Emergency Medicine Doc

Scott Gottlieb Gets It Right on Obama Healthcare

EMDoc — Tue, 02 Sep 2008 18:44:00 GMT

Today's Wall Street Journal has commentary from Dr. Scott Gottlieb on the Obama healthcare plan I have been blogging about. He notes how successful Federally Qualified Health clinics have been in Chicago.

"those clinics have been hampered by state and federal regulations that try to promote "fairness" in our health-care system, only to undermine simple, local efforts aimed at genuine reform.

First among these regulations are mandates that require clinics to offer certain health-care services. In many cases a particular mandate can be defended. But the accumulated total makes it harder for some bare-bones clinics to offer any services at all."

As discussed previously, Mr. Obama wants to pull patients from private type insurance into a similarly federally mandated program.

As I have been ranting it is about access to care not insurance or registering in a federal program. Dr. Gottlieb agrees and adds to our reasons why access is the problem:

One big challenge is attracting and retaining skilled medical professionals. Pay is low, and the risks to providers high. Here, Sen. Obama's plan is no help. The Economic Policy Institute estimates that the Obama plan will cost about $1.6 trillion over 10 years. Give or take a handful of billions, funding his plan will eventually mean the same cuts to providers working under programs like Medicare and Medicaid that were used to subsidize other big health-care expansions.

Finally, the Federally Qualified clinics even had built in immunity much like the docs in the military, but recently even some of this protection has been taken away. Certainly, the Democrats do not support tort reform, so what else is there to attract good docs to such a program.

Marie Coco - Health Care Fight

EMDoc — Thu, 14 Aug 2008 18:22:00 GMT

8/12/08 Marie Coco, syndicated columnist with The Washington Post, echoed my sentiments regarding the health care crisis. Mentioning that if it was not for the price of gas, the real estate market crumbling, and the credit and banking crisis, healthcare would be the number one issue.

The reason I like her perspective is because for the first time she and I agree. Quote:

"To say you're going to provide affordable coverage to people is not the same as giving them health care," she says. "Just because you have insurance coverage does not guarantee you access to the care that you and your doctor decide you need. And people with insurance understand that."

This has been the montra of the Democratic platform for decades, and frankly as I mentioned previously in my columns about the McCain and Obama health platforms, providing access to care, not just insurance is lacking. As all of us know, just because you have insurance does not mean you can go to a doc when you want where you want easily.

Emergency Departments - Your Primary Care Provider

EMDoc — Thu, 07 Aug 2008 13:39:00 GMT

In a front page article by the San Francisco Chronicle , they describe a report by the CDC, that reveals what we in Emergency Medicine know all too well. We have become the primary care providers of the community. To quote the article:

"The likely cause is there are just fewer and fewer primary care physicians," he said. "If you were to get the flu and your doctor says, 'Sure, I'll see you in two weeks,' you may not be able to wait. It's hard for even insured people to get quick appointments and be seen quickly."

The study over 10 years from 1996 to 2006, reveals that the number of uninsured has increased by 5 million in that 10 year time frame, while the number of ED visits has increased by 32% from 90 million to 119 million visits. At the same time the number of emergency departments that have closed dropped by nearly 5%. This puts added pressure on existing emergency departments and hospital systems. I would add that those closings also do not necessarily mean more money for hospitals as most hospitals are losing money on nearly every ED visit or admission.

To quote Dr. Billy Mallon, current California ACEP Chapter president:

""The main problem with ER overcrowding is I can't get the admitting patients out. I can't get them to the ICU, to the operating room or to the wards," Mallon said.

He said people who lack access to other care options contribute more to overcrowding than patients who rush to the emergency room in nonemergency situations. "

Ahhh, finally what I have been saying all along. The Obama, McCain camps and all these other state universal health care plans that are being tried have it wrong. It is not about being insured, it is about having access to care. Insured patients cannot get access to their primary care doctor or their orthopedist or their dermatologist or their gynecologist so they are going to where they know they can get the care they need....the country's emergency departments.

So how can this be solved?

The primary care specialties need incentives to attract students. Why would a medical student select internal medicine, family practice or pediatrics, put in long hours and hardly make a living , when they can be in a surgical specialty that may pay them 400-500% more and have a better lifestyle. With the aging population the demand on ED's and hospital admissions will increase, so while it is easy to say we need to cut Medicare programs now, we will pay the price in the future. Hospitals need more dollars to have capital expansion projects in areas of need. What will Atlanta do if Grady hospital closes? Will everyone move out of Atlanta?

The state of our health care system is a shambles, to say the least. I would say it is a "crisis". In as little as 5 years time, I predict the system will completely collapse, meaning every ED and every hospital will be beyond capacity everyday, not just a couple days per week as it is now. The next presidential administration and congress needs to grab the bull by the horns, and get it fixed or what will develop is a system of the haves and have nots. Smart industrious healthcare administrators will start cash only hospitals and clinics that those that can afford will go to primarily and the rest will suffer in s system with little access and poor quality care. ( I won't even mention what could happen if there is a major terrorist event or natural disaster.)

McCain's Health Plan for America

EMDoc — Fri, 01 Aug 2008 18:25:00 GMT

Senator McCain's Health Care plan says that the problem with healthcare is that it is too expensive and that there are 47 million who are uninsured.

The McCain plan wants it to be easier for families to get the insurance they need. This will be done with a tax credit of $2500 for individuals and $5000 for families. You choose the insurer and the money from the credit goes directly to them. I would prefer to have the credit go directly to me and let me put it in a Health Savings Plan.

He plans on expanding the benefits of health savings accounts.

The plan then goes on to a number of ways to lower the cost of healthcare, which includes tort reform of some kind. Tort refrom is the only issue not present on Mr. Obamas plan, otherwise the plans closely mirror one another.

So to summarize, both candidates offer some form of a move to socialized government controlled medicine. Is this really what we want as a nation? Time and again we have seen the inefficiencies of Medicare, Medicaid and Social Security. Neither addresses the issue that is really at hand and that is access to healthcare. Hospitals and healthcare providers need to be paid for the services they provide, if the plans do not pay adequately then hospitals and health care providers will not participate. Those who can afford to , will pay out of pocket to get the care they need and those who become part of this government run madness will be forced into a system that will be more stagnant than the one we have now.

Barack Obama's Plan for a Healthy America

EMDoc — Tue, 29 Jul 2008 16:31:00 GMT

I wanted to devote some time to my thoughts on the presidential candidates' healthcare plans as they are currently written. I will start today with a review of the Obama plan and then in a subsequent entry the McCain plan.

To quote the Obama plan:

"...the Obama plan will save a typical American family up to $2500 every year on medical expenditures by:

Providing affordable , comprehensive and portable health coverage for every American;
Modernizing the US health care system to contain spiraling health care costs and improve the quality of patient care; and
Promoting prevention and strengthening public health, to prevent disease and protect against natural and man-made disasters."

Wow, that sounds great, this is certainly something every American would want, but let's look at this a little more closely.

So how will every family save $2500 dollars per year? The Obama plan tells us how:

Health IT investment, which will reduce unnecessary spending in the system that results from preventable errors and inefficient paper billing systems.
Improving prevention and management of chronic conditions.
Increasing insurance industry competition and reducing underwriting costs and profits, which will reduce insurance overhead;
Providing reinsurance for catastrophic coverage, which will reduce insurance premiums; and
Making health insurance universal, which will reduce spending on uncompensated care.

I certainly agree with investing in IT and all of its benefits, but its upfront costs are huge. He says he would invest $10 billion a year over 5 years to cover this, he ventures this would save $77 billion per year once implemented. Not sure where the $10 billion dollar per year number comes from, but this seems low to me. Improving prevention and management of chronic condition will be done by mandating coverage of smoking cessation programs and cancer screenings and by emphasizing to Americans that they should live in a "healthy environment that includes sidewalks, biking paths, and walking trails; local grocery stores with fruits and vegetables;" and "Obama will increase funding to expand community based preventative interventions to help Americans make better choices to improve their health." Whoooo, that is a whole lot of fluff.

The 3^rd way was to lower overhead for insurers. Last time I checked the insurers were making record profits, do you really think that lowering their overhead will make them pass that savings on to the working man.

It is not clear from the plan how providing reinsurance for catastrophic coverage will reduce premiums for all of healthcare. If an American only has catastrophic coverage then aren't they missing out on all the great preventive measures in the plan that are going to save so much?

Finally, making insurance universal, my favorite. This will reduce spending on uncompensated care. This will be a new plan like the one Senator Obama has called the Federal Employee Health Benefits Program (FEHBP, needs a fancier sounding abbreviation). This sounds like Medicaid to me, which as you know, very few physicians and other medical providers participate in. So where will patients go for their care? Your emergency department.

Another issue is "Reforming medical malpractice while preserving patient rights...Barack Obama will strengthen antitrust laws to prevent insurers from overcharging physicians for their malpractice insurance." Funny how he does not seem to understand that the price of malpractice is not the issue, the number of wasteful lawsuits against hospitals and physicians is the issue. The plan also will work to reduce physician error. Unfortunately, error is not why patients enter litigation; bad outcomes whether the doctor did anything wrong or not is the reason.

And finally, the most important part of how the plan will be paid for, besides on the backs of the small business owner, is "by allowing the Bush tax cuts to expire for people making more than $250,000 per year, as they are scheduled to."

Any takers....

ACEP Seattle

EMDoc — Tue, 21 Aug 2007 23:33:00 GMT

Well the ACEP Scientific Assembly is coming up in October. You had better hurry and register now, Seattle is a fun city and everyone wants to be there, especially after the New Orleans convention last year. It is a chance to recharge your emergency medicine batteries, see old and new friends and have a great time. It is a time to elect new board members. This year I think Mike Gerardi from New Jersey is the right man for that job. He brings an energy for our specialty that is hard to find.

It is also a time to think about making a donation to the Emergency Medicine Foundation. This is a nonprofit group founded by emergency physician to raise money and garnish grants for research solely in our specialty.

So see you in October.

4 Hour Antibiotic Window Little Effect on Survival in Pneumonia

EMDoc — Wed, 01 Aug 2007 12:41:00 GMT

Most docs have recognized the ridiculous science behind the Quality rules requiring antibiotics in Community Aquired Pneumonia within 4 hours of arrival at the hospital. Finally, there is a study from our home NJ Medical School in Newark, NJ that reveals that giving antibiotics in the first 24 hours has little effect on survival. The study found that despite increasing the number of patients that received the antibiotic in 4 hours over 3 years there was no change in survival.

While it intuitively makes sense that we should give antibiotics in a timely manner for pneumonia, the science behind the quality of measuring it is flawed and should no longer be measured.

Busting Some Myths About Dying

EMDoc — Fri, 06 Apr 2007 18:13:00 GMT

The National Safety Council put out the odds of dying from injury based on 2003 data. I recently reviewed this very interesting data and thought it was time to break some myths. The media typically makes a big deal about shark attacks, alligator attacks, death by guns in the home, air crashes, etc. These are the big ticket items to get attention and ratings.

What is the reality?

Here are the top causes of death and the odds of dying from them:

Cause Odds of Death

Heart Disease 1:3.6

Cancer 1:4.5

Stroke 1:15

Lung disease 1:20

Accidents 1:22

For example 1 out of 15 people will die from a stroke. But more specifically let's look at some stats based on the lifetime risks of dying from various types of accidents. Let's start with Transportation related risks:

Pedestrian 1:626

Bicycle 1:4919

Motorcycle 1:1020

Car occupant 1:237

Pick-up or van occupant 1:900

Heavy transport vehicle 1:8480

Bus 1:104,113

Train 1:156,169

Streetcar 1:1,874,34

Well this all seems to make sense, the larger and heavier the vehicle the less likely you are to die. The exceptions being a street car which I always thought of being more like a heavy bus which is extraordinarily unlikely to result in death, and being a pedestrian being safer than being an occupant of a car. I guess it all depends where you walk. But you say wait EMDoc, everyone says air travel is pretty safe, and it is, with odds of 1:5051. Not however better than a bus, train or streetcar. Why Greyhound and Amtrak are not capitalizing on this I have no idea.

There is often discussion about how dangerous it is to have firearms in the home. Opponents of the right to bear arms would say that they might accidentally misfire and kill someone.

Unintentional Firearm Discharge 1:5134

Assault By Firearm 1:314

I think this justifies my having a firearm to protect my family who has a much greater chance of killing me than I do accidentally killing myself or one of my family members.

Most towns require fences around your pool that are a minimum of 4 feet tall, anyone could hop over them, it is a joke. What's the real risk of drowning:

Bathtub 1:11,289

Swimming Pool 1:7278

Natural Body Water 1:3060

Last time I looked 4 foot fences were not required around the oceans, lakes and streams, but you have more than double the chance of drowning there. And if you did not notice you are safer in a bus, train or streetcar than in your own bathtub!

And to those of you who continue to believe that using illegal drugs like heroin and other psychedelics is okay, your odds of dying is 1:406, making it nearly as risky as walking down the street. Sadly, death from complications of medical and surgical care is 1 out of 1313. A number that in my mind I should always be trying to improve during my clinical practice. Going to your doctor should never be more dangerous than riding in a bus in my mind.

There is so much more interesting information at the National Safety Council site so go check it out....in the meantime I've got to run off to a shift, I think I'll catch the streetcar.

EMDoc Gets a Facelift

EMDoc — Fri, 30 Mar 2007 23:58:00 GMT

Well, those of you returning to my site will see that we have had a major facelift. The color scheme is better. The whole format is easier to navigate and to use. I have the easy ability to publish photos. The comments sections are more controlled so hopefully there will be no more spam.

A big kudos to my buddy DonXML for helping me get this done!

What Is The Cure For Overcrowding?

EMDoc — Mon, 05 Mar 2007 17:27:00 GMT

So you say overcrowding is an issue at your hospital. Your ED is regularly filled with admitted holds (patients admitted to the hospital waiting for beds, for those non-emergency affiliated readers). Your emergency nursing staff is burdened with inpatient care that they are not familiar with providing and/or documenting. Your ED docs are forced to see patients in hallways, lobbies, ambulance bays, waiting areas, wherever space allows. It is a highly inefficient, demoralizing and undignified way to provide care. Your patients are very unhappy. You are unhappy. Weekdays maybe you get some beds but Fridays and weekends are filled with staff call-outs, and having to close units. Do you have a headache yet?

So what is or are the solutions? Well, there is no magic pill. The Vicciellio concept is one: place the admitted holds one on each unit in the hallway upstairs on the floors. While this has been accepted by many state departments of health, it is put to little practical use by hospitals. Nursing unions do not like it, and short of forcing the issue by taking a patient up to a floor yourself and leaving them in a hallway against your administrations wishes, risks your job and probably your groups contract.

So what else? Well you could try and push for state legislation to provide disincentives for hospitals that continue this practice. This would take a while, in our state it could take years. So is it possible to fix the overcrowding situation? Yes (in this case I am an optimist). No one person however, is capable of making this drastic change. It involves changing the hospital culture to recognize that the ED for many places is the front door for their admitted patients, and therefore the ED should be treated as one of the hospital’s best customers. It involves every department of the hospital making sure the ED and floors have staffing and supplies they need to operate at full capacity 24 hours a day, or at least at peak volumes hours, compared to the current 9am-5pm model that most hospitals operate under now. For instance, if a low risk patient is placed in 24 hour observation on a Friday night to receive an MRI during the stay but your MRI unit is closed on Saturdays, then you won’t get the patient out in time. Money will be lost. It involves pushing your medical staff to recognize their own inefficiencies. Rounding once per day on inpatients is not enough. Patients need to be discharged as soon as possible, waiting until the next morning is no longer an option if they are ready to go at 5pm the day before. Case managers, social workers in the ED watching admitted patients from the ED to discharge is a necessity. Nursing homes must accept discharged patients at least 12 hours per day, I say 7a-7p, not just until 4pm, like many practice. If your hospital does not have a VP of quality along with a VPMA then you are behind. Finally, the ED docs, and nursing need to have a central reporting structure within administration. The time for nurses in the ED to only report to theVP of nursing and the docs to someone else is over. Our goals as docs and nurses in the ED are the same. There needs to be a commitment from administration to make this work at all levels; they need to acknowledge that admitted holds are not good for patient care. Finally, you need metrics. Measure every aspect of the patient moving through the entire hospital; from the time they walk through the ED to the time they are discharged. We need to look for prediction models of staffing, volume and throughput. Do you know what happens 24 hours after your hospital’s length of stay increases by 0.5 days? I don’t, but I would bet the number of holds in my ED will be going up. Imagine if you could staff for that ahead of time. Well there is a lot to swallow here. Our hospital is striving for many of these points, and I will keep you abreast of how the process proceeds.

Emergency Department Crowding

New Jersey Emergency Deparment Overcrowding/Surge Capacity

EMDoc — Mon, 19 Feb 2007 22:12:00 GMT

NJ ACEP in an effort to push overcrowding and surge capacity to the forefront recently held a townhall meeting/press conference on the topic. This was through a grant from national ACEP.

The event was featured by the following press agencies:

The Record, NJ 101.5 radio and a letter to the editor in the Star Ledger, among others.

Highlights included the recent IOM report and the ACEP National Report Card, where NJ has received an A for quality medical care, an F for malpractice issues and C+ for patient access. The link will bring you to the site and you can see how your state ranks.

A recent article in the Annals of Emergency Medicine highlights the national scene and NJ plight even farther. For instance, 2 NJ hospitals are moving out of the local residential communities and to the major highway corridors. Is this a way to get out of the overcrowding situation? Is this purely to allow ambulances faster easier access or is it a way for them to avoid the burdens of charity care patients whom may not be able to easily get from their residential communities to the highway location? Interesting concept, not sure if it will hold to bear.

Gardner's Gate

EMDoc — Mon, 19 Feb 2007 21:38:00 GMT

Well, I am happy to see that the American College of Emergency Physicians is doing all it can to keep up with evolving technologies. From having our council meeting with wireless connections and live web presentations to now the addition of blogging.

Yes, they now have the Gardners Gate, hosted by Dr. Angela Gardner, Secretary/Treasurer and member of the Board of Directors of ACEP. The blog is full of interesting and timely information about what is happening in emergency medicine and in ACEP. If you get a chance go check it out.

A Message From Above

EMDoc — Sun, 01 Oct 2006 01:35:00 GMT

I was having a bad day, a small squabble at home, I hit a curb with my car, the usual B.S. and politics at work, it was morning, etc. I was starting to feel better, made an appropriate apology, but still a little aggravated, (none of which is good for my borderline blood pressure). I was walking from my office and saw a worker in the hospital. I see this worker almost daily. I say hello, sometimes he says hello sometimes he doesn't. Sometimes he looks at me sometimes he doesn't. He is older than I and reminds me of my father-in-law who past away a few years ago... Irish, built like a horse. Well today I saw him multiple times and he was working hard, so besides saying hello, I said, “Boy, they sure have you working hard today.” With that he stopped what he was doing and began talking to me, quite pleasantly how he loved his work, even though some people thought less of him for it. How it made him a good living. How he provided for 3 daughters, who went on to be very successful. All of this without really looking right at me, and sort of talking out loud rather than to me directly. He then said he was very thankful for all he had, and he knew I was too because of the work I did and suddenly looked me right in the eye, touched my arm with his big rough hands, and quietly said, “You need a gratitude list.” He then winked, looked away, and said, “Thank you.”

At first, I did not think a whole lot of this, but as I walked away I felt a chill in my neck, and thought was this man telling me something more. Even more, I saw him again later, and said hello again, and he hardly acknowledged my existence as had been my experience in the past. So was this my imagination recognizing that I was having a weak, vulnerable moment and reading into something more than a simple conversation or was it something more. I have friends who tell me they have experienced things they cannot explain. As a physician, I have seen many people live who should have died and died that should live. I usually can explain or rationalize these things and if I cannot I do believe that God no matter what I do has the ultimate power over my life. Was He speaking to me through this gentleman? While I have never heard the term 'Gratitude List', I am starting one now.

Once Again Technology Fails

EMDoc — Thu, 10 Aug 2006 18:57:00 GMT

The other day I saw a patient with abdominal pain. The patient had the pain for some time. They had a CT scan of the abdomen at an outpatient radiology facility the day before. I asked if she knew the result, and she said, “No, but can't you just pull it up off of your computer?” The answer of course was “No.”

This statement should turn the world of information technology on its head! When I answered “No.”, she replied, “Well, I know you can access the records from my personal doctor.” I said, “With all due respect, it is a Saturday night, how would I do that? I doubt your doctor's office is open.” Her reply in a very frustrated way, “ You mean you honestly don't share all your computer information with him?” Again, “No, nor any other doctor in the area for that matter.”

So here a layperson, whose current job is working as a cashier in a supermarket, sees everyone with wireless phones, broadband internet access, satellite TV, has the ability to view and pay her bills online thinks it would be safe to assume that this should occur at every level in business and especially in healthcare where a life may hang in the balance.

As mentioned in my previous blog entry this is a widespread issue that is frankly strangling the business of medicine. Reports to look at why something like length of stay is long are impossible to generate since there are 3-4 different systems that look at all the data and none of them speak to one another. Well, now I'm frustrated, I've blogged about the same topic 2 posts in a row, granted they were far apart, I've got to find another pet peeve.

Physicians and Computers, Gaps Remain

EMDoc — Fri, 09 Jun 2006 16:36:00 GMT

This article per Reuter's reveals something that I am not surprised about. Physicians especially in their privat offices are not using computers to document patient records, write prescriptions or to track patients' routine preventative care. Working at a facility where in the Emergency Department we do use all computerized systems I would find this hard to live without. I can sit at my workstation, see every patient in the department, view their chief complaint and triage note(when completed), view their prior visit history , including all the old history and physicals, lab results, etc. I can order all my tests and view new and old plain xrays, CT Scan and ultrasounds. I can also access the internet to see this sight and my toolbox, as well as view email, and anything else the hospital doesn't filter out. Granted this near utopia I work in is paid for by the hospital.

But what is the solo practitioner or small group internist to do financially to pay for these things when their is really little monetary incentive. Sure you could argue that with a prescrition writer, less mistakes will be made, and that better office charting could protect you in a lawsuit. But the internists, family practice and pediatricians still have pretty reasonable malpractice rates so this doesn't help much. Finally, there is the “it is good for my patients'”argument. Again, when the upfront cost come right from your take home salary this too is hard to swallow.

Unfortunately, this lack of technology is prevalent across all fields in medicine. Those of you in the technology field would think that the paramedics who come to your house could easily download all the information about your care in the field to the hospital when you arrive. Nope, doesn't happen. You would think that most information from the hospital could easily be sent right to your doctors office anutomatically. Nope, doesn't happen. If you order a medication in the hospital, and it is the wrong dose or frequency, someone will notice, not always.

So to all of you techies out there, we need open architecture systems that are easily adapted and customized to our needs and can quickly speak to one another through a common language (XML?), and finally this needs to be affordable to the masses (think Microsoft Office for every aspect of healthcare). We as the customers are tired of technology that is rammed down our throats , forcing us to change our processes to work around it!

healthcare technology open source architecture