Archive for the ‘Medicine’ Category

Do you think I went too far in my last blog post, calling out some journalists as “pontificating parasites” who love nothing more than to slam physicians and blame us for the cost of healthcare?

If you do, then you must not have read Elisabeth Rosenthal’s latest salvo in the Feb. 16 New York Times, where she says physicians are in “a three-way competition for your money” with hospitals and insurers, as if we’re all equally well-funded players at a craps table.

Even National Public Radio, often no friend to physicians, acknowledges that physician pay adds up to a mere eight percent of total US healthcare costs.

What stings even more, hearing that kind of accusation from Ms. Rosenthal, is that she used to be a physician herself before she quit emergency medicine to edit Kaiser Health News. I’m sure it’s a better gig: no nights, no weekends, no holidays. But, as Julius Caesar noted, it’s always worse when the stab in the back comes from someone you thought of as a colleague, if not a friend.

Surprise medical bills

The topic of Ms. Rosenthal’s one-sided op-ed is out-of-network billing, also known as “surprise” billing. Emergency physicians (along with anesthesiologists) may be the doctors most often accused of not being “in-network” with insurance companies and sending patients large “surprise” bills after the fact.

However, the American College of Emergency Physicians (ACEP), which represents Ms. Rosenthal’s former colleagues, is no happier than anyone else about out-of-network bills. “Much of this conflict over surprise billing is playing out in the media,” ACEP notes, “and insurers have been trying their hardest to paint emergency physicians in a bad light.”

ACEP is right. The facts about out-of-network bills, and the history behind them, differ from what Ms. Rosenthal would have the public believe.

What is a narrow network?

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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?

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“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.

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