Friday Flashback - First Pass

She was, my patient conceded, "a bit overweight." In medical terminology, she was morbidly obese. She weighed about 280 pounds, and her BMI was somewhere over 50, seeing as she stood only five foot two. In more vivid verbiage, she might have been described as resembling nothing so much as a bowling ball, a round body with spindly legs and arms jutting out at improbable angles.

Her complaint was "headache" and her temperature was 102.8 degrees Fahrenheit. She was on multiple immunosuppressants, including steroids, for a mixed connective-tissue disorder. There was no apparent explanation for her fever -- no urinary tract infection, no cough or runny nose. As I gently flexed her neck forward, she winced.

And I winced.

Because there was just no option -- she needed a spinal tap to assess for meningitis. And with a body type like hers, the likelihood was that it would be a flog. I could see where this was going to end up -- a half hour of torturing this nice lady trying to get the tap myself; a call to interventional radiology and the obligate half-hour delay in the call-back; enduring the open scorn (best case) or scathing abuse (worst case) of the radiologist who was called in the middle of the night to do the procedure under x-ray guidance. There was seven hours left to go in my shift, I reflected, and I would be lucky if I could get the disposition accomplished before then.

So, first off, I got set up to give it the obligate college try. Lie her on her right side and set up the table as usual, as if this is anything other than going through the motions. I set up the test tubes, neatly in a row, as if there is a chance they will soon be filled with glistening CSF. I go through my usual pre-procedure patter, trying to put her at ease and trying to get myself to believe that this is just like any other tap I will do this week.

Sitting on my little stool, face to face with the small of her back, I could not find a single anatomic landmark to guide me. The spinous processes were buried under a thick layer of fat and not at all palpable. The iliac crest at the top of the hip-bone was similarly obscured. For that matter, I couldn't even positively identify the midline! The nurse and the patient's husband watched me, their expressions full of a simple confidence that I would quickly put this to rest. How little they know, I thought. I was careful to give her a healthy dose of numbing medicine and premedicated her for the procedure with dilaudid, figuring I was about to be causing her some pain. I made my best estimate of the locations and angles I would try, placed the needle against her clean skin and closed my eyes before sliding the needle in by feel alone. I waited for the sudden, hard resistance that would indicate I had just rammed the needle into bone. But it didn't come. Bemused, I pulled the stylet back and peered into the hub of the needle. Crystal clear fluid briskly welled up and began to drip out.

My jaw was hanging open behind my surgical mask, but my eyes and voice hid my astonishment as I said "We're in," in my most professional tone and began to collect the fluid. The nurse cooed, "There, that wasn't so bad, was it?" And the patient replied, "I didn't feel a thing. Is it always that easy?"

Easy? Yeah, that's the word for it: easy. Well, as far as they know...

-----------------------------------------------

The icing on the cake came an hour later:
WBC: 0
RBC: 0

Originally Posted 16 July 2007

Restrictions on opiate prescriptions in WA state?

This is interesting (via NYT):

Move to Restrict Pain Killers Puts Onus on Doctors

The effort, in Washington State, represents the most sweeping attempt yet to stem what some experts see as the excessive use of prescribed narcotics, and it is being closely watched by medical professionals elsewhere. Among other things, Washington would apparently become the first state to require a doctor to refer patients on escalating doses of pain killers for evaluation if they were not improving.

Experts in pain treatment and drug abuse prevention say the growing use of long-acting pain killers like OxyContin, fentanyl and methadone has been a crucial factor in a nationwide epidemic of overdose deaths, largely from the abuse of such drugs.

Drug makers and patient groups have complained that new restrictions would unfairly punish pain sufferers who rely on the drugs. Others, including some doctors and regulators, have argued that the drugs are potentially so dangerous that they need to be even more tightly controlled.

However, the Washington State initiative appears to reflect a growing view that the status-quo is no longer acceptable. Last Friday, an advisory panel to the Food and Drug Administration overwhelmingly rejected an agency proposal to better control drugs like OxyContin as too weak because it did not require special training for doctors who prescribe such medications.

The effort in Washington is also directed at controlling how doctors use narcotics to treat legitimate pain patients, not at people who illegally obtain the drugs for recreational use. While many patients benefit from pain killers, there is growing evidence from studies, including one in Washington State, that others suffer significant side effects, including lethargy, increased sensitivity to pain and, in the most severe instances, potentially fatal overdoses. [...]

The panel is expected to require that, among other things, doctors refer patients to a pain specialist for review when their daily medication increases to a specified dosage level and they do not show improvement. The specialist can then determine whether to continue the drug, reduce it or use other treatments like physical therapy.

Recently, the Centers for Disease Control issued a similar recommendation to doctors.

Pain specialists and regulators in Washington State said they thought the requirements were essential because doctors were giving high daily dosages of powerful drugs for ailments like back pain for far too long without evidence that the drugs worked.

The law that created the new regulatory effort in Washington State did not propose specific sanctions or penalties. However, officials there said that a doctor who chose to ignore the new rules could face sanctions from state licensing boards, including potentially losing the right to practice. The company that makes OxyContin, Purdue Pharma, lobbied against the law, saying the new regulations could deprive patients of appropriate treatment.

The initiative sprang out of the efforts of Dr. Cahana and two other people, including a Washington State representative, James C. Moeller, who is also a substance abuse counselor.

Mr. Moeller, who works at a facility in Vancouver, Wash., run by Kaiser Permanente, said he had treated a steady procession of patients in recent years, nearly all of them young and physically dependent or psychologically addicted to high dosages of pain killers.

In the process, Mr. Moeller said, he realized that many doctors who prescribed such drugs had little training in either pain management or substance abuse. So, wearing his legislator’s hat, he drafted a bill to require doctors to take a training course to prescribe narcotics.

He said he quickly encountered opposition to the idea from a professional group that represented doctors. [...]

“There is a dissonance in not recognizing the nexus between poor pain management and the hyperconsumption of opioids,” said Dr. Cahana, who works at the University of Washington Medical Center in Seattle, using a medical term for narcotic pain killers like OxyContin.

Dr. Franklin, whose department oversees the state’s workers’ compensation program, said he had long seen the problem play out among claimants. “Injured workers were coming into the system with low back pain and dying two or three years later” from drug overdoses, he said.

This year, Dr. Cahana and Dr. Franklin testified during a legislative hearing on the proposed training requirement, suggesting that legislation should instead require a set of medical practices based on the best available evidence. Dr. Franklin said that a draft of rules would probably be finished by this fall and that the new regulations would be in place by next year.

A major hurdle to making the program work is the lack of pain management specialists, particularly in rural areas of the state, where patients could be referred for evaluation. Dr. Franklin said the state hoped to increase the use of telephone consultations as well as help to finance the training of doctors in pain treatment.

 

I'm not sure what to think about this.  I've been pretty appalled by the proliferation of narcotic super-users, people on what you might call "hyper-doses" of pain meds for chronic and incurable conditions.  The most striking thing I have noticed is the high likelihood, when I see a patient on 160mg of oxycontin TID, is that it's not working, and they are still complaining of uncontrolled pain! I can concede that there is a selection bias in the ER and I am more likely to see people whose pain is uncontrolled by the nature of the setting. However, it is striking that the pain specialists seem to have a similar experience.  I really think that it would be an overall social good if the wanton use (because it is in many cases wanton) of these medications by non-pain-specialists were reined in.

But. (You knew there was a but coming, right?)

It's inarguably true that there are not and will not be in the foreseeable future enough pain specialists to see all the people who might need this "referral." Medicaid patients (who are more likely to be on chronic pain medicines because there is a high correlation between chronic pain, disability and the poverty that qualifies one for medicaid) have it even worse since pain specialists are no more willing to see money-losing patients than any other office-based physician is.

There's a similar concern regarding the requirement for special training requirements for doctors to prescribe Oxys and the like, since my experience is that many primary care doctors are reluctant to take these course and might simply use it as a pretext to stop prescribing these drugs at all.  So the effect might be that many patients, many who are appropriately treated, might simply get cut off.

It's a tough problem. I don't see an easy solution, or any solution without significant risks.  But it is clear that the status quo is not acceptable and that something needs to be done.

From the comments

Regarding my post on blogging toxicity, Mark commented:

Replace "the Navy" with "emergency medicine".

In the common, natural course of events physicians, surgeons and apothecaries are faced with enormous demands for sympathy: they may come into immediate contact with half a dozen deeply distressing cases in a single day. Those who are not saints are in danger of running out of funds and becoming bankrupt, a state which deprives them of a great deal of their humanity. If the man is in private practice he is obliged to utter more or less appropriate words to preserve his connection, his living; and the mere adaption of a compassionate face as you have no doubt observed goes some little way towards producing at least the ghost of pity. But our patients cannot leave us. They have no alternative. We are not required to put on a conciliating expression, for our inhumanity in no way affects our livelihood. We have a monopoly; and I believe that many of us pay a very ugly price for it in the long run. You must already have met a number of callous idle self-important self-indulgent hard-hearted pragmatic brutes wherever the patients have no free choice: and if you remain in the Navy you will meet a great many more.

--Stephen Maturin, The Nutmeg of Consolation by Patrick O'Brian

Wonderful quote, and very apt.  It's that much better that it comes from one of my favorite literary series.  If you haven't checked out the Maturin/Aubrey series (the movie Master and Commander was based on them) you really should.

Let it be noted

The patient was in her late sixties. She presented with an acute headache and confusion. She was diabetic, with a high white blood count, and had a fever at home.  She also weighed 350 pounds and stood all of 5'2".

There was no way around the unpleasant fact that she needed a spinal tap.

I avoided the procedure for a solid hour, finding other important tasks to keep myself busy, but eventually I had to face the music and try the tap.  These are tough enough on only moderately plump folks, and in the morbidly obese patient they are incredibly difficult.  This lady was too weak to sit up on her own, so I had two techs wrestle her into an upright seated position, and, sweating, brace her in place while I contemplated her back.  There were no hints as to any landmarks but, sitting up, at least I had a vague idea of where the midline was. I (literally) closed my eyes and jabbed the needle in at random.   I shoved it all the way in, burying the hilt and even pushing it in further, indenting the skin and subcutaneous fat.

It is hard to register my shock and delight when pressurized CSF came jetting out.

I collected my specimens and the techs gratefully laid the patient back down.  I then proceeded to the nursing station where I did the "I Am So Awesome Dance of Victory and Unrestrained Joy."  One of the nurses put a couple of ice cubes down the back of my shirt, terminating the "I Am So Awesome Dance of Victory and Unrestrained Joy."

But I am still awesome.

Here we go again

Back in the day when we were a small group, we were what you would say is "very stable."  People came and tended to stay for a long time, and we had very few job openings due to people leaving.  The jobs that we created were usually due to volume growth and the occasional retirement.

So recruiting was a simple affair, conducted once a year. We figured out how many new docs we would need and recruited them out of residency.  They started in July and we could forget about it until the following year.

But once we hit a certain size threshold, it suddenly became apparent that attrition was going to become a more prominent factor in our staffing.  When there are fifteen docs in a group, stability is the norm. When you are up to thirty, things seem to happen with more frequency. People get sick. They decide to move back East or back to California to be with family. They decide that Emergency Medicine is just not the right career for them.  They have kids and decide to go half-time. Life happens, and as a result we start hiring to replace as much as to expand. (The one good thing is that we almost never have docs leave to go work for a local competitor.)

Still, we kept on our once-a-year recruiting schedule, just now with larger numbers of hires. As you get a little short-staffed during the year, you suck it up until the new crop of docs shows up over the summer.  And in July, watch out! A bunch of wide-eyed new attendings hit the floor all at once.

But we continued to grow. Now we are up to 45 docs, and we have had to switch to a more continuous hiring cycle.  We just can't afford to wait until July and get all our new staff at one time. So it's like a treadmill, reviewing CVs and interviewing and reference checks, we keep going and going and going.

I actually don't mind -- it's a lot of work but it's fun and it's important. I have now personally hired over half the docs in our group and it's very satisfying to see what a great group of physicians and people they have turned out to be.

We are just finishing orienting the summer hires and are collecting CVs for fall/winter hires. If you are an ER residency-trained doc interested in working in a large community-based democratic practice in the Pacific Northwest, feel free to email me and I will tell you more about the practice and the opportunities here.

And now I'm off to check some references.  Here we go again...

Finding the right tone

Dr Wes has a timely post today which reflects something I also have been struggling with of late. I get disheartened, sometimes, sifting through the dark swamp that is the med-blogosphere.  A substantial fraction of physicians' blogs, especially some of the emergency physicians' blogs, are unpleasant to read.  Which is not to say that they are wrong about things, or that their politics are simply opposed to mine or that their perspectives are not valid.  It's just that there is, for some, a toxicity: anger and resentment, inchoate but always present, in so many blogs. 

The ones that I simply cannot stand are the ones which are hostile or disrespectful towards patients.  I get it -- the ER is an incredibly effective bottom filter for society.  We see the weirdest things, we see people when they are at their worst. I've been known to marvel at the things that come through the door from time to time.  I try, maybe with imperfect success, to be respectful of patients' dignity and humanity.  Yes, you shake you head and wonder what the hell they were thinking.  When it's funny you can't help but laugh. Amid it all, though, I always try to remember that these poor souls are here for my help (whether I can help them or not) and that it's an utter betrayal of my raison d'etre to belittle or attack them.  There was an ER blog a few years ago which commonly used the acronym "WPOS" to describe patients they didn't like -- "Worthless Piece of Shit."  That's the sort of thing that gets me.

Some ER docs also use their blogs to vent about their challenging patients. That also bothers me. Again, I get it -- ER patients can be really nasty characters sometimes, and FSM knows I don't like all of my patients. They are frustrating and maddening sometimes. Venting can feel therapeutic. Whether it's appropriate o not, I will leave to the ethical censors of the internet, but for myself I feel uncomfortable reading physicians rant about how pissed off they are at their patients, with venom in their tone.

And then there's politics. This has nothing to do with Right or Left, but with rage. There's such a stark divide between the cool dispassion of the health policy blogs and the anger that wells up from doctors when they discuss the system we work in. There's a fair argument that if you are not angry then you are not paying attention, and that it's a maddening system to work in.  But who wants to be around someone who is spitting mad all the time, who seizes on every new bit of information with an aggrieved and indignant voice?  Some folks cherish their anger and stoke it carefully to maintain their fever pitch of righteous fury.  Which is their right, of course. I'm just tired of reading it.

So for me the solution is obvious.  I culled my reader list aggressively (a difficult task for the information omnivore that I am) to reflect the blogs that are written by someone I feel like I would like to sit down and have a beer with. And rather than spending a whole post bemoaning the negatives, I thought I would take a few moments to highlight a few doctors' blogs which I very much enjoy reading.  This is very much not a comprehensive list:

ER docs:
Life in the Fast Lane
The best EM blog on the net, in my opinion.  These Aussies (and at least one Kiwi) have a blog which is educational and fun to read. I admit that I don't always "get" their "humor" which includes a set of obtuse specialty societies such as the UCEM (Utopian College of Emergency Medicine) and the Society for the Prevention of Surgery, but if you chalk it up to living in a culture which produced the didgeridoo and Yahoo Serious, it kind of makes sense.  They don't do patient stories or cases per se, but have lots of actual teaching content and if you're not careful you might learn something.  I have resisted that urge thus far.

StorytellERdoc
Could be viewed as a companion to LITFL. While they are highly academic, StorytellERdoc strives to depict the humanistic and literary side of Emergency Medicine. Seems like a really nice guy who cares about his patients.

GruntDoc
I only put him on the list because I'm afraid he'd shoot me if I didn't. I hear he's becoming quite the marksman.
GD no longer writes much about life in the ER, but he's been around since before electricity and we've had many an engaging conversation. If I ever stop over in DFW I'll let him take me to the shooting range and we won't talk politics.

Other specialties:
Dr Rob
There's something seriously wrong with his brain, in a good way. He's funny and silly and sounds like the sort of doc I'd want to take care of my kids. Yet he's also a techie and pretty savvy on the business and policy side of medicine, too.  If it weren't for his inadequate appreciation of Apple products I might have a man-crush on him.

other things amanzi
Bongi, a surgeon in South Africa, has a wealth of amazing stories -- some because the humanity or the medicine is simply incredible, some because the practice environment is so otherwordly.  He's a great writer, too, even if he hasn't yet figured out that the "shift" key makes capital letters.  Maybe they don't have "shift" keys in South Africa.  I was terribly bummed not to get to meet him in Vegas last year.

Buckeye Surgeon
As a graduate of Northwestern University with vivid memories of our Wildcats losing 63-0 to the Ohio Buckeyes in football, it's hard for me to say anything nice about a blog so named.  But Jeffrey Parks tells good stories -- great medical cases as well as occasional heart-breaking human tales, interspersed with the occasional political rant.

Suture for a Living
Dr Bates is officially the Nicest Person on the Internet.  Her blog varies between quilting and plastic surgery and linkfests. Every so often I send her pictures of interesting lacerations. Lord knows why I would think she would be interested, but she's always been very polite about it.

Respectful Insolence
Orac is amazing. He really shows the difference between being an amateur and a professional blogger. He's a surgeon, a Primary Investigator medical researcher, and also has 7.7 million hits on his blog.  He writes passionate and meticulously detailed articles debunking anti-vax autism loons and all other sorts of pseudo-scientific charlatanry.  How he does it all I'll never know.

db's Medical Rants
"Dr Bob" aka Robert Centor is an academic internist at the University of Alabama School of Medicine. You can tell he's an internist because he cares about the interpretation and meaning and a mixed acid-base disorder, and will frequently torture quiz readers with electrolyte or blood gas puzzlers.

Musings of a Dinosaur
A Family Practice doc in solo practice, she is among the last of a dying breed.  Skeptical of woo-based medicine, she's fierce in her defense of the family practitioner and also wrote a real honest to goodness book. On paper. Yeah, I know.  Weird.

These are just a few of the blogs I read and really enjoy (I read over a hundred, so please don't feel offended if I left yours out).  When I get kind of down about the nastiness out there it can be helpful to reflect that there are a lot of really cool people out there blogging.

Karaoke

Undercover Karaoke with Jewel from Jewel

This is silly but turns out to be utterly charming: Jewel goes incognito to a karaoke bar and sings her own songs.

Friday Flashback - Best Chief Complaint Ever?

I love nurses. Specifically, I live our triage nurses. At our facility, they only let the best nurses, with the most experience and the best bullshit meter (and best ability to spot the one "sick" patient amidst the worried well) to work at triage. It's a little bit of a controversial policy, since the better nurses don't all like to work triage, and some of them feel punished having to work out there more often. But it works well, operationally.

We have a computerized patient tracking system which incorporates all the nursing notes, including triage. The patient's chief complaint is chosen from a preformatted list, and if the complaint just doesn't fit any of the options, our triage nurses default to "PAIN - MULTIPLE" and explain in the narrative portion of the triage note. Sometimes they have a little fun with the story-telling, in an understated, "you need to read between the lines" sort of way. Because it's the medical record, you can't write anything that will get you in trouble. But they still want to say "Holy Shit!" at some of the things that come through triage.

Picking up a patient described as "PAIN - MULTIPLE" is something like unwrapping a present from a schizophrenic gift-giver. It could be something as simple as a MVA on a backboard or it could as easily be an anxious patient with multiple somatic complaints. So it is always with a sense of curiosity and utter dread that I open up the triage note to see whether I have unwrapped a nice little gift or a proverbial lump of coal.

So today, I saw my obligatory "PAIN - MULTIPLE" patient, and with a mixture of horror and delight read the following narrative (which I swear is reproduced verbatim, in its entirety):

22 y/o male, reports that 2 years ago, during foreplay, allowed GF (girlfriend) to squirt douche up his penis. Ever since then, complains of: excessive sweating.


Originally Posted 24 July 2007

I am not Mitch

Just for the record.





But the point is fairly taken, and thinking back, oh yeah, there are stories about me and my classmates that you simply do NOT want to know.

(via: the most excellent Abstruse Goose, which you should be reading.)

Can you see it?

Funny.

Dewey Defeats Truman

Who knew?



Via failblog, of course.

Annals of Crappy Journalism, part 27

This article was sent to me by no fewer than a dozen people, including ACEP and my wife.  So I thought it was worth a response.  It's an AP article with the splashy headline:

Health overhaul may mean longer ER waits, crowding

Interestingly, the article itself is mostly accurate and well-written.  It quotes a friend of mine, Dr Eli Berg, and also Dr Arthur Kellerman, who is rightly highly respected in the field, and it accurately lays out the stresses and challenges in running an efficient ER and trends leading to overcrowding. So on the article itself, I have little quarrel.  With one exception: the headline is misleading and not factually supported by the article itself.

The central thesis of the piece is that the healthcare law will increase ER overcrowding.  While the article nicely describes the causes and problems related to overcrowding, it fails to provide any basis for its suggestion that health care reform will cause further overcrowding, nor does it compare the future-more-overcrowded ERs to the case in which healthcare reform had not passed.

The sole support for the central thesis is the vague reference that Medicaid patients are more likely to use the ER, and also that the Massachusetts experience shows ED volume growth "a bit" ahead of national trends.  Moreover, the author ignores the provisions of the health care law which would alleviate the ER burden (increased training slots for primary care and increased investment in community health clinics, for example).  This is particularly relevant given the implication that the expansion of Medicaid will drive ER use. Medicaid patient overuse ERs (in part) because they have limited access to primary care physicians' offices -- an expansion of Community Health Clinics would be expected to directly mitigate that driver of volumes.  Similarly, the author never examines the revenue effects that the healthcare reform law will have on ERs. Increased volumes combined with improved payer mixes should provide facilities more ability to invest in their ERs, which are by and large chronically undercapitalized, in order to meet current and future demands.  Which effect will be greater is an interesting question that has not been tested to my knowledge, but the honesty of the article is compromised by the fact that the author cherry-picks facts to support a predetermined conclusion.

It would be wrong, of course, to deny the reality that ER visits will continue to increase in coming years. It was pointed out by many during the reform debate that numerous aspects of this bill did not go far enough and that it would be only a "first step" in addressing the problems we have in health care.  My cynical side suggests that if reform opponents had engaged with something more constructive than "death panels" the final product might have been better.  That, however, is water under the bridge.

My issue here, however, is with the misleading headline, which smacks of an agenda to undermine support for the still-contentious reforms.  It's a newsworthy piece, since the fact that the ER crowding crisis is not going away and that more reforms are needed is important. A more accurate headline would have been:

Despite health overhaul, ER crowding to worsen

Which would have dovetailed nicely with suggestions from policy-makers and leaders like Dr Kellerman of things that the government should do to improve the problems facing the nation's ERs.  Instead readers are left with the false impression that the reform bill somehow is making things worse, and no idea how things could be improved.

It's disappointing, because you don't often see such good reporting on the ER crowding crisis in the the lay media, and this otherwise-excellent article will have readers take away exactly the wrong conclusion.

Friday Flashback - Professional Courtesy

I drive too fast. It’s a bad habit I have, and I am unapologetic about it. At least I could say that until recently, I had never bent sheet metal. (And that event occurred at less than ten miles per hour!) As a result, I have had many opportunities to discuss the various nuances of the traffic statues with law enforcement authorities by the roadside. One of the perks of my profession is that the police tend to take a lenient view of my infractions, especially if I was traveling to or from work. We work together a lot in the ER, and that does buy you some license (deserved or not). For example, we see a lot of patients brought in by the police for a “pre-incarceration medical screening exam,” or what the nurses call an “okey-dokey for the pokey.” And we make sure to give them special service – in and out, no waiting.

So I was pretty chapped not too long ago when I actually got a speeding ticket. I was tired and not paying attention after working a night shift, but I can’t complain – it was 76 in a 60. The conversation went like this:

“Hi, I’m Trooper Jones with the State Patrol. Do you know how fast you were going?”
“Well, sir, I’m not sure there’s a right answer to that question.”
(Taking in my scrubs and stethoscope around my neck) “Are you going to work?”
“No, sir, I’m on my way home. I was the overnight doctor in the ER at The Big Hospital.”
“Ah, I see. May I have your license and registration?”

And so on. I was annoyed, but busted fair and square.

But then, two days later, around midnight, who should come into The Big Hospital with an “OK to book” but Trooper Jones! I saw him and said hi; he didn’t recognize me at first. “Remember?” I prompted, “Saturday morning on the trestle, 76 in a 60?” His face went white. He remembered.

But I am a consummate professional, and also not a complete dickhead, so I was resolved to get the trooper back out on the street ASAP. Also, I wanted to get my revenge by being extra nice and service-oriented, to make the cop feel guilty for ticketing me. But I was busy with a couple of actually sick patients, so I ordered an x-ray on the prisoner and made a mental note to get back to them shortly. As it happened, my partner (we are double-covered overnight) signed up for the patient in the interim, so I figured I was off the hook. Oh well.

Three hours later, I walked past the room and noticed the trooper sitting there with a forlorn look.

“What on Earth are you still doing here?” I asked, stunned.
“I don’t know,” replied the trooper. “They came and took an x-ray and never came back.”

I went to my partner. “Bill, what are you doing with the trooper in room 8? He’s been waiting forever!”
“What trooper?” Says he. “There was one in room 7, hours ago, but they left.”
“No, Bill, they’re in 8, and still waiting!”
“Oh, shit!”

So Bill rectifies his error and gets them promptly discharged, belatedly. On his way out, the trooper approaches a nurse he knew socially: “Did I have to wait three hours because I gave that doctor a speeding ticket?” She explained what he really happened, and I am glad, because I would not have wanted him to think I was so petty and vindictive.

But I am glad he got to sit and think about it for a couple of hours…

Greatest Movie Insults of all Time

 

Sheer brilliance.  And of course, NSFW.

Happy Fourth of July wishes (ER style)

Just got an business email from an associate, a fellow ER doc. She and I had been commiserating that we were both working the Fourth, and how crazy it was likely to be.  

She closed her email with the wish: 

Hopefully the rain will keep people in their homes.

Only an ER doc (or, I suppose a police officer) would wish such a thing...

Friday Flashback - Advice for Interns Part Five

Compensation.It's a dirty topic in medicine. Nobody ever wants to admit how much they make, or how that number is derived, or even that money ever has any role in patient care. But that is an elaborate fiction. Money talks, and nothing motivates people like money.

In EM, there tend to be two camps with regard to pay: hourly and productivity-based. Hourly pay is exactly what it sounds like -- you clock in and clock out and get paid a flat hourly rate. Rates vary widely (especially based on geography) but my understanding is that nationally, the average ER doc will get about $125-150/hr.

Productivity pay systems can be much more complex, but generally can be summarized as: instead of an hourly pay rate, you get paid per patient. In most cases, the compensation is determined by the number of patients you see and by the dollars billed per patient. Dollars billed per patient generally relates to how well you documented the patient encounter and your decision-making process and whether your charting quality was sufficient to allow your coders to capture all the legitimate charges.

Some might find this to be off-topic: what does compensation methodology have to do with efficient operation of the ER? I include this here because I strongly believe that in order to optimize the processes in your ED, it is important to have medical staff who are motivated to be as effective as possible. I have worked in settings in which pay was hourly and those which were 100% incentivized. The difference is remarkable. In environments in which a person's individual compensation is not at risk, the motivation to give 100% effort is attenuated. Some docs will do their best because they are altruistic, or for Press-Ganey scores, or just because they are energetic – they are usually the top 25% of docs in any group, either way. But the average doc does about 10% less work, and the bottom quartile really dog it when there is no disincentive against phoning it in. The cumulative effect of this productivity decrement is significant and can really impact the smooth operation of the ER, not to mention the bottom line of the group.

I am sure the comments will fill with stories of lazy ER docs who went to the cafeteria while charts piled up in the racks, places where one doc would be busting his hump while the other spent hours dictating, where two lazy docs played a game of chicken to see who could go the longest without picking up the 300-pound vaginal bleeder. I've seen it time and again. The nurses ask, "Can they not schedule Dr Tortoise with Dr Slug? The department comes to a halt when they are working together." Cases like that are far far more common when the docs are paid hourly.

But when each patient has a direct measurable financial value to the practitioner, each additional patient is viewed not as a burden and extra work, but as an opportunity. What a tremendous transformation in perception! This directly translates into docs who are eager to see patients, and even docs competing to get the next chart from the rack, which in turn translates into shorter waiting times and faster patient flow through the department.

I will also editorialize that I believe productivity-based compensation is fairer. If an individual highly-productive doc is responsible for a certain amount of income for the group, it is perverse to take some of that revenue and redistribute it to the less-productive practitioners. This is what effectively happens under hourly compensation systems. Docs are aware of this fact and it certainly breeds resentment and damages the group morale.

Having said that, there are challenges to a pure productivity payment system. There is an incentive for docs to chart surf, to skip the time-consuming patients in favor of the quick and lucrative patients. The only solution to this is a strong ethic and trust among the partners that cherry-picking is not permitted, or alternatively, a pod system in which patients are assigned to doctors (instead of the other way around). Similarly, there can be an incentive to skip the uninsured or Medicaid patient in favor of the fully funded patient. Our group handles this by paying docs a flat rate per RVU generated, which effectively blinds the practitioner to the patients' payer class: a Medicaid patient is potentially worth exactly as much as a Blue Cross patient.

Some groups try to compromise by utilizing a hybrid system – part base salary and part productivity. The drawback to the hybrid system is that the hourly base salary weakens the incentive effect of the productivity component. If you imagine the productivity distribution of ER docs, there is a normal bell-shaped curve just like in any other population. About 50% of the docs cluster around the mean, and about 25% excel and 25% underperform. So in an "average" hybrid system, something like $80/hr is guaranteed, and $40/hr is based on production. That half of the docs whose production is about average will have pay within a few dollar an hour of the mean. For those who are high or low performers, there is a variation in pay, but the typical range is relatively small compared to the base salary ($5-15/hr). More significantly, the reward for working harder is small, and the punishment for inefficiency is small.

Conversely, the magnitude of the incentive in a fully productivity-based system is much higher; the range between the highly effective and less effective docs can be $50/hr or more. That sort of variation in pay provides a very powerful motivation to all the docs to be as efficient in moving the meat.

There are some counter-arguments I have heard to this approach, which have not been borne out in my experience. For example, concerns that docs who are too motivated by the money will lose focus on quality of care and rush patients through without taking the time to ensure that the diagnosis and treatment are right. However, the fear of being wrong, and the fear of liability provide a powerful counter-balance, which seems to keep docs honest. Some said that if docs get paid based on dollars billed, they'll just order a lot of unnecessary tests to make the bills bigger. But in real life, a CT scan takes a long time and prevents the doc from seeing other patients in that bed, so unnecessary tests actually tend to hurt docs financially. Others were concerned that doctors would hurry through the personal interaction with patients and the satisfaction scores would go down. But truly, patient (dis)satisfaction is more strongly linked to delays in care, and by reducing the door-to-doctor time, scores are more likely to go up, even if the docs spend less face time with the patient.

Physician compensation is complex, and there's no one right way to do it. Some groups, or some EDs, may have unique circumstances which would render incentivized compensation undesirable. But if your ED is underperforming and the docs are the rate-limiting step, smart utilization of financial incentives can bring your performance up to where it needs to be. If you are a graduating resident looking for a practice in which the docs are paid fairly and have a direct financial stake in the operation of the ED, make sure you get the details of the physicians' reimbursement system.

Debunking quackery, in cartoon form

A wonderful primer on the fundamentals of homeopathic "medicine"

Well worth the read, especially for anyone who might be considering pursuing homeopathic treatment.

This author also put together a nice explication of the Wakefield Autism Vaccine Fraud.