Road To Hellth

Mar
23

More on Our National Effort to Dumb Down Physicians

The digital ink was barely dry on our most recent post about manipulating the training of American physicians to make them perfect Renaissance men and women, when an article was published on the topic in JAMA by the brother of President Obama’s former White House Chief of Staff, Ezekiel J. Emanuel, MD PhD, and Victor R. Fuchs, PhD.

In our last post we described how the Association of American Medical Colleges (AAMC) recently decided to de-emphasize the sections addressing scientific knowledge in the Medical College Admissions Test (MCAT). Instead of stodgy old biology, chemistry and statistics, the new test would emphasize psychology, ethics, cultural studies and philosophy in an effort to make physicians of the future less scientifically skilled, but more sensitive to the needs and feelings of patients and families. We then examined yet another proposal to make physicians even more intellectually diverse by requiring them to be able to explain their medical bills to patients, again by shifting time and educational efforts from medical science to medical finance.

Against this setting Drs. Emanuel and Fuchs seem to think that we’re not doing nearly enough to dumb down and shortchange the medical training of those who will be doing our cardiac catheterizations and brain surgeries.

We don’t have full-text access to JAMA, but we do have access to a short blog piece that The Washington Post published on their proposal. The post quotes the JAMA article thus:

“Why is medical school 4 years in length? The answer probably has to do with the Flexner Report’s recommendation in 1910 for 2 years of preclinical science training followed by 2 years of clinical training. Yet most physicians could be trained in significantly less time. Since 1997, the University of Pennsylvania has only 1 years of preclinical science training.

The important patient care skills can be obtained in less than 2 years of clinical training. The medical school at Harvard University requires students to complete only 15 months of clinical rotations….This change would be consistent with the increasing emphasis on individualized instruction and assessing students on core competencies rather than on time served. Consistent with this proposal, Texas Tech School of Medicine as well as 2 Canadian medical schools now offer 3-year programs.”

The Post then goes on to report that:

“Emanuel and Fuchs suggest reducing doctors’ training time by 30 percent, from 14 to 10 years. That would create space to train more doctors, they argue, while also reducing physicians’ debt burdens. It could also have the effect of driving down American doctors’ salaries, which are double that of doctors in most other countries, but often justified because of the profession’s expensive training costs here.”

It should therefore be no surprise that while the JAMA article is entitled: “Shortening Medical Training by 30%”, the blog entry in the Washington Post is called: “One way to cut health care costs: Cut medical training”.

Let’s take a moment to summarize:

We know from our last post about carefully crafting the politically correct physician, that the American public (or at least the AAMC) wants us to be admitting medical students who know less about science, and more about cultural awareness, empathy and ethics. This is presumably so that patients feel better about being denied care that might have helped them had their doctors only known what was wrong with them and how to treat it.
Other folks have proposed substituting training in healthcare cost accounting and finance for clinical medical training early in the residency process.
Drs. Emanuel and Fuchs have now decided that, once admitted to medical school, medical students are learning far more than they need to know about things like anatomy, biochemistry, pharmacology, microbiology, biostatistics, neurobiology, histology and other things that would only come in handy if one were to eventually want to diagnose and treat physical and mental diseases.
Meanwhile, the Accreditation Council for Graduate Medical Education (ACGME) has implemented restrictions on the number of hours medical and surgical residents may work each week. Although these restrictions were imposed for the laudable purpose of ensuring that physicians-in-training weren’t so tired that they would make lots of mistakes, they inevitably reduce the total amount of time that medical residents spend seeing patients, discussing cases and generally learning the very serious business of being a doctor. Any weakness in one’s medical school training will be amplified by having less time to make up the difference while undergoing on-the-job-training.
As if that weren’t enough, poorly conceived, poorly executed electronic medical records have turned medical residency training from an educational experience into something more akin to secretarial school. Attending physicians – the older and wiser doctors who have traditionally walked the wards and clinics with residents to show them the ropes of clinical care – now hold back for fear of taking too much time from their keyboard duties. For a flavor what residency training has become in an era where administration and documentation has become more important and time-consuming than either patient care or medical education, we highly recommend this article by Michael B. Edmond, MD, MPH, MPA, and an attending physician and mentor to medical residents for over 20 years:

“Those of you who trained in the last century, as I did, will recall that the team room was the nerve center for managing the group of patients to whom you were assigned. It was a hub of activity that contained a large table where the housestaff reviewed thick paper charts, wrote their history and physicals, ate meals, and all the while shared the stories of their lives and their patients’ illnesses. It was strewn with EKGs, x-rays, photocopies of journal articles stained with coffee, and a worn edition of Harrison’s Textbook of Internal Medicine. You could walk into the team room at any time and immediately sense activity, observing multiple interactions among residents, students, and attending physicians.

Now, fast-forward to the modern-day team room: It still has a table, which if not physically then certainly figuratively much smaller and generally devoid of clutter. All of the action now occurs in the periphery of the room at a bank of computers where the housestaff sit nearly all of their working hours facing the wall. The room is silent except for the rhythmic clicking of multiple keyboards…

Before enforcement of the 80-hour workweek rule, residents would simply work longer in response to any unforeseen event, such as a patient’s sudden deterioration, or a planned event that took longer than expected. Part of the maturation process for young physicians was coming to terms with the daily unpredictability and lack of control associated with caring for acutely ill inpatients. However, the ability to stretch the day to accommodate the complexities of care has ended, and strict departure times have clearly added to the stress that our current house officers face daily….

I feel guilty if I ask the residents questions about themselves or what they did over the weekend as they type (and they are always typing), because I’m distracting them and using precious time. So I find that I don’t know them very well as people, and I suspect that they don’t know each other very well, either… One of my colleagues, a master clinician and superb attending physician, says that he now feels guilty when he attempts to teach, because he can see the look of fright in the residents’ eyes as they wonder how the teaching session will impact their time.”

Incredible. That we should create and maintain a system that makes attending physicians feel guilty for taking the time needed to pass on their unique and precious knowledge. Simply incredible.

Yet amidst all of these demands culturally sensitive non-scientists who are trained faster and cheaper (solely so that the resulting doctors can be paid less), there has been absolutely no change in the level of expertise or performance expected of these same physicians by the public, by payers, by the legal system, or by the literally dozens of certifying and regulatory boards that now roam the nation. The medical malpractice system – and clinical perfection demanded by its attorneys and juries – has not changed in 30 years. Medical specialty boards pursue profits by filling their certification exams with needless trivia. The federally mandated RBRVS payment system and scores of Medicare and Medicaid rules and regulations manage to suck up hours of time and money, add new “pay for performance” requirements and mandate the use of awkward and even defective electronic medical record systems, all while reducing net physician each year since the mid-1990s.

How can one country possibly be so schizophrenic, or unrealistic, about the investment it wishes to make in its physicians and the standards to which it wants them held? And why on earth is the nation’s political leadership so obsessed with slashing physician income, when literally trillions of dollars are being wasted on administrative complexity and a host of other non-productive uses? The money is just not there.

Let’s do a quick calculation. There are about 800,000 clinically active physicians in the U.S. Let’s say that each one is paid an average of $300,000. (This is an absurdly high estimate. The true weighted average is nowhere near that amount. Many doctors don’t even have gross practice revenues that total that amount.) Simple multiplication tells us that total amount of money directed toward American doctors each year is $240 billion. Total U.S. healthcare spending in 2009 was $2.5 trillion, an order of magnitude greater than all physician income combined. Even if every doctor in the country were forced to work for free as slaves, total medical expenses would drop by less than 10%.

Short of some actual mental illness, what would explain this sort of behavior? Doctors are supposed to be experts on healthcare science and the management of disease. Who will benefit from making them less expert, less trained and less experienced, all in the name of conformity, saving money, cultural values and software-mediated regimentation? The most plausible answer is anyone who wishes to transform physicians from independent, scientifically informed advocates for patients, into relatively uninformed followers-of-guidelines. Doctors following federally mandated guidelines for screening, diagnosing and treating patients don’t need to know any science; they just need to do what they’re told.

The end result may or may not be best for any given patient (perhaps you or a member of your family), but it will be less expense for Medicare, Medicaid and your private insurance company to have their doctors follow guidelines than to customize care. Meanwhile given the lack of progress in reforming the world of medical malpractice liability, the blame for whatever happens continues to rest with the physician him/herself. After all, he or she is the board-certified “expert”.

Well. At least they were experts…

Categories : Business and Law, Clinical Care, Economics, Ethics, Healthcare Policy, Politics, The Practice of Medicine

Mar
19

Carefully Crafting the Politically Correct Physician

by Dr. Doug Perednia

Pop Quiz: You’ve just been in a car accident, or been diagnosed with cancer, or struck by lightning, or you’re coming to your doctor’s office as sick as a dog with something you got last week and you haven’t been able to keep anything down for the past 48 hours. What’s your top priority with respect to what you want your doctors to know? Do you want her to be: (a) culturally sensitive; (b) financially aware; or (c) know how to fix you? If you answered (c), you’re clearly behind the times.

One of the strangest things about efforts to “reform” the U.S. healthcare system is how easily people seem to forget the purpose of the whole endeavor. For example, based upon the key provisions of the Affordable Care Act (aka, “ObamaCare”), one could easily conclude that the purpose of the healthcare system is to provide health insurance coverage, even if that coverage is as inherently defective and unsustainable as Medicaid. At least one self-described “liberal” blog has accused “right-wingers” of thinking that:

“The purpose of a health care system is to support a profitable health care industry. For example, regulations that mandate insurance companies insure people with pre-existing conditions are bad, because they are bad for business.

On the other hand, if your underlying assumption is that the purpose of a health care system is to provide health care to people who need it, you must be a liberal.”

Unspecified in the “liberal” definition are, of course, many details including what one can or should define as “health care”, whether one person should be required to pay for the care of another, or how many healthcare goods and services any individual should be entitled to.

But these are simply a couple of exhibits that demonstrate that our national discussion of healthcare “reform” is increasingly missing the point. The real purpose of any healthcare system can and should be getting patients and physicians and other clinicians together in an effort to impose chemical, structural and biological changes that will result in better, longer lives for the patients affected. The inimitable Dr. Rich produced a good and purposeful definition in the course of writing his first book on the subject:

“The purpose of healthcare services [i.e., the healthcare system] is to maintain or restore the individual’s health when possible or to optimize functional capacity, control symptoms, and compensate for restrictions when a disease or disability cannot be cured or prevented.”

In other words, the single most important purpose of any healthcare system can and should be to minimize the ravages that nature would otherwise impose upon our bodies and lives. Most notably you can’t fight nature with insurance, you can’t fight it with profits, and you can’t even fight it with the utmost in empathy, cultural awareness and good intentions. At its very core one can only fight the infirmities wrought by a completely objective and indifferent Mother Nature, with science.

We’re forced to remind our readers of this reality as a result of recent changes and proposed changes to the medical education, candidate selection and training process. Like many aspects of modern culture, these changes seem to be the result of an effort to replace logic and science with something warmer, fuzzier and more politically correct. For a few weeks ago, the American Association of Medical Colleges (AAMC) announced that it was changing the content of its Medical College Admissions Test (MCAT) to de-emphasize scientific knowledge and skills, and instead concentrate on ensuring that physicians of future are more in touch with their sensitive side than anatomy, biochemistry or statistics. As reported in MedPage Today:

“The change means that the MCAT will stop focusing solely on biology, physics, statistics, and chemistry, and also will begin asking questions on psychology, ethics, cultural studies, and philosophy.

The announcement of the change — made Thursday by the Association of American Medical Colleges (AAMC), which administers the test — represents a major shift in thinking on what makes a good doctor. Instead of training doctors that can spout off disease causes and treatments with encyclopedic knowledge, the new test is meant to begin training doctors to empathize and communicate better with patients, and to improve their bedside manner.

According to AAMC president and CEO Darrell Kirch, MD, a recent survey showed that the public has high confidence in the medical knowledge and ability of doctors, but feels physicians often lack the basic social skills required to really connect with a patient.

‘Bedside manner is a complex mix of understanding people, where they come from, and why they behave the way they do, and we think this shift in emphasis [of the test] will actually help us round out that dimension of a good doctor,’ Kirch said on a Thursday afternoon call with reporters.

The MCAT was created in 1928 and has been used for decades as a crucial component of getting into medical school. The standardized test hasn’t seen a major change since 1991, when a writing sample was added. The current test has two natural science sections (including concepts taught in college biology, organic chemistry, biochemistry, and physics classes), as well as a reasoning and a writing portion.”

The new test will add a section called “Psychological, Social, and Biological Foundations of Behavior,” which includes questions on behavior and behavior change, cultural and social differences that influence well-being, and socioeconomic factors, such as access to resources.”

Far be it from us to be pessimistic party poopers, but let’s think for a second about what the good Dr. Kirch just said. Patients currently feel quite confident about the medical knowledge and ability of physicians selected and trained under the previous system, so the AAMC thinks that it’s a good idea to potentially jeopardize those qualities in order to recruit doctors who may be medically ignorant and inept, but have a great perspective on the cultural differences between Puerto Rican Hispanics, Cuban Hispanics and Mexican Hispanics. Too bad a Clostridium difficile infection doesn’t much care whose gastrointestinal tract it’s infected any more than an auto accident cares whose chest it’s traumatized. They’ve all got to be treated properly or all the sensitivity in the world isn’t going to result in a patient who is any less dead.

In fact given the exponential increase in the rate of scientific knowledge and clinical data, one could argue that even the nerdiest dual biology and chemistry major is still going to be struggling to catch and keep up throughout the course of their medical career. As just one example, a recent article in the Annals of Internal Medicine took doctors to task for their frequent inability to interpret cancer screening statistics with a high degree of accuracy. An editorial on the topic in the same issue bemoaned a lack of statistical expertise in medical students and physicians that has now gone unaddressed for decades:

“Medical students do not understand statistical concepts well, and Wegwarth and colleagues’ study in this issue suggests that fully trained physicians do not either. A decade ago Sheridan and Pignone reported that despite a relatively high level of numeracy among medical students, (77% correctly answered 3 numeracy questions), only about half correctly interpreted risk-reduction data for the treatment of a hypothetical disease… Physicians clearly do not understand how to interpret cancer screening statistics themselves – expecting them to communicate this information to patients is a stretch.”

The editor might well have added that it is a stretch regardless of how culturally sensitive a given physician might happen to be. (Incidentally, Dr. Elaine Schattner has written a nice commentary on this recent article on her Medical Lessons blog.)

But perhaps we’re being too harsh and concrete in our thinking about whether people of Slovak ancestry would like to get an appropriate diagnosis and treatment as much as those who are Native American. Clearly there is merit in the idea that individuals vary tremendously with respect to their cultural attitudes, education, intelligence, religion and a host of other factors. In our clinical experience, for example, many Native Americans seek and receive services from both conventional medical doctors and native medicine men. Devout Muslim men are reluctant to have their wives and daughters examined by male physicians. Why shouldn’t all professionals in every walk of life benefit from a culturally sensitive and socially aware educational background, and have the nation modify all school curricula to require these courses for plumbers, hair stylists, attorneys and politicians as well as physicians? Our legislators have the power. After all, the State of California is now requiring that gay, lesbian and transgender history be included in all social studies courses. Requiring all Americans to receive a similar cultural education (but modified to include the particular foibles of every race, creed, color, country, size, shape, disability and a host of other factors) is just a simple law away. Why not make this change for all Americans with the very best of intentions?

But why stop there? The healthcare system doesn’t simply operate in a medical and social environment, but also an economic one. Shouldn’t our medical professionals also be required to be proficient in the sciences of economics and business management?

It should come as no surprise that this has already been proposed by Dr. Frederic W. Hafferty, PhD., professor of medical education and associate director, Program in Professionalism and Ethics, Mayo Clinic, Rochester, Minnesota, and colleagues in a recent paper in the journal Academic Medicine. Assuming that these authors are serious (and we believe that they might be, although we ourselves could easily have offered up the same paper as an instructive piece of sarcasm), we must allow them to speak for themselves:

“The nation teeters on the precipice of financial insolvency. Health care costs darken the economic horizon. Public trust in medicine is at an all-time low…

Key to this alienation is that physicians lack insight into the economic and social burden of the services they orchestrate. As a consequence, the most pernicious threat to health care and medical education in the United States today is not patient safety, nor the lack of an evidence-based practice, but rather the alienation of trainees and physicians from the financial cost to patients of their work.

We propose, therefore, a training process organized not around disciplines, organ systems, diseases, or clinical problems, but around cost. Beginning with the admission process, all medical school applicants will be required to demonstrate proficiencies in micro-, macro-, behavioral, and health care economics, and to document community service and related shadowing experiences in clinic business offices or sites related to the recording and payment of medical charges. A new MCAT exam, Kaplan course work, and premed advising will all mirror this shift…

…The first two months of medical school (with preexisting courses taxed to create this curricular space) will be devoted to the economics of care. This block will involve multiple pedagogical approaches from traditional didactics and problem-based learning to simulation and social networking. Instructors will range from topic experts to patients and members of the public whose lives are being bludgeoned by health costs. Preceptorships will be community based and will focus on student experiences in educating the public on the cost of both schooling and health care. Once this competency is mastered, students will begin to meet with patients upon discharge (clinic or hospital) to explain all charges. There will be no traditional “patient care” contact until students are fully able to decode and explain the highly cryptic billing statements that encumber patients. As students enter the biomedical side of their training, patient meetings will begin to add explanations of diagnoses and treatment options to those of cost. No student will be admitted to the care side of the educational continuum until he or she is fully able to explain to patients what has been done to them and why.”

And there you have it. If we put all of these requirements together the physician of the future will be culturally sensitive, empathetic, well-rounded and financially eloquent. They may also have received some actual medical training along the way, although perhaps not enough to actually diagnose and manage your particular problem.

Obviously this can’t go on forever, so where do we draw the line?

What we have here is completely classic problem in economics. Resources are finite. In this case the relevant resources are the time and tuition that any prospective physician must spend in order to stuff information into his or her head. On the other hand people’s wants are infinite. In this case people want every medical doctor to be a renaissance person – medically perfect, culturally sensitive, financially aware, gentle, understanding, self-sacrificing and (incidentally) typing 120 words per minute and completely skilled in the use of computerized medical records. Every time we expand the non-medical training requirements or place other political, social and bureaucratic demands on clinicians, it comes at a cost. The most obvious trade-off is that we will have culturally sensitive doctors who have an increasingly difficult time acquiring and keeping the skills they need to deal with actual medical conditions. Few if any of these conditions really care about the social graces, yet all of them answer to science.

This leads to the obvious question: Exactly how many additional days of illness, lost productivity and death are we willing to trade in exchange for the cultural and financial sensitivity gained by diverting physician training in this direction? We know that there must be a tradeoff – the only question is how much. Did the AAMC estimate what this potential impact might be? Did those calling for these changes even consider that it might be their friends and loved ones who might be adversely affected when the time came? We can only hope so. Unlike people, Mother Nature doesn’t mess around.

Categories : Clinical Care, Economics, Ethics, Healthcare Policy, Politics, The Practice of Medicine

Mar
8

Medical Specialty Certification Exams: The Real Scandal

by Dr. Doug Perednia

Note to our readers:

This article was recently published on The American Thinker website, where it can be found here. We’ve added some additional comments at the end of the article based upon reaction to the original, and some additional thoughts and news we’ve had since publication.

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Earlier this year, CNN broke the story that generations of dermatologists have been “cheating” on their specialty board certification exams. Like their colleagues in radiology and most other medical specialties, large numbers of dermatology trainees have been studying for the boards by using massive collections of historical exam questions that were memorized and shared immediately after each year’s test. Having access to these questions is useful because many specialty boards re-use questions from previous tests. Until this year about 20% of the questions used by the American Board of Dermatology (ABD) were recycled from previous years, compared with about 50% for the written exam in radiology.

The widespread use of these so-called “airplane notes” or “recalls” has been common knowledge in the medical world for decades, but the flurry of recent press reports has caused consternation in the powerful board certification industry. Stung by the publicity, the American Board of Medical Specialties issued a press release condemning the practice and calling it an unethical violation of copyright laws. Apparently caught by surprise, the executive director of the ABD admitted that she’d “never seen airplane notes, but I’ve heard about it”, and subsequently cancelled a scheduled on-camera interview on the topic. Meanwhile, the American Board of Radiology hurriedly announced that its 2012 certification examination will be composed of entirely new questions for the first time in ten years. But while the lay press often frames the issue as one of “public safety”, the real scandal surrounding specialty board certification is quite different.

Modern specialty boards are holdovers from a time when there was little standardization or regulation of medical training. The American Board of Dermatology was founded in 1932, a time when various programs to train dermatologists ran for either one, two or three years. This era ended for good in 1981 when the Accreditation Council for Graduate Medical Education was established to regulate and accredit residency training programs for all medical specialties. Every physician in America is now superbly trained over a period ranging from three to seven years depending upon their specialty. As quality and standardization improved, medical boards began making test questions increasingly esoteric in order to preserve a normal statistical distribution of scores. Most boards also began grading “on the curve”; failing a percentage of examinees with the lowest test scores regardless of whether the content they missed was critical to the practice of safe, high-quality medicine. “Recall” and “airplane notes” developed in direct response to these “fail somebody” policies. As one radiologist said to CNN: “”If they had a test where you could study relevant radiology knowledge and they tested on it, that would be fine. Part of the problem is the test and the questions that they ask. Because some of the questions are so obscure, that unless you know that they like to ask questions about that topic, you’re not going to study it because some of them are completely irrelevant to the modern practice of radiology.”

None of this would matter except that medical boards have managed to turn their monopoly on physician certification into a multi-million dollar gauntlet of tests and more tests that must be passed in order for physicians to stay on insurance plans and hospitals’ staffs. Taking the initial dermatology board certification exam comes with a $2,500 fee, while regularly required “maintenance of certification” tests cost nearly $1,000 each. And therein lies the true scandal in the saga of board certification and “recall” questions: it’s not that the tests are allowing incompetent physicians to care for patients, but that they are keeping many highly qualified doctors from entering practice and earning a living.

The math behind this injustice is relatively simple. The nearby figure shows the score distributions of two hypothetical board certification exams like the one given by the ABD, each composed of 300 questions. The left-hand curve shows a normal distribution of scores if none of the examinees have access to questions from previous tests that are re-used on this one. The right-hand curve shows the change in scores that will result if 90% of the test takers already know the answers to 60 out of the 300 questions as a result of studying “airplane notes. Let us further assume that the specialty board in question decides that it will flunk out the bottom 10^th percentile of test takers as a matter of “ensuring the quality” of its certification procedures.

Although the curves look similar, the use of recall notes produces a big difference in the specific score that will be used to fail test takers. In turn, this translates into a major change in who will be allowed to pass the test. Over half of doctors who did not use “airplane notes” and who would normally have been safely above the 10^th percentile threshold will now flunk as a direct result of their inability to answer all of the re-used questions correctly. These well-trained and competent physicians will be wrongfully kept from medical practice while they prepare for next year’s $2,500 test. If they’re smart they’ll find a set of “airplane notes” to study from rather than risk failure yet again. It’s no wonder that training program directors have been known to encourage their young doctors to seek out every review course, old test question and study tool they can find.

In the modern world of American healthcare, none of this multi-million dollar hoop-jumping is necessary or even appropriate. Every accredited specialty training program director already knows exactly what their residents know because they work with them each and every day. By the time physicians completes their specialty training they’ll have been asked tens of thousands of questions by a host of attending physicians in almost every conceivable setting, from the surgery suite to the lecture hall. Training programs have the ability to hold back or terminate questionable residents at any time.

Gilding the medical lily with endless layers of deliberately esoteric tests and certifications does nothing to improve patient safety or well-being; it simply prevents significant numbers of competent physicians from providing much-needed healthcare services. It’s time for the medical establishment and the general public to decide that high levels of excellent training are far more important than all the testing in the world.

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In an effort to be perfectly constructive, we would like to suggest two alternatives to the current mess. The first is that one might have a board certification test that encompasses the truly important and mainstream information and examples of work-ups and treatment decisions that everyone in a given specialty ought to know. A pass rate of 100% should be the goal. What’s the point of flunking out ANY clinicians who know this basic and critical information? Make the old exams public for everyone to study. The entire point of the exercise needs to be ensuring basic awareness and good decision-making, not putting million of dollars into the coffers of self-selected specialty boards. A second alternative is asking residency training programs to do their own self-assessments of knowledge, decision-making and basic skills, and hold back or fail anyone who fails to meet their standards. This can again be based upon a national consensus of training program directors that documents those elements of training that are needed to produce good clinicians. Again, the goal should be a pass rate of 100%.

One has to wonder if there is not a class-action that should be taken against the medical specialty boards who recycle questions, that should be filed on behalf of all those who may have taken these exams and failed – quite possibly through no fault of their own – over the past 15 years.

One comment about the American Thinker article that struck us as being particularly interesting in light of the impending shortage of physicians is this one by someone using the pen name “Sud”:

I am boarded in 3 subspecialties and on my initial exams scored in the 90th percentile in my primary specialty with no special access to old questions. As of last year I am employed by a hospital that requires only 1. I will not recertify in the others. There is no economic advantage, and patients apparently perceive no quality advantage when they are perfectly willing to see a nurse practioner and refer to them as their doctor.

I believe “keeping many highly qualified doctors from entering practice and earning a living” is the whole point Dr. Perednia. Qualified physicians still cost more than government payers wish to spend. They have initiated price controls on physician services, inducing workforce shortages in primary care specialties so that when the baby boomers all start dying, and physician access is nil the sheeple will embrace single payer, and Big Brother can install less thoroughly trained alternatives as the answer to a failed system, whose failure big government has ensured. They may be PAs, NPs or eventually a newly minted CNA with a clipboard and clinical decision flowsheet at the end of a 1-800 number. If they don’t want physicians in general seeing patients, why on earth would they want board certified subspecialists.

Sud’s observations may sound a bit like a conspiracy theory, but the fact is that it makes absolutely no sense whatsoever to be making it harder and harder to be “qualified” to practice medicine as a physician, while at the same time expanding the ranks of lesser trained and lesser qualified physician assistants and nurse practitioners who are expected to make up for a shortage of doctors.

After this article was posted on The American Thinker, we were contacted by the folks at the organization Change Board Recertification. This organization has done some extraordinary work documenting the tens or hundreds of millions of dollars of “non-profit” profits that are flowing into specialty board coffers each year. RTH readers may well find this organization, and the specialty board tax returns that it has made available on-line, worth a second and third look.

Categories : Abuse of Power, Business and Law, Clinical Care, Economics, Ethics, Healthcare Policy, Politics, The Practice of Medicine

Mar
5

Two Interesting Posts That Mosey Down the Road to Hellth

by Dr. Doug Perednia

Megan McArdle over at The Atlantic is one of our favorite bloggers, as she routinely discusses various practical aspects of combining economics with human behavior. Megan has apparently committed herself to another project for the next few weeks or months, and has left her blog in the hands of several guest bloggers – a couple of whom often write about healthcare. Today two of them posted pieces that we found quite interesting, and we wanted you, our readers, to know about them.

The first of these two articles, entitled Need a Reason to Question Obamacare? Just Look to Louisiana is by Avik Roy, who usually does a great job blogging at The Apothecary blog over at Forbes. In this post, Mr. Roy talks about “The Louisiana Purchase” – the deal made with Sen. Mary Landrieu’s (D., La.) that was supposed to give her state $200 million in extra federal Medicaid Funds in exchange for her support for the Patient Protection and Affordable Care Act (“ObamaCare”). In one of those unaccountable mistakes that can only happen in the halls and back rooms of our nation’s capital, it seems that in the course of torturing the language of the bill so that only Louisiana would get this special deal, they accidentally awarded Ms. Landrieu’s constituents $4.3 billion due to “a drafting error”. From Mr. Roy’s post:

On March 20, 2010, hours before the final vote on the health care bill in the House of Representatives, the Congressional Budget Office and the Joint Committee on Taxation issued their fiscal scoring of the bill. According to their analysis, the “Louisiana Purchase” would cost $0.1 billion in 2011 and $0.1 billion in 2012, with no additional spending thereafter for a total of $0.2 billion, or approximately $200 million.

Republicans were angry, as were many voters. But while President Obama voiced some opposition to the special deals cut in Congress in support of his signature legislation, he made an exception for the Louisiana Medicaid adjustment, incorrectly asserting that the language also applied to Hawaii:

“Something that was called a special deal was for Louisiana. It was said that there were billions–millions of dollars going to Louisiana, this was a special deal. Well, in fact, that provision, which I think should remain in, said that if a state has been affected by a natural catastrophe, that has created a special health care emergency in that state, they should get help. Louisiana, obviously, went through Katrina, and they’re still trying to deal with the enormous challenges that were faced because of that…That also–I’m giving you an example of one that I consider important. It also affects Hawaii, which went through an earthquake. So that’s not just a Louisiana provision. That is a provision that affects every state that is going through a natural catastrophe.”However, in November 2011, when the Centers for Medicare and Medicaid Services (CMS) tried to make sense of the legislation, they came up with a much larger number: $4.3 billion. This was, in part, because the text of the law didn’t phase out the adjustment in two years, as originally intended, but rather increased the federal subsidy in out-years.

The language in Section 2006, wrote CMS, “results in increased, rather than phased down, financial assistance to [Louisiana] each year, and allows [the state] to continue to qualify for assistance after their underlying FMAP has stabilized. The resulting assistance will be higher than initially projected.”

You can say that again. In fiscal year 2012 alone, the federal government sent about $700 million in supplemental funds to Louisiana’s Medicaid program, with another $3.6 billion to be spent in fiscal years 2013-2015. In FY13, the law changed the feds’ share of Louisiana Medicaid spending from 61 percent to 72 percent: a billion-dollar adjustment for the Bayou State.

Take a few minutes to read the article. It reads like a how-to manual on destroying the U.S. healthcare system by drafting laws that are either wickedly clever in their deceit of the public, or sublimely incompetent in the drafting.

The second Megan’s-guest-blogger article we’d like to highlight is “You’re Fat and You Know It: Why Government Anti-Obesity Efforts Fail” by Katherine Mangu-Ward. It’s hard to swing a cat anymore without having some part of it’s anatomy strike a state or federally-funded study or public education program designed to tell members of the heftier segment of the public that, contrary to what they might have heard elsewhere, being obese is actually not that good for you!

One interesting question is what the purpose of these messages is other than to spend everyone’s tax dollars? Is there anyone who does not know that being obese is not so great for your health? As it turns out, no:

Fat people have a surprisingly accurate sense of the health costs of being fat, for example:

“Finkelstein et al. conducted a survey of 1,130 adults in the United States to test whether overweight and obese individuals believe they are at greater risk of obesity-related diseases and premature mortality. They found that obese and overweight adults forecast life expectancies that are 3.9 and 2.4 years, respectively, shorter than those of normal-weight adults….The authors concluded that mortality predictions generated from the survey were “reasonably close” to those generated from actual life tables for adults in the United States.”

Numerous studies have found that lack of information about a healthy diet or opportunities to eat well aren’t the problem either. Cramming calorie counts and other nutrition information down customer’s throats doesn’t do much to change food choices. A second Marlow paper, forthcoming in what I’m told is the respectable journal Applied Economics Letters, finds that living near fast food doesn’t cause weight gain. That finding is supported by another recent study in the Archives of Internal Medicine, which found that living near supermarkets doesn’t improve diets, and (with the possible exception of young, low-income men) living near fast food doesn’t make for a less healthy diet.

So if telling people about the problem over and over and over does nothing to solve it, why does the government keep spending money on this? Why do we do the same unsuccessful thing over and over again in healthcare? Are we stupid or something?

To quote Forest Gump’s mom, “stupid is as stupid does.”

Categories : Business and Law, Clinical Care, Economics, Ethics, Healthcare Policy, Political Hellth, Politics, The Practice of Medicine

Mar
1

Year After Year, Medicare Keeps Flushing Perfectly Good Kidneys (and Dollars) Down the Drain

by Dr. Doug Perednia

As most of our readers know, Medicare is the government-sponsored health insurance program for the elderly and disabled. What many Americans may not realize, however, is that Medicare has, by law, for many years been unusually and selectively dedicated to the care and feeding of kidney function. This leads us to the question for today: when our elected leaders pass laws about the coverage of specific healthcare services, what logic (if any) dictates the services that will be provided? Is common sense involved? And most importantly, is healthcare policy formulated mostly in the brain, or mostly in the kidneys?

For those of you who may not be overly familiar with them, we should note that kidneys are certainly among the most amazing organs ever created. Their functions include regulating the amount of water and salt in the body, balancing the amounts and proportions of sodium and potassium in the bloodstream, maintaining an appropriate blood pressure, helping to manage the production of red blood cells and various other tasks of great utility, such as detoxifying and/or eliminating potential poisons. There is no question that anything we can do to mitigate the loss of kidney function is a useful social and medical endeavor.

Perhaps as a consequence of the kidney’s great importance in our lives, in 1972 Congress passed an amendment to the Medicare law that essentially made the federal government responsible for the cost of all care associated with end-stage renal disease (ESRD). Since that time this has included both kidney dialysis (a process whereby the blood is filtered by a machine that amounts to an “artificial kidney” when it comes to eliminating excess salt, water and toxins in the bloodstream), and covering the cost of transplanting real kidneys from human donors into ESRD patients. Medicare’s coverage is based upon Congress declaring that any American with ESRD would be declared to be “disabled” for Medicare purposes.

Of course all of this comes with a price. As a recent review article in the New England Journal of Medicine recently documented, this has been considerable:

“In 2008, there were more than 112,000 new patients with ESRD in all eligibility categories (elderly, disabled, and ESRD-only). There were approximately 548,000 U.S. patients with ESRD (about 382,000 of whom were undergoing dialysis) at the end of 2008, but many of them were not covered by Medicare, either because they had not yet fulfilled the initial waiting period or because they had received transplants and their coverage had ceased after 3 years. Medicare expenditures for ESRD in 2008 were $26.8 billion for Parts A and B. Non-Medicare expenditures for ESRD (covered by employer-sponsored group health plans or paid directly by patients) added another $12.7 billion, for total national expenditures of $39.5 billion. According to an analysis by the U.S. Renal Data System, ESRD beneficiaries represented 1.3% of all Medicare beneficiaries and used 7.9% of Medicare expenditures.”

So it was with great pleasure that we met a patient just this week who had directly benefited from this program. She is a middle-aged diabetic woman who had been on dialysis for several years before being able to find a compatible kidney donor. The good news was that she was doing very well with her new kidney and was both pleased and relieved to have been able to discontinue the ritual and inconvenience of dialysis. She felt better, looked better and felt that she could really enjoy life for the first time in years. The bad news was that she was worried. Very worried. In spite of her new kidney she has not yet been able to find work – or at least find work with health insurance. She was most worried about being able to keep using the drugs that were preventing rejection of her kidney. But wasn’t she still covered by Medicare we asked?

“I am for a few more months,” she replied, “but Medicare benefits automatically terminate three years after a successful transplant.” But won’t Medicare continue paying for her transplantation drugs and insulin even after that if she’s unable to find other insurance? After all, if her diabetes rages out of control and she’s unable to take her transplantation medications, she’ll lose her kidney.

“I know. That’s what I’m worried about.” She gave a grim, twisted little smile. “But at least if that happens I’ll qualify for Medicare again and we can start all over.”

In fact, she’s right about that. It’s written in black and white, right here in this document that describes Medicare benefits for those with ESRD:

“If you have Medicare only because of ESRD, your Medicare coverage will end:

• 12 months after you stop dialysis; or

• 36 months after you have a kidney transplant and no longer need dialysis.

Your Medicare coverage will continue if:

• You start dialysis or you get a kidney transplant within 12 months after the month

you stopped getting dialysis; or

• You start or resume dialysis or get another kidney transplant within 36 months after the month you have a kidney transplant.

Your Medicare coverage will resume if:

• Your ESRD Medicare ends and you resume dialysis or get another transplant for kidney failure. Your Medicare can start right away without any waiting period.”

Now here is something strange.

One common theme in the great commotion about healthcare in America today is the concept of “waste, fraud and abuse”. A second one – most common among intellectuals such as President Obama and former head of Medicare Dr. Donald Berwick – has to do with the need to institute and disseminate “best practices” in medicine. And a third has to do with not delivering more care, but “smarter care”. In light of all of these let’s consider the facts of this particular patient’s case.

A kidney transplant costs between $100,000 and $125,000.

A year of hemodialysis costs between $6,000 and $10,000 per month, or about $71,000 to $120,000 per year.

Put them together and you have the same amount of money that would place a taxpayer in the top 2% of annual income. This is so much money that the President routinely lumps households like this into the general category of “millionaires” for tax purposes.

A month of immunosuppressant medications to prevent rejection of a transplanted kidney costs between $1,000 to $3,000 per month, less than one-third the cost of hemodialysis.

But even now, several years after the passage of the Affordable Care (“Obamacare”) Act, the federal government’s own health insurance program will pay for the entire cost of years of dialysis and a kidney transplant to get patients like this one off of dialysis, and then completely squander those investments by discontinuing coverage of the immunosuppressant drugs after 36 months, regardless of whether this will cause the patient to lose the kidney and go back on dialysis.

Lord knows we hate to be critical, but this is just plain stupid – even for a government agency whose healthcare policies routinely seem to be, er, ill-considered. And clearly the patient we met this week is hardly an isolated case. The briefest of Web searches on the topic uncovered this 2009 New York Times article about a patient on her second Medicare-funded transplanted kidney. She lost the first one when she started stretching out her doses of immunosuppressant drugs due to cost considerations.

Perhaps what baffles us most about all of this is that so many people continue to place so much faith a single-payer healthcare system run by the federal government. On what basis can they possibly believe that it will be efficient and/or well-run? These are people who will appropriate and spend $17 billion to force physicians and hospitals to deploy expensive, inefficient and frequently despised and quite possibly even dangerous electronic medical record systems, but they can’t find the money to preserve organs they already paid to transplant once already? Can’t this whole kidney program be considered a rather pure and special form of wasting and abusing taxpayers’ dollars?

Under these circumstances it’s hard to say which is in shorter supply: kidneys or common sense.

Categories : Business and Law, Clinical Care, Economics, Ethics, Healthcare Policy, Politics, The Practice of Medicine, Waste Fraud and Abuse

Archive for March 2012

More on Our National Effort to Dumb Down Physicians

Carefully Crafting the Politically Correct Physician

Medical Specialty Certification Exams: The Real Scandal

Two Interesting Posts That Mosey Down the Road to Hellth

Year After Year, Medicare Keeps Flushing Perfectly Good Kidneys (and Dollars) Down the Drain

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