DISQUS

The beauty of the "crowd-sourcing" techniques is that it aggregates the reasonable observational capacities of the crowd (by-in-large objective, reproducible, verifiable). A singular observer's bias (good or bad) is nullified by the sheer weight of the crowd's members singular observations. It trully is a "reasonable persons" assessment of an event -- emphasis on event and the fact that events are always external and always subjected to the same observational behaviors of other members in the crowd. Contrast this with the notion of crowd-sourcing a "clinical trial" where what is being aggregated are internal opinions, feelings, beliefs, etc. This is the aggregation of the subjective, irreproducible and non-verfiable. Crowd-sourcing traffic patterns in not the same as crowd-sourcing menopause. The ponderables for traffic are easily discernable by all. The ponderables for menopause may or may not be known or expressed to there fullest. Bolt's "11 wonders," despite the rhetorical mish-mash, does point to serious problems with present "scientific" studies. But stretches all credulity with the implicit notion that all professional studies being flawed means all non-professional studies should be considered under the banner of crowd-sourcing.

There are many things not known in science or poorly known in an historical perspective. We have limited knowledge of vast area of the Moon's geography, it is wholly illogical to assume that crowd-sourcing will fill this informational void. Why? Because the crowd does not have access to the observational skills to render singular observation that can be aggregated. Are there limitations in both methodologies? Of course. But a limitation in one does not mandate a strength in the other. And, singular successes do not assure generalized successes.

If the best shot the H20 pundits have to level at "clinical trials" is Bolt's 11-wonders, they need to pack up their tents and go home. These are very serious topics during serious times. We have many without healthcare in this country and crisis-level financial troubles present and for years to come. The H20 vision has much to be admired, but has much that cuts to the image of creating a true healthcare caste system in the US. They would do well to trade the rhetoric laced with neologisms for reason and goals that address today's healthcare realities.

Now David, a question -- how about crowd-sourcing the legal profession? Certainly what's good for the goose, should be good for the gander. I think we should crowd-source that question...

I certainly understand what you are saying; however, this was not a reprimand. King failed to meet its contractual duties under the CMS/Medicare contract. These failures were noted on several visits over several years. CMS, consistent with the contract, removed funding. With the lack of funding, Los Angeles County can not run King. There was no reprimand, but a repeated failure to fulfill contractual duties to receive Medicare funding.

A reprimand implies some form of a discipline for a transgression, this was much more formal and serious.

Agree, but the risk is that you might contradict something you put in one forum (e.g., a blog) and later put in another forum (e.g., court). Consistency is what set Flea up for failure—we as physicians know exactly what he meant. The problem is how it is portrayed for the jury. If Flea did not settle the case, he would have had his character impeached with an inconsistent statement. Lethal? We will never know.

"[I]t was like watching an accident as it was happening." That was my very first impression—along with, this will end very badly.

Charles

I think you are missing the point, it is the physicians and their investors that are acting just like the ones you are indicting, "the legal profession, the insurance cartels, the pharmaceutical companies...." Profit has motivated the creation of specialized hospitals that lack basic safety features.

Your statement, "[t]he issue is not what those with, can afford, but what those without, can not afford[,]" has no logical relevance to the article. Specialty hospitals *only* cater to those with the ability to pay.

This article is, plain and simple, another example of cream-skimming the healthcare dollar, and doing so in a manner that may potentially harm or kill the very clients they seek. Trading a savings for a potential threat is not a wise investment.

As more cases of harm and death mount, Congressional angst will rise and specialty hospitals will become the subject of ever increasing regulatory burden and their profitability may very well vanish. They may die, not because they are not successful, but because they are not safe.

The other side of the coin, which I have touched upon before, is what is the cost of cream-skimming to acute care hospitals and the overall cost to healthcare in the communities served by specialty hospitals. A search in this blog on "specialty hospital" will show several related articles.

> Welcome back!

Thanks

> Is the bar exam done?

Not yet, see the "CBX Countdown" upper left sidebar. The exam is Feb 27, 28 and Mar 1.

If I'm following the facts, woman saw OB, and OB wanted to admit patient to facility A, but patient showed up at facility B by mistake -- can facility B give directions to facility A? Or do you mean patient was directed to OB through regular hospital admitting (registration) and showed up at ER registration? I think it depends on what the woman says in either case.

But I think Laura says it best…

> best solution for emergency physicians is to drop all contracts with insurers

And don't we wish we could; however, since we are one of the "RAPE" specialties (radiology, anesthesiology, pathology, and emergency medicine) our hospital contracts are almost always linked to contracting with every and any insurer out there that may be looking for a "break" from the "local hospital." In theory, it makes sense -- in reality, never. Especially, in heavily capitated markets -- where competition is severe and it is always based on cost and "discounts."

I have the same (Windows XP/IE6) -- but mainly use Firefox and Opera -- I'll do some checking, I think the it has to do with window size in IE. If the window width is smaller then the minimal size for the three columns then you will see the effect you are seeing. I've only seen this with IE6, and not Firefox/Opera.

At least one glitch: no electrons, no EHR...

Agree. That is the dilemma with AHA and these particular neurologist -- they want to be aggressive and want to treat CVAs/TIAs like unstable angina and AMIs -- but there is not the infrastructure or the wherewithal in the neurologic community to effect the types of capabilities and capacities we see in the cardiac community. When we first started using thrombolytics in the ED there was a very willing and supporting infrastructure of cardiologists and cardiac surgeons -- lots of cath labs. Where is the similar committment for CVAs. Its not the same and NINDS is part of it. I don't think either of us would want thrombolytics for ourselves or our families' CVAs but we would want it for ours and theirs AMIs. There is a tremendous disconnect and of course JCAHO seems to be oblivious to the danger of ratcheting up demand for a service that has a non-existent supply side. California has over 400 hospitals and only about 10 have stepped forward for CVAs. All have stepped forward for AMIs.

Yes, Mrs. Symtym. :coolsmile:

jb, I'll join you in the choir...

Deprecation from Wikipedia:

Etymology

In mainstream English, the verb "to deprecate" means, simply, "to disapprove of (something)". It derives from the Latin verb deprecari, meaning "to ward off (a disaster) by prayer." Thus, for a standards document to state that a feature is deprecated is a recommendation against using it. Alternately, (and somewhat more dramatically), the writer implores users against using an old, bad feature so that it can be removed.

It is sometimes confused with the word "depreciate". (Using deprecated programming language features may, nonetheless, cause the value of a program to depreciate: eventually, the features will be removed, and the program will no longer run.)

<div align="center">:coolcheese:</div>

Cream skimming and a great example of incentivized behavior. Two birds are killed (if you can walk your practice away from a general hospital) with the specialty hospital:

1. better reimbursements, "weller" patients

2. get out from the EMTALA umbrella and on-call duties

I agree, they are just a symptom of the greater issue of how healthcare is funded in the US.

I know Tulsa well, lived there during medical school. My wife worked L&D at St. Francis. Our first son (21 in July) was born at St. Francis. Small world!

In eastern Oklahoma, medical helicopters make more sense then many areas of northern California where I live now. We have 8-9 in large urban areas — where only sometimes ground transport and traffic are significant problems.

I don't disagree with your analogies; however, there are distinguishing aspects for the physician ordering as opposed to the mechanic or contractor.

<ol>
<li>When you utilize the mechanic/contractor there is a contract and there are no surprises that included in their cost will be a profit. More service implies more profit. The point being there is disclosure of the inducement.</li>
<li>With the physician there is no financial disclosure of any profit from ordering. The patient is highly unlikely to even consider the possibility of inducement or that the physician may receive $X reimbursement from service provider A and $Y reimbursement from service provider B.</li>
<li>The customer always has a choice with a mechanic/contractor.</li>
<li>A patient may have no choice of a physician. Many reasons: emergency situation, HMO with limited provider list, no one taking new patients, rare specialty, etc.</li>
<li>I would suspect that if disclosed that the physician charged $X in the office and retained a percentage of $X and the patient could go to another service provider and be charged $Y, where Y is significantly less than X, that they would go to the other provider. I would think the payers would be very concerned as well.</li>
</ol>

Bottom line here is that there needs to be disclosure of the financial inducements that are neither apparent to the patient nor to the third party payers (governmental and non-governmental). I think the type of business activities discussed in the article are going to land these participants in a world of hurt. When we consider how drug benefits are going to be covered, how the boomers are going to be covered, and how we can cover 45 million disenfranchised from healthcare (either under- or un-insured) — then the silver lining the pockets of those that have exclusive control over particular utilizations of healthcare dollars become low enough hanging fruits to be plucked.

Similar themes here and here.

I think it would be important to distinguish between the situations where the cost to the ordering physician was $40 (inclusive of the lab ordering charge and cost incurred by the physician ordering the test), the charge (amount billed) was $80 and the actual payment was $40 with the situation where the actual payment is $80. The former has a $0 inducement for ordering and the latter has a $40 inducement/order. Is it proper (and ethical) to have "medical necessity" (where medical necessity is the necessary underpinning for ordering a test) under the pale of a known and regular financial renumeration to the physician? Should physician reimbursements come from the testings ordered in the course of diagnosis and treatment that they are already being reimbursed for under physician billing for services? Seems to me a situation very ripe for fraud and abuse.

The inducements seem even stronger when you consider the practice where the physician is charged a flat rate of service (in the article, scan time), e.g., X patients per day, where the physician pays whether or not X patients per day are referred. This seems almost like an HMO, the physician is capped for service expenses at a rate of X patients per day. As potent is the inducement for an HMO to control cost when working under a cap, there is a not dissimilar potency inducing the physician to exceed the "cap" under which he/she loses if not exceeded.

I think there is a very real potential ethical problem any time there is a linkage between physician reimbursement and what a physician has exclusive control over in ordering. "Medical necessity" comes under the pale of inducement.

With regards to "there are very many not board certified FP/IM docs out there practicing general medicine" and "about a cardiothoracic surgeon opening a general medicine clinic" I think we would very much agree; however, there is a major difference, where your analogy fails — general medicine is not a specialty and has no specialty board. Additionally, no one practicing general medicine challenges established certifying boards or suggests that established boards are monopolistic.

And with regards to "other specialties being as sensitive about it as some EP’s are," the seeming uniqueness of this sensitivity stems from the uniqueness of EM being the only specialty that is commonly challenged by those not board certified as to the quality of the certification and to monopolistic practices. Again the core of my argument is that there is a double standard invoked with EM — your analogies and conclusions only serve to accentuate that double standard at play.

It really is very simple. ABMS certifies the specialty boards and the specialty boards certify the training of medicine's specialist. All specialties and all certified specialist should be treated similarly. If, for whatever reason (and there are good ones), you, as a physican, have chosen either not to go through the recognized specialty certification process primarily or at some later time choose to practice in a specialty where you don't desire certification in (all well in good) there should be absolutely no criticism or suggestion of unfairness, monopolistic practices, etc. The rules are plain for everyone, if you want to be board certified in a specialty this is what you do[.]

Similarly, the notion that training in one specialty is "well train[ing]" for another specialty is sheer conjecture — it says more about the individual's quality than the quality of original training. It is inconceivable that a surgical internship would provide anything more substantial than an R1's exposure to surgical cases that may have presented to the ER. It provides no training for the 70-80% of the ER population, which constitutes general medical and many social problems.

Where I practice we have had an FM training program for many years, the FM residents do their 1 or 2 months in the ER. It is the rare one that demonstrates the wherewithal to be able to practice EM right out of the box (residency). Those that "can," are the types of physicians that really would do well in any specialty (we all knows those types) — it just so happens that they chose a residency that they became disenchanted with (many reasons). Will they do will in EM practice? Probably just fine, but that speaks more (at least to me) of the quality of the person and less so to a particular type of specialty residency.

To draw this to a close, the sensitivity you perceive is based upon the perceived uniqueness in the manner EM is treated by those that come to EM by other paths other than board certification. Unless you can show otherwise, that treatment is a profoundly unique double standard amongst the House of Medicine's 24 specialties.

Emergency Medicine is a specialty, we don't want to be treated special, we want to be treated just like all the other specialties! No double standards!

Your comments reflect the real world dilemma many ER physicians face, we would like to be completely straightforward about the diagnosis and what should be done based upon our clincial evaluation. But, by time the patient arrives the advice nurse or primary care provider may have been called or even the triage nurse has given an opinion about what should happen that our hands are tied in terms of patient (or parent) expectations.

There are two levels of expectations, those of the patient (and parent) and those of the referring agents (physician, mid-level, advice nurse, etc.). In a sense, we must be mindful that a "successful" encounter must address both sets of expectations. The irony here from the third party advice nurses is that we may get a letter about our quality of care if we don't get a CT based upon their telephonic interview.

Yes, see here.

But a jackass would destroy the allusion to Curious George.

How do you highlight the previous posts? That’s cool.

Use the blockquote tag and I use an HTML editor to compose with (I cheap <img src="http://symtym.com/rsc/smiling.gif"> )</img>

You’re right it is what everyone does. But not everyone seeks legislation that harms third parties in an attempt to right that wrong.

I don't necessarily disagree, but that's what the legislative process is all about. What can be enacted by the prevailing influences of constituencies — the heart of democracy. Are there unintended consequences? Sure, there will always be third parties that may or may not be benefited or harmed with every legislative action.

While my initial comment was over the top, and indeed designed to invite comment, do not mistake the respect I have for physicians. I vehemently disagree with the legislative proposals many are backing these days, but I would not denigrate the profession as a whole. Personally, I think it’s sad how the two most noble professions have turned on each other. We’re all so quick to paint with a broad brush these days.

As with many legislative actions, to a certain degree, they represent the collective angst of the proponent constituencies. Medicine, not unlike many professions, is too complex to legislative without significant downsides. I don't believe legislation per se will fix the "medical malpractice crisis." Part and parcel with the need for a "fix" should be how do we "fix" medical errors and how are the truly harmed reasonably compensated.

And my initial comment was not meant as a personal attack on Kevin, it was an open question to all. Although I do wonder when physicians became so sensitive, considering the things regularly said about lawyers.

Understood. Perhaps it is the inherently adversarial nature of our legal system and the average physicians' contact with that system will by necessity and design be adversarial in nature. Contrast that with the average lawyers' contact with the medical system — by-in-large it is not adversarial …

It’s not a hard thing to understand. The medical blogosphere is filled with stories expressing dissatisfaction with the practice due to reimbursement rates, patient attitudes, the perceived legal climate etc. (not that different from the legal blogosphere I might add). But at some point, there is a dollar value that makes it all worthwhile. What is that dollar value? That’s all there is to my question. And so far only one brave soul has dared answer.

I probably follow as many legal blogs as I do medical blogs, and I agree there is a difference — I'm not sure there is a single or multiple factors that I could identify. I would venture a guess that it has more to do with fundamental differences between lawyers and physicians as to training and communication abilities. Additionally, what is happening to medicine is widespread, pervasive, and seemingly longlasting — not just malpractice, but managed care, regulatory burdens, etc. Again, I don't think you'll get a specific dollar value — it is much more complex. I'm sure many physicians would settle for a lot less if there was no regulatory burden, no third party authorizations, etc. Conversely, there are certain practice setting no one will take at any cost.

I sympathize greatly with the reimbursement issues. Dealing with insurers is one reason I don’t do insurance defense work anymore. By the way, just because you can CHARGE a reasonable fee, that’s no guarantee you will be paid. Being in business for yourself is one of the great risks of our professions. That’s why some lawyers do insurance defense work, for the guarantee of the steady paycheck even if you do have to fight some to get reimbursed fully. And there are some lawyers, just as there are some physicians, who would rather set their own fee schedule. It’s a matter of who is willing to take the risk.

I think you answered your own question, regarding a dollar value — it depends. Depends on the work, the risk, guaranteed compensation, etc.

There are tremendous similarities between the medical and legal professions — and both have similar metrics for measuring value for what product they produce and what compensation they should receive. On our side of the street 50-60% of our reimbursement can be traced to governmental sources and 40-50% to non-governmental sources (third parties) based upon payer sources. Very few patients pay cash. Analogizing medicine to the legal profession, there is no pro bono pool of 45 million clients that can not pay or pay much less than a reasonable rate. Healthcare is very much perceived as a right or a basic utility, yet funded at a level orders of magnitude less than that demand. Legal representation is not, except for constitutional protections in criminal actions and the ethical recommendations (MRPC) for pro bono work.

I’ll ask you what I asked Kevin - how much would it take to make you feel loved?

I don't believe it really is a question of about "feel[ing] loved," but rather about not feeling the love for the profession many of us felt in medical school and in the early years of practice. The complexities of practice are ever increasing -- not just the litigous aspects, but also the risk avoidance, regulatory, etc. aspects.

You know that physicians on average make much more than lawyers, correct?

And both the physician and the lawyer make much more than the general population. So what? I'm unaware of any linearity between income and "feel[ing] loved." And just because X makes more then Y is no argument that X should be happy and not whine (isn't that the gist of your argument?).

And all lawyers have restrictions on what they bill. Insurance defense lawyers have the same insurance reimbursement problems physicians have. And for the rest of us, we’re in the private market, competing with everyone else and with cost conscious clients. Do clients who pay the bill not count as third parties? What makes you think that being in the private market would be such a boon for physicians? Do you think physicians wouldn’t undercut each other on price?

No, lawyers have a reasonable fee imposition. "Insurance defense lawyers" [may] have the same reimbursement issues that physicians have. But it is the rare physician that is not reimbursed, in whole or part, by insurance or from governmental sources (third parties). There is a vast gulf between "reasonable fee" and "may" participate in insurance work and mandatory third party fee schedules.

C'mon, "attorney-client" relationship -- that's the first and second parties. No, clients are not third parties! You know that! That is a basic legal ethics question -- who is the client and who are the third parties.

You are confusing terms, I see no such argument for a "private market." What is being compared is a marketplace where competition is based upon a "reasonable fee" vs. a marketplace where competition is based upon who can survive or prevail based upon third party payments.

There are no reasons to suspect (or suggest) that physicians and lawyers would act and perform in similarly situated marketplaces; however, the crux of your argument is that you believe they are similarly situated. I believe the economic dynamics of their respective marketplaces are vastly different.

A major food source for another profession? Can you define that for me? How many lawyers make their living doing med mal plaintiff’s work? What’s your definition of major? One thing law school will teach you is that bullshit phrases like that don’t hold much water without facts to back them up.

The point? You don't like being baited either. The more subtle points are: predation is commonly felt (albeit sans facts, but such is the nature of feeling) and there is no medical discipline that specializes in the treatment of lawyers (although one can envision a variation of acupuncture using 16G needles). Psss, I have my stethoscope on, I'm way too young to be wearing scales …

My question is simple - how much would it take to make physicians feel loved. We keep hearing how tough it is - so what would make it worthwhile?

You have asked two very different question, and the asking suggests (at least to your mind) that they are linked. Anyone going to a professional school has some expectations as to what they will be earning. Many professionals soon find the realities of the marketplaces do not fit with the images they had during professional training. It is the clashing of the realities and the aspirations of medical practice. To some degree more income may compensate for the shortcomings of the practice environment, but their will be limits.

To answer your questions succinctly, there are no linear relationships between "how much would it take," "feel loved," and "worthwhile." To use a legal phrase, those are highly factual questions. To ask for simple answers trivializes the complexities of the issues at play. I would not expect a lawyer to be able to answer those questions for their profession either.

In medicine, over the last generation we have seen legal actions against physician morph from contractual and tortious theories to negligence as the all prevailing theory of malpractice. Not dissimilar from the legal profession's theoretical bases for malpractice.

In that same generation, medicine has gone from fee-for-service (not dissimilar from the legal profession's "reasonable fee") to predominantly (if not exclusively) third party payment (governmental and private) based upon schedules. Coupled with this are the regulatory burdens.

Physicians go on and on about how much lawyers make, and how med mal is a “windfall” for victims, but they won’t talk about how much they make or how much they want to make. They just complain about their expenses.

Some physicians do -- here's another irony, you traipse into the medical blogosphere with the expectation that physicians writing (predominately personal perspectives) would be anything different from a physician's perspective and not voice commonly held themes amongst the medical and greater healthcare communities (whether or not factually based is not really the point). Try criticizing the argu[ment] and not the holder of the beliefs.

Not talking about income and only complaining about expenses -- well that sounds just like everyone that works!