10Jul11 Debunking Medical Urban Legend

He likes it!!

Like Mikey, the Life cereal kid who died from mixing Pop Rocks and Coke, or the spider eggs in Bubble Yum that help make it so soft and chewy, Medicine has its share of urban legends.

Did you know, for example, that if you’re hospitalized and decide that you want to leave “Against Medical Advice” [AMA], that your insurer won’t pay for the hospitalization?

Bunk.

Apparently, this canard is pervasively believed amongst doctors and passed from generation to generation of trainees just like the nonsense about cute ol’ Mikey.

A few years ago, a medical student came to me with a case of moral distress. She had seen the doctor-in-training with whom she was working become upset at a patient for declining an invasive heart procedure.

Rather than try to reason with the patient and convince her that the test was indeed indicated and would be of greater benefit than possible harm, the resident doctor in question quickly became rattled and informed the patient that if she refused the procedure and signed out AMA, she’d be financially responsible for the entire cost of the hospitalization, as her insurer would decline to pay.

The student was horrified at such browbeating of a patient; in addition, using the hospital bill as a cudgel to coerce cooperation smacked of the worst kind of paternalism and just seemed wrong. “Aren’t there ethical safeguards against this?” she wondered.

Her moral distress led to a research project that debunks this notion [we hope] once and for all.

I can’t give you the specifics (an article on our findings is under review at a medical journal) just yet, but GlassHospital and FutureDocs are happy to share with you the educational fruits of our findings to date. You can click over here to learn more in true interactive fashion, or if you prefer, watch only the cameo-encrusted video tour-de-force right below. [Who is that guy playing angry Mr. Smith? He looks familiar. And who, for heaven's sake, does his wardrobe?]

Let us know your thoughts! On the video, the website, the urban legend. What other medical urban legends would you like to see debunked?

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6 Comments Posted by in health care finance, hospital care, humor, medical ethics, medical urban legends, patient experience
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26Jun11 Google Strikes Out

Yeah, that’s right. Google, the fabulously successful internet search giant, has been humbled in at least one market:

Online health records.

Like other tech companies before it, Google has learned the hard way that health care is a behemoth industry that is resistant to change its decades-old practices.

[By old practices I am referring here to health care financing and documentation; I'm not alluding to the pace of actual medical innovation, which seems to occur faster and faster with each passing headline.]

Google started the service, Google Health, in 2008. You can read the bulletin about its demise from the company here.

The idea is simple: Empower patients to upload their own health records online, stored in the “cloud,” so that they can be available anywhere anytime for use by the patient and whomever she chooses–doctor, nurse, specialist, consultant, physical therapist, yoga teacher, etc.

What’s not to like?

For one thing, privacy advocates worried about the security of such records. Libertarians worried about government and/or insurance companies using the records to screen out potentially unhealthy individuals to deny them coverage.

Perhaps the bigger barrier to adoption: inertia. Patients are very used to the idea of the doctor/practice/medical group/hospital keeping the records. It’s tradition, after all. One that’s apparently hard to shake.

As someone who works in this sector, I’ve increasingly come to feel that test results, lab values, even doctors’ notes that involve me should at the very least be shared with me. Freely and openly. Why should I have to jump through so many hoops to obtain them, like the dubious copying charges that health entities set up as a barrier to providing free documentation. Why not offer it all right up–electronically?

I keep an old fashioned paper record of my results. But I’ve never gone to the trouble of scanning the documents or uploading them to a cloud-based service like Google Health or Microsoft’s HealthVault.

Hmmm. I guess I can see why a pretty good idea like personalized online health records hasn’t panned out.

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3 Comments Posted by in medical innovation, personal health information, technology
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20Jun11 Thinking about Moms on Father’s Day

Archival poster.

Last week an anesthesiologist in Los Angeles named Karen Sibert stirred up a hornets’ nest of controversy in an op-ed piece that was published in the NY Times.

The piece, titled “Don’t Quit This Day Job,” addressed the hackneyed issue of physician shortage in the United States.

Citing federal subsidies for graduate medical education (i.e. residency training), Dr. Sibert suggested that in order to stem the tide of part-timers (mostly women) contributing to the physician shortage, “…we can only depend on doctors’ own commitment to the profession.”

All well and good; yet depending on the magnanimity of those in a profession to save it from itself is never a successful strategy without a robust marketplace of ideas and innovation.

Dr. Sibert’s solution to the problem, however, was anything but hackneyed:

Students who aspire to go to medical school should think about the consequences if they decide to work part time or leave clinical medicine. It’s fair to ask them — women especially — to consider the conflicting demands that medicine and parenthood make before they accept (and deny to others) sought-after positions in medical school and residency. They must understand that medical education is a privilege, not an entitlement, and it confers a real moral obligation to serve.

Really?

We should ask women about their child-rearing plans before letting them go to medical school or take on a residency? Does that seem like a sensible way forward?

Dr. Sibert, citing her own full time commitment to the profession, declares:

You can’t have it all. I never took cupcakes to my children’s homerooms or drove carpool, but I read a lot of bedtime stories and made it to soccer games and school plays. I’ve ridden roller coasters with my son, danced at my oldest daughter’s wedding and rocked my first grandson to sleep. Along the way, I’ve worked full days and many nights, and brought a lot of very sick patients through long, difficult operations.

I’m glad for Dr. Sibert, but she comes across as self-righteous in the personal revelation in support of her larger claim. I certainly respect her right to have worked full time, but I’d never begrudge another professional the opportunity to work part time to help raise a family.

As you may imagine, there were some outraged letters sent in, including this one:

To the Editor:

While Dr. Karen S. Sibert’s point about the shortage of doctors entering primary care fields is valid, her proposal to address it by querying women on their future child-rearing plans smacks of patriarchy and sexism. Even if every medical school seat today were filled by a male student, at current rates of matriculation into primary care fields it would do little to mitigate the problem.

I chose to work as a part-time doctor early in my career to be supportive to my full-time physician wife. Being asked about my parenting intentions at any point in the process would have been chilling.

JOHN HENNING SCHUMANN
Chicago, June 13, 2011

I’d love to hear your thoughts.

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7 Comments Posted by in health care reform, medical education, primary care
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14Jun11 Bookends

Good news/bad news from the world of medicine last week. Both stories from the business section of the NY Times and “business of health care” reporter Reed Abelson.

The bad news first: Huron Hospital, a community hospital in East Cleveland, will be closed down by its corporate overlord, the Cleveland Clinic. Like many community hospitals, Huron has declining numbers of admissions and isn’t staffed or equipped to provide the cutting edge care [e.g. transplant, cardiac surgery, or interdisciplinary cancer treatment] favored by behemoth academic medical centers.

I’m sentimental about Huron’s closure for many reasons:

  1. One man's ceiling is another man's floor?

    Further evidence of Cleveland’s decline. After all, Cleveland ranked #5 on Newsweek’s list of dying American cities.

  2. Huron was originally built on part of the estate of John D. Rockefeller, one of America’s original “robber barons.” Rockefeller also bequeathed a nice sum to start a university on the south side of Chicago.
  3. I rotated at Huron as a medical student, working in the ER; I learned a thing or two about suturing and triage.

The Cleveland Clinic makes it clear that closing the inpatient hospital is a business decision. CEO Toby Cosgrove acknowledges that the decision is a difficult one. The hospital is not only considered a local public resource; it’s the largest employer in the community of East Cleveland.

The news is not entirely bleak, however: The Clinic plans to open an outpatient family health center on the site. “When we took over the hospital, we signed up to look after this community,” Cosgrove said.

Contrast the Clinic’s decision with that of Blue Shield of California. The non-profit health insurer made news by unilaterally declaring that it will limit its annual “profit” to a maximum of two percent of revenues. Monies earned over that figure are plowed back to the company’s members, most often in the form of credits on premium payments.

This in effect helps subsidize the cost of insurance for members of that plan.

Sounds good, but you have to wonder:

If a non-profit insurer is making enough “profit” to offer premium credits, you’d think they could just charge lower premiums in the first place. After all, when we talk about annual double digit inflation in health care, isn’t our insurance premium the first place we feel the pain?

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3 Comments Posted by in health care finance, patient experience
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5Jun11 Docs & Politics

There was a fascinating piece in the NY Times suggesting that on the whole, the medical profession is moving leftward politically.

Here were the main reasons cited:

Definitely need some weathermen to know which way the winds blow.

  1. The demise of private practice in favor of salaried work. [For an analysis of this phenomenon, read here.]
  2. The hassles of administration [i.e. paperwork and bureaucracy] leading to a preference for a more idealized, streamlined form of “care for all.”
  3. Moral outrage at a patchwork system of health coverage the currently excludes ~50 million Americans.
  4. More women (and part-timers) in the profession.

What do you think?

If you’re a doctor, have you felt your politics changing or standing more resolute in the face of the passage of health care reform?

If you’re a patient, do you ever talk politics and/or health care reform in the U.S. with any of your doctors? What’s your take on their positions?

Rather than give you more of my spin, I’ll just excerpt the last four paragraphs of the article here to save you some clickage:

Even in Texas, where three-quarters of doctors said last year that they opposed the new health law, doctors who did not have their own practices were twice as likely as those who owned a practice to support the overhaul, as were female doctors.

Dr. Cecil B. Wilson, the president of the A.M.A., said that changes in doctors’ practice-ownership status do not necessarily lead to changes in their politics. And some leaders of state medical associations predicted that the changes would be fleeting.

Dr. Kevin S. Flanigan, a former president of the Maine Medical Association, described himself as “very conservative” and said he was fighting to bring the group “back to where I think it belongs.” Dr. Flanigan was recently forced to close his own practice, and he now works for a company with hundreds of urgent-care centers. He said that in his experience, conservatives prefer owning their own businesses.

“People who are conservative by nature are not going to go into the profession,” he said, “because medicine is not about running your own shop anymore.”

Not about running your own shop anymore…

Does he mean that the folks choosing medicine as a career nowadays are less entrepreneurial? Or simply less interested in controlling the means of ‘production’?

These are excitin’ times in the world of doctoring.

If you don’t believe me, just read ol’ Dr. Gawande’s commencement address at Harvard Med, courtesy of the New Yorker.

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4 Comments Posted by in advocacy, health care reform
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