Sunday, February 28, 2010

The Health Care Reform Summit: ‘Breaking News’ or a TV Rerun?

 Tinkerbell in Bronze

I never thought I would have a chance to watch the health care reform summit on live TV this past Thursday. Fate took a U-turn. 175px-Tinkclose-1-[1] I didn’t expect to be in a New Jersey blizzard on Thursday morning. I was scheduled to be in the ICU performing an endoscopy examination of the stomach on a patient who I had seen in the emergency room a day before with intestinal bleeding.

The plan was to fly to New Jersey on Thursday evening so that we could witness the milestone event of my brother being sworn in as a Superior Court Judge in on Friday afternoon. No human plan, however, can prevail against an Act of God. A torrential blizzard was descending upon the east coast and was threatening to postpone the event that was the result of years of my brother’s work and hopes. Unlike his anonymous gastroenterologist blogging brother, Robert has a deep network of judicial and political luminaries, developed over a career in the U.S. Department of Justice and the U.S. Attorney’s Office. Speakers at his swearing in were to include the newly elected Governor, the Chief Justice of the New Jersey Supreme Court and a Federal District Court judge, who is awaiting senate confirmation to the Court of Appeals. These aren’t hired speakers, but are folks who Robert knows intimately.

As I write this, it is likely that the swearing in will not take place tomorrow. Will the world end? No, but this will be a deep disappointment to Robert and to all of us who are gathered here. Imagine you are about to attend a great family or professional celebration to be attended by hundreds of friends and family, and are confronted by a sudden power failure that aborts the event?

When I returned home from work on Wednesday, after trying to make constipated patients looser and looser patients more constipated, my wife gestured and whispered that she was on the phone with Continental Airlines. They had contacted her. This is never a hopeful sign, as airlines do not call customers to cheer us up. For example, here are some examples of phone calls we have never received from Continental, or any other airline.

“Dr. Kirsch, we noticed that we had extra First Class seats on your flight and wondered if you wanted to be moved from your seat in the baggage department at no charge?”
“Dr. Kirsch, we noticed that your last flight was delayed 2 hours. We felt it was only fair to reimburse you for your time. Please advise us of what 2 hours of a gastroenterologist’s time is worth, so that we can promptly reimburse you.”
“Dr. Kirsch, thanks for your recent email commenting on our meal service. We understand that some might not agree that a foil pouch of honey-roasted peanuts is dinner, even though our Culinary Committee has determined that this food item meets the corporate threshold for meal definition. Because customer satisfaction is paramount, we are shipping a crate of Omaha Steaks to your home with our compliments.”
Continental called my wife to advise her that all Thursday flights were now cancelled. With a lot of diligence and a lot of time, she arranged for us to fly out 2 hours later on Wednesday night, hoping that the swearing in ceremony would still proceed, since all 7 of us would be headed to New Jersey on planes and trains from different parts of the country. Is this sounding like fun yet?

We raced to the airport and hustled to the absolute farthest gate to discover that our flight was cancelled. (There’s a reason that airlines try not to give you this news until customers have passed through weapons detectors.) Then, a small miracle materialized in this morass of madness. There was a flight bound for Newark that had been delayed 2 hours and was presently parked at its gate. We made that flight home. There are times when passengers are grateful for delayed flights.

So, Thursday morning I am looking out a New Jersey window watching snow come down, instead of scoping a stomach in a Cleveland ICU. Then, I realized that a new opportunity was before me. I could watch on live TV the health care summit meeting that the President had convened. This was the historic event where a year of suspicion, rancor and bitterness would be washed away in just a few hours, once the President, in a Tinkerbell moment, sprinkles bipartisan dust throughout the room. Bitter rivals yesterday, the GOP and Democrats would suddenly join hands, drink some Kool Aide and sing Kumbaya. Who could predict what unexpected outcomes might develop after this bipartisan love-in? Here’s a sampling of some potential Shnagri-la moments that we might witness at Blair House.

Harry Reid would smile and state that the public option should be abandoned.
Chuck Schumer, who is usually welded to a microphone, would yield his time to John McCain.
Nancy Pelosi would state that tort reform must be an integral part of health care reform.
Chuck Grassley would reflect and remark that we need to cover the uninsured no matter what it cost. “Can we afford not to?” he would ask rhetorically.
Mitch McConnell would suggest raising taxes, not merely on the wealthy, but on everyone so that every American can have the government run health care they deserve.
Lamar Alexander would suggest that the pharmaceutical companies be prohibited from earning any corporate profits, donating the money to close the dreaded ‘doughnut’ that is sapping seniors of their savings. When asked why a drug company would risk tens of millions of dollars to develop a new drug without the lure of a profit, Alexander would respond, “They will do it because it’s good for America.”
Well, I have just watched the first half of the conference and I have not seen even a Kumbaya nanosecond. The august group of bloviators is now on lunch break. I heard the same positions this morning that I’ve heard repeatedly over the past year being regurgitated. (As a gastroenterologist, I have been trained to recognize various forms of regurgitation.) I learned nothing new, and I doubt any of them did either.  The conference was political theater, but only a weak matinee that is not ready for prime time. It’s been a yawn so far, and I don’t think that any minds in the room, including the president’s, will be changed. Even a Nobel Peace Prize winner is not sufficient to bridge the chasm that separates the two sides.

Bloggers at both poles of the political spectrum struggled to conclude that anything worthwhile occurred.  For example, Josie Raymond from the left at and Philip Klein from the right at American Spectator, who likely agree on very little, both wrote that the conference didn't alter the dynamics of the health care reform issue.  There were partisan bloggers, of course, who claimed that their side prevailed over their craven adversaries.

How will the public react? I suspect with indifference. We will read the performance reviews in our Friday newspapers and then watch pompous pundits on the airwaves opine on who won and who lost. I think it will further decrease the already abysmal approval ratings that Congress now enjoys. It will reinforce that these guys and gals simply cannot get anything done for us. The President has succeeded to an extent to hover above the partisan fray, but he is still tarnished by the process and the results.

The GOP had to show up, because they couldn’t leave bunch of empty chairs in the room to be used against them. Judging by the what I’ve seen so far, the GOP held their own. The electoral victory in Massachusetts has given them some wind at their backs. All sides know that the public is deeply skeptical of the health care legislation that has been passed. If the Dems try to force their version through with reconciliation, by simple majority vote, then they will risk an even greater backlash in November than already awaits them. I do not think that they will do this, and am not even certain that the Dems in the House and Senate can reconcile their own plans.

The pressure is on the Democrats here. They can jam their stuff through and risk a very Black November. Or, they can retreat and pursue incrementalism and further alienate their base. Good luck, guys.

I wish there had been some bipartisanship. This might have created a glow and a radiance that might have caught the attention of the Almighty. Perhaps, then, pleased by this unexpected display of humanity and brotherhood, He might turn New Jersey snow into a light rain, so that my brother can put his hand on the Holy Bible tomorrow and take his oath.

Tuesday, February 23, 2010

Whistleblower Grand Rounds Vol. 6 No. 22: It’s ‘Alimentary’, Doctors!

Jacobs Ladder PHOTOCREDITi[1] It’s been a while since I’ve attended a conventional medical Grand Rounds. These were events where a medical luminary would fly in to give a medical audience a state-of-the-art presentation on a medical subject. Ideally, the speaker was a thought leader and a researcher on the issue.

These presentations were usually not a demonstration of the virtue of humility. We physicians, as a class, have generous egos. Academic physicians occupy a higher rung on the ego ladder. Medical Grand Rounders (MGRs), who are on the GR speaking circuit, often must bring their own ladders to assure they will be able to reach their desired atmospheric height.

Jacob’s Ladder Photo Credit

At least in the old days, before the GR speaker would assume his position behind the rostrum, a designated pre-speaker would offer an introduction. The audience would hear a list of awards, achievements, journal editorial positions, department chairmanships, honorary degrees, publications and book chapter authorships, military service, Boy Scout merit badges and various other hosannas. How do these introducers, who may have never met the main event personally, know their bios so well?   Do the MGRs provide their own intro speeches?

During the traditional GR presentation, seasoned MGRs periodically demonstrate a tincture of haughtiness with a rhetorical technique that has irked me since my medical training days. When the MGR refers to some world famous, pioneering medical researcher, a name known to every physician in the audience, the MGR casually refers to this near deity by his first name, as if they are drinking pals. Here’s a hypothetical example.
The Scene:        MGR giving Grand Rounds on polio.
Power Point:    Data from Jonah Salk’s vaccine research.
MGR:                 “Here’s what Jonah was getting at here…”
Sorry readers, but I’ve been waiting 20 years to ‘blow the whistle’ on this one.

To any academic physicians, or even MGR who is still reading, please forgive my light hearted poking. Every practicing physician, including me, is in your debt.

For me, as this week’s Grand Rounds host, I assure you that I approach the task with great humility, stretching to reach the first rung of the ego ladder. I am honored and delighted to offer a compendium (or should a gastroenterologist use the word smorgasbord ?) of the medical blogosphere. There is great talent in this community.

In visiting some prior Grand Rounds, I was awestruck by the technical wizardry wielded by many of the hosts. Either they have graduate degrees in information technology, or there was a 12-year-old kid nearby. I have neither of these advantages, so there may be a fewer bells & whistles, even for an avowed whistleblower.

I received 33 blog entries to review, or digest. While they were all meritorious, there must be some mechanism to separate the truly great from the merely awesome. But, how best to accomplish this? Should I adopt the ‘Rock, Paper, Scissors’ method used by Ivy League admissions’ offices?  Perhaps, a random lottery draw? Eeny, meeny, miney mo?  No, all blog entries will have to prove their resilience and worth.

All entries will travel a road mined with traps and hazards waiting to disable them. Which will be cut down and which will survive the journey?  This will be a blogger’s version of The Odyssey, where the winning post must overcome deadly obstacles as he strives to return home
Every entry forwarded to me appears on this post, even the procrastinators who offered various lame excuses .

250px-Tonsils_diagram[1] The 33 entries have all entered the oral cavity, the start of the alimentary canal.  It’s a long way to the rectum. Let the games begin!

The entries are now being masticated, or chewed, and bathed with saliva. Allergy Notes gets crunched by powerful rear molars.
Allergy Notes warns asthmatics not to take Long-Acting Beta-Agonists (LABAs) as sole treatment. The post doesn’t explain why, but it does suggest a doomsday scenario if LABAs are taken alone. Perhaps, this is common knowledge to all physician specialties except gastroenterology.
The remaining 32 posts are propelled into the esophagus, the muscular tube that quickly transmits food into the stomach, But, there is a stealth trap waiting to ensnare an unsuspecting blog post. This esophagus has a Zenker’s diverticulum, a sneaky pouch just beyond the throat.

zenkers-surgery[1] Teen Health 411 gets trapped in the Zenker’s.

Photo Credit

Nancy Brown at Teen Health 411 offers us a brief tutorial on transgender issues, admittedly a subject that hasn’t entered my universe.

esophagus The remaining 31 entries tumble down the esophagus.  Behaviorism and Mental Health and The Cockroach Catcher gets stuck at a tight sphincter, or valve, at the bottom of the esophagus. 

See endoscopist’s view of the esophagus at left. 

Patrick Hickey, a retired psychologist, writes in Behaviorism and Mental Health that schizophrenia is caused more by nurture than nature.  His post is entitled, Schizophrenia is Not an Illness.  While this is beyond my field, I had not heard this view previously.
Am Ang Zhang points out in The Cockroach Catcher that Harvard MBA graduates have not achieved a legacy of success.  Your humble GR host had some difficulty following this post, but perhaps some of you will nail it.
Twenty-nine entries have made safe passage into the stomach and are rafting in rough waters. They confront torrential waves of powerful digestive chemicals and stomach acid.  Ask An MD and Dispatch from Second Base cannot tolerate these harsh conditions and they are dissolved.
Jackie, a new blogger, writes in Dispatch from Second Base about how a second medical opinion gave her a new path to the same destination. She offers a personal voice to the emotions and trials of surviving cancer.
Dr. D, for our amusement, weaves La Cosa Nostra into the development of medical education casting Abraham Flexner in a nefarious light. For the Whistleblower, this post in Ask An MD  is slightly conspiratorial, but judge for yourself. We report – you decide.
stomach Twenty-seven drenched entries are still afloat and are being tossed about in a toxic soup as the stomach tries to neutralize them before they can exit. 

A scope’s eye view of the stomach!

250px-Stomach_endoscopy_1[1] The remainder manage to exit the stomach and enter the duodenum, the initial portion of the small intestine, 20 feet of tubing that culminates in the colon, or large bowel.

Dark spot in photo at left is called the pylorus. This opening separates the stomach from the first portion of the small intestine, called the duodenum.

In the first portion of the duodenum, called the bulb, a large ulcer traps Dr. J’s HouseCalls.  Since acid is a major force in ulcer formation, her post is likely to make the ulcer worse.
Mary Johnson’s post in Dr. J’s HouseCalls easily survived the stomach’s acidic waters as her post had more acid than the stomach. Mary expresses strong views about our government and I surmise that she will not be posting on 'Obama for President' yard sign in 2012.
Beyond the ulcer, but still within the duodenum, the pancreas and liver secrete digestive chemicals. Highlight Health and The Fitness Fixer, who were not donning recommended protective gear, fall victim to these caustic fluids. They will be missed.
Walter Jessen in Highlight Health informs how we should dispose of unwanted medicines so that our medications don’t enter the food chain. While this post is not quite a spellbinder, it does offer practical advice on a relevant subject.
Jolie Bookspan in The Fitness Fixer relates that elderly individuals who have been hospitalized have higher fracture rates after discharge. While I am not persuaded there is cause and effect here, she reminds us that we often overlook certain aspects of health in our hospitalized patients. In my experience, nutrition, is another frequently neglected issue.
In the duodenum, there is a very small opening that leads to tunnels that connect to the liver and gallbladder.  Suddenly, the gallbladder hurls a gallstone through this tunnel which is ejected into the duodenum like a projectile.  It smashes into Insureblog and Health Business Blog like an aerial drone attack.  Both entries are pulverized on contact.
Henry Stern of InsureBlog relates an anecdote of a physician who is billing a patient’s insurance company for a service that I suspect has no authorized ICD code. I cannot attest to the veracity of Henry’s vignette, but I appreciate his brevity.
David Williams, in Health Business Blog, discusses that screening mammograms in elderly women cause more harm than healing.  There’s been more press on mammography in the past 6 months than there has been in decades.
small_bowel_2 And then there were 22, who have now entered the endurance phase of the journey. With 20 feet of small intestine, this becomes a blog entry’s marathon run.  Obviously, only a trained entry can survive this Blogathlon event.

Photo of small intestine.

ACP Internist, Shoot Up or Put Up, Supporting Safer Healthcare and ACP Hospitalist thought they could coast to the finish line relying on prayer, instead of preparation. This was a miscalculation. All four were carried from the field in a state of exhaustion and dehydration. The rest sail onward along the tortuous 'Highway to Hemorrhoids'.
Ryan DuBosar of ACP Internist informs us about several states that are incentivizing primary care physicians to serve in rural and underserved urban regions. As in medicine, making the diagnosis is easier than finding an effective remedy.
You know the bloggers at Shoot Up or Put Up are from ‘across the pond’ because they spell the word favourable wrong. In this post, diabetes is viewed through a Disney prism. This niche blog has attracted 131 fans, perhaps including Mickey, Donald and Pluto.
Rita Schwab of Supporting Safer Healthcare must be important because she has lots of letters following her surname. Rita shares an overview of the the power and hazards of the social media world. This is a good intro review, but not quite a 140 character tweet. Word count: 750 words.
Kirk Mathews on ACP Hospitalist summarizes James Orlikoff’s address to hospital leaders advising them what they need to do to stay solvent. For example, he instructs that hospitals view patients as their customers, and not physicians.
As the Darwinian journey continues, more than half of the original blog entries are still viable.  But, unseen hazards remain.  As Diabetes Mine, Cases Blog and  Colorado Health Insurance Insider round a sharp bend of small intestine, they lose control and land on a patch of viscous mucous, which ends their alimentary sojourn.  No, they won’t starve.  They are amidst a nutritional stream that will maintain them until, hopefully, a miracle or a rush of fluid will set them free. 
Amy Tenderich in Diabetes Mine shares an interview with Olympic cross-country skier Kris Freeman, who is a Type I diabetic. I had to give Amy a point deduction for exceeding Grand Rounds submission length limit, but I enjoyed her post and her enthusiasm. I was most amazed to learn that Kris Freeman has 30 pairs of skis with him!
CasesBlog shows us a Venn diagram from 3 locales where folks live beyond a century. If you’re interested to equal their longevity, check out the post. I confess that I did not view the 22 minute and 12 second YouTube presentation, but those of you with idle time are welcome to do so.
Colorado Health Insurance Insider either knew, or guessed, that overutilization of imaging studies is a recurrent Whistleblower rant. This post discusses why MRIs are overused and how this abuse can be curtailed.
Oh my stars, look ahead!  What is that slimy monster slithering upstream?  It is a sea monster that is charging straight for the entries with hostile intentions.
230px-Ascaris_lumbricoides[1]It’s the dreaded intestinal parasite, Ascaris, a worm who lives inside guts.  InteractMD freezes from fright. How To Cope With Pain and Medical Justice are immobilized by the beast.  These three entries ‘take one for the team’ as they occupy and distract the enemy allowing the others to pass by.

Michael Benjamin of InteractMD is a full service medical blog.  He posts interesting stuff daily on various medical subjects.  It’s worth checking out.  Michael speculates whether denture cream users will be the next major class action lawsuit.  Find out why.
How To Cope With Pain is devoted to a critical issue, coping with chronic pain, This piece, a guest post on the blog, is a thoughtful piece on making peace with pain. The blog is a great resource for those who suffer from chronic pain and those who suffer with them.
Medical Justice is a blog devoted to pursuing meaningful tort reform and points out absurdities in the current medical liability system. In this post, MJ advises physicians who might be contemplating a romantic tryst with a patient’s spouse, how they can avoid legal jeopardy. For those who have suffered the anguish of wrongful litigation, this site can be your sanctuary.

Intestinal life is fickle.  Just as the surviving entries creep past the predatory roundworm Ascaris, the worm snaps his tail like a bullwhip, taking out Healthblawg and the Happy Hospitalist. (I guess the beast likes the letter ‘H’.) 
David Harlow, of Healthblawg, gives a wonk’s analysis of the state of health care in Massachusetts. In short, it ain't pretty. In summary, costs continue to rise; price variations are unrelated to outcomes and there is an excess of academic and specialty medicine. Find out what David’s views are on the governor’s plans to mandate medical price controls. More noteworthy, this is the only piece I’ve read recently on Massachusetts that doesn’t discuss the recent electoral victory of Scott Brown.
The ever Happy Hospitalist was slightly less happy than usual in his post that explained why chiropractors succeed in promoting their healing in the absence of medical evidence. HH expresses both frustration and admiration. If I can paraphrase Happy, ‘It’s the Wellness, Stupid!’
250px-Schongauer_Anthony[1] Novel Patient, Everything Health and Six Until Me are all moving downstream at a steady pace, unaware of an impending ambush. Suddenly, they are served with legal papers by plaintiff attorneys, who inhabit certain digestive organs, who allege they have committed medical malpractice on patients none of them can recall.  They are hauled off to depositions and can no longer compete.

Painting of St. Anthony plagued by demons.

Lauren, at Novel Patient, inspires us with her piece on the power of positive thinking and prayer. She is afflicted with autoimmune diseases with neurological involvement. Her post relates that she took a ten foot walk, her 2nd walk in a year. In her own words, she plans ‘to take in one step at a time’. To Lauren, Godspeed.
Toni Brayer, bloggerette extraordinaire, introduces us in Everything Health to an extraordinary physician, William Halsted, a nineteenth century surgical pioneer and innovator, who attended at Johns Hopkins Medical Center. Toni reviews the book, 'Genius on the Edge – the Bizarre Double Life of Dr. William Steward Halsted’, pointing out that Halsted, like most geniuses, are complex individuals. For those drawn to medical history, read Toni’s post and then read the book.
Kerri, at Six Until Me, shares a tale that all of us have experienced. She involuntarily enters the labyrinthine domain of insurance company billing. She manages to extricate herself without inflicting harm on anyone. She proposes a novel use for broccoli spears that might be of interest to ENT (ear, nose & throat) physicians.
Seven remaining sailors are meandering toward the end of the long and tortuous small intestine, headed for the primary domain of the gastroenterologist – the colon.  To gain entry into the promised land, the entries must pass through a valve, which serves as a gatekeeper between the small and large intestines.  In a modified game of Russian Roulette, 6 pass through, but then Evidence in Medicine is crushed when the valve clamps shut without warning.
David Rind, an academic physician, recently introduced Evidence in Medicine and is already gaining traction in the blogosphere. He laments the success of snake oil salesmen hawking unproven or disproven remedies. I agree that these hawkers need to be reined it, but snake oil, eyes of newts and cat’s claw can only be sold if there are buyers. We need to target both the supply and demand channels of quackery.  Nicely done, David.
colon Six surviving entries now enter the colon.  They are swimming in a sea of …, I guess you all know what they're swimming in, even if you are not trained gastroenterologists.  The photo at the left is their current home in the colon.  

They are survivors and, like other Survivors, they have colluded and voted Fibro World off the colon.  It’s become Lord of the Flies, GI style.
Dot, along with her Fibro Mom write Fibro World blog. In this post, Dot gives a preview of a new medicine that is under FDA review for fibromyalgia. Blog posts that discuss a single medicine can be hypnotic, but Dot has made her post lively and personal. It’s well done and worth the read.
230px-Polyp-2[1]WIKI PHOTO CREDIT What do I espy in  the distance?  It’s a polyp, similar to the thousands I’ve removed .  This is a pedunculated polyp, meaning it’s like mushroom with a stem attached to the colon’s wall.  It starts swinging wildly and, like a medieval knight’s mace, it strikes down MedLibLog and Dinosaur Musings.
Photo Credit

Laika, of MedLibLog, rants about complementary and alternative medicine, or CAM, which I suspect she would support renaming as, SCAM. She details an accusation that Wordpress kicked out a blogger who was critical of a naturopath. Don’t grab your pitchforks yet, as we don’t know the facts about why the blogger underwent debloggification. Perhaps, his post broke the decency barrier. Laika’s post is well done and worth reading. CAM has become controversial, but like Laika, I’m not sure why it should be.
Dinosaur Musings has an excellent post on medical futility. In a twist, she states that we physicians often peddle the snake oil with the same enthusiasm and results as ‘alternative’ medicine practitioners. Quacks are not the only ones quacking, according to DM. This is a worthwhile read.
There are 3 excellent posts remaining. As we are witnessing each night in Vancouver, only 1 contestant can get the gold. The 3 are have traversed most of the large intestine and are headed for the rectum. There is light at the end of the tunnel. In his zeal to prevail, as the name of his blog suggests, Life in the Fast Lane accelerates and is impaled on a chicken bone that was inadvertently swallowed by the individual who has graciously loaned his GI tract for this issue of GR.

Chris Nickson in, Life in the Fast Lane, shows us his great wit in a post arguing why ADHD emergency room physicians are uniquely qualified. Chris includes a flow chart which I rank between clever and hilarious. Great stuff from ‘Down Under’.
190px-Hemorrhoid[1] The final two posts are hurtling toward the outside world.  It looks like we may need an endoscopic photo finish.  Hippocratic Oaf lunges forward, risking it all, and smashes into an internal hemorrhoid. Dazed and reeling, he falls back, within reach of the finish line.

Hippocratic Oaf, the creation of a 3rd year medical student, is well done. With puckish British humor, or humour, he lets us watch him puncture some folks with needles and catheters. This post offers a realistic and behind the scenes view of medical training.  It made me recall the day I was ‘taught’ how to draw blood from a veteran.  For me, it was do one, see one, teach one.
We are left with the winner, a post by a blogger who is trained in orifice emergence. Academic OB/GYN has reached daylight.

Nicholas Fogelson of Academic OB/GYN writes an outstanding post that should be required reading for medical students who are contemplating a surgical career. Nick nicely separates the craft of surgery from the profession of surgery, and explains why the latter is more important than the former. Judging by his post, I suspect that he is an excellent teacher.

There were many great posts, and I hope you will sample them.  Enjoy and have a great week!
Next week’s Grand Rounds host will be Doctor Anonymous.

Sunday, February 21, 2010

Where's My Whistleblower?

This week, there is no formal Whistleblower post. I am sorry to disappoint the tens of thousands of readers who race to this site each Sunday morning for a weekly dose of amusement seasoned with satire. Did I develop  blogger’s block? Hardly. There is more stuff to write about than any blogger has time to write.

I am honored to serve as the host of this week’s Grand Rounds, which will appear on this site on Tuesday, February 23rd. I have been occupied sorting through the many fine submissions I have received this week.  It's been fun getting acquainted with blogs and bloggers that had been outside of my personal blogoverse.

For those procrastinators who still wish to submit a post, please note that the deadline is noon today. If you miss the deadline, and you grovel sufficiently, then I will likely grant you an extension. Instructions for submitting posts can be found on the last Whistleblower.

As for today, brew the coffee, crack open the New York Times and watch the Sunday morning news programs. If you do, then wear a coat because the politicians on these shows spin so wildy, that you might catch a chill from the cold air rushing out of your TV set.

See you on Tuesday.

Sunday, February 14, 2010

The Health Care Reform Summit: A One Act Play

Whistleblower Grand Rounds Submissions!

Whistleblower will be hosting Grand Rounds on February 23rd.  All submissions are welcome.
Here are some tips to maximize your chances of acceptance, which will guarantee that your blog posting will receive worldwide exposure.

  • Send your posts to
  • Write Grand Rounds in the subject line.
  • Include the URL of the post in the email message.
  • If you do not receive an email confirmation, then I did not receive it.
  • Remember, brevity is the soul of wit.  If you are torn between 2 of your masterpieces, please send me the shorter one.
  • Please include a sentence in the email expressing the point of your post.  This is your opportunity to  wield your razor sharp wit.
  • DEADLINE for submission is Sunday, February 21st at noon.  Earlier submissions are preferred. Please send your stuff at your earliest convenience. In other words, now is not too soon.

Now, on to this week's Whistleblower.

How many times have we all been issued the directive, choose the best answer, in our academic lives? In our society, those who test well enjoy many advantages, even though standardized testing skills may be less useful in real life. Pre-med students, for example, are measured numerically, even though the skill sets for MCAT success and clinical medicine are quite distinct. Nevertheless, we measure our students by the numbers. High school students and their hovering parents, who are aiming for elite institutions, hire personal coaches and tutors who promise 3 digit score increases on the SATs.
Most Whistleblower readers are well beyond the standardized testing zone and no longer have to fill in rows of ovals using #2 pencils. It was nearly 35 years ago that I faced off against the wily SAT opponent. But, the memories of these experiences are still vivid. Back then, we brought our school ID cards with us for verification. There were no fingerprint checks, retinal scans or other sophisticated biometric analyses to confirm a student’s identity. In a few years, a quick oral swabbing for a spot DNA check may be the new standard.

I still recall the bold faced warnings that were also read to us by humorless proctors.

Do not open your test booklets until you are told to do so.
Make no stray marks on your answer sheets.
Fill in the oval spaces completely.

Standardized testing skills are like tying your shoes or roller skating. They are lifelong. I’ll prove it to you with simple standardized test question that is so easy, that even a physician can get it right.

Which of the following scenarios is most likely to result in a harmonious outcome? Choose the best answer.

(a) A boa contrictor and a mongoose sharing a dorm room
(b) Ken Starr going on a hunting trip with Bill Clinton
(c) A medical malpractice plaintiff’s lawyer mountain climbing with a group of anesthesiologists and OB- GYN docs
(d) Bernie Madoff lecturing investment firms on how they can recapture lost assets
(e) President Obama meeting with GOP leaders on February 25th for a public airing of their respective health care reform (HCR) views.


The White House announced prior to the Superbowl that it was convening a half day conference to meet with Republican leaders to discuss the health care reform quagmire. Unlike the adminstration and the Democrats' previous backroom dealings, this meeting will be televised. The GOP readily accepted the President’s proposal to meet, but they are wary of his intentions.

The administration has described the meeting as bipartisan, but a duel is a more accurate description. Why should bipartisanship bloom now after months of bitter recriminations, misrepresentations and political intrigue? It won’t. Just this past week, Roll Call reported that Speaker Nancy Pelosi is disparaging the Republicans and threatening to ram HCR through with a simple majority vote that could defy a fillibuster. While this is red meat to the political left, it spooks Democratic moderates who fear that the ghost of of Scott Brown’s electoral masterstroke could haunt them this November. The GOP, in contrast, sees Brown’s victory as a magic carpet ride that could lead them toward the political promised land of majority control.

If the Democratic position at the meeting is to begin negotiations where the House and Senate legislation left off, the GOP will push back, knowing that the public is increasingly skeptical of these expansive and expensive health care ‘reform’ proposals. The Dems, of course, will reject rewinding back to the status quo ante, and will want their legislation to be the essence of the final product.  At this very moment, Democratic leaders are trying to meld the Senate and House versions in advance of the upcoming television special, provoking GOP angst.  Does any reader see the makings of an agreement here? If so, then you should be immediately dispatched to D.C. as you may be the only individual alive who can forge a deal.

This ‘summit’ meeting, as with much of HCR, has nothing to do with health or reform. It is about achieving political power and influence. It's unspoken objective is to tarnish the other side.  In the campaign, candidate Obama promised us C-Span coverage of health care deliberations. We never got the ‘Span’, only lots of spin. Now, with HCR teetering on a precipice, we will be able to watch live action of this political Kabuki dance. Desperation breeds transparency.

This will be political theater where each side will try to gain advantage over the other. The most recent New York Times/CBS polling shows that the public believes that the President gets higher marks for bipartisanship than the GOP.  President Obama hopes that the upcoming meeting will widen this gap, while the GOP aim to exploit public skepticism.  Each side will accuse the other of intransigence, while claiming to be compromising and conciliatory. This will not be a substantive policy review, but a carefully crafted performance by all players.  The speechifying may sound medical, but it will have nothing to do with health care. Every word spoken and every phrase uttered on the last Thursday this February is directed toward the first Tuesday in November.

When the 'bipartisan' health care summit fails, which of the following statements will be issued within minutes of the meeting’s conclusion. Choose the best answer.

(a) “We will not adopt the Republican’s Bush-Cheney Health Care Plan.”
(b) “The President extended a hand in friendship, and was greeted by GOP brass knuckles.”
(c) “Republicans stood with America and wouldn’t accept the President’s prescription of government-run socialized medicine.”
(d) “Their plan is great for the health of trial lawyers, but is bad medicine for the American people.”
(e) “The Professor-in-Chief lectured us like school kids. The Final Exam is this November.”
(f) All of the above.

Pencils down!

You've heard my view.  Now, what's your prediction?

Sunday, February 7, 2010

The Fee-for-Service Follies: The Good, the Bad and the Ugly - Part II

As detailed in Part I, FFS or Salaried Medicine, I was a salaried gastroenterologist for 10 years. I resigned, but not in search of the fee-for-service (FFS) cornucopia. The multispecialty group (MSG) that employed me had been purchased by one of Cleveland's medical behemoths a few years before I signed on. After happily practicing gastroenterology (GI) for several years, the corporate owner emerged from the background and forcefully exercised its ownership rights. The business edicts they issued conflicted with our professional mission to advocate and care for live human patients. For example, the community hospital that we had served for half a century was now verboten. This meant that our elderly patients who lived near this hospital, and had been treated there for their whole lives, now had to be hospitalized downtown, if they wanted us to be their physicians. You get the idea.

While I acknowledge that these decisions promoted the corporation’s health, they jeopardized our patients’ well being. An irreconciliable conflict was created once the business’s interests and our patients’ interests were no longer alligned. The businessmen were pleased, but the physicians and patients were increasingly frustrated. Since I am a physician who cares about patients more than balance sheets, I resigned.

I entered the FFS universe. My income increased, but this was never my motivation to change positions. In fact, had our corporate overseer not poisoned our beloved MSG, I would still be there. A few years after I left, the group vaporized.

Adjusting to FFS medicine was not a seamless transition for me. Previously, I never performed a colonoscopy unless I believed that the procedure was necessary and that no preferred alternative existed. I had never practiced as a technician. While those ideals sound noble and virtuous, they will not pave a pathway to success in the private practice world. In this milieu, procedurists are subject to many external pressures. While I hopefully still practice at a high ethical level, I no longer enjoy complete ‘ownership’ over the procedures I perform.

Private Practice GI FFS Medicine - The Good!

• More money. This is not evil.
• Personal freedom. Time off when I want it.
• Improved orthopedic health. Preserves knee function by no longer genuflecting before administrators.
• Enhances professionalism. While no doctor who is still breathing practices autonomously, private physicians can practice more freely. For example, we can send a patient to a rheumatologist we select, rather than refer to an official consultant list, as we did in in the MSG arena. [At the MSG, we were never expressly forbidden to consult outside the network, but those who dared to do so, would spend a few weeks in reeducation camps to reflect on their errant behavior. After a voluntary confession, the rehabilitated physician would rejoin his brethen.]
• Camaraderie and esprit de corp in an ever shrinking pool of private practitioners. These doctors will soon be on an endangered species list here in Cleveland. Then, we will be eligible for federal protection.
• Increased technical proficiency from the excessive volume of procedures we FFS doctors perform. Since numerous medical studies confirm that volume = quality, our office should qualify as a Center of Excellence.
• We hire our own staff.
• The FFS model is an incentive to improve service to patients and referring physicians.

Private Practice GI FFS Medicine - The Bad!

• Financial conflicts of interest. Sorry, my FFS confederates, but we need to admit this.
• Sending fruit baskets, candy, wine and other delectables to primary care physicians. Our practice does not do this, but our competitors do. I’d like to think it doesn’t matter. How many candied cashews is a colonoscopy worth?
• Every hour of vacation is lost income.
• Ruthless competition from regional medical industrial conglomerates.
• It’s our business. We pay for every paper clip.
• Do medical procedures on request, similar to radiologiists. Don't 'own' the procedures anymore.
• Read repeatedly that we FFS profiteers are the cancerous lesion in our health care system.
• In Fee-for-Service, fees decline but services don’t. The letters should appear as FFS to reflect proportionality.
• Personal sacrifices from missed and interrupted family events. In general, the lifestyle of private practice is more stressed than that of our salaried colleagues. It's a tough lifestyle. I doubt that any of our 5 kids will pursue a medical career, although we have tried to maintain neutrality on this issue.

Private Practice GI FFS Medicine - The Ugly!

• Hustling for patients. For me, this is the ‘root canal’ of private practice specialty medicine.

So, in the case of Salary vs FFS Medicine, which side has the better argument?   You be the jury.

Photo Credit

Sunday, January 31, 2010

Fee-for-Service or Salaried Medicine? Part I

I am qualified to opine on physician compensation formulas, because I’ve spent hard time on both sides of the payment seesaw. For the first 10 years of my career, I was on salary. We were told, however, that we could earn productivity ‘bonuses’, but these rewards were trivial. An ‘employee of the month’ parking spot near the entrance would have been worth more, especially during the frigid Cleveland winters.

After 10 years, I moved over to the dark side, where I was paid for each service I provided. In Part I this week, I present pros and cons of salaried medicine. I suspect that I've overlooked some of the advantages and drawbacks of paycheck medicine, so  I hope that readers will correct my errors and omissions.

Good Stuff About Paying Gastroenterologists a Salary
  • Lowers health care costs by underpaying specialty physicians
  • Eliminates financial conflicts of interests. The colonoscope is not a capitalist tool.
  • Reduces unnecessary medical procedures as gastro docs would rather read The New York Times than scope for free. This not only increases gastro docs’ knowledge of the world, but also reduces job cuts at the Times and other newspapers facing financial challenges.
  • Lowers medical costs by reducing the volume of GI consults, since primary physicians know there is a high threshold for pulling the ‘scope trigger’.
  • Dinner with the family every night since salaried physicians turn their beepers off at the appointed hour.
  • Strengthens character by shielding salaried specialists from greed and other sins and temptations.
  • Creates more relaxed and rested GI specialists. Every minute of alloted leisure time is taken. Hey, the boss is paying! I know this because I've been there.
  • No need to devote even 2 neurons to payroll, overhead and cash flow issues.
  • No hustling for patients.  For me, this was the sweet spot of salaried medicine.

Crummy Stuff About Paying Gastroenterologists a Salary
  • Eliminates an important incentive to increase performance.
  • Patients often told that the schedule is full. Why squeeze in a patient ?
  • Patients with acute issues are often directed to urgent care centers or emergency rooms by staff personnel, or physicians, who have been affected by the shift work mentality of a salaried culture.
  • Creates fun turf conflicts when salaried gastroenterologists spar with salaried primary care physicians over which of them should go the to ER to see a diverticulitis patient at midnight. Since neither will get paid for the encounter, each graciously volunteers that the other do the doctoring deed. Here’s a hypothetical conversation that every emergency room physician has heard repeatedly.
Internist: “Diverticulitis is a pure gastrointestinal condition and you should admit the patient STAT!”

GI Guy: “I did an internal medicine residency also. We never dumped on our specialists. Aren’t you an internist? Would you ask a pulmonary specialist to admit a patient with a cough? Would you ask a nephrologist to admit a patient with a urinary tract infection? Are you a real doctor or a triage machine?”
  • Loss of professionalism when medical policy and employment edicts are issued by ‘suits’.
  • Measurement, monitoring and tracking of absurd performance standards that can be used to provide ‘bonus’ payments to compliant physicians. Read: You will be docked if you don’t fall in line.
To my salaried colleagues, please don’t grab a pitchfork and head to Cleveland. Many of you are excellent physicians and don’t sit around reading The New York Times like I do. Remember, for half of my career, I was one of you. There are clear advantages to the health care system when financial conflicts of interests are reduced. Nevertheless, I maintain that financial incentives can increase quality and performance in any occupation, and that the profit motive can be a force for good. Conversely, employees who are paid by the hour or by the week, may be less likely to provide the highest levels of personal service, although I admit that this is a generalization.

When I enter a hardware store that is a family business, I am greeted at once by smiling human beings who are anxious to assist me.  When I enter a big box warehouse retail outlet, I have to hire a private investigator to track down an employee who is under cover, hoping that I will at least be told the longitude and latitude of my desired purchase. 

Fee-for-service medicine is often demonized, but is it really the enemy?

Next week, Part II: the good, the bad and the ugly of coming off salary.