Cat Scan
11 years ago
Thursday, June 25, 2009
Time to Get to Work...
Orientation is in full swing. Patient care begins early next week. I'm starting my intern year with three months of ortho, so I hope to have some interesting stories to tell. Stay tuned...
Wednesday, June 10, 2009
Blank Check Medicine
I read this New Yorker Article by Atul Gawande today. It talks about the outlandish amount of money spent on healthcare in a small bordertown in the Southwest. In the end, Gawande's conclusion is that the reason this ridiculious amount of money is spent in this town is that the doctors there like to practice what I'm going to call blank check medicine. Instead of using some discretion in ordering tests and procedures in this community, the physicians have decided that doing is better than not doing. The down side is that the outcomes are not any better in this community. In fact, better outcomes seem to be found in places where less many is spent on healthcare. Just goes to prove, more is not always better.
Healthcare is a topic of furious debate right now, as President Obama continues to push for reform now or never. One of the major tenants of this impending healthcare plain will be cutting costs. No question we need to slow the amount of money our nation is spending on healthcare, but is all of this a "Buck stops here" situation? I'm sure that physicians can have a significant impact on how monies are spent, but it's hard for me to believe that writing a few less orders and doing less surgery is going to make the impact that we need.
I believe the major impact will come from spreading out the cost of healthcare. Right now, a major problem is the fact that only a few pay for everyone. Imagine if a person could go to the grocery store and get some food for free. Imagine grocery stores were required to have this food on hand at all times. On top of that, let's say that the grocery store owners were required to pay for this on their own. How would they do it? They would raise the prices of the rest of their food in the grocery store, effectively charging the people who came to the store to pay for their food for the free food. Now, superimpose that situation on American healthcare, and you'll see part of the problem. Health insurance premiums are astronomical. A large portion of small business owners in the country cannot afford to pay their employees, help to provide them insurance and still make a profit. The health insurers insist on making a profit. Don't get me wrong, if you run a business, you deserve to make a profit - but I believe every penny of our healthcare dollars should be going to healthcare. Imagine what we could do with this 42.5 million dollars.
I guess the point I am trying to make is that there isn't an easy answer here. Perhaps, we need to stop worrying about the money - and how much we are going to get paid - and look for a system that will allow us to take care of our patients. This isn't a situation where we can just remodel the kitchen and move into a new house and live happily-ever-after. This is a situation where we need to tear the house down, rip out the foundation and start from the ground up.
Healthcare is a topic of furious debate right now, as President Obama continues to push for reform now or never. One of the major tenants of this impending healthcare plain will be cutting costs. No question we need to slow the amount of money our nation is spending on healthcare, but is all of this a "Buck stops here" situation? I'm sure that physicians can have a significant impact on how monies are spent, but it's hard for me to believe that writing a few less orders and doing less surgery is going to make the impact that we need.
I believe the major impact will come from spreading out the cost of healthcare. Right now, a major problem is the fact that only a few pay for everyone. Imagine if a person could go to the grocery store and get some food for free. Imagine grocery stores were required to have this food on hand at all times. On top of that, let's say that the grocery store owners were required to pay for this on their own. How would they do it? They would raise the prices of the rest of their food in the grocery store, effectively charging the people who came to the store to pay for their food for the free food. Now, superimpose that situation on American healthcare, and you'll see part of the problem. Health insurance premiums are astronomical. A large portion of small business owners in the country cannot afford to pay their employees, help to provide them insurance and still make a profit. The health insurers insist on making a profit. Don't get me wrong, if you run a business, you deserve to make a profit - but I believe every penny of our healthcare dollars should be going to healthcare. Imagine what we could do with this 42.5 million dollars.
I guess the point I am trying to make is that there isn't an easy answer here. Perhaps, we need to stop worrying about the money - and how much we are going to get paid - and look for a system that will allow us to take care of our patients. This isn't a situation where we can just remodel the kitchen and move into a new house and live happily-ever-after. This is a situation where we need to tear the house down, rip out the foundation and start from the ground up.
Thursday, June 4, 2009
Misuse of Medical Services
The concept of misuse of medical services is being debated quite vigorously on a couple of the medical blogs that I like to read regularly. Look here and here. The question is simple: What constitutes proper use of the emergency department? The answer is unclear and the debate is hot. I thought I would weigh in. The post is somewhat lengthy...
I spent my last two years of medical school working in an urban ED in my "spare time." I have definitely seen my fair share of low acuity patients, and even spent some time trying to figure out why a nineteen-year-old mother of three would call 911 and bring herself and her children into the ED to be evaluated for a non-productive cough for less than 24 hours at 3AM. Of course, every patient who comes to the ED for tooth pain has talked to a dentist, but couldn't get in to be seen and every patient who ran out of their narcotic pain medications cannot get an appointment to see their "regular doctor" until 3 weeks from now.
Of course, there is that perception of what is and is not an emergency. Patients do not have the 1-5 triage system memorized and most of them lack advanced degrees in health care. EMTALA doesn't help. Although only a screening exam is "required," it's important to point out that most people that I have encountered believe that the mandate has become much greater than that. I believe that after their "screening medical exam," we should be able to point a patient towards a different venue of care, say back to their PCP or to a neighborhood clinic. I understand that, at times, real emergencies can present with non-threatening symptoms, and I would be interested to see how the number needed to treat comes out.
There is another issue here. Access to care is becoming much more complicated. Today, I read an article which said that the average wait to see a physician (in both primary care and sub-specialties) has increased by almost one week since 2004. This is especially true for patients who cannot afford private insurance. I'm not sure that I would be willing to wait 24 days to be evaluated for my fever and sore throat. If I had strep pharyngitis, I may already have rheumatic fever by the time I can be seen. Then, I'd have to sue my PCP for not being able to see me - and why not do my part to increase the cost of medical care in our country.
I'll tie it all back to education. We need to be explaining to our patients - in a respectful way - what is appropriate use of the ED and the cost associated. We need to make our patients aware of the fact that they are required to pay for our services. The orthopaedic surgeons in my area catch a lot of flack for requiring patients to pay before they are seen. I see both sides of this coin. I have been in school for 21 years and have 5 years of residency and one or two possible year(s) of fellowship ahead of me. It seems reasonable that I should be able to collect a fee for my services. I'm not sure I need to collect it right as the patient walks in the door, but I should be getting paid, and I'm not talking Medicaid rates either. No self-respectable lawyer (aka lawmaker) in this country would accecpt such an insult. Last I checked, members of congress were still giving themselves raises and doctors haven't gotten a raise for almost as long as I've been alive. I know, I know, we make enough money all ready, but the double standard seems a little insulting some times.
Maybe we could establish a system where, let's say level 1 and 2 patients are brought straight to a room without a discussion of costs. Every other patient will at least be advised of the necessity that they pay for their care and be given an option to instead follow with their primary doctor or perhaps go to the ED a the hospital where thre care is assigned (and medicaid - or its equivalent - will actually pay something for their visit). When a patient comes to the ED to request a UPT, the admitting clerk should be able to hand the patient a cup and show them the restroom. The patient should also be informed that they will be allowed to wait in the waiting area for their results, which will be provided after they remit a $50 fee.
I don't think that, in the end, I have a problem with patients using the ED for non-urgent care, but they need to be willing to pay for it. Similarly, I don't care if rich people fly on private air plans - but I don't expect to have to foot the bill...
I spent my last two years of medical school working in an urban ED in my "spare time." I have definitely seen my fair share of low acuity patients, and even spent some time trying to figure out why a nineteen-year-old mother of three would call 911 and bring herself and her children into the ED to be evaluated for a non-productive cough for less than 24 hours at 3AM. Of course, every patient who comes to the ED for tooth pain has talked to a dentist, but couldn't get in to be seen and every patient who ran out of their narcotic pain medications cannot get an appointment to see their "regular doctor" until 3 weeks from now.
Of course, there is that perception of what is and is not an emergency. Patients do not have the 1-5 triage system memorized and most of them lack advanced degrees in health care. EMTALA doesn't help. Although only a screening exam is "required," it's important to point out that most people that I have encountered believe that the mandate has become much greater than that. I believe that after their "screening medical exam," we should be able to point a patient towards a different venue of care, say back to their PCP or to a neighborhood clinic. I understand that, at times, real emergencies can present with non-threatening symptoms, and I would be interested to see how the number needed to treat comes out.
There is another issue here. Access to care is becoming much more complicated. Today, I read an article which said that the average wait to see a physician (in both primary care and sub-specialties) has increased by almost one week since 2004. This is especially true for patients who cannot afford private insurance. I'm not sure that I would be willing to wait 24 days to be evaluated for my fever and sore throat. If I had strep pharyngitis, I may already have rheumatic fever by the time I can be seen. Then, I'd have to sue my PCP for not being able to see me - and why not do my part to increase the cost of medical care in our country.
I'll tie it all back to education. We need to be explaining to our patients - in a respectful way - what is appropriate use of the ED and the cost associated. We need to make our patients aware of the fact that they are required to pay for our services. The orthopaedic surgeons in my area catch a lot of flack for requiring patients to pay before they are seen. I see both sides of this coin. I have been in school for 21 years and have 5 years of residency and one or two possible year(s) of fellowship ahead of me. It seems reasonable that I should be able to collect a fee for my services. I'm not sure I need to collect it right as the patient walks in the door, but I should be getting paid, and I'm not talking Medicaid rates either. No self-respectable lawyer (aka lawmaker) in this country would accecpt such an insult. Last I checked, members of congress were still giving themselves raises and doctors haven't gotten a raise for almost as long as I've been alive. I know, I know, we make enough money all ready, but the double standard seems a little insulting some times.
Maybe we could establish a system where, let's say level 1 and 2 patients are brought straight to a room without a discussion of costs. Every other patient will at least be advised of the necessity that they pay for their care and be given an option to instead follow with their primary doctor or perhaps go to the ED a the hospital where thre care is assigned (and medicaid - or its equivalent - will actually pay something for their visit). When a patient comes to the ED to request a UPT, the admitting clerk should be able to hand the patient a cup and show them the restroom. The patient should also be informed that they will be allowed to wait in the waiting area for their results, which will be provided after they remit a $50 fee.
I don't think that, in the end, I have a problem with patients using the ED for non-urgent care, but they need to be willing to pay for it. Similarly, I don't care if rich people fly on private air plans - but I don't expect to have to foot the bill...
The Away Rotation...
OK, so I have to promise to start posting regularly. Right now, as I am in between graduating, closing on a place to live and finally starting, there isn't a whole lot that is exciting to talk about. I thought, however, that in honor of the beginning of June, I might talk about the away rotation. This is going to be a stream of thought kind of post, so I apoligize in advance if it rambles on a bit.
I matched at the place where I did my away rotation, so I believe that this can be an important experience. The important thing is to work hard, but not to over do it. In many ways, the 1.5 day interview that you will have for most residency spots is too short. In many more ways, the 30 day interview that you might have during an away rotation can be WAY too long.
The most important advice would be to just be yourself. No reason to concoct some fake personality to try and impress the people you are working with. If it turns out that your personality matches with the attendings and residents at your visiting program, that's the person people will expect you to be when you show up for your interview, and if you match there, for day one on the job.
Once you've gotten in touch with your inner self, if you are given the choice of who to work with, do a little homework before you submit your preferences. Is it possible to work with the program director? Do you know what sub-specialty(ies) you have an interest in? Do you know anyone who goes to that school? Just like doing a rotation at your home institution, it is important to look for someone who will be enjoyable and productive to work with. Spending a month in a temporary place is an expensive investment. I spent about $7,000 on my away rotation, but it got me a job, so I guess it was worth it. Make sure you make a good investment.
If there is a resident at the program who graduated from your home institution, try to contact that person ahead of time. Ask them questions about who to work with, where you can stay, etc. They can provide you with lots of good information, and in the end, can be an excellent advocate for you when it comes time to make the rank list. In my opinion, it is a good sign if there are multiple people from your home institution in the program. This means that the program trusts graduates from your school, and that will be a positive when it comes time to make the rank list.
The rest of the advice is pretty self-explainatory, or at least I think it should be. Be the first person there and the last person to leave. Help out whenever possible in the OR, take call and find a way to be an asset to the residents that you are working with instead of a ball and chain. Be prepared for the operating room. Know what cases you will be participating in. If you don't already own these books, I would recommend you gets your hands on them: Hoppenfield's Guide to Physical Examination and Hoppenfield's Approaches Book (or some other approaches book) to help you with surgical anatomy. You might want some text to read about orthopaedics as well. There are several out there - and I don't think I can recommend one over another.
One last thing to think about is timing. I did my away rotation after I had already turned in ERAS, and too late to ask for a letter of recommendation. The upside to making that decision was that I had already done a couple of ortho rotations and was much more familiar with things. The downside, if you are looking for letters, is that it's too late to make that happen. I only did one rotation, and at the cost that I mentioned above, I'm not sure that I could have done many more. I know, that in some situations, residents will offer to let you stay in an extra room. I have to say, that seems like an extra risk, and extra pressure that I didn't want to deal with, but it would be one way to save some money. Of course, if you know someone in the area where you are going to do a rotation, you might be able to save money by crashing with them.
Well, I think that's all of the advice that I can think about for now. Have fun and happy hunting!
I matched at the place where I did my away rotation, so I believe that this can be an important experience. The important thing is to work hard, but not to over do it. In many ways, the 1.5 day interview that you will have for most residency spots is too short. In many more ways, the 30 day interview that you might have during an away rotation can be WAY too long.
The most important advice would be to just be yourself. No reason to concoct some fake personality to try and impress the people you are working with. If it turns out that your personality matches with the attendings and residents at your visiting program, that's the person people will expect you to be when you show up for your interview, and if you match there, for day one on the job.
Once you've gotten in touch with your inner self, if you are given the choice of who to work with, do a little homework before you submit your preferences. Is it possible to work with the program director? Do you know what sub-specialty(ies) you have an interest in? Do you know anyone who goes to that school? Just like doing a rotation at your home institution, it is important to look for someone who will be enjoyable and productive to work with. Spending a month in a temporary place is an expensive investment. I spent about $7,000 on my away rotation, but it got me a job, so I guess it was worth it. Make sure you make a good investment.
If there is a resident at the program who graduated from your home institution, try to contact that person ahead of time. Ask them questions about who to work with, where you can stay, etc. They can provide you with lots of good information, and in the end, can be an excellent advocate for you when it comes time to make the rank list. In my opinion, it is a good sign if there are multiple people from your home institution in the program. This means that the program trusts graduates from your school, and that will be a positive when it comes time to make the rank list.
The rest of the advice is pretty self-explainatory, or at least I think it should be. Be the first person there and the last person to leave. Help out whenever possible in the OR, take call and find a way to be an asset to the residents that you are working with instead of a ball and chain. Be prepared for the operating room. Know what cases you will be participating in. If you don't already own these books, I would recommend you gets your hands on them: Hoppenfield's Guide to Physical Examination and Hoppenfield's Approaches Book (or some other approaches book) to help you with surgical anatomy. You might want some text to read about orthopaedics as well. There are several out there - and I don't think I can recommend one over another.
One last thing to think about is timing. I did my away rotation after I had already turned in ERAS, and too late to ask for a letter of recommendation. The upside to making that decision was that I had already done a couple of ortho rotations and was much more familiar with things. The downside, if you are looking for letters, is that it's too late to make that happen. I only did one rotation, and at the cost that I mentioned above, I'm not sure that I could have done many more. I know, that in some situations, residents will offer to let you stay in an extra room. I have to say, that seems like an extra risk, and extra pressure that I didn't want to deal with, but it would be one way to save some money. Of course, if you know someone in the area where you are going to do a rotation, you might be able to save money by crashing with them.
Well, I think that's all of the advice that I can think about for now. Have fun and happy hunting!
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