Archive for the ‘Medicine’ Category

If physicians are “muggers” and co-conspirators in “taking money away from the rest of us”, then journalists and economists are pontificating parasites who produce no goods or services of any real value.

I don’t think either is true, but the recent attacks on physicians by economists Anne Case and Angus Deaton, and “media professional” Cynthia Weber Cascio, deserve to be called out. You could make a case for consigning them permanently, along with the anti-vaccination zealots, to a healthcare-free planet supplied with essential oils, mustard poultices, and leeches.

My real quarrel with them — and with the Washington Post, which published their comments — is that they have the courage of the non-combatants: the people who criticize but have no idea what it’s like to do a physician’s work. More about that in a moment.

Ms. Cascio was enraged by the bill from her general surgeon, who wasn’t in her insurance network at the time she needed an emergency appendectomy. She doesn’t care — and why would she? — that insurance companies increasingly won’t negotiate fair contracts, and it isn’t the surgeon’s fault that Maryland hasn’t passed a rational out-of-network payment law like New York’s, which should be the model for national legislation. She doesn’t care that Maryland’s malpractice insurance rates are high compared with other states, averaging more than $50,000 per year for general surgeons. She just wants to portray her surgeon as a villain.

The two economists are indignant that American physicians make more money than our European colleagues, though they don’t share our student loan debt burden or our huge administrative overhead for dealing with insurance companies. They resent that some American physicians are in the enviable “1%” of income earners. But do they have any real idea what physicians do every day?

Stress?  What stress?

I wonder sometimes what it would be like to go to work in the morning and NOT have to worry that I might kill someone. If journalists or economists get their facts or predictions wrong, it might be annoying, but it won’t be fatal.

If anesthesiologists have trouble getting enough oxygen into a patient’s airway for very long, permanent brain damage or death result. Every time we put in an epidural, for a woman in labor or a patient who needs one for post-surgical pain control, we know the epidural needle is mere millimeters from the spinal cord. Our ever-present fear is that we might injure our patients.

That’s a stress level most people wouldn’t even want to think about.

My stress level, though, is arguably less than the surgeon’s — especially when their day involves using a saw to cut directly through the breastbone, taking care not to saw through the heart in the process, or dissecting out a brain tumor millimeter by millimeter, where the smallest error could leave the patient unable to think or speak.

Even routine operations can turn quickly to disaster. Gynecologists perform laparoscopic procedures every day — but could puncture a hole in the aorta with their instruments. The gynecologist and the anesthesiologist are well aware of that, but we try not to dwell on it, or we wouldn’t have the nerve to come to work.

Ms. Cascio, in her Washington Post column, sounded irked that her operation only took 35 minutes, as if that somehow justified less payment. In fact, that’s a sign of an efficient and experienced surgeon, who didn’t puncture her intestines or her liver in the process, and kept her from being under anesthesia longer than necessary.

The primary care physicians aren’t exempt from fear and stress either. Think about it. A patient comes in with a persistent cough, and the internist or the family practice physician ponders whether this could be lung cancer, and how much grief the insurance company is going to cause if they try to get authorization for a CT scan. The pediatrician sees a child with a fever, and always has to worry if this is a self-limited viral illness — or the beginning of meningitis that could lead to death within a day.

I wish the economists, the journalists, the pundits, and the lawmakers could watch a busy OR getting started for the day. The ritual of putting on hats, masks, gowns, and gloves always reminds me of girding for battle. Everyone knows all that can go wrong, and we’ll do all we can to make sure that none of it happens that day, on our watch.

Even more gallant are the young interns and residents who are starting out in their careers. They’re often moving from one moment of anxiety (or terror) to another, before they start to gain some confidence and hit their stride. Our role as faculty is often to reassure and cheer on as much as to teach, and to let them know that we have their backs.

Regrets over choosing medicine

The tragedy that’s happening in medicine today is that the loss of respect and the constant threats to fair payment are making physicians regret that they ever chose medicine. They were fascinated with science and wanted to help people, and their reward is insult.

It’s no wonder that some newly trained physicians leave anesthesiology quickly; there’s little risk to running a hangover clinic in Las Vegas. Many physicians from all specialties get MBAs because they see that the real rewards in healthcare lie in becoming a CEO. Look at the salaries of top executives: the CEO of Anthem made more than $14 million in 2018, as an example, while insurance companies did everything they could to avoid or delay signing fair contracts and paying clinical physicians for patient care.

There is a growing shortage of physicians, not just in primary care but in specialties too. The American Association of Medical Colleges (AAMC) estimates that the US will be desperately seeking surgeons in the next 10 to 12 years, and looking for more anesthesiologists to work with them. As older physicians retire, and younger ones aren’t willing to work the long hours that used to be routine, this will only get worse, while increasing numbers of older Americans will need more complex medical care.

Maybe your barber will learn to operate on you, just like the barber surgeons of old, and your local gun store will sell you a bullet to bite on. Best of luck.

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Gentle readers:

Please be aware that I will not publish further comments to this post on scope-of-practice issues, or on the role of non-physician professionals in healthcare. Enough has been said already — perhaps too much.  Comments about the actual issues discussed in this post are welcome.

It is difficult for all of us to know what we DON’T know, but the more education and experience we have, the less likely the knowledge gaps are to cause harm to a patient. I will always be happy to work on a medical team with anyone who wants to work with me, and I will always oppose the elimination of the physician from the team.

Yours very truly,

Karen Sibert, MD, FASA

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Recommended reading:

Nobel prize winner insults all doctors, by Skeptical Scalpel

If doctors wanted to be wealthy, they would have become UPS truck drivers, by Neil Baum, MD

 

“Each man or woman is ill in his or her own way,” Dr. Abraham Verghese told the audience at the opening session of ANESTHESIOLOGY 2019, the annual meeting of the American Society of Anesthesiologists. In his address, titled “Humanistic Care in a Technological Age,” Dr. Verghese said, “What patients want is recognition from us that their illness is at least somewhat unique.”

Though we in anesthesiology have only limited time to see patients before the start of surgery, Dr. Verghese reassured listeners that this time has profound and immense value. He pointed out that there is “heightened drama around each patient” in the preoperative setting. “Everything you do matters so much,” he said. What patients look for are signs of good intentions and competence, and the key elements are simple: “the tone of voice, warmth, putting a hand on the patient.”

Dr. Verghese, a professor of internal medicine at Stanford University and the acclaimed author of novels including the best-selling Cutting for Stone, believes that patient dissatisfaction and physician burnout are the inevitable consequences of today’s data-driven healthcare system, where physicians seldom connect with patients on a personal level or perform a thoughtful, unhurried physical examination. “Our residents average 60 percent of their time on the medical record,” he said.

“It’s the ‘4000 clicks’ problem,” Dr. Verghese said, citing a study in which emergency room physicians averaged 4000 mouse clicks over a 10-hour shift, and spent 43 percent of their time on data entry but only 28 percent in direct patient contact.

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The Hahnemann Disaster

Though the news at first stayed local in Philadelphia and the northeast, it’s gaining traction nationwide. ZDoggMD is on it. Bernie Sanders held a rally.

What happened? The venerable Hahnemann University Hospital, the main teaching hospital for Drexel University College of Medicine in Philadelphia, is bankrupt and will soon close its doors after more than 170 years as a safety-net hospital serving inner city patients.

Why should we care? After all, there are other teaching hospitals in the immediate area with capacity to absorb the patients, and they had several months’ warning to prepare.

We should care for many reasons, but I’ll start with the plight of the 570 residents and fellows who are being displaced from their jobs. Getting a residency position in the first place is a perilous process – there aren’t enough spots for all the graduating medical students who want them. Only 79% of the more than 38,000 applicants in 2019 snagged a first-year or internship position in a residency program.

So the Hahnemann residents – the “Orphans from HUH”, as they’ve started to call themselves – are scrambling on their own to find new jobs at a time when most residents are thankfully settling in to the new academic year. There’s no organized program to help them.

Even for the residents who’ve already found new positions, there are other boulders in the road. To begin with, they haven’t been released yet. They can’t start their new jobs and the Medicare funding for their positions is still tied up in bankruptcy court.

They’re still at work, wandering around a nearly empty Hahnemann with only a handful of patients left. The ER isn’t admitting any new patients and will shut down completely on August 16. The labor-and-delivery ward has closed. The new interns aren’t gaining any real experience and will be lagging behind their peers wherever they go.

“Doctors have been writing notes to update plans of care and people have come in as part of the liquidation to take away their computers,” a third-year internal medicine resident named Tom Sibert, MD, told Medscape reporter Marcia Frelick last week.

Tom Sibert? Any relation? Why yes; he’s my son. You can understand, I’m sure, why I went into full-blown mama lion fury when the Hahnemann situation blew up, and why I was beside myself with worry until he locked in an acceptance to an excellent program where he’ll finish his training.

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If you’re a parent who is still on the fence, trying to decide whether or not to vaccinate your children, I’m going to try to be kind and helpful. Here is a link to a video by a physician and father, Dr. Zubin Damania, with facts that may address some of your fears.

If you’re firmly pro-disease and anti-vaccine, however, I am baffled at your irrationality and frankly enraged by it. I am speaking from the intensely personal point of view of a physician and mother who knows what it’s like to attend the funeral and watch the coffin of her own child being lowered into the ground.

My daughter Alexandra is dead. There is no vaccine that could have saved her. The only thing that could make that enduring grief any worse would be the knowledge that there was a vaccine, and she didn’t get it because of me.

The only bright side to the recent outbreak of measles in the northwestern U.S. is the fact that some parents are finally deciding to protect their children with vaccination, as the New York Times reported on February 16.

I’m old enough to remember the terror that my parents went through every summer as polio epidemics swept the country, and the miracle of standing in line to take the sugar cube with the first oral vaccine in 1961. I have two dear friends who are paraplegic as the result of childhood polio, and you don’t want to have the anti-vaccine conversation with them, I promise you.

Our duty — all of us, as human beings in a civilized society — is to make sure that we and our children are immune to measles, chickenpox, whooping cough, and other infectious diseases so we can protect those who can’t be vaccinated due to real medical problems. We are the herd that has to take responsibility for herd immunity.

Every single one of us has a duty to the cause of public health to be vaccinated ourselves, and a duty to our children to make sure that they are vaccinated on schedule. Yes, I understand that in rare cases the flu vaccine can result in Guillain-Barre syndrome, but I still get the shot every year. It’s my duty to protect my patients, my husband, my children, and my grandchildren from being exposed to the flu, which could happen in the early stage before I might even realize that I was getting sick.

It’s particularly mind-bending to see that some parents think diseases like measles and chickenpox are benign. For every 1000 children who catch measles, one to three will develop encephalitis. Of those, 10 to 15 percent will die, and many more will have permanent neurologic damage. Chickenpox too can lead to encephalitis, and the blisters can get infected and cause full-blown sepsis or pneumonia.

The death of Olivia Dahl

Have you read any of Roald Dahl’s books to your children, and watched Charlie and the Chocolate Factory or James and the Giant Peach with them? Did you know that his seven-year-old daughter Olivia died of measles encephalitis in 1962, before the MMR vaccine was available? Here is what Mr. Dahl wrote:

As the illness took its usual course, I can remember reading to her often in bed and not feeling particularly alarmed about it. Then one morning, when she was well on the road to recovery, I was sitting on her bed showing her how to fashion little animals out of colored pipe-cleaners, and when it came to her turn to make one herself, I noticed that her fingers and her mind were not working together and she couldn’t do anything.

Are you feeling all right?’ I asked her.

‘I feel all sleepy’, she said.

In an hour, she was unconscious. In twelve hours, she was dead.”

For the rest of his life, Mr. Dahl pleaded with parents to vaccinate their children. Even today, there is little that can be done to save a child who develops measles encephalitis. What we can do is prevent it by vaccinating.

I would never wish for any parent, no matter how irresponsible and irrational the pro-disease advocates are, to suffer the relentless and indescribable grief of their child’s death. In centuries past, parents frequently lost more than one child, but the fact that children’s deaths were common didn’t lessen the pain. If you don’t believe me, read this:

There’s a narrow ridge in the graveyard
Would scarce stay a child in his race,
But to me and my thought it is wider
Than the s
tar-sown vague of Space.

Your logic, my friend, is perfect,
Your moral most drearily true;
But, since the earth clashed on her coffin,
I keep he
aring that, and not you.

Console if you will, I can bear it;
’T is a well-meant alms of breath;
But not all the preaching since Adam
Has made Death other than Death.

It is pagan; but wait till you feel it,—
That jar of our earth, that dull shock
When the ploughshare of deeper passion
Tears down to our primitive rock.

Communion in spirit! Forgive me,
But I, who am earthly and weak,
Would give all my incomes from dream-land
For a touch of her hand on my cheek.

That little shoe in the corner,
So worn and wrinkled and brown,
With its emptiness confutes you,
And argues your wisdom down.

That poem, “After the Burial“, was written by American poet James Russell Lowell, who suffered the loss of three of his four children in the mid-nineteenth century. He hit the mark. So did Ben Jonson, writing about the death of his first daughter in 1593.

I will never write as eloquently as they have. So here’s the bottom line. Get a grip. Vaccinate your kids.

For several years now, I’ve been the social media curmudgeon in medicine. In a 2011 New York Times op-ed titled “Don’t Quit This Day Job”, I argued that working part-time or leaving medicine goes against our obligation to patients and to the American taxpayers who subsidize graduate medical education to the tune of $15 billion per year.

But today, eight years after the passage of the Affordable Care Act, I’m more sympathetic to the physicians who are giving up on medicine by cutting back on their work hours or leaving the profession altogether. Experts cite all kinds of reasons for the malaise in American medicine:  burnout, user-unfriendly electronic health records, declining pay, loss of autonomy. I think the real root cause lies in our country’s worsening anti-intellectualism.

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