Overdoctored

Rocking Your Fragile World-View

Let us again consider Albania, a tiny country tucked into a little corner of Europe which is only now emerging out of the communist Dark Ages in which it had stagnated while the rest of Europe moved on. This very poor country sits on the Northern border of Greece for whom it serves as a sort of Balkan Mexico, sending a steady stream of poor illegal immigrants into Greece looking for a better life and overwhelming the Greek welfare state. The average life expectancy (a statistic that sleek United Nations bureaucrats and the People Who Love Them use as a surrogate indicator for the quality of a nation’s health care system) of an Albanian is close to 78 years. A typical Frenchman, since France is held to be some sort of medical Shangri La by many Americans, can expect to enjoy pointless cinema, runny cheese, and l’ennui francaise for around 79 years. The typical American might live a few months less than a Frenchman or other comparable European but he can reasonably expect to live as long as an Albanian as will the typical Greek. The United States spends the most per capita on medical care followed by the French, the Greeks, and lagging way, way behind, the hardy Albanians who, despite spending less per capita on medical care than many Americans spend on frothy coffee drinks, still manage to hang on for a long life that is only a matter of months shorter than that enjoyed by a Frenchman, a Greek, an American, or just about anybody in the the rest of the developed world.

Indeed, those thrifty Albanians manage to spend less than 400 bucks apiece per year on medical care, have almost none of the advanced treatments available in the United States or the European Union, very sketchy access to doctors, and still manage to live long, healthy lives eating their Tavi Kosi and smoking their harsh Red Star Tractor Brand unfiltered cigarettes. By comparrisson, we spend close to 6000 bucks per head per year, the Greeks spend about 2500, and the effete French spend around four thousand. If you look at the rest of the developed world, there appears to be a similar discordance between health care exenditure and longevity. Past around six hundred bucks, typical of most of the Balkans and other emerging European nations that have reasonable sewage and other public health measures, there doesn’t seem to be much of correlation between spending and longevity. Maybe a two or three year difference between the top and the bottom which shouldn’t be anything to get excited about. I can easily think of a couple of cultural factors that might account for a bit of this slight difference. In the United States, for example, every Tupac harvested early to the Lord in a pointless rap war, besides being a mighty blow to the music world, drives down the average life expectancy.

I have also never seen, in all of my extensive travels in Europe, anything remotely similar to the four or five-hundred pound behemouths that roam the American landscape in vast herds, making the buffet lines tremble from the thunder of their comfortable shoes and darkening the parking lots of all-you-can eat waffle joints across the fruited plains. I mean, I’m treating obese kids with with type II diabetes, most of whom have free health insurance via medicaid and of which their parents avail themselves with the same gusto they otherwise reserve for nacho cheese biscuits. Lack of health care is not the problem here, nor is access.

In earlier articles I have suggested that we waste a lot of money in the medical industry. How much, exactly, I am unsure. There is a large gray area between what I would consider the completely appropriate use of medical resources and what I know to be the equivalent of flushing burning hundred-dollar bills down the toilet. But I think that most of my learned colleagues on the medical internet will agree that wasted money accounts for a horrifically large percentage of our total two-trillion-dollar yearly spending binge.

Oh my loyal and long-suffering readers, you who I delight in entertaining with detailed prose as I attempt to wrap the truth of the world, or at least how I see it, in a little bit of humor, a little bit of sarcasm, and a little bit of shameless pandering to the understandable instinct to despise the French; I confess from the depths of my black, misanthropic heart that I am not much of a writer. I try hard, of course, and I can occasionly tame an idea or two in my brain long enough to lead it to paper but since I am having a hard time thinking of a clever way to illustrate exactly how much money we waste in this country on medical care, I’m just going to say it plainly with no art or interesting literary devices. Just Keep in mind two things. First, I’m going to tie it all in to the Albanians and second, every patient I’m going to describe costs the system money even if they are what is optimistically called self-pay (a cheerful euphemsism for “There is No Way in Hell I Would Pay a Dime for my Medical Care”). The temptation is to say, “Well, since they can’t pay there is no money changing hands and therefore no real cost to the health care system.” This, however, is a stunning example of wrong-headed thinking. Every patient costs money to somebody if only because the infrastructure to deal with them has to be maintained. Of all the individuals and organizations involved in delivering medical care, the only ones who will work for nothing are doctors. Try getting a nurse or a radiology tech, for example, to work a few extra hours or fill in some holes in the hospital’s schedule for free. They’d laugh, as would the janitors, clerks, and even the nice ladies slinging the chili mac down in the cafeteria. Medical care is a huge team effort involving expensive infrastructure and many highly skilled and not-so-skilled people, none of whom would even consider volunteering their time except, as I mentioned, physicians who are not only regularly asked but expected to work for nothing as the need arises (a typical Emergency Physician working on a production basis and not as hospital employee, for example, gives away a hundred thousand bucks of his time every year).

So let me just state that In the United States, we are terrifically over-doctored. Much of what we spend is to overtreat either self-limiting things or to throw marginally effective therapy, at least in regard to decreased mortality, at chronic medical problems, most of which are lifestyle related. Either that or we burn through money like drunken sailors on futile end-of-life care for people who have absolutely no quality of life unless we are now measuring quality by how long you can lay motionless in your own urine before a minimum-wage nursing home caregiver decides to roll you around a little. Let me give you a few examples of typical patients to illustrate the many ways in which your money is squandered.

“There, you see? She blinked! I love you Grandma!”

I see this patient or some variation at least once on most shifts. An incredibly frail, some might say cadaverous, woman, somewhere in the neighborhood of ninety who has been in a nursing home for a decade and was doing all right with her end-stage renal disease, advanced senile dementia, and congestive heart failure until about a year ago when something broke loose during dialysis and she suffered a stroke, turning her from a demented elderly lady who had broken her hip twice to a demented, aphasic, ancient lady; completely immobile except when indifferently turned by the staff of the warehouse in which she is stored. Because she can no longer swallow the surgeons obliged her family with a PEG tube (to pour liquid food directly into her stomach) and to protect her airway she breathes humidified oxygen through a tracheostomy (a hole in her neck, with another tube sticking out of it). On a philosophical level we can debate the nature of quality of life but I’m going to go out on a limb here and suggest that laying in your own feces on eroded bed sores is not much of a quality of life. In other words, we’re not talking about a hale and hearty nonagenarian who will live to be a hundred provided she can avoid being admitted to the hospital. This is a patient who is living on borrowed time, one who will not last another six months despite our best efforts and yet, in those last six months we will spend large sums of money on her, probably more than the total spent in her whole pre-stroke life, in an inexplicable quest to stave off death, spending money at an increasing rate the closer she gets to actual “reaper” death and not the living death to which she is condemned.

It is also both amusing and edifying to peruse a list of her medications which, after a decade or two of failing health, has grown into a two-page manifesto, a declaration or our faith in evidence-based chemistry. For starters she is on three-hundred dollars a month of Namenda, a new drug that is only marginally effective in improving the memory of patients with early Alzheimer’s but, if you think about it, is kind of ridiculous to use in a patient who is so far gone that even before her stroke she couldn’t even remember how to feed herself. Because of her cardiac history, she is on the obligatory statin and beta-blocker although against what looming cardiac event we are protecting her is not clear. Because of her atrial fibrillation, for which she recieved an implanted defibrillator two years ago, she is on coumadin. Now that she has no risk of ever getting up to fall it has been cranked up, giving her the occasional gastrointestinal bleed as her doctor disinterestedly tries to control her wildy fluctuating levels. As a little bit of seasoning she is on the digoxin to keep her heart beating as well as the usual four or five narcotics which are poured carefully into her feeding tube at regular intervals with the rest of her medications.

We pour expensive medical care into her in equal measure. The PEG and tracheostomy are only the latest procedures. If the squad of specialsts following her play their cards right, she’s good for at least a few bronchoscopies, an echocardioram, and maybe even a battery change on her defibrillator before they’re through

And she’s a full code. The family wants “everything done,” no matter what, up to and including artificial ventilation, defibrillation, and even more tubes. You see, “She knows we’re in the room, doc. Can’t you see how she perks up when we speak?” Against this kind of faith there is no argument possible, not in our totally out-of-control health care system where, since somebody else is always paying, money is no object. I have no doubt that the last six months of her life is going to cost a couple of hundred thousand dollars. A day in the intensive care unit by itself costs a cool four grand. She will probably burn through a couple of weeks of these before the final, terminal admission where at last, somebody has the common sense to say “no mas” and, after one final orgy of spending (for old time’s sake), we finally let her go.

Where’s the Fire?

Every now and then our already busy Emergency Department is innundated with a surge of patients. The waiting room is packed and the over-flow are seated in folding chairs in the hallway. The chart rack spills over, five rows deep instead of the usual two and you’d think a plane had crashed or the Four Horsemen were abroad. A quick survey of the new charts, however, shows the usual minor complaints, things that eventually turn out to be colds or vague abdominal pain. The panic begins, tempers get short, and, already working at a dangeorus speed, we are expected to double our efforts and move patients. God forbid we get a critical patient at a time like this because that will gum up the waiting room to an unacceptable degree. Why, and please try to choke down your horror, people with minor complaints might even get tired of waiting and leave the department without being seen. Which is sort of the problem. While it is no doubt true that hidden among the irritated patients spilling into the hallway is a real, honest-to-God heart attack or a smouldering acute appendicitis about to become dangerous, the majority of the deluge are patients with complaints that turn out to be minor, self-limiting things or even no problem at all except the siren call of the only representative of the all-giving and all-powerful Man that is open at 2 AM.

Now, I’m not saying that patients don’t need to be seen. Many have no other access to medical care and some are really quite sick. Although I would hate for the Emergency Department to become a primary care clinic for the indigent (a direction towards which we are lurching as hospital bureaucrats think up even more ways to jack up Press-Ganey scores), there is a need for medical care that somebody has to fill. On the other hand many of the complaints are so minor that they don’t need to be seen at all, even if the patient has premium insurance and is followed by the best internist in town. A request for a pregancy test, for example, should never make it past triage. Likewise what is obviously a cold in an otherwise healthy young adult. It is true that both of these complaints might be more than they seem, the pregancy may be an ectopic and the cold may be a Wegener’s friggin’ Granulomatosis but that doesn’t mean that they need to be worked up, a difficult concept for people to understand.

Or, to put it another way, if we work up every minor complaint under the sun looking for a big, bad, macho, internal-medicine-type thrill kill we won’t miss it when it pops up but we are going to have a horrifically expensive health care system with money being spent where it will do the least good. I’m not implying that every cold gets the million dollar workup. We still have a little common sense left. But these patients are dutifully triaged and seen, leading to crowding in the department, already more than a little constipated with “Emergency Department Admissions” (patients with orders for admission but no available beds or nurses in the hospital). There is no “Triage to Home” which is what we really need (and not just in the Emergency Department but in the whole medical profession), that is, a designation for a patient who has been quickly assessed by a skilled nurse, a PA, or even the Emergency Physician making waiting room rounds to not be sick enough for a full work-up and diagnosis. Because somebody pays, you know. Every chronic back pain, every cold, every vague psychosomatic disorder costs money somewhere. The tab is either picked up by Medicaid (and Medicaid patients are ravenous consumers of free healthcare), Medicare, private insurance, or even on rare blue moons when lightning strikes, by the patient himself…but it is all part of the two-trillion dollars we spend every year. Even if the care is unreimbursed the cost to maintain the needed capacity is very real and paid for by everybody.

The idea that some socialized, quasi-socailized, it-ain’t-socialized-much-cause-it’s-single-payer, or any other scheme to give everyone free medical care is going to alleviate the problem is laughable. While there is currently some restraint in the system against using medical resources for minor complaints, it really only effects those who make co-pays for their medical care. If you pay nothing, there is no incentive not to crowd the doctor’s office or the Emergency Department for your free pregnancy test or your motrin. All you have to spend is your time and while our department sometimes slows to a crawl with ten hours waits, you can usually be seen in three or four hours. A long time but I have waited an hour or two to see my doctor for my annual physical (itself largely a waste of money for an otherwise healthy guy) when he is running behind. What’s another couple of hours if it’s free?

What We Have Here is a Failure to Communicate

How many cardiac workups does one person need in a year? Or how many CT scans? Because I work in the Emergency Departments of two rival hospitals I am in the unique position of getting a patient admitted for vaguely cardiac-sounding chest pain and then, as if nothing happened, seeing him at the other department often only a few days later with the same complaint and, unless he remembers me which he may not, no mention in his past medical history of his completely negative nuclear stress test and exhaustive workup. The story is the same for all manner of patients. Some, like drug seekers, attempt to game the system and make the circuit of local Emergency Rooms, shamelessly spinning a tale of woe four or five times a week. Others just don’t know any better and, despite having various deadly conditions definitively ruled-out on multiple occasions at other hospitals, are perpetually looking for the definitve second opinion, or attention, or someone to take care of them for a few days…who knows. Some people just feel bad all the time and have developed a co-dependent relationship with the hospital. They suck down many, many scarce medical dollars in redundant tests, consultations, and brief hospital stays where, in reading the discharge summary, you can sense the dictating physician trying to express his frustration without out-and-out accusing the patient of malingering. For our part, they are what we call “weak admissions,” embarrassingly weak, the kind that make you cringe to discuss with the admitting service.

Some patients, let’s say someone with a volvulous, are incredibly strong admissions. All you have to say is, “The patient definitely has a surgical abdomen, is distended, tender, guarding, and vomitting,” and the admitting surgeon will say, “Okay, I’ll be right in.” Some admissions are decent, like a 65-year-old smoker with pneumonia. You will rarely get an argument or the telephone equivalent of rolled eyes. Some admissions are weak but so routine that the admitting service will demur with little complaint. Some are so weak, so worthless, and such a waste of money that I cringe to hear the voice on the other end of the line, rippling with sarcasm, saying, “You know we admitted him for that last week and found nothing, don’t you?”

Or worse yet, “Oh, we had to discharge him from our practice for violating his pain contract and trying to get narcotics from almost every hospital in the state.”

And you’re left holding the bag, playing a game of legal chicken. The patients may cry wolf but there is going to be a real wolf someday and, like a game of hot potato, nobody wants to be holding the spud when the music stops. I have a patient like this, a serial abuser of Emergency Services whose hospital tab must run in the millions, who came in one day in her usual excruciating pain but which this time was not relieved by her customary dose of narcotics and who turned out to have a perforated colon.

There are two salient points here. The first is that the medical profession does a poor job of coordinating information. It almost makes one wish for a standard, nation-wide electronic medical record accessible by every physician and made mandatory for everyone. In this manner, every prescription, test, study, and discharge summary could be pulled up and viewed by any doctor. The second point is that what we need isn’t a Good Samaritan clause (protecting physicians who offer free care) but a “Wolf Clause” to set an upper limit on the amount of work-ups and Emergency Department visits allowed for one patient. I have a 22-year-old patient, an otherwise healthy young woman, who has been to our department thirty times in the last year, been hospitalized a few times, been worked-up redundantly at both of our big hospitals, and there is nothing physically wrong with her. But she is a spud, and since I’d rather spend your money than risk my livelyhood, we take her seriously every time we see her. We may joke about it and roll our eyes but we don’t dare put our money where our mouths are.

What’s Albania Got to Do With It?

Nothing, really. Except that the Albanians don’t have anywhere near the access to high-tech health care that our citizens enjoy. Like the Greeks and many other Europeans, even their sickest patients are not typically on a long list of medications. There is nothing like our buzzing Emergency Medical hives in Albania where every Albanian who is not feeling well can get relatively instant access to almost every labratory test, imaging study, and specialist known to the medical profession. In Albania, much of what we consider the standard of care is unheard of and reserved for those who can pay for it up front. You certainly will not have your terminal illness interupted by too many of the heroic measures which are routine in our country, even for the poor. People grow old, get sick, and die almost as they have been doing since my ancestors regularly invaded and enslaved theirs.

Ah, Albania! Tarnished Jewel of the Balkans! Despite no medical care to speak of you live as long as we do and even give the perfidious French a run for their money. What does that say about how we spend money? I am pefectly willing to concede that there are quality of life issues at play. Certainly I’m glad that I may one day get an artificial knee if mine should ever wear out. And I also concede willingly that if I were critically ill, I’d be immensely glad to be in Pocatello, Idaho and not Tirana. But I’d like to humbly put forth the notion that most of the money spent on medical care in the United States and Europe is spent on the margins, which is not to say that people don’t want it and don’t demand it, but only that it is spent in large amounts with very little to show for it. Maybe past a couple of thousand a year we’re just pissing in the wind. And maybe what we need to do is to start doing less for most patients, most of time, reserving our big guns for worthy targets and not for killing gnats.

Overdoctored

The Non-Crisis in America’s Emergency Departments: The Death of Triage

Staying Power

I suppose the only good thing about my patient’s twelve-hour wait in the Emergency Department waiting room before he even made it into a room, and his subsequent two-hour wait before he finally saw me, was that the results of the basic lab work ordered in triage where immediately available and, as his chest xray had been done (also out of triage) ten hours previously, it was a matter of five minutes to diagnose him with a fairly serious case of pneumonia for which he was easily admitted. I spent more than five minutes with him of course. When you wait that long, especially with the degree of patience and good humor exhibited by this most excellent gentleman, you deserve some of your doctor’s time, your moment in the sun, whether you need it or not and even if all you want to do is complain (which he didn’t). His total time in the department was about 21 hours because, although quickly admitted, there is such a backlog of patients in our hospital that he didn’t actually go upstairs until almost the end of my shift.

Most patients don’t have to wait that long to be seen. Some days are busier than others and occasionally we get a big run of traumas or critical patients which slows the flow of less-urgent patients to a crawl but twelve-hour waits are the exception, not the rule. Four, five, or six-hour waits are not unusual however, nor is it uncommon for me to admit a patient and find them still in their room (albeit in a more comfortable hospital bed in place of the Emergency Department folding slab) when I come in for my next shift. And occasionally a patient is admitted, receives his definitive treatment, and is discharged from the emergency department.

It can get busy. It has gotten busier lately because my hospital has just opened its new Emergency Department, a huge, modern facility with all the bells and whistles which, because there is such a severe crisis in Emergency Medicine they advertised the hell out of and are now reaping a bountiful crop of patients. So many in fact that the waiting room can take the appearance of a disaster zone with patients draped over every available piece of furniture, fitfully sleeping under hospital blankets while the late arrivals spill into our brand-new architectural gem of a lobby; regrettably confounding the best computer rendered images of its architects who depicted it with smart, well dressed people sitting in casual conversation and not full of three-hundred pound asthmatics crouching amid the greasy detritus of their extended wait. It was so crowded on a recent shift that our sardonic Charge Nurse asked to set up some kind of MASH-like field hospital to start treating the small minority of patients who really needed to be seen sooner than we were getting to them. Maybe an eighty year-old-man incontinent of urine and leaving puddles on the waiting room chairs need to be seen a little more quicky than we are otherwise able, especially as the majority of patients who we see have minor complaints that probably don’t need to be seen by a doctor at all.

Apparently there are some fairly serious complaints waiting for hours at a time which may or may not turn out to be anything but used to be an almost automatic free pass through triage. I’d like to think that our triage system is working but sometimes it gets so busy that even if your chief complaint is chest pain, the only way you’re getting back quickly is if you have EKG findings. Patients with cardiac and pulmonary complaints get an EKG which is shown to a physician who can then decide whether to jump the line and bring the person back. Unfortunately, the word has leaked out that we take chest pain seriously so many less than scrupulous patients work a little chest pain into their chief complaint, muddying the waters and subverting the triage process. But whatever the complaint, it cannot be denied that our Emergency Department along with many others is being deluged with patients.

Many reasons for this are proposed. The mythical 47-million uninsured Americans are dragged in as handy scapegoats. While there may be 47-million people in the United States without health insurance, the majority of our patients have insurance of one form or another. Almost every child we see in our new Pediatric Emergency Department has at least Medicaid (CHIP), to reap the bonanza of which they built the thing in the first place, as do many of the conveyor-belt mothers who bring them in. The elderly who make up the largest segment of our patient population have Medicare and are not shy about using as much medical care as they possibly can. Additionally, while the auto industry is struggling in our state, almost every other patient not in the first two categories seems to have medical insurance courtesy of your car note, not to mention that many private employers still provide comprehensive medical insurance. Our uninsured population is small, as a total percentage of patients, and is mostly illegal or recent immigrants, the working poor, and most especially the young who are invincible and even if they could afford it, wouldn’t dream of spending a dime of their disposable income for anything as prosaic, as non-trendy, as medical care. (In fact, the battle cry of Generation “Y” or whatever they are called nowadays might as well be, “A Thousand Bucks for my Tatoos but Not One Penny For My Doctor.”)

It is also true that many of our patients wade into the morass of our waiting room because even if they have a primary care doctor, not necessarily a given even if you are insured, the waiting time for an appointment can be weeks or even months and any testing or studies beyond basic lab work will be done in a disjointed manner over the course of several visits and referrals with no definitive resolution in a timely manner. There is an understanding in the community that while you may have to wait with winos and hookers, once you get into the department studies and tests will fly thick and fast, allowing those with worrisome but let’s just say less-than-emergent problems to usurp the traditional deliberative slowness of primary care medicine. In this we are perhaps victims of our own success. Many of our attendings are somewhat old-school and are not shy about discharging patients to follow-up with their own doctor but many are not and we find ourselves working up the damndest things. I mean, I’m as interested in uterine fibroids as the next guy but maybe it’s not going to make much of difference if the patient has to wait an extra week to be given the bad news.

Primary care doctors, for their part, take advantage of this and have been known, by the bye, to send a patient or two to the Emergency Department with the expectation that they will get a rapid work-up. Not to mention that as primary care doctors are extremely busy nowadays and are not generally paid enough to make the prospect of late night house calls appealing, the default advice whenever you call your doctor is, “Go to the Emergency Room.” I ask almost every parent who brings in their child at 2AM with what is nothing more than a cold why they hauled the family out of the house and braved the snowy roads of our wintery state to bring the kid in. The inevitable reply is that they called their pediatrician (or whoever was on call) and were instructed to come in.

As a factor contributing to long wait times in the Emergency Department, neither can it be denied that the relative scarcity of not only hospital beds but hospital beds of the required type leads to admitted patients langushing in the department for hours if not days, occupying space and nursing time that is unavailable for new patients. (Chest pain patients, for example, no matter how stable or how unlikely they are to have coronary artery disease but who are admitted for an exercise stress test which will be, as sure as the Pope wears funny hats, completely negative, need a telemetry bed. ) The bottleneck in the department is not real estate per se, you understand. We can always put patients in hall beds, something we aren’t supposed to be doing but which is often unavoidable, but as there is a finite supply of both nurses and doctors there is an upper limit to the number of patients that can be safely managed at one time. It’s not as if we can forget about the admitted patient either, many of whom are actually quite sick and demand a lot of their nurse’s time. How many patients can a nurse realistically be expected to follow anyway? Five? Six? If you think they can handle more you don’t know the amount of work involved in nursing.

As for doctors, we can follow more than that because we’re not actually doing much of the actual patient care (with the exception of invasive procedures) but even we have an upper limit. My attendings can follow a fair number at one time but even they will tell you that past twenty or so, which they can only do because they have residents working for them, things start to get insane and not a little unsafe. I start getting into trouble at around eight or nine, especially if a few of them are complicated, and past that most of my time is spent spinning my wheels as the inefficiency inherent in breaking my attention into too many little chunks starts to overwhelm my ability to concentrate on new patients.

As cognizant as we are in Emergency Medicine of the need for speed, we cannot just run the patients through like cattle which is what would be required on some nights to meet the hospital’s goal of a thirty minute door-to-doctor time. The paperwork alone on any patient, even a simple one, takes a minimum of ten minutes and that’s rushing it. This is not to say that a simple SOAP note and a couple of orders take that long to write but we also document for billing and liability, both of which greatly magnify the complexity of documention. There are also numerous home-grown paperwork initiatives at our hospital, either thought up de novo by an underworked bureaucrat or an over-reaction to the heavy hand of JCAHO or one of several other hospital accrediting crime families.

At my hospital, because an intern denied washing his hands when asked by a JCAHO consigliere, the residents now have to provide a list of their patients by medical record number for every shift with the initials of the attending or the charge nurse verifying that we did, in fact, wash our hands before we touched the patient. Now, if you think about it, to comply with the spirit of the rule every time we washed our hands we would have to have an attending physician, an individual with a staggering amount of education and impressive medical credentials, stand over us at the sink with a stopwatch timing the lathering. Either that or get the Charge Nurse, a gal with two days worth of work to fit into her 12-hour shift, to do the same. This would take, what? five minutes per patient? Suppose I see 18 patients in a typical shift, that’s an hour and a half of valuable (and billable) patient care time involved in a useless task which is not only humiliating but so stupid that it burns. The ironic thing is that for most of my patients, many of whom have only an indifferent relationship with soap, I cannot wait to wash my hands after I examine them and feel like a leper until I can get to a sink.

What actually happens, as you can guess, is that at the end of the shift we make a hasty list of our patients and the attending or the charge nurse just runs down the list initialling, turning a poorly conceived effort to change behavior into more of joke than it already is and producing in the end just another useless piece of paper to be found by future archaeologists excavating “Stupid Age” ruins. But it is a piece of paper that eats twenty minutes of useful time. It all adds up. I haven’t actually turned one in yet. In a training system that thrives on humiliating residents, this is perhaps the most humiliating thing I have ever been asked to do and I’m not going to do it unless they threaten to fire me in which case I will cave…but I’m going to make my attendings or the charge nurse watch me wash my hands. If we’re going to do it, we’re going to do it right.

I digress a little but this does actually lead me to two points.

First of all, in most of the country there is no real crisis in Emergency Medicine except one that is entirely man-made and entirely correctable if there was a real interest on the part of hospitals and even many in our profession to do so. It is true that there are a lot of patients but the real problem is that as a society, we are terrifically over-doctored and while a fair number of our patients have actual, bona fide medical problems which either need immediate intervention or cannot wait for a leisurely referral and a delayed admission, the majority have relatively minor complaints that are either non-life threatening exacerbations of chronic problems, minor but legitimate medical problems that can wait a bit and would be better and more easily handled by the patient’s primary care doctor, or mostly so trivial and of a self-limiting variety that no medical attention is really needed at all. Consider the first four patients of a recent shift, all with a complaint of “the flu” and all of whom were young, relatively healthy people with what turned out to be minor upper respiratory tract infections. Basically nothing more than colds, maybe bad ones but colds none-the-less. Two of them had been seen the day before for the same complaint but took to heart the boilerplate admonition on their discharge instructions to “Return if not Better” and had dutifully waited four or five hours to be told, once again, that while we can send a man to the moon we have no cure for the common cold. If there was really a crisis in the Emergency Department, these four patients would never have gotten through triage. An experienced nurse would have met them at the door and said, “Are you crazy? Go home. Drink some chicken soup like yer’ granny told you to. We are packed to the gills and there is no way you’re going to occupy a valuable bed and the attention of my nurses for an hour just because you have no common sense and nothing better to do.”

They don’t say this, of course, and the patients are dutifully triaged and eventually may even get a five hundred dollar work up for a cold, something for which most people don’t even go to the doctor or interrupt their day in any manner. I assure you that I have worked with a cold or a severe but self-limiting gastroenteritis many times worse than that of many of my patients but the thought of going to my doctor, let alone the Emergency Department, never crosses my mind. (Residency is like that. You’re overworked, don’t have time to eat right, and are exposed to every virus in town.) It’s just common sense. Or used to be until we decided that absolutely everything was not only a medical problem but an emergency.

The lack of common sense is unfortunately built into the system as a result of the Emergency Medical and Active Labor Treatment Act of 1986 (EMTALA), a law designed to prevent patient dumping but which has also had two major unintended consequences. The first is the inability to refuse treatment to anyone for any reason. Ostensibly the law only requires a screening exam to exclude an emergency medical condition, the absence of which allows a participating hospital (all of them, by default, because they all take Medicare and Medicaid money) to send the patient home without any further treatment. Practically, however, when combined with the dangers of an out-of-control and exceptionally predatory legal system nobody is ever refused treatment for any condition, even the aforementioned minor complaints, which has turned the nation’s Emergency Departments into hyper-expensive Urgent Care Clinics that also dabble in a little Emergency Medicine. Unfortunately, unless you are actively dying, even if you have a legitimate medical complaint you are bound to languish in the department because for every one of you there are five people who really have no business occupying a bed. So sorry. Write your congressman.

The second unintended consequence is to make most Emergency Departments highly lucrative profit centers for their hospitals. To defray the cost of providing the free care quasi-mandated by EMTALA, many departments started to aggresively market their services to paying customers, those with insurance, who would have previously never even dreamed of coming to the Emergency Room, once a fearsome place usually located in the worst part of town with scary parking and close exposure to dangerous-looking people. In this respect our specialty is becoming just another customer service business competing for a piece of the two-trillion dollars we spend every year on medical care. That kind of treasure attracts a lot of desperados and there is now even less of an incentive to exercise a little restraint or to educate the public about the limitations of modern medicine. Unfortunately, the minor complaint is the bread-and-butter of most Emergency Departments. They pay well for the time invested and you can run them in and out quickly.

My second point is that for all the howling about a crisis, very little is done to free up more of the doctor’s and nurse’s time, the real bottleneck in the process. The converse is true as we are, as I have pointed out, continuously subjected to one poorly conceived bureaucratic initiative after another, very few of which have any effect on the patients but serve only to tie up valuable time in non-patient care activities. Most of my time is spent looking at a computer or filling out documentation that, it is hoped, will live up to its promised talismanic powers of legal protection. Not likely, of course. I shudder to think of the treasure trove of hastily written documentation, much if it incomplete and a very poor representation of what actually happened for the patient, waiting like some vast treasure trove to rival Cibola and the other Seven Cities of Gold for the intrepid legal conquistador who first dares land on the shores of this savage and incomprehensible land.

The Non-Crisis in America’s Emergency Departments: The Death of Triage

How I Am Learning to Throw Money Away With Both Hands and a Big Shovel

Other People’s Money

Medical care is expensive and to a large extent this is unavoidable. Medical knowledge has advanced considerably in even my lifetime and there are hundreds of new medical therapies and technologies of unquestionable value to both individuals and society as a whole. It is therefore impossible to bring back the Good Old Days when doctors were paid in chickens or bushels of produce from their grateful patients, all of whose medical care the kindly country doctor could provide out of his well-used black bag. On the other hand, it cannot escape anyone’s attention who works in the medical industry that we waste prodigious sums of money with very little to show for it. I happen to be at the cutting edge of this profligacy but only because we have easy access in the Emergency Department to most of the expensive toys, not to mention that the nature of our specialty predisposes us to use them even when maybe we could substitute a little clinical judgment for technology.

We don’t, of course, for various reasons most of which are out of our control. It cannot be denied, for example, that the threat of litigation drives a lot of our medical decision making. As our good blog friend the Happy Hospitalist points out, a large percentage of the money we spend in medicine is to rule out conditions that are either rare in and of themselves or, if common, not very likely given the clinical picture of the patient. We spend the money anyway because there is very little incentive for most physicians to control costs. Just one successful lawsuit against a physician for a missed diagnosis can damage his ability to maintain his credentials, cost him the average income of any two or three Americans in increased liability insurance, jeopardize his financial assets, and even end his career. Why risk our own money when we can use somebody else’s to protect us, even if it costs millions?

And I do mean millions. Not meaning to brag but I am a veritable titan of excessive medical spending. A brawny legend of mythical proportions. Where my ancient Greek ancestors proudly arrayed the sacred hecatomb before the shrines of their gods, I call them base amateurs. My pen casually checks tiny boxes on order sheets that every day effortlessly transfer many times the value of their paltry burnt oxen from the public treasury to the altar of my gods, chief among them being Expediency, Haste, and Fear.

I have ordered, for example, expensive CT scans of the brain by the hundreds, the only purpose of which was to rule out that one in fifty-thousand chance that we’ll find something requiring an intervention, on people who had no neurological deficits, no symptoms of intracranial pathology, and not even a decent mechanical reason why they should have something wrong in their head. This is not to say that every CT I order is inappropriate. A patient who has never been to the Emergency Department before and presents with the dreaded “Worst Headache of My Life” needs to get a CT of the head, even if his lumbar puncture is negative. That’s just reasonable suspicion and due diligence. But an otherwise healthy young adult with normal vitals, normal physical exam, who tripped on the ice, bumped his head, and has been sitting in the waiting room for five hours eating stale vending machine nacho chips and watching the Fresh Prince of Bel Air? Does he really need any workup at all?

I am embarrassed to say that, just to be legally safe and in proportion to the number of times any particular attending of ours has been named in a frivolous lawsuit, we often obtain a five-hundred-dollar CT of the brain even in face of a normal neurological exam and a chief complaint (“I bumped my head”) that didn’t even exist forty years ago when we had less technology but maybe more common sense..

(We actually have a CT scanner in our department you know….and, By The Blood of the previously mentioned Triune God, we’re going to utilize the hell out of it. The only reason we didn’t put it at the ambulance entrance and have the paramedics run everybody through it was their fear of a little ionizing radiation.)Â

This kind of thing is not confined to the head, of course, or to the overuse of CT imaging. The CT scanner is just the most obvious example of Medical Testing Gone Wild.

It is hard to say exactly how many of the laboratory tests and imaging studies that we order are unnecessary. The point, however, of good clinical medicine is to only order a test to answer a question. If a patient complains of vague abdominal pain but has a benign abdomen (soft, non-tender, non-distended) and if twenty dollar’s worth of quick, in-house labs show a normal white count and no electrolyte abnormalities, then the correct play would be to suspect, strongly, some intestinal gas and send the patient home with strict instructions to return for fever, vomiting, or increased pain. Hell, throw in a serum lactate if you’re worried about mesenteric ischemia and a two-dollar pregnancy test if you have even a slight suspicion about an ectopic pregnancy and you’ve pretty much ruled out everything immediately deadly to the patient and answered almost every possible clinical question in the negative. There is no need for the inevitable ultrasound or CT scan of the abdomen with oral and intravenous contrast which not only costs a couple of large ones but also ties up a bed in the department for two hours at a minimum (the time to drink the contrast, transport, and have the study read). We only order these tests out of fear of sending a patient home with something like an early intussiception and having them decide not to return even if clearly told to do so. What does it hurt, after all, to send the early abdominal pain home except that if it turns out to be something and the patient doesn’t come back, all the jury will care about is that you sent somebody home, not that you exercised what seemed like good clinical judgment and a laudable regard for the public treasury?

Thus does the expectation of zero-defect medicine make cowards of us all. I have ordered hundreds of expensive imaging studies and in almost all cases, where the clinical suspicion of anything being abnormal was low, the studies have been negative. Even the studies that I order with solid history, physical exam, or lab abnormalities as a justification and where I expect to hit paydirt are usually negative. I understand that sometimes a negative study is as important as a positive one but if the pre-test probability is low, maybe we should save ourselves the car fare and give the zebra a little more time to cook. Give the problem time to declare itself, I mean, if it really exists. It sounds cold-blooded but you can’t expect everyone to get a ten-thousand dollar workup for every complaint and then complain about the high cost of medical care. Everything is not an Emergency.

If, on the other hand, we remove enough clinical judgment from the medical profession by penalizing it so severely on the rare occasions when it is wrong, we may as well load every patient on a conveyor belt where, despite their complaint, they pass through a full-body CT scanner, an ultrasound station, an indiscriminate lab station, an automatic EKG, and then have cut-rate physicians in India email treatment recommendations to minimum wage technicians at the end of the line.

On another note, the health care system itself, independent of the threat of litigation, is set up to encourage waste. While we don’t actually have a Health Care System per se, just a bunch of independent doctors and hospitals, there are two common threads that run through all of our medical endeavors and which serve as perverse unifying principles. The first is the obvious and inevitable fragmentation of care in our hyper-specialized industry . The second is the sure knowledge of everyone involved that nobody is actually spending their own money.

Consider the typical Family Practice physician seeing his typical panel of thirty patients a day. If he just manages to keep to his schedule giving each patient fifteen minutes of his time that’s a full eight-hour day, not even counting the various patient care tasks for which he receives no reimbursement but still impose an inexorable demand on his time. Unlike lawyers who bill for every minute of their time, a physician is reimbursed for the amount of time the government (and the private insurance firms that follow the government lead) think he should spend with the patient and not how much time he needs to or actually does. Because the reimbursement is so low physicians are forced to substitute volume for quality, running increasingly comorbid patients (the inevitable result of advances in medical knowledge) through their practice at a breakneck speed without the possibility of adequately addressing their many medical problems safely or economically. In their haste to see all of their patients, primary care doctors are forced to refer many of them to expensive specialists for things that they could diagnose, treat, and manage themselves if they had more time. In this manner, specialists are used more as physician extenders than learned consultants who are only brought into the case to help solve thorny diagnostic puzzles or to perform interventions outside the primary care doctor’s scope.

This “gatekeeper” model, where the primary care physician’s chief purpose is to be a clearinghouse for referrals to other physicians, has been a disaster, both from a financial and patient care point of view. A patient being followed by a squad of specialists, none of whom have the time to adequately coordinate care, not only costs many times what it would cost to just let the primary care doctor bill for the time he needs but it leads to a dangerous fragmentation of care where one set of doctors literally have no idea what the other set might be doing. I have seen it many times, often in the elderly patient on a long and bewildering list of dangerous and often medically contradictory medications. When specialists refer to other specialists sometimes even the primary care physician doesn’t know what the hell is going on.

Volume is the problem. Medicine is not like ordering fast food and most of it cannot be automated or standardized despite the best efforts of our friends in the electronic medical records industry, most of whose products are designed more to capture billable activities than medical information. The patients are becoming more complex, not less, and to continue to increase the speed with which we process them will only lead to more fragmentation and expense. Or to put it another way, medicine is not like building an automobile where individual pieces are built off-site, brought together on the assembly line, and efficiently assembled into economical automobiles by reaping the advantages of specialization and division of labor. Our current medical practices are more akin to hauling the chassis of the car to various locations around town, putting on one piece here, another there, none for exactly the correct model and none in any rational order, and then several years later when it is done wondering why the ignition won’t crank and the “engine warning” light won’t go off.

We tolerate this state of affairs because, no matter how much we spend and how fragmented the care, somebody else is always paying for it giving the end user of medical services no incentive and more importantly, no leverage to change things even if they wanted to which most don’t. My demented granny may be followed by a squad of specialists, she may have had every imaging study and intervention under Heaven and Earth ordered for her, she may have hundreds of thousands of dollars spent to extend her life by a handful of months but since I ain’t paying a dime, spend away and the Devil take the hindmost.

How I Am Learning to Throw Money Away With Both Hands and a Big Shovel

Throwing Money Away and other Medical Topics

(I confess, what with the feasting, shopping, caroling, and wassailing of the holidays I cannot collect my thoughts to write anything coherent longer than a couple of paragraphs. My apologies. -PB)

Taking Leave of our Common Sense

In a previous article I mentioned that politically, health care reform was not a big issue for me and I was instead more concerned about national defense and killing terrorists. I reiterate that from a purely utilitarian point of view, building, equipping, and manning a Carrier Battle Group is a better way to spend our national treasure than attempting to guarantee free health care for all. I know that as physicians we’re supposed to believe in medical care like foxes believe in chickens but there are more important things in life most of the time, for most people, most of whom don’t need that much medical care except on infrequent occasions. It is more the fear of not getting medical care that is driving the current electoral panic rather than any real risk that anbody is going to be left outside the door of the hospital for lack of insurance. While it is true that there is a small subset of the population who have no medical insurance, this doesn’t mean that the majority of them have no access. We act as if access can only be had if somebody else pays the bill but large numbers of the uninsured could afford major medical insurance and their own primary care (which is not expensive) except that they have other priorities. There is nothing preventing their access to medical care except their reluctance to divert money from other, more important discretionary spending.

That and a lack of primary care physicians but that’s not a problem that can be solved by giving everybody free health care. Even the insured have difficulty finding a doctor and waving a magic wand, declaring that the unwashed now have access, and even throwing a bunch of money at the problem is not going to materialize a couple hundred thousand primary care physicians out of nowhere.

The real question is whether somebody who doesn’t care about their health should get free health care courtesy of the public treasury. A pack of cigarettes costs around five bucks in my neck of the woods. That’s 150 bucks a month, to which we can add another couple hundred for booze and other irregular pleasures. With this kind of money changing hands even among the Holy Underserved, it is inexplicable why you or I should be asked to finance their routine health care except through some sort of quasi-extortion where the usual suspects pushing We-Swear-It’s-Not-Socialized-Medicine hold a gun to the patient’s head and threaten us with higher costs down the road if we don’t cough up some money now. Or look at it like a mugging where, to avoid getting hurt, we’re supposed to hand over our wallet without making any trouble.

The key concept is that primary care is not expensive and, under the care of a physician who has the time to think about a patient, it can be extremely effective in keeping chronic conditions stable or at least delaying the inevitable expensive interventions significantly. But only if the patients give a crap about their health which no amount of free health care will do a thing to encourage. In other words, a good predictor of how much or little expensive medical care you will eventually need during your life is the amount you care about your own health. If you care, you will pay for the occasional doctor visit even if you have no insurance and both take your medications (which are hopefully inexpensive generics) as well as take steps to modify your lifestyle. If you don’t care then you will ignore your doctor, decide that personal watercraft are more important than your blood pressure medication, and despite getting all the free primary care in the world you will still end up dying the death of a thousand interventions as you decompose slowly in the medical triangle trade. (Nursing home to Emergency Department to Intensive Care Unit.)

To smoke a pack a day in the face of severe emphysema or to choose booze over your antibiotics is to demonstrate that you don’t give a rat’s ass about your health. If you don’t, why should anybody else except because of the previously mentioned blackmail mentality?

Throwing Money Away

Primary care is dying in this country, largely because the the government which sets both the amount that doctors are reimbursed for their time as well as pattern by which private insurance reimburses, has decided that cognitive skills are less valuable than throwing a lot of procedures at the patient. Most of this is a lack of trust by parsimonious bureaucrats who reflect the general American character trait of preferring action to deliberation. A typical patient, if he gets a large bill from an internist who did nothing but ask a lot of questions, poke him a little bit, and then lean back in his chair staring at the ceiling while he thought about the case, feels as if he’s been cheated. After all, he spent an hour with the guy and he didn’t do a thing but change his medications a little and give him some advice.

The motherfucker didn’t even order any tests.

On the other hand if he presents to the Emergency Department and is loaded to the gills with intravenous contrast dye and then assaulted with every possible test and invasive procedure imaginable, the typical patient or his family will settle complacently into their happy zone convinced that now, finally, they are getting their money’s worth. Doesn’t matter that much of what is done is unnecessary or at least could have been replaced with a little bit of sound clinical judgement, nobody’s happy until they see some action.

This is not to say that people don’t want to spend a lot of time with their doctor, just that they don’t feel they should have to pay more than a couple of bucks for the privilege. Thinking is easy, after all. It’s not like the doctor had to do anything. The government has picked up on this philosophy and has subsequently come up with the perfect formula to save money which, as is typical when people who are qualified for nothing else but government come up with a plan, has resulted in large amounts of money being thrown away.

Consider the typical internist or family physician trying to keep the lights on in his practice. The amount that Medicare or Medicaid (and private insurance as they typically take their reimbursement guidance from the government) pays the doctor for his cognitive skills; the traditional history, physical exam, and clinical judgment, is so small in relation to both his expenses and his completely reasonable desire to make as least as much as a decent auto mechanic that he is forced to run a high volume practice. Of course, not every patient requires a long visit and certainly a more complicated patient can be given a little more time but when you are seeing thirty patients a day, you can see that it is impossible to give the truly sick and the multiply co-morbid the time that they need.

The typical elderly patient who needs anything more than a routine physical exam cannot have her problems addressed in a fifteen minute visit, much of which is taken up by compliance and admininistrative tasks. Consequently, there is a disturbing tendency to consult specialists for every medical problem that will take more than fifteen minutes to address (a tendency that is completely separate from the legal imperative to fend off the predatory plaintiff’s attorneys). The result of this is that you have three or four doctors doing the work that one could do with all of the lost time and inefficiency that this entails. Additionally, under the theory that to the man with a hammer everything is a nail, when you send a patient to a specialist they are going to use their signature procedures to the full extent allowed by reimbursment and ethics. In other words, the default position of a gastroenterologist is to perform the colonoscopy because short of this, he may be adding nothing of value to the patient’s care. Now, I’m not saying that there is no use for specialists, just that sending a patient to a specialist to confirm something you already know or to implement a treatment plan that you would start yourself is a waste of money…except that the economic realities of primary care make it impossible not to use them like this.

Many specialists are used as nothing more than physician extenders, kind of like mid-level providers if you think about it, for busy primary care physicians who know what to do but don’t have the time.

The Ticking Time Bomb

Having patients followed on a routine basis by a cadre of specialists is not only wasteful but dangerous. Under the team-based health care delivery philosophy, physicians are supposed to communicate with each other but, as talking to other doctors is generally non-reimbursable time, communication suffers for the same reason every other poorly-reimbursed activity suffers. The danger is that patients who are being followed by a disorganized squad of specialists will receive dangerous interventions and studies seemingly willy-nilly and, most importantly, are placed on long lists of medications, the interactions of which cannot possibly be fathomed except that someone has the time to sit down and spend an expensive half hour doing it. I regularly see patients with one-page medication lists taking three or four medications of the same class as well as medications that seemingly act at cross-purposes, not to mention having the potential for dangerous interactions.

I know perfectly well that many patients require this kind of complexity but after you see enough unexplainable altered mental status, coumadin levels (INR, I mean) through the roof, as well as the effects of everybody’s favorite loaded gun, digoxin, you sometimes wonder if anybody has ever taken the time to verify that yer’ demented granny really needs to be on 20 different pills.

Now, and I’m just thinking out loud here, what cardioprotective effects are we getting by keeping an 89-year-old woman on a beta-blocker, a statin, and an ACE inhibitor that are not completely offset by the possibility of side-effects and dangerous interactions with her other medications? It is this and other questions that need to be addressed and decisively answered by one doctor who has the time, via adequate reimbursement, to do it. The alternative is highly fragmented and slipshod care.

And no, it is not enough to expect the patient to keep track of these things. Some can of course, but it is very common for the multiply comorbid patient to know nothing more about his medications than their colors and shapes or that one is a water pill and another is for his “gouch.” In an ideal world, the only variable would be the compliance of the patient, not the confusion that results from trying to coordinate the care of various specialists.

Happy New Year

Another one has come and gone. One day, as the memory of medical school and residency fades and I have to devote most of my free time to moonlighting at Taco Bell to make ends meet under whatever silly health care reform comes out of the trailer parks, ghettos, universities, and other islands of provinciality and entitlement in America, I may grow tired of this blog. As I am, however, still going strong, I appreciate your taking the time to spend your time reading and I hope I can continue to provide you with a good reason for doing it. As always I appreciate all comments even the ones I have to delete.

Hey, we have rules on this blog. I had to go to a moderated comment format because of a few people with bad manners and I hope this hasn’t been too much of a burden. Not to mention that my spam filter catches about a thousand spam comments a day which leads me to this question: What on earth has Britney Spears done to deserve this kind of attention? Fully half of all the spam comments I receive promise to link me to naked pictures of her in all kinds of situations. I’m just not that interested. In fact, my interest in Paris Hilton, Anna Nichole Smith, and Anglina Jolie, the other members of the internet Gang of Four, is about a 0.001 on the ten-point pain scale.

Throwing Money Away and other Medical Topics

Putting Granny Down and Other Health Care Conundrums

(I hesitate to present this article because everything in it is so indisputable to those who work in health care that I might be accused of belaboring the obvious. With this in mind I ask for the indulgence of you, oh my regular readers, who may skip this article entirely as nothing new will be covered. I submit this article in the hope that random internet passers-by, people who have no idea how health care is delivered, will find something interesting in it and that it may give them a different perspective from their usual desire to pay as little as possible for a service that they think comes as easily as turning a tap provides water. I also want to give a hat-tip to the Happy Hospitalist for his excellent series of articles laying out some of the facts of life about health care and its cost.-PB)

Bread and Circuses

This is not a political blog and I like to avoid discussing politics as much as possible for not the least of which reasons that civil debate is impossible even with many who consider themselves well-informed and open-minded. You can, for example, have what you believe to be a reasonable conversation with what you take to be a rational person when something inside them snaps and they start foaming at the mouth about the CIA plot to topple the World Trade Towers, blame the Muslims, and allow President Bush to assume dictatorial powers. This sort of thing used to be confined to the lunatic fringe but now even otherwise respectable political candidates, sensing that kookery has become more prevalent, will cater to these kinds of impulses. This is not to say that we don’t have long history of colorful politics in our country but only that we have not advanced much in our political discourse in the last 231 years. The mob gets an idea in its head, placed there or at least reinforced by its political leaders, and the thing is obliged to run its course no matter how destructive or ridiculous.

The latest idee fixe of the mob is that Health Care is a right and sensing the political winds, even some of the Republican candidates in the impending presidential election, ostensibly from a party that traditionally serves as a check to some of the more destructive initiatives coming from the left, have embraced the notion. What the left means, of course, by declaring medical care to be a right is that someone else needs to provide it regardless of the effort required. The Holy Grail of the left, after all, is the quest to have someone else take care of all of their basic human needs leaving them free to work at some meaningless public service job from which they can never be fired and which shelters them from the productive sector. (College professors, who strive mightily for tenure and the shelter from the world that it provides, perfectly epitomize the desire of many to fall into the comforting bosom of the nanny state.) As it has never been hard to convince people that things should be free, in this particular lying season the race is on to see who can give away as much of other people’s time and effort as possible. Some political candidates will be more overt taking the more obvious socialistic route while others will be more circumspect, inventing ingenious formulas to prove that we can pay for all the health care everybody needs without spending every dollar of tax revenue doing it and without comprimising any of the other legitimate functions of government. We have but to fix the health care system and everything is going to fall into place.

The premise of the health care debate is wrong, however. The health care system in this country is not broken. It is a beautifully evolved creature, functioning perfectly, and exquisitely adpated to the political, legal, and economic environment in which it operates. In other words, every initiative to fix health care wil be useless, as ineffectual as rearranging the china while the bull still rampages, unless the underlying conditions that dictate the current system are addessed and there are very few political candidates with the political courage or even the understanding of the problem to do it.

Consider first the legal environment in which we operate. It has been correctly pointed out that awarded damages and even malpractice insurance costs account for a relatively small fraction of total health care expenses. This fact is used by plaintiff’s attorneys to justify their depredation on physicians and hospitals, tacitly admitting that while they may be somewhat overzealous as they chase ambulances, their activities amount to very minor parasitism and should be ignored. It cannot be denied, however, by anyone who has been less than a quarter of a mile from a real patient that a large portion of a physician’s work, and by extension the support staff’s and the hospital’s, is devoted to keeping the lawyers at bay. What is most paperwork, after all, but an attempt to cover oneself legally against every possible bad outcome, even those that are an inevitable result of either the patient’s own incredibly bad health or equally incredible irresponsibility. On the witness stand, unfortunately, every patient is a sympathetic figure who has been harmed by an incompetent doctor from whom not only absolute perfection but absloute omniscience is expected.

It is no wonder then that much of a physician’s time is spent wrestling increasingly detailed paperwork designed to automatically protect against legal jeopardy. Little of this time has anything to do with patient care and yet oppressive paperwork is so indispensable in modern medicine that it would be no exagerration to say that most of every physician’s time is spent typing at a computer or writing notes even though it is common knowledge that from a purely medical point of view, everything pertinent about most patients most of the time could be written in big letters on one side of an index card. Who is seeing patients, the real deluge of which is looming and has yet to hit the system as the baby-boomers discover that their coronary arteries are no different from their parent’s, when the doctor is trying to devise medicolegal documentation to dissuade the lawyers?

No one. They tell me that we have a physician shortage and yet the paperwork burden on physicians keeps increasing as even the very hospitals which should be lobbying against this kind of thing invent even more complex paperwork systems to ensure that if anyone should step out of line, the trail of plausible deniability is intact and somebody else, the physician who never completed his JHACO certification in hand washing for example, is the culpable party. It is this lack of trust, this hopeless desire to avoid legal risk, that adds an incredibly expensive burden on our health care system.

In addition to the paperwork requirements, the wasteful and futile effort to prevent the legal profession from finding chinks in our professional armor, the threat of litigation forces the physician to ignore good medical practices and common sense in how health care resources are spent. There is, it seems, no complaint too trivial or no presentation of a chronic condition that does not require a physician, if he wishes to avoid placing his career and property in jeopardy, to order every test and study under the sun on a fishing expedition to avoid the possiblilty of a missed diagnosis. Thus do many patients with vague abdominal pain and unimpressive physical exam findings receive a healthy volley of testing and imaging, the exact extent of which is often dependent on how often or if the physician has ever been sued for a missed diagnosis.

The point here is that some conditions will be missed. If you want to minimize this probability, already vanishingly small just using the traditional skills of history and physical exam, it is going to cost money, a lot of money, as we are well within the realm of diminshing marginal returns and playing the zero-defect game, while it may pick up the rare silent presentation of a deadly disease, results in a huge number of expensive, low probability studies which only confirm what we already know, namely that the patient is not sick. You cannot have it both ways, on one hand opining that health care is expensive but on the other insisting that expensive technology should always trump medical judgement. The current system is adpated to allow physicians to survive both the onslaugt of the legal profession and the often unreasonable expectaions of patients who are conditioned to expect a test or a study and won’t believe a doctor unless they see the labs.

Things Cost What They Cost

I had a patient several months ago, a very pleasant, otherwise healthy middle-aged gentleman who looked fit and had obviously spent his life taking care of his health. He stated that he was an avid runner and he looked the part, several orders of magnitude fitter than most of my patients that day who were half his age. His presenting complaint was a vague, intermittant sensation of chest pressure which had started several months before and which he had been ignoring until his equally fit, highly intelligent wife had finally ordered him to come to the Emergency Department. He was without symptoms at presentation with a completely normal EKG and, other than his age, had absolutely no risk factors for coronary artery disease. As he had a very good cardiac story, we began our standard cardiac workup (that we actually do even if the story is not so good), fully expecting that all of his laboratory studies would be negative and he would be admitted for a routine exercise stress test which would probably be negative after which he would be easily discharged with the usual boiler-plate discharge instruction for chest pain of an unknown origin.

Twenty minutes after I first saw him he developed a mild, constant nagging ache in his chest which was initially relieved by subligual nitroglycerine. A repeat EKG showed what are known as ST-segment depressions (indicators of ongoing ischemia) in the lateral leads. This was followed shortly by an unequivocally positive Troponin, one of the standard cardiac markers. Clearly there was something going on and our disposition plans changed accordingly to an immediate cardiology consult for an as yet urgent (but non-emergent, you understand) coronary artery catheterization. He was definitely “ruling in” as we say.

Shortly after our call to cardiology the patient develop more severe chest pain which could only briefly be managed with a nitroglycerin drip and morphine before it became excruciating, doubling the patient over with pain and nausea. Another EKG now showed pronounced ST-segment elevations, the harbinger of ongoing myocardial infarction, in the inferior leads. The patient was now having a massive heart attack, all in the space of less than an hour from a standing start of a normal EKG and no symptoms. He was taken to the cath lab for an immediate catheterization which showed an almost complete occlusion of his entire right coronary artery, not quite as bad as an occulsion of the Left Anterior Descending Artery (also known as the widow-maker) but bad enough and certainly a life-threatening or life-ending event all the same.

He walked out of the hospital two days later “feeling great” with plans to contnue his healthy lifestyle.

Fifty years ago this gentleman would have either died in the Emergency Department or shortly thereafter. At the very least he would have left the hospital after a several week stay so debilitated that a normal life would have been impossible and probably would have continued to have heart attacks and arrythmias until one or the other finally killed him, probably fairly soon. Although he may have had an extensive hospital stay, he would not have received forty thousand dollars worth of life-saving medical interventions and the health care system would be spared the inevitable expense of the complications that would have developed as my patient aged and, despite his healthy lifestyle, reached and passed his pre-programmed genetic obsolescence.

This is one patient. A guy who is doing everything he’s supposed to and yet I have no doubt that the cost of his health care will eventually run into the millions of dollars as greater and greater efforts are made to save his life. Now consider that most of my chronically sick patients are in no way making even the slightest effort to take care of their health and, where my otherwise healthy patient had an isolated cardiac event which should be relatively easy to manage, these patients each have several to a dozen deadly medical problems which are only prevented from killing them by the expenditure of vast sums of health care dollars. Fifty years ago they would not have survived the intial heart attack or the the failure of their kidneys. Their kindly country doctor would have arrived at the house with his well-worn doctor’s bag, examined the patient, looked appropriately grave and directed the family to call their priest and the funeral home. The total cost to the health care system would have been whatever the doctor charged for his visit and the patient’s family themselves would have paid the bill.

It is therefore senseless to complain about the cost of health care and long for the fairly recent days when providing medical care did not suck up a fifth of our gross domestic product. Times have changed. Medical care today is expensive because it is a sophisticated enterprise employing some of the highest-skilled and most intelligent people in our society. Fifty years ago, while doctors were equally intelligent and trained to be superlative diagnosticians, the treatment options for serious medical conditions were severely limited and the deteriorating course of a cancer patient, for example, was followed more for the intellectual exercise than for the ability to intervene. There was no Golden Age of medicine when doctors were more caring and provided effective and economical treatments. Doctors may have been more caring fifty years ago but thats’ all they had to offer. It was just play-acting which is not very expensive.

You then, who complain about the cost of medical care should look to yourselves and your own families. Keeping your aged grandmother alive is expensive. The majority of all health care expenditures for a typical pateint are incurred towards the end of their life. As their medical problems accumulate their care becomes a constant battle, waged with expensive specialists and procedures, to briefly stave off the inevitable and ends up costing the health care system thousands of dollars for every month added to the life of the elderly and multiply comorbid. Whether this is a good or a bad use of resources is the subject for another debate. But you can’t have it both ways, on one hand expecting that no expense will be spared squeezing the last dregs of life out of you and your family while at the same time acting shocked, yes shocked, that your health insurance premiums are so high. As the Happy Hospitalist notes, you can’t insure a burning house. The amount of money required to keep your aged gandmother alive at the twiglight of her life far exceeds any health insurance premiums, either to private insurance of Medicare, that she has paid in her life. The money has to come from somewhere. To demand that expenses be reduced is the same as asking that care be withdrawn from somebody else’s grandmother, something that sounds reasonable as long as it is done to somebody else.

Throwing Good Money After Bad

I see the same patient, it seems, several times a day: An octogenerian, severely demented nursing home resident who spends their day laying in their own feces and urine except when they are sent to the Emergency Department by the nervous staff for an exacerabation of one of their many comorbidities. The EMS report usually states that the patient, a person who has not stood upright or talked to anyone since the Clinton administration, has had an alteration in their mental status, a brief interval of decreased oxygen saturation in the setting of severe emphysema, or an irregular heart rate which did not resove under the automatic ministrations of their second Automated Implantable Cardioverter Defibrillator. They are usually found to be septic from one source or another and are often admitted to the ICU for a week or two of highly expensive critical care to stabilize them enough so they may be returned to their warehouse until the next time. This little drama is repeated many times until finally we reach the limit of our ability to cheat the reaper and the patient finally dies in the ICU, usually after one more round of expensive interventions demanded by the family who want no expense spared in the effort to squeeze out one more week of life for the patient..

For perspective, maintaining an ICU bed costs a hospital several thousand dollars per day which someone, somehow, has to pay. Medicare and insurance companies can low-ball doctors with impunity but as the cost of a physician’s services are a relatively small portion of the total cost of running the ICU, an enterprise that involves many highly trained nurses and the latest equipment, there is no way to realistically decrease the expense of taking care of a critical patient.

My European friends, some of them physicians, are amazed at the measures we take to keep patients alive who have absoutely no quality of life and no chance of recovery. The Europeans may have cradle-to-grave socialism but they have a fairly well-defined idea of when to let the patient go to their grave. In the United States it seems sometimes that we want to follow the patient into the mausoleum, trying to the very last to get one more day or even one more hour of life for the patient regardless of cost. This is a mindset that is built into our system, evolving as it has from the egalitarian and extremely misguided notion that the patient or their family should be an equal partner in medical decision making. I say misguided because putting the patient or their family in charge of health care without at the same time making them responsible for their decisions is a formula guaranteed to lead to excessive spending. It is easy to say, “We want everything done,” if someone else is footing the bill. If we but required families of terminally ill patients for whom all care is futile to pay even a fraction of the cost for their care there would be a mad scramble for the proverbial plug.

Whether it is good or bad that patient’s families have so much say in the decision to continue futile care is also the subject for another debate. But as long as there is no disincentive for the families and no ability for the physician to finally throw in the towel, our system is going to be ridiculously expensive at the terminal end and there is no way this will ever change until a political candidate has the guts to say, clearly, that to save money it may be necessary to put your granny down.

Putting Granny Down and Other Health Care Conundrums

What ED Crisis? (And Other Random Thoughts)

Shake that Money Maker

They say there is a crisis in the Emergency Rooms and while I certainly see a little of its effects at my own program, the crisis is not universal. Some Emergency Departments compete for patients, at least this is my understanding from the numerous billboards I saw the other day as I drove towards Detroit. Surely you’ve seen those billboards? You know, the ones with the pleasant looking ethnically ambiguous doctor, stethoscope carried jauntily around his neck, beaming down at a cherubic youngster whose boo-boo he has just fixed with the caption underneath promising a “New Vision of Health Care” with a guaranteed thirty-minute-or-less wait.

And no, they are not advertising for Urgent Care even though they are clearly angling for urgent care patients. The caption clearly indicates these clean, ultramodern medical establishments are Emergency Rooms. Naturally every Emergency Medicine resident must roll his eyes and curse at the idea of attracting even more ridiculoulsy trivial complaints to make his day even more hectic. On the other hand not every Emergency Department is over-crowded and packed with the indigent and uninsured. A nicely appointed ED in a good part of town can generate real income if it has a favorable payer mix. Even if emergency services themselves are not a money maker they can serve as a loss leader to bring paying customers into the hospital (and out of the specialty centers).

I am not against making money and I certainly realize that competition is ultimately good for the consumer in terms of better services and lower prices. On the other hand one can’t help notice that we are, with the exception of the small fraction of the uninsured who can’t bring themsleves to stiff the system, ridiculously over-doctored in the sense that large amounts of health care firepower, the physician’s time being one of the most important, are brought to bear on complaints that are either so trivial as to be laughable or so serious that they are impervious to our best ordinance.

Take, as one example, my patient of last night who the triage note said was a febrile, nauseous, anorexic, dehydrated infant. The nurse rolled her eyes when I picked up the chart which usually tells you all you need to know. Febrile was an axillary temperature of 99 measured at home and 98.7 in triage. Anorexic was a disinterest in feeding earlier in the day but breast feeding vigorously when I introduced myself. Dehydrated was an extremely wet diaper. Not exactly as billed on the triage note.

I have four kids. Every now and then a viral illness sweeps through all or most of them leading to a solid week of vomiting, diarrhea, and sleepless nights as one child after another succumbs and recovers. I have never taken my kids to the Emergency Department and we rarely take them to the doctor, especially for self-limiting things like that. They’re kids. They get sick. They usually recover. I understand that occasionally a “stomach flu” is meningitis so we are justifiably cautious with ill or toxic-looking children but come on now. EMTALA aside, what we really need is the ability to send people home from triage, as in, “Are you crazy? This is an Emergency Department and you ain’t sick.”

We don’t of course, and the large minority of patients for whom we can and should do nothing contribute to the excessive waiting time for patients who, while not exactly critically ill, never-the-less should be seen sooner than the what can amount to a ten hour or more wait in some departments.

On the other extreme, I see many incredibly old, incredibly sick, fantastically complicated patients who all present for some variation of being as old as dirt and sick as stink. Perhaps complicated is the wrong word. There’s nothing complicated about impending death. When you’re pushing 100 nothing is really standing between you and the Grim Reaper except he’s finishing his bagel and latte and he’ll get to you when he gets to you, dammit. We do what we can but we’re hard up against biology. The interesting thing about these patients is that they swim through the murky depths of American medicine accompanied by a small school of physicians who, like pilot fish, dart ineffectually around their decrepit shark picking off an occasional parasite. Between the cardiologist, the neurologist, the internist, the oncologist, the nephrologist, and the nice young girl in physical therapy who manipulates the fins every now and then these patients devour an incredible amount of medical resources.

My point? Nothing really except we get the health care system for which we pay. The current system can not help but be ridiculously expensive because of the way it is structured. Nothing wili ever change, no matter how or to whom you shift the costs because:

1.Patients are not encouraged or expected to take personal responsibility for their own health.

2. As every insurance scheme insulates the patient from the true cost of health care, there is no incentive for patients to make good economic decisions.

3. The legal environment makes it impossible for anyone in authority to exercise common sense. When I was younger, for example, drunks went to the drunk tank at the police station. Now they all come through the Emergency Department where they are expensive, space-occupying lesions. I understand that in our risk-averse society this is necessary to prevent the possibility of a habitual drunk aspirating his own vomit and dying without immeidate medical care. At the same time this kind of risk management isn’t cheap. If the public knew the cost they might be willing to live with slight chance of a drunk or two dying in police custody.

4. Futile care, which is in no way discouraged, sucks up a vast amount of medical care, everything from the physicians time to the cleaning lady mopping the floor of the ICU. Maybe by the time a patient is being fed through a tube, urinates through a tube, defecates through a tube, and breathes through a tube it’s time to let them go.

5. Doctors don’t know how to say “no” or admit defeat. The temptation, to which we easily succumb, is to shift responsibility by consulting specialists. I understand the need for specialists but by the time a patient accumulates a small platoon of them its time to examine, in terms of mortality versus cost, what all of the hired guns are really buying us.

The true crime is that the zealots believe a single-payer system or some other scheme of “We Swear It’s Not Socialized Medicine” is going to make health care less expensive. Unfortunately, until the structural problems are addressed, health care will just keep getting more expensive. To address them is, ironically, to preclude the need for anything other than consumer driven changes which are the only kind that will work.

What ED Crisis? (And Other Random Thoughts)