an inpatient ward, and be discharged........and come back a few weeks later with another, sometimes successful, attempt.

As a person, this issue hits close to the heart. I have missed the signs of overwhelming depression. I have missed the subtle (and not so subtle) clues that someone is contemplating taking their own life. It is part of the reason that I started writing this blog, trying to find a way to express my own thoughts and emotions about whatever crosses my mind. You see, my brother was successful in his attempt a few years ago. And I have to live with that every day.

Thursday, April 28, 2005

Melanoma in the News

This AP story showed up in my local paper today, and has been widely circulated in papers across the country. Unfortunately, given the constraints of reporting on complicated medical issues, there is much more to the story. Most adults are aware that the rate of melanoma in this country has been increasing at an alarming rate, and now comes this report about an increase in melanomas in children. What is hard for most folks to grasp (including thick-headed surgeons like myself) is that sometimes it is quite difficult to diagnose a melanoma. This is particularly true in children, who are more likely to have a lesion called a Spitz nevus -- it looks quite like a melanoma, but behaves differently. I know a world class dermatopathologist who has agonized over this differential many times, and occasionally we simply have to say "we're not sure." That certainly leaves treating physicians without a solid basis for treatment, and leave parents extremely nervous.

I am often perturbed about "medical" stories put out by the media, as they often miss the point, and just as often mislead. In this instance, even though the story is somewhat incomplete, I think it may do some good, getting parents to keep sunscreen on their kids and getting the kids with worrisome skin lesions in to see a dermatologist.

More thoughts from Dr. Andy.

Wednesday, April 27, 2005

The Answer

Dr. Bard Parker and Mr. McGinni were correct -- this is a small bowel endoscopy camera ("pill camera"), not usually seen on abdominal X-Rays. It is used to visualize the vast area of the small bowel, previously difficult to visualize endoscopically. This lady's story, however, is a bit more complicated.

After an upper endoscopy, which was relatively normal, the small bowel endoscopy camera study was recommended and performed about 6 months ago. The findings were pretty nonspecific, but she does not remember passing the camera. She eventually made her way to an enteroclysis (a very thorough X-Ray study of the small bowel), where this little guy was seen sitting in the distal ileum, bumping up against the first of five radiation-induced small bowel strictures beyond which it could not pass. The appearance of the bowel proximal to this was unremarkable, and I suspect that the stricture looked fairly similar to the ileocecal, it appeared like a normal study. Because patients have this procedure done as an outpatient, it is unusual to have any radiographic study which shows the capsule, so the radiologists may misinterpret the picture as showing something outside the abdominal cavity.

Monday, April 25, 2005

Grand Rounds XXXI

Dr. Tony, who sounds like a reasonable ED physician (is that an oxymoron at 3AM?) was kind enough to list my post for Grand Rounds XXXI (eventually this will have to change to Arabic numerals; my Latin classes ended many moons ago). He does a marvelous job of doling out the information from various specialties and interests.... kind of like he does with patients in the ED. There are many more interesting and literate posts to see there! Check it out!

Foreign Body

This is a plain abdominal X-ray of an 85-year old lady who has undergone an extensive, fully modern evaluation for iron-deficient anemia. The object circled in yellow in the left pelvis was read as an "unknown metallic object likely on the abdominal wall; clinical correlation needed." Her past history is significant for TAH/BSO and radiation therapy in the 50's for cervical cancer, a lap chole about 6 years ago, and arthritis (not on NSAIDs). Anyone want to guess at the nature of the radiographic finding? I'll post the answer on Wednesday.

Caricature Flaw

OK. I know that I meet many of the "standard" criteria to be a surgeon as far as docs go. I'm a white male, in my 40s, pretty damn conservative, get up early, work late, and I'm pretty "Type A." So, when patients make some assumptions about me, they are generally right. Except about one thing.

I don't golf.

Not only do I not golf, I don't even "get" golf. I love football, hockey, skiing, and lacrosse, but the allure of hitting a small ball several hundred yards and somehow willing it to go into a small hole in the ground is lost on me. I don't dislike golfers, and it seems like they enjoy themselves quite a bit on the course. More power to them!

But, when a patient expresses shock that I will operate on them on a Wednesday afternoon, stating "I thought all doctors golfed on Wednesdays," I start to see red. Usually, their surprise is stated earnestly, as they honestly believe that mid-week golfing is the norm for every surgeon. To make matters worse, when I explain to them that I happen to work Wednesdays, their next assumption is that I must take off every Thursday afternoon to golf. Uh-uh. Nope. Sorry. I work Monday through Friday, at least 1 out of every three weekends, and throw in there at least 5 nights of trauma call per month. That leaves little time for family, much less several hours on the golf course.

I guess I should give in, start wearing these to work, and respond to such questions with "How 'bout a Fresca?"

Thursday, April 21, 2005

Representative Mac Thornberry (R., Texas) has put forth a proposal that may help foster a change in the current malpractice climate in the US. Basically, it would set up "health courts" administered by full-time judges with health care expertise; the sole focus of these courts would be to address malpractice cases, and there would be evaluations carried out in regards to their effectiveness.

I don't think this is a perfect solution, but it is certainly far better than the current system, and may be a stepping stone to future reforms. I would encourage anyone interested to contact Rep Thornberry and express their support, and to contact their own Congressional representative as well. More information is available at Common Good.

Hat tip to Dr. Charles.

Wednesday, April 20, 2005

Three noteworthy items...

On call today, browsing on the internet, and I came across three reasonably related articles. The first two come by way of Kevin's blog, the first of which is this article written for Florida's Herald Tribune by Anthony DeSpirito, a retired academic pediatrician. He addresses the importance of malpractice reform in the ongoing debate about health care costs, stating:

True health-care reform cannot occur until the issue of medical malpractice is seriously addressed. A national health insurance will lead to loss of patient autonomy and an indeterminate delay in the provision of services. Honest legislative decisions, made with input from those intimately associated with the issues, can lower the cost of health-care delivery, thereby providing better access to care for the poor and underserved while lowering the cost of care for all -- providing choice in medical care for all our fellow citizens.
This perspective on universal health care coverage is often ignored by policy makers, but the current legal system costs all of us an inordinate amount of money which could be better utilized in providing care (see Overlawyered and Common Good for more information). Going farther down the road towards universal health care coverage is Vermont, where there are going to be wholesale changes in coverage.... but perhaps not enough primary care physicians to perform the work! This is a challenge in the era of high medical school debt, poor reimbursement, and fewer physicians training in primary care. There is a simple solution, along the lines of "Field of Dreams" --- if you pay them, they will come.

Last is a great look at what a socialized/universal coverage system means in the end. It comes from Mark Steyn, who is a great commentator on many political matters.
"Waiting" is built into the concept of a government health service: As my own non-government doctor put it, making idle chit-chat as his fingers explored my fleshly delights, "When the government runs the system, every time you get operated on, it costs the government money. So it's in their interest to restrict or delay your access. When you look at the overall budgets - salaries, buildings - it's not hard to understand that the level of service you provide to the patient is one of your few discretionary costs." The janitor and the janitorial services consolidation review consultant expect their cheques promptly on Friday; you're the one who can be postponed.....Britons expect "control" over the cars they drive and the DVD players they buy and the internet porn sites they subscribe to, yet they live with a health system frozen in 1945. It's a curious inversion of priorities to demand "control" over peripheral leisure activities but to contract out the big life-changing stuff to the government.

(Hat tip to Kitty Litter for the last bit)

Tuesday, April 19, 2005

Gastric Bypass in the News

Since I perform these operations (my group has had a program for 25 years), I have been reluctant to say much about gastric bypass surgery. But, you just can't get on the internet, look at a magazine, watch TV or read the newspaper without running across morbid obesity and gastric bypass stories on a daily basis. This article and this article basically are saying the same thing: patients tend to do better at centers where a high volume of gastric bypasses are performed. When the article (here's the abstract) is actually read, however, it is really a documentation of their own learning curve --- patients do better with laparoscopic RYGB now than earlier in their experience. There are a large number of procedures for which a "learning curve" is reasonably well-documented, and this is certainly no different. Somehow, this learning curve process is being construed as "don't go where the surgeons haven't done X number of these operations."

In some respects, this benefits me. I work at a tertiary care facility, and we have a high-volume program with a very good (0% 30 day mortality) track record. What is troubling to me, however, is the way that major university programs and the American College of Surgeons may use this as a means to eliminate some of their competition. If a low volume program has the same complication and mortality rate as the big university, should it be shut down because of potential problems based on statistical predictions? Should there be a moratorium on new programs based upon these statistical predictions? We can also turn it around --- why should Tufts have gone through this learning curve process, when there were other, older programs in existence who had better records?

Beyond the surgical politics, there is something more important that needs to be driven home, and the news media does not seem to "get it." These patients are not healthy! To expect superb outcomes and a zero M&M rate with gastric bypass procedures is to ignore reality --- these patients come to the OR with sleep apnea, diabetes, cardiac disease, restrictive lung disease, hypertension, ..... etc. Some are clearly better candidates than others, but many would not be a good candidate for any other operation. It is therefore unreasonable to "shut down" programs based upon postoperative mortality unless it can be demonstrated that proper care was not administered.

Patients should be encouraged to investigate the physicians and facilities at which they will receive their elective surgical care. The facts, however, are often much more complicated than sheer volume of procedures.

An Excellent Post

In The Orange Man, Orac gives an excellent description of how "alternative medicine" is harmful to patients, and to their families. It's a very well written and worthwhile read, and more such information can be found at Quackwatch.

Grand Rounds XXX

Grand Rounds XXX is up and running at Girl Scientist! Check it out!

Monday, April 18, 2005

And so it begins!

And so it begins, as I expected ----- American Academy of Cosmetic Surgery's Outrage Over FDA Advisory Panel's Silicone Breast Implant Recommendations. This debate looks like it could turn nasty (emphasis is mine).

  • "Although we do applaud the panel's decision to allow these implants to return to the general marketplace, this recommendation is not only discriminatory, but it will prove to be a huge loss for patients. People deserve quality care and there is no proof that a board-certified plastic surgeon is better qualified to perform a breast augmentation with these implants than a board-certified cosmetic surgeon," said American Academy of Cosmetic Surgery President Claude H. Crockett, Jr., MD, FACS.
  • "This recommendation has been made without the proper information. Plastic surgery includes both reconstructive and aesthetic surgery, while cosmetic surgery is based upon aesthetics. This debate is rightly about the safety of the implants, rather than the specialty and qualifications of the surgeon," said American Academy of Cosmetic Surgery Trustee and Board-Certified Plastic Surgeon, Michael H. Rosenberg, MD, FACS.
  • "Electing to have cosmetic surgery is ultimately about choice. To deny women the right to choose who is administering their implants is a clear violation of an individual's basic, patient rights," said American Academy of Cosmetic Surgery's Past President and renowned general surgeon Robert F. Jackson, MD, FACS.
I am not sure if the FDA has ever recommended restricted use of devices or drugs in this manner -- for example, can only board-certified orthopedic surgeons implant the newest artificial hips? By the same token, it is in the manufacturer's best interests to ensure the highest quality care for the patients receiving those implants. Endovascular prosthesis makers won't allow the use of their devices by physicians who have not been properly trained. Just more food for thought.

Sunday, April 17, 2005

Interesting Precedent

There have been a flurry of stories regarding the FDA's recent decision to allow silicone breast implants back on the market. What is thought provoking about this announcement is the restrictions placed on the manufacturer, Mentor, to ensure that patients receive appropriate care and follow-up. As noted in Surgical Diversions:
But they stressed that sales should resume only if Mentor meets some strict conditions:

  • Prospective patients must sign consent forms acknowledging implant risks, including that they ultimately may break and require removal or replacement.
  • Mentor may sell silicone implants only to board-certified plastic surgeons who complete special hands-on training to insert implants in a way that minimizes odds of breakage.
  • Mentor must open a registry to track how patients fare long-term, and continue more formal studies to nail down how often implants rupture within 10 years, something no one yet knows.
The issue of instructing Mentor to only sell these implants to board-certified plastic surgeons is interesting. What about board-eligible surgeons? What about those surgeons who perform breast augmentation, who are broadly termed "cosmetic surgeons?" There is much to ponder here, and the FDA is making a big statement if it goes through with this proposal. As well, as noted by Surgical Diversions,
I think that if the FDA tries to enforce this second point they are opening themselves up to a restraint of trade lawsuit.
I believe in the board certification process, but because of the vagaries of how physicians are trained, there are a mind-boggling number of "boards" out there, particularly in plastic/cosmetic surgery. Each board is careful to note that they do not want to be viewed as preventing non-certified physicians from practicing their chosen field; that is left up to hospital credentials committees. This is clearly laid out, for example, in the web site of the ABPS:
The Board is not an educational institution, and certificates issued by the Board are not to be considered degrees. The certificate does not confer on any person legal qualifications, privileges, or license to practice medicine or the specialty of plastic surgery.
It is not the intent nor has it been the function of the Board to define requirements for membership on the staff of hospitals, or to define who shall or shall not perform plastic surgery procedures.
Either the FDA is giving the board certification process additional clout (which may be good), or it will have to back down.

Unitended Consequences

When politics, money, and medicine collide, the resulting multi-car pileup seems to grow exponentially. I don't presume to have any answers, but this Washington Post article illustrates the law of unintended consequences quite well. No one would argue that more transparent and honest accounting practices are critical to our economy, and no one would argue that we should not have a safe vaccine supply.... and yet these two seemingly unrelated issues are causing a big headache. If there is an amusing aspect to this situation, it is to hear the one Congressman who has done the most harm to the practice of medicine in the past 50 years, Henry Waxman (D., Calif.), whine that it is all the fault of the Bush administration:

"It's inexcusable that even though the administration had the money for this, they haven't made any progress," Rep. Henry A. Waxman (D-Calif.) said recently. "I don't care how they solve it -- they should just solve it."

Perhaps, Mr. Waxman, we should encourage manufacturers to develop and make new vaccines, rather than punish them for making a profit.

Tuesday, April 12, 2005

Grand Rounds

Grand Rounds XXIX is being hosted at GruntDoc. There's a great cross section of medical information and thoughts on display!

Sunday, April 10, 2005

We're not just blowing smoke...

The medical malpractice problem in this country is real. It doesn't take a genius to understand that the constant threat of legal action adversely affects how physicians see (as potential legal adversaries) and treat (with defensive medicine) their patients.

It's long past time for a new system. While there are docs who provide inadequate or outright bad care, sometimes things just don't go right in medicine.....just like in all other aspects of life. We are free, even encouraged, to purchase travel insurance in case a hurricane disrupts your expensive island vacation. Why can we not offer "unexpected outcome" insurance for patients at the time they sign their consent forms for surgery? It would certainly be cheaper, and far more honest, than the current malpractice process, which makes adversaries out of people who should focus on trying to help patients get well.


Bard Parker from A Chance to Cut is a Chance to Cure let me know that there is an online (PDF version) edition of Surgery News. The whole article described below can be accessed here.

If you decide to follow the link, there is also an editorial by Tom Russell, M.D., about recent efforts by the American College of Surgeons to intitate surgeon monitoring and regulating programs. There is far more to that story than meets the eye, and if I can think of a concise way to present both sides of the arguement, it's worthy of a deeper look.

Friday, April 08, 2005

Pay for Performance II

I just received the new edition of the "throw-away" mag Surgery News ("The Official Newspaper of the American College of Surgeons"). Unfortunately, there is no online edition to refer readers to. It contains an article written by Joyce Frieden entitled "Is Pay for Performance Premature?" which echoes some of the themes in my post from a few weeks ago. CMS Administrator Mark McClellan, M.D. is quoted as stating that physicians are not the major cost issue for Medicare (emphasis is mine):

"Physicians account for a small fraction of total costs, but doctors have a lot of good ideas and they have the knowledge it takes to get more results for what we actually spend....I think [pay for performance] can potentially save significant amounts of money. At the same time, we're also going to be paying attention to clinical equality."

Me thinks he speaks with forked tongue! There is no question that physicians have a lot of good ideas about how to care for patients in a cost-efficient manner. Who orders the diagnostic tests? Who is (or is not) available for patients to see on an urgent basis, which alters ER volume? Who rounds on patients more than once a day in the hospital to decide which patients are ready to go home? But who has been left out of the development of this pay for performance plan, and who is the target of its ultimate goal of cost cutting? What I fear is yet another layer of Medicare bureaucracy to deal with to make sure that all of the "performance" guidelines are met --- nurse administrators carrying lists of checkoffs to be sure that every patient gets a flu vaccine, every physician follows the latest beta blocker recommendation from the American College of Cardiology, etc. .... but without the simple clinical insight to decide whether it is appropriate for each individual patient. How is this plan to be administered and monitored for the huge numbers of physicians who practice solely in the outpatient setting? Will this further intrusion cause an even greater number of primary care physicians to stop seeing Medicare patients (an already significant problem in my community)?

  • Evaluating whether patients receive appropriate care can seem simple, but rating the process is convoluted and prone to error and abuse. I can give two very simple examples of this which every physician can relate to.
  • When I was in my last year of surgical residency, the VA hospital associated with our program went through JCAHO evaluation while I was rotating there. It was common knowledge amongst the nursing staff and residents that the most problematic department on campus was Respiratory Therapy --- slow to respond to urgent calls, inappropriate with patients, and (most worrisome) there was only one RT available from 6PM until 8AM, a potentially life-threatening issue in a hospital campus with 6 separate buildings full of sick chronic smokers. Their paperwork, however, must have been impeccable -- RT was the only department to receive the highest level of commendation from JCAHO during that inspection.
  • About two years after I started practice, one of the other general surgeons in town pulled me aside to let me know quietly about some concerns that had been raised in Peer Review. It had been noted that I had a disturbing rate of prolonged postoperative ileus! When the surgeons on the panel actually looked at my charts, what they found was my (then frequent) notation after a bowel resection or enterolysis that we were "awaiting resolution of post-op ileus." The hospital's coders, under orders to squeeze every dollar out of Medicare possible, listed this expected process as a complication, even though my postoperative discharge date averaged lower than the general surgeons practicing at the hospital!
My point in citing these two examples is that documentation of quality care is far from an exact science at this point. I think CMS knows this, and is using this as a tool to further decrease physician reimbursement. Doctors do know how to decrease overall costs, and have been railing about one glaring example for years - tort reform - which is not mentioned at all by health care policy pundits as a viable option.

Finally, what if we find that good quality care is more expensive, rather than a means to control costs? Another part of the article quotes Denis Cortese, M.D., the president and CEO of the Mayo Clinic:
"I noticed that performance was defined as reducing costs. I was tempted to ask, 'What happens if the quality goes up and the cost goes up with it?' If the value rises higher than cost, are they really going to pay for it? I don't believe they will."

Unfortunately, neither do I.

Wednesday, April 06, 2005

More on Primary Care -- Who' is Going into FP Residencies?

As a follow-up to the post below, there are several interesting discussions regarding primary care in the US today. In particular, a simple review of the NRMP match data demonstrates that of the 2,761 slots available, 82.4% filled --- but only 49% were filled with US medical school applicants. That means that 51% of the family practice residency slots were filled by non-US medical school applicants. The percentages would have even been worse if the number of slots offered was as high as it was in 2001 (total of 3,074 slots).

This interesting statistic, in line with trends over the past several years, belies the constant drumbeat heard in our medical schools and from public health officials that "primary care is good, specialist training is bad." Take a group of young, highly motivated, intelligent people (many, like me, fairly "type A"), and give them a range of options for careers in medicine......surprise! They choose those fields which are most interesting, exciting, and monetarily rewarding to them. With the average medical student graduating over $100,000 in debt already, a career in a lower paying specialty looks like a quick trip into financial hardship. I would even argue that medical schools are not even attracting many of the same types of applicants that were commonplace in the past --- yesteryear's hard-charging and well-compensated cardiac surgeon is today's investment banker.

Many involved in this process point fingers at specialists, saying that we take too much money out of the pie for doing too little, etc. I don't want to get into that type of arguement, but would invite any grumbling primary care provider to spend a week with me in the hospital. We all choose our specialties for a variety of reasons. It would be more appropriate to work towards a better system of reimbursement, something that our specialty societies blatantly ignore (mine included).

Lots of (better written) thoughts about the meaning of the match results from Kevin, M.D., A Chance to Cut is a Chance to Cure, GruntDoc, and Blogborygmi.

Tuesday, April 05, 2005

Here we go again!

I kind of feel like I'm stuck in a time's 1980 and Ronald Reagan is telling Jimmy Carter in a debate, "There you go again!" It seems that every 5-10 years, many in the public health arena start taking potshots at specialists, stating that we have too many/they charge too much/they are only out for money/etc. Now comes this study which takes the position that mortality rates are better when there are more primary care physicians and fewer specialists. The author of the study, Dr. Barbara Starfield, states

"Decisions about the physician supply should be made on the basis of evidence for their utility in improving health and reducing ill health and deaths...Currently, the United States has many more specialists than do other comparable countries with better health levels."
She also found that a higher specialist-to-population ratio did not decrease mortality rates. In fact, she determined that too many specialists negatively impacts communities because patients are more likely to have unnecessary tests and procedures.

I have not had the chance to read the published article, but on the face of it, it is difficult to get a grasp of how the methodology of such a study can be accurately constructed to achieve meaningful results. There are a whole host of factors that must be taken into consideration, not the least of which is where specialists congregate:
Specialists, Salsberg said, tend to concentrate in urban areas that draw patients from large geographical areas, so they can see enough cases to be clinically sharp and financially viable. At the same time, the population that dominates urban areas tends to be higher risk and has higher mortality rates.

An analysis of mortality rates also does not capture quality-of-life improvements that specialists provide, he said. Ophthalmologists might not save lives, but cataract surgery can make the difference in a person's ability to see to drive or read.

Clearly, there are a number of problems with the health care system in the United States, but I think it is pretty hard to argue that an over supply of specialists is the main problem. Medical students are going to go into the fields that attract them the most, and I truly believe that potential income is a secondary, but very important, motive in the choice of a specialty. It would be naive to think that physician reimbursement has very little to do with what and how doctors practice, just as it would be naive to believe that the omnipresent threat of lawsuits leads physicians to practice defensive medicine. In fact, I suspect that if tomorrow it was mandated that all patients were required to have all of their care delivered by primary care physicians, the rate of "unnecessary tests and procedures" (as Dr. Starfield describes them) would go up dramatically. It is unreasonable to expect every primary care physician to feel comfortable with, for example, differentiating between postoperative discomfort and postoperative pulmonary embolism.

Additionally, who is a primary care physician? A large percentage of patients referred to me have never met their PCP, and are cared for by a nurse practitioner or PA employed by a PCP. Should we do a study comparing mortality rates in locations where there are more nurse practitioners and PAs and fewer PCPs compared with the obverse?

As I have stated before, the primary care community as a whole has also actively worked to abdicate responsibility for the care of very sick patients. Who do patients see in the hospital? Hospitalists, rather than PCPs. What do those hospitalists do? Order more tests than their PCP or specialist counterparts, frequently duplicating tests already performed in the outpatient setting.

I believe that a strong primary care base provides good quality, comprehensive patient care. It cannot, however, supplant the need for a good specialty care base. The economic factors involved have driven much of our current trend towards specialization, as primary care physicians have been inexorably squeezed by Medicare and insurers. That, rather than a perceived excess of specialists, should be our main focus of concern. It should be a basic tenet of reimbursement that physicians should get paid for caring for patients, and the sicker the patient, the greater the pay.

For another surgeon's viewpoint, check out A Chance to Cut is a Chance to Cure.

Sunday, April 03, 2005

Surgeon's Prayer

I am hardly the most eloquent physician that's ever lived, and I certainly feel inadequate in trying to say something about Pope John Paul II's life and passing. He was, however, the kind of man who always turned his attentions outward, and rather than asking one to offer a prayer for him, would ask that they instead pray for themselves and others. With that in mind, here is the best physician's prayer that I have ever found -- it comes not from a priest or theologian, but from a surgeon who had seen the best and worst that medical care could offer. It clearly speaks to today's physicians, and surgeons in particular:

"A Medical Litany"
From inability to let well alone;
From too much zeal for the new and contempt for what is old;
From putting knowledge before wisdom, science before art and cleverness before common sense;
From treating patients as cases; and
From making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us.
Sir Robert Hutchinson, 1871-1960
(Consulting Physician to the London Hospital and President of the Royal College of Physicians)

Call Blogging

On call, and it's a beautiful Sunday afternoon. Nothing like being stuck in the hospital on a sunny day...
For a long time I have kept a little collection of diverse quotes that are sometimes funny, sometimes poignant, and sometimes are just inside jokes for physicians. Here are a few of my favorites:

  • You should not prevent patients from getting well on their own. Sir William Osler
  • The patient died of old age -- he just happened to be in the hospital. Anon.
  • All postoperative complications begin in the operating room. Larry Carey, M.D.
  • Technology is sometimes more advanced than our ability to apply it properly. Anon.
  • Despite frantic urgings from the referring physician, avoid operating on dead people. Anon.
  • The feasibility of an operation is not the best indication for its performance. Lord Moran (Churchill's physician)
  • Always remember that I have taken more out of alcohol than alcohol has taken out of me. Sir Winston Churchill