crime_writing_comic-scaled500Wayne Tarrance: How about you get down on your knees and kiss my ass for not indicting you as a co-conspirator right now, you chickenshit little Harvard cocksucker?

Mitch McDeere: I haven’t done anything, and you know it!

Wayne Tarrance: Who gives a f**k? I’m a federal agent! You know what that means, you lowlife motherf**ker? It means you’ve got no rights, your life is mine! I could kick your teeth down your throat and yank ‘em out your a**hole, and I’m not even violating your civil rights!

From The Firm, a novel by John Grisham. In it Mitch McDeere graduates from law school and takes a job for a lot of money with a prestigious law firm, then discovers that they (and by extension he) are working for the mob. The discovery is courtesy of Federal Agent Tarrance.

We have 77 students in our medical school class. They chose their “senior advisors” this week. These are the people who will guide our students through the complex career choicces leading to a  a residency. There are specialties to chose, audition rotations to plan, and interviews to schedule. We had 3 select family medicine as their potential specialty. This is as opposed to 13 choosing surgery, 9 choosing psychiatry and 9 choosing medicine-pediatrics. Not what we want to see out of our class and, as only 4 chose family medicine from last year’s class, we have been doing some departmental soul searching.

As opposed to the other clinical rotations at our school, we send our students out with physicians in practice. We tell ourselves that this pulls them out of our safety-net hospital environment and teaches them what the real world is like. We also interview our students after their clinical rotation in family medicine. What we are discovering is that this exposure to the “real world” is turning them away from primary care in general and family medicine in particular. The most painful was the student who said “I can see myself doing Family, but I think I am going to do psychiatry. Family doctors don’t know their patients.” On the psychiatry rotation, we have found out, they see 3 patients a day, Monday through Friday. As students they really get to know these patients. It seems that the life of a psychiatrist seeing 3 patients a day has a certain appeal.

The federal government has released the payment information on physicians who took Medicare in 2012 (found in a searchable database here). Turns out, the Internal Medicine faculty member in our institution most engaged in teaching medical students took care of 32 Medicare patients in the hospital in 2012 and oversaw 100 outpatient visits. The psychiatry attending admitted 16 inpatients who stayed about 4 days apiece. Although they take care of other types of patients (these are only the ones over 65), they probably both had a lot of time to interact with students.

One of the community family physicians we send our students to had about $100,000 in Medicare payments in 2012 and the following numbers:

  • 815 office visits at $39.33
  • 179 less intensive office visits at $26
  • 89 more intensive office visits at $56
  • 66 hospitalized patients who were in the hospital an average of 4 days. He (or she) made $143 for the initial visit, $52 for the other hospital days.
  • Gave 264 steroid shots at 18 cents apiece.

These numbers are what goes to the practice, not home with the physician at the end of the day. Half of that, as our students are no doubt told, goes into paying the people required to generate the bill to get paid by Medicare.

Had the students spent time with the busiest community psychiatrist in town (based on $157,000 in Medicare payments), they would have seen a doctor with almost 660 hospital visits, over 200 nursing home patient visits and who supervised 300 medication visits with the medication given by a therapist. With the busiest community oncologist ($1.7 million)? Over 40,000 injections of levoleukovorin.

In The Firm, Mitch realizes, too late, that “the law” he learns in law school is not the law he signed a contract to practice at his new law firm. I’m afraid that in our Family Medicine clinical rotation we are providing a dose of unwanted reality to the students. They are seeing that the business of medicine is a lot about running people through as fast as you can in hopes of getting the insurance company’s $20 (or, in the case of triamcinalone, $0.18). As a consequence, the students are voting with their feet into other specialties only to find, once out, that to make the big money you have to sell a lot of antibiotic and steroid injections no matter the specialty.

I’m afraid that unless the payment structure changes, chasing $20 bills is what the real practice of medicine is about. Maybe to increase interest in family medicine we just need to do a better job of hiding this inconvenient truth from our students until they go into practice. As Mitch McDeere found out, it’s not like you can leave.


Price Conscious 512My wife is reading (or listening to, I can never tell which) a book about “private life” (called At Home).  One of the vignettes is about the development of safe drinking water. The central character in this story was John Snow, a physician living in London in the time of cholera (temporally in the 1850s). The legend is that using a map (this was the first documented use of a map to determine the source of an outbreak, very cool stuff) he plotted the cholera deaths and placed them proximate to a fresh water concern on Broad Street. He attempted to get the local government to act on his theory that the water pump was contaminated and the cause of the outbreak. Convincing the authorities (the local Board of Guardians) to remove the handle, he is credited with stopping the outbreak (or at least preventing a resurgence in the neighborhood).

A couple of things about this story. First, Doctor Snow had lived through a previous outbreak of cholera several years earlier, and as a consequence he was unconvinced of the prevailing theory that miasma (bad air) caused the disease. His theory, that the disease was limited to the gastrointestinal tract and death was caused exclusively by dehydration, was consider not a little kooky. He was working on very little evidence as the existence of a cholera organism, though described in Florence roughly at the same time, was unknown to physicians in London. Robert Koch, the man who really put germs on the map as causative agents of disease, would not develop his postulates until 30 years later.  Doctor Snow, it turns out, was looking for an opportunity to test his theory, and the St James Parish outbreak happened to have everything he needed (water contaminated with sewage with little competition from clean water and so delicious that people knew of pump by name, people who were dying of cholera at a fast clip, and a Board that was willing to try new things out of a sense of responsibility to their parishioners). As luck would have it, the water was VERY contaminated (wash water from an infected baby’s diapers and fresh water kinda mingled right where the pump intake was) and so the intervention was successful. John Snow lives on as a medical hero.

Not everyone bought into the “drinking water causes disease” meme for a couple of reasons. First, miasma as a cause of disease had a lot going for it. If God made things smell bad, it must be for a reason, amirite? Second, because bad smells and disease tended to intersect where poor people lived, bad things must be happening to “bad people.” The slums were filled with people moving from the countryside during the Industrial Revolution, people who “were not nice people.” Therefore, in the Victorian age “the miasmas that seemed so prevalent among the poor slums were seen as God’s punishment for immoral lifestyle.” Over time, the sanitarian won and, by first building sanitary sewers and providing drinking water and later providing vaccinations, outbreaks of diseases like cholera and polio were conquered.

So, in this country we are heading into our own Broad Street Pump moment. 26 states have elected to take full advantage of the Affordable Care Act, including expanding Medicaid to those who make below 138% of poverty as a sole qualifying criteria. In these states, Medicaid rolls have grown by 8%. This means that more than 3 million adults will have the security afforded by knowing they are not one illness away from bankruptcy. They will have access to care for complaints such as “blood in my stool” which would have gotten them triaged out of an emergency room before but now, under the right circumstances, a colonoscopy to find and cure their colon cancer. They will get treatment for bladder infections, pneumonias, and cellulitises without needed to get so sick as to require hospitalization.

24 states, including Alabama, have not expanded.Their rolls have expanded by 1%. These folks are mostly working, some at several jobs. They are using their common sense to tell them when to seek expensive care. I f they guess right, bankruptcy and an opportunity continue to work and pay off medical bills. If they guess wrong, death from a preventable illness. Meanwhile many, including public officials, are convinced that they are uninsured because they are undeserving.

So, who will be our John Snow? Who will look at those dying from a lack of access in states like Alabama and say enough? How many deaths from preventable conditions will it take? Anyone know how to use Google Maps?


About two weeks ago I wrote a response to a “study” done by at Koch Brothers, err, Troy University that misused numbers to identify Medicaid as an evil the likes of which have not been known since the Great Flood. The only reason I knew about this study was that Scott Beulier, the author, has a “column” on where he is, as part of his “academic” responsibilities, allowed to spew forth “information” and then hope that others don’t try to untangle the half-truths and mis-statements that would never be allowed to appear in peer-reviewed academia.

I was glad to see that I’m not the only one who is taken on the task of reviewing his “work” on Mediciad. Alabama Political Reporter looked into his “assumptions” (found here) and came to the same conclusions that I did. I will say though, that I went looking before “Dr.” Beulier let the cat out of the bag by saying, “We just relax a few of the assumptions made in their studies.” He is being too modest. He actually made two assumptions and supported them with his NEW “study”:

Assumption #1 – Since Medicaid is bad, any information that identifies it as good is inherently biased:

From the “study” – The media coverage has been primarily centered around two economic impact studies commissioned by the Alabama Hospital Association: …This paper seeks to examine the assumptions, models, and conclusions of the two studies.

From the Alabama Political Reporter – “Alabama Political reporter has confirmed that the Alabama Hospital Association did not commission or in any way fund the initial University of Alabama at Birmingham study, according to Danne Howard, a senior official with the group.”

Assumption #2 – There are no unbiased facts -

Despite this, the Troy University study – which purports to more accurately assess assumptions – inaccurately assumes the worst of its Alabama public four university brethren, and Troy Professor Beaulier continues to assert emphatically that there is likely political or financial incentive for the UAB and UA studies’ conclusions about Medicaid expansion the the Yellowhammer state – no matter how true that may or may not be.

What did happen to peer review? I would accept even cursory review.

elephant-in-the-roomI have to admit that I, like the rest of the world, have become fascinated by the disappearance of the Malaysian jet. Partly because it makes for such great media speculation (“it went down in the ocean by Vietnam,” “no it was shot down by terrorists,” “no, the pilots WERE the terrorists”) and partly because there are few great mysteries in this world. Can alligators climb trees? We now know courtesy of Wired that the answer is yes! The Peruvian lines on the grounds made to look like animals? Turns out ancient Peruvians could make balloons!

The other reason people seem to be fascinated by the airplane is that it allows them to let their imaginations run wild in the “comments” section of any web story that peripherally mentions the Malay Airplane incident.Usually the commenters have a name like TrueAmerican123 and the comments go something like this:

Why did the pilots do it ? Well, the pilot with the weird name, you know Zariesomething, belongs to this terrorist political party and he stole the airplane and flew it to Diego Garcia, an island in the middle of the Indian Ocean, where they have stolen nuclear material and they will make a bomb and drop it on some other country and it’ll be a false flag operation.

To read the comments, Cliff’s notes are often required. What are Malay terrorist issues? Where is Diego Garcia? What is a false flag operation?

What’s more needed is an editor who can add a note that says: TrueAmerican123, let’s avoid stupid speculation such as this and focus on facts…Oh wait, do you even know where Malaysia is?

Unfortunately, there are few informed people delivering information to us, the information consumer. No one pays for content anymore so we are left with ill-informed people making dumb comments on half written stories and it is our job to discern reality. For things like the Malay Jet, the only thing we have to consider is whether the plane flying over our head is loaded with stolen US nuclear material that will be dropped on our heads. For things like Obamacare, the tendency towards reporting opinion as fact is much more of a threat to the Republic., the Alabama news webblog, is running a series entitled “Obamacare and you.” To put this together, they have solicited everyday people, like you and me, and had them write down their sense of how Obamacare has ruined (or not ruined) their life. Today’s offering, Anger over changing health care due to Affordable Care Act, was particularly egregious. In it, a person who didn’t get to keep the insurance he liked, blamed Obama for his loss. His story went like this:

[He] said his company cancelled the employees’ health insurance plan with Blue Cross Blue Shield that he liked for a new one. According to Carlson, the new plan significantly increased his co-pays, deductibles, and maximum out-of-pocket costs.

In previous entries, has pointed out that the perception that Obamacare was responsible for the perceived injustice was almost always incorrect. Apparently this practice has stopped. As of this writing there are 325 comments. I have not waded through all of them but why our deeply conservative commenters are not siding with the business owner who changed insurances presumably to improve his or her bottom line (which he could do before, after, or  during Obamacare) is beyond me.

To heck with local “news.” I’m going back to Google Maps to find me an airplane.

I was at a North American medical research conference in Ottawa, sitting in the hot tub having a spirited discussion about (or aboot) the relative benefits of the Canadian single payer health care system as opposed to a pluralistic one such as we have in the States when one of the Canadians turns and says “You know, you Yanks spend as much in FEDERAL money on health care as we do in Canada, then you double it and still get worse outcomes.” That kinda hurt…

My “throwdown” with the Canadians ended with us buying another drink and going to dinner. I hope the same can be said for Senator Burr (R-NC) and Dr Danielle Martin. Dr Martin was brought in to testify aboot the horrors that are Canadian health care. Senator Burr, a proud consumer of health care, anticipated waving the American healthcare flag in Dr Martin’s face. The exchange can be seen on C-Span and was covered by the LA Times. The exchange goes something like:

BURR: Why are doctors exiting the public system in Canada?

MARTIN: Thank you for your question, Senator. If I didn’t express myself in a way to make myself understood, I apologize. There are no doctors exiting the public system in Canada, and in fact we see a net influx of physicians from the United States into the Canadian system over the last number of years.

She goes on to point out that the Australian experience proves that adding more choice does not necessarily reduce wait times

BURR: What do you say to an elected official who goes to Florida and not the Canadian system to have a heart valve replacement?

MARTIN: It’s actually interesting, because in fact the people who are the pioneers of that particular surgery, which Premier Williams (the Newfoundland Primae Minister who had a valve replaced in Florida) had, and have the best health outcomes in the world for that surgery, are in Toronto, at the Peter Munk Cardiac Center, just down the street from where I work.

She goes on to point out that innovation and quality are more likely to be found in Canada

BURR: On average, how many Canadian patients on a waiting list die each year? Do you know?

MARTIN: I don’t, sir, but I know that there are 45,000 in America who die waiting because they don’t have insurance at all.

The Senator goes on to have the last word, however, and point out the Americans can always go to the Emergency Room. Dr Martin refrained form pointing out that the Canadians can as well. They just don’t have to.

df940103In 1987, during my internship, there was a cautionary tale making the rounds about violating patient privacy and the consequences.  I was in Norfolk but a friend swore he had heard it from a friend who was working in an emergency room in Philadelphia. It seems that a local newscaster showed up after a night of fun with friends with a little problem…a gerbil had “wormed” its way up the newscasters exit hole and had to be extracted. Oh, it was very true, I was assured, the newscaster even had to go to surgery (gerbils are unable to survive the passage through the large bowel no matter how entered). What’s worse, the health care workers who provided the public service of notifying the inquiring public were not only left unrewarded but FIRED.  Can you believe??

These were the days before internet and to be honest, since I didn’t know anyone in Philly the story meant very little to me. I will say I had a friend who happened to be gay that I did tell the story to and he proclaimed it BS. He, as it turns out, was correct. No one, not even Richard Gere, has ever been x-rayed with gerbil remains “up there.”

Doctors see a lot of stuff. For those of us who collect stories, it is a really neat job. People pay money, sit down, look me in the eye, and after I say “How are you today” they say “Fine, except for this gerbil…” Okay, there are no gerbils, but they do tell me a lot of stuff. One of the key classes in medical school is the one where the student is reminded to keep a straight face and show no emotion no matter what comes out of the patient’s mouth. As a physician, your job is to problem-solve, educate, and  instruct, but not to judge.

Doctors have the bond of “guess what silly thing my patient did” in common. The number of people who come in with a Coke bottle where it shouldn’t be and a lame story such as  “I slipped in the shower while drinking a Coke” is actually quite high. Doctors’ lounges used to be places away from the average citizen where these stories could be recounted in a private, safe, environment. Now much health care occurs outside of the hospital, many doctors have little time to lounge, and (at least in the lounges around here) docs hollering, “Say it, Brother Sean” at the TV blaring Fox tend to drown out other conversation. So who can blame doctors for moving this conversation to social media?

Dr Milton Wolf is one such doctor. A Kansan and distant relative of Barack Obama, he graduated about 10 years ago and is a practicing radiologist in Kansas. He is one of 20 some-odd physicians running this year. The odd part, for some, is Dr Wolf’s use of Facebook to “educate.” Turns out that prior to deciding that a career in politics was in order, Dr Wolf found humor in radiographic images of people who suffered tragically, mostly from trauma. He collected these images and posted them, with comment, on a blog and to a Facebook account. One such exchange:

Wolf launched a Facebook chat about the 3D image by explaining it was taken from a postmortem examination. A Facebook friend, Melissa Ring-Pessen, responded that she performed the scan on Jan. 22, 2010, and was admonished for improperly positioning the man’s head.

“Seriously?” she wrote.

“Sheesh Melissa,” Wolf replied, “it’s not like the patient was going to complain.”

There is a video of the reporter confronting Dr Wolf about this post and it is worth watching. Apparently this particular image and discussion was posted before the patient’s funeral.

The Federation of Boards of Medical Examiners has suggested some guidelines for physicians when using social media that include using candor regarding possible personal gain, respecting the privacy of patients, and maintaining professional integrity. For anyone who is in the medical profession and uses social media, this is a must read.

The Doctors’ lounge had a couple of things. It had a door that separated “us” from “them.” The conversations were evanescent; if something untrue or hurtful was said, it didn’t sit on the Internet for years. If someone was too much of a jerk, they wouldn’t get patients sent their way. Lastly, when someone was a persistent problem, the medical staff president was always there to threaten a loss of privileges. Unfortunately no one seems to police the virtual Facebook lounge. Notice that the cautionary tale about the misplaced gerbil ends in a firing. The real story about the real patient (Google search “homicide victim” “Johnson County” Kansas on that date and I bet you can find the decedent’s name) ended in the guy getting on Fox and Friends and running for Senate. Go figure.

dismal scienceThey call economics the “dismal science.” This phrase was coined by Thomas Carlyle who, per Wikipedia, used it to contrast economics to the more “gay sciences” of song and prose. The work where it was found, Occasional Discourse on the Negro Question, was about the  utility of  enslavement in improving the human condition. The dismalness,  I suppose, was that one could prove “scientifically” that slavery was a net plus. Economic analysis, in common with other sciences,  is typically based on a series of assumptions. Assumptions can either be based on empirical facts or (more commonly in economics, some say) on the introspection of the investigator. Carlyle’s “assumptions” about slavery, for example, included “slave ships aren’t that bad” and “slave owners are benevolent overlords.” Based on these assumptions, he concluded that slavery was better than the alternative of idle workers.

Troy University’s Manuel H. Johnson Center for Political Economy has determined that providing healthcare for Alabama’s poorest citizens would cost money (al,com article found here). They determined this not by doing their own bit of research but by taking studies done by UAB and UA and reanalyzing them using a different set of assumptions. Their assumptions include: 1) the chronic shortage of primary care physicians is keeping health utilization low which is a good thing 2) Alabama’s Medicaid will cost more than projected and 3) Tax revenues will be less than projected. Given these assumptions, they “demonstrate that the cost of expanding Medicaid will outpace the benefits.”

Let me offer another set of assumptions:

1) Access to health care is not a luxury but is necessary for economic growth. Improving coverage in rural Alabama will stabilize (and likely improve) care delivery making job creation more likely in these areas. In addition, creating a more rational system of care delivery based on value as opposed to encouraging over-utilization with improve the care delivery environment, leading to improved health outcomes. This can only be done with the money that comes through the Medicaid expansion. We must either support our care infrastructure or move people our of rural Alabama.

2) Demand for health care services is driven not only by care seeking behavior but by providers offering low value, high priced alternatives to patients with limited ability to discriminate value. America medicine costs more as a consequence of increase use of technology, expensive medication, and excess payments to providers that do not lead to improved care. Creating a more rational system of care delivery, which Medicaid can take the lead in facilitating if the expansion is done correctly, will allow Alabamians to receive a better value closer to home.

3) Inefficiency of the Alabama Medicaid system is a problem but some of us are working on solutions. The governor and the legislature have  created Regional Care Organizations to help move effective care delivery closer to the patients’ homes. These are community-led networks that will coordinate the health care of Medicaid patients in each region, with networks ultimately bearing the risks of contracting with the state of Alabama to provide that care.

I guess it all comes down to assumptions. I have to assume people want better health care closer to home. Am I wrong?


toon840For those who watch professional football, there is nothing worse than seeing your team’s quarterback blindsided. A quarterback, for those who do not watch football, is the guy who takes the ball from the center and either hands it off to someone else, runs it himself, or passes it to a person down the field. He does this with about 1500 pounds of collective humanity chasing him. Quarterbacks tend to be runty by comparison (Johnny “Mr Football” Manziel, it turns out, is under 6 feet tall and weighs 207 in gym shorts) and when turned to their dominant side cannot see people coming from their other (blind) side. If two 300-pounders meet at the quarterback they can turn a hundred million dollar investment into just another confused short person, especially if the quarterback isn’t expecting it.

Football teams learned that having a good quarterback was good, and good protection was better. Left tackles, the 300-pound dudes who keep the other guys’ 300 pound dudes off the quarterback, have quietly become among the highest paid ball players in the NFL, second only to the quarterbacks. Part of the reason is that the number of 300-pound men who can run fast, have tremendous peripheral vision, are smart enough to understand an NFL playbook,  and can fight off other 300-pound men are few . The other part of the reason is that without one of those dudes, you are paying a confused short person a lot of money to run for his life in front of a lot of empty seats. It wasn’t until players renegotiated the collective bargaining contract and lineman were able to become free agents that the true value of a great left tackle (for a right handed quarterback) was realized.

As Uwe Rheinhart discussed several years back, we have yet to learn the value of left tackles in American medicine. Every medical student wants to be the star who gets to brag about the robotic surgery success in the doctor’s locker room after the game and collect the star’s paycheck (an consequence of our current payment system). Fewer want to be the primary care doctor, who facilitates collaboration, engages in  probing conversations with patients, and takes the myriad of small steps that avoid medical errors. The primary care doctors, the left tackles of medicine, were left behind by the payment structure.

What free agency did for fast, smart, 300-pound guys, health reform might do for primary care. By paying less for bad care (readmissions, excess test utilization) and more for good care (satisfied patients, meeting benchmarks for chronic illness care) Medicare might add value to the primary care visit. While primary care docs will likely never generate over $200 an hour in a fee-for-service world like our surgical and radiologist colleagues do, in the future we will add value to their care by reducing bad care and improving care within the system. By holding the system accountable, everyone working as a team will allow effective care delivery to happen. For some now, for others of us in the near future, more money will flow into systems that deliver better care.

Of course, as a healthcare left tackle, this may just be my fantasy. Some think that left tackles are over-rated. Perhaps we can have the line count 1001, 1002, 1003, 1004, 1005 before they run in. Then everyone could be a quarterback.

bob-zahn-didn-t-george-washington-floss-cartoonMe (in grocery): Why are you taking a picture of the almond cookies?

Lucy (my daughter): Dad! Spencer loves almond flavored sweets. We’re Snap Chatting.

Spencer is up to his knees in snow in Hartford and we are in Mobile. In the world where “selfie” is the trending word, people think they need to know everything about everybody, instantly. This has taken a lot of mystery out of life and out of death. Look at Phillip Seymour Hoffman’s tragic death. I don’t know how word got out but rumors about the place (bathroom), situation (using heroin), and backstory (“Oh, he had a problem for years. Went to rehab and told some interviewer that he was back on the stuff) were Facebooked, Intagrammed, Snap Chatted, Four Squared and Twitted before the ambulance left his his “Greenwich Village pad.” We have no clue what his last words or thoughts were but, based on my experience with patients in similar situations, it must have been along the lines of “Oh crap!” For all I know, he may have posted that to his Linked-in account before dying. I wasn’t in his Linked-in circle.

Things were different in George Washington’s time. Based on rank speculation on PBS, experts in the field of 18th century medicine (or maybe just people willing to be quoted by PBS) have ascertained that Mr. Washington suffered at some time or another from diptheria, tuberculosis, smallpox, dysentery, malaria, and pneumonia before finally succumbing from what was likely a bacterial infection in his neck area (possibly Ludwig’s angina or Lemiere’s disease), all diseases that are treated today with antibiotics or prevented with vaccination. Well, Washington actually may have died of blood loss anemia (his physicians bled him of 2/3rds of his blood volume in an attempt to cure him). All present at the death agreed that the former president’s last words were “I die hard, but I am not afraid to go.”

I doubt those were his last words. It was important at the time to give great men great last words. What we know for a fact is that after losing most of his blood he was able to summon the strength to tell his docs to “Go away!” and stop taking any more of his blood. In this case, I suspect his doctors’ last words on the subject were something along the order of “Oh crap,” because they were seeing their paycheck lying dead in the bed and, as the last in attendance, it may not have been the best resume builder. We also know that today this infection if treated appropriately almost certainly will not lead to death.

Most people today, when given a choice, seek medical care when they fear death might be an illness outcome. If they have insurance they will come to a physician’s office for a skin infection. The reforms included in the Affordable Care Act include mechanisms to ensure access, allowing infections to be treated early with antibiotics. No American should have to “die hard” from a skin infection.As a rule the the cost is a lot more than a lancet and a bucket (the tools needed to treat President Washington’s final illness) and even more so if the person waits until they are near death.

In our hospital we serve an uninsured, poor population and generate bills that we hold people responsible for. Last year almost 700 people risked bankruptcy to wait in our waiting room, hoping that they could get antibiotics to cure their skin infection. 350 of them had no insurance coverage but were able to leave only owing us about $750 with 10 days worth of antibiotics in hand. Over 150 of those waited too long and had to be admitted. Half of these were uninsured and owed us on average $11,000 for their 3 day hospital stay. On average, this is half of their total income for the year. If our governor had accepted the Medicaid expansion, many of these people would (as of January 1) be able to access the health care system without fearing death or bankruptcy but by his inaction remain uninsured.

Maybe our doctor-governor will issue some lancets, buckets, and last words.

barbara-smaller-it-s-fine-to-discover-cures-but-remember-chronic-conditions-are-our-br-new-yorker-cartoon (1)Forever there has been a power struggle between the medical school faculty and physicians in the community. For those of you who are versed in House of God, the book about medical care in the early 1970s, attendings and residents at the House as well as the students who went to BMS (Best Medical School) would reference care delivered by LMDs. This term referred to “Local Medical Doctors,” known uniformly for taking crappy care of patients who were then transferred to the “House”  where life-saving intervention would occur. The protagonist soon realized that there was more to medical care then doing stuff to people, culminating in realizing the truth in Fat Man’s Rule 13 (THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE). In the 1970s, the reality is that physicians on medical school faculty tended to earn less, a LOT less, that the LMDs, may have adding to the tension.

Somewhere about 20 years ago, LMDs traded their label for another that was even more pejorative – PCP. The Primary Care Provider concept was created in part to reduce the confusion around training requirements of physicians (Family Medicine, Internal Medicine, Pediatrics) and non-physicians (Physicians Assistant, Advanced Practice Nurse) who might provide primary care to a given patient. Patients don’t use the term, PCPs find the term demeaning, and the term doesn’t really reflect the complexity of care delivery that happens in the primary care office. Teaching hospitals, though, became Academic Health Centers and were distinguished in part by their lack of PCPs as well as their lack of desire to train them. The Academic Health Center was home to Specialists.

It is now almost 40 years since House of God was published. Obamacare is the law of the land and  the law encourages the use of primary care. This is in part because the work of Barbara Starfield demonstrated that health care is just better when people have access to primary care, and in part because a lot of work was done to demonstrate that specific models which incorporate primary care lead to better health outcomes. Programs like the Massachusetts Blue Cross Alternative Quality Contract and truly integrated systems like Kaiser and Health Partners  led to better outcomes. The work on Patient Centered Medical Home initiatives led to this specific type of primary care being incorporated in the law as well. Good primary care, so the saying goes, will keep you healthy. If you happen to get sick, it will help keep your costs down by keeping you out of the hospital. If you happen to go to the hospital, it’ll keep you from being harmed and help maintain quality care.

This week, the Houses of God are fighting back against the LMDs. The University Healthsystem Consortium (the trade organization for Academic Health Centers) put out a video entitled Through the looking glass: a new perspective on population management. Their video tells us the following in convenient cartoon form: 1) Most people just randomly become ill so don’t need a specific LMDs but instead need access to a CVS with a nameless Pee Cee Peee (their pronunciation) sitting and waiting for you to show up (and perhaps willing to give you a Z-pak “to prevent pneumonia”).  Oh, yeah, and prevention is too expensive so let’s blow off trying to get people Pap smears and mammograms and focus on treatment. 2) If you are chronically ill or sick with a serious illness, you don’t need a Pee Cee Pee at all but a House of God led team of folks. According to the video, they are sitting on the steps of the House just waiting for you to show up. 3) If you suffer from an early chronic illness you might want a Pee Cee Pee, but only get one who has the number to a specialty hotline, just in case you need one of the specialists at the House. You know how those Pee Cee Pees are.

The UHC’s vision is a dystopian one where patients are taking ambulances to the Academic Health Center for their not-well-controlled diabetes because the local House of God is 2 hours away and the Pee Cee Pee is unqualified to administer insulin. The evidence they cite for the effectiveness of this model is dated and incorrect. I can only hope that the Academic Medical Centers and their research arm, UHC Research Institute (TM), have a better plan for survival before the next “House of God” is written without them.



Get every new post delivered to your Inbox.

Join 279 other followers