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Wednesday, July 6, 2016

Lacking a Choice, or Hobson's Choice

Perhaps it is just the Baader Meinhof phenomenon, however I seem to be inundated with choices as of late.  While these choices are indeed not choices at all, but instead, ultimatums, they are presented under the guise of choice, and therefore free will.

This is a troubling pattern in modern medicine, the Hobson Choice that physicians and surgeons meet when it comes to practice rights.  Laws, rules, and regulations exist for a reason, and that is to explicitly state the rules of the game.  Rules are black and white and level the playing field, to some degree, by allowing anyone interested in participating in medicine to know and understand the intricacies nuances involved in being a doctor.

Unfortunately, rules, and moreover, laws, tend to be rather difficult to implement.  The reason is two-fold.  Doctors tend to prefer less regulation in favor of self-set limitations.  This allows for a wider scope of practice with less difficulty in achieving it.  Second, those who make the rules, often, would prefer to not have to go through the normal channels, so in essence, the rules are subject to change or intelligibility.  Do you see where I am going with this?

Enter Hobson's Choice.  Numerous entities, loosely, or closely, affiliated with the practice of medicine have interjected themselves between the doctor and his patient.  They set certain requirements, all of which are "optional," however lack of compliance with these entities beck and call results in the inability of the doctor to practice.  Indeed, the doctor dose have a choice, "Do as I say or you can no longer be a doctor."

These entities, often request significant sums of money (thousands and thousands of dollars), require doctors to maintain various educational or social constructs, and have even spawned a cottage industry of test preparation and review services as well as coaches.

So yes, I do have the choice. Take it or leave it.

Some choice that is.

Friday, June 3, 2016

Save Our Vets

One of the more polarizing topics of late is the encroachment of midlevel providers on physician practice.  For those not in the know, midlevel providers hold master's level terminal degrees (or doctoral in some nursing programs) and titles such as nurse practicioner, physician assistant, certified registered nurse anesthetist, anesthesia assistant, and midwife.

Many of these training programs are derivatives of the military and the surplus of qualified, trained individuals with clinical experience, but lacking a formal medical education.  Thus, the creation of a midlevel provider, e.g. with more training and a higher purview of care than a nurse but less than a physician.

Over the years, this role has significantly transitioned from physician extender to physician replacement.  Much of the blame should be placed on lazy physicians who saw these providers as an opportunity to do less work themselves.  As such, the midlevels became familiar and comfortable with things that likely never should have been in their scope of practice.  Naturally, that begs the question, "well what do we need the physician for then?"

In many less acute areas of medicine, such as the outpatient, primary care setting, it has been advocated that these providers could supplement the already dire shortage of physicians taking care of people.  While for the majority of well visits, or common complaints of cough, cold, sore throat a midlevel is sufficient, abandoning the doctor entirely is not terribly palatable to most patients.

With medicine as a field transitioning from a cottage industry of small business owners, e.g. private practice physicians and surgeons, to an integrated business, the egg heads and tie wearing MBA graduates in the executive office naturally see a room for creating efficiency.

Physicians themselves are being squeezed for more and more production at less and less compensation.  We are simply a revenue source for the system, and simple business practice dictates cut costs (salaries) while maximizing revenue (billing) and profits will soar.  This is abundantly evident by the six and seven figure salaries by health care executives at many of these larger group practices.

A more recent phenomenon, however, is simply replacing the doctor with a midlevel provider.  Cutting costs can only go so far, physicians are highly trained professionals and command relatively high salaries.  Replacing these with lessor trained, and arguably comparable providers, at a third of the cost seems intuitive.  Again, why pay more for the same product (care)?

The Veterans Administration, in their most recent handbook, have proposed departing with physician anesthesiologists entirely.  Instead, they intend to use nurse anesthetists exclusively.  There has been some uproar in the medical and veteran community, sparking a petition to continue the current physician led model.

While I agree, the physician role is to lead the medical practice team, and short-sighted of the VA to try to cut costs by abandoning physicians as providers.  What is more troubling, is it is another step in the wrong direction of creating an independent practice pathway for undertrained individuals.

The current environment has been slowly developing and transitioning, ad hoc, over a number of years to the current dilemma we face.  Namely, there are a significant number of these quasi doctors out there, caring for our patients and fulfilling a need.  Perhaps, a re-writing of the rules, en block, would be in order creating a clear limitation to the ability of these providers and their scope of practice.

Unfortunately, for us physicians, we were asleep at the wheel for the last 20-years.  We have given up our role as the leaders of the hospitals, and the patient doctor relationship.  We now have to pay the price, having allowed these insurgents to our sacred bond of caring for our patients to take our role.

The practice of medicine has changed dramatically over the past 50-years, as has the practice of nursing.  Unfortunately for us, many nurses no longer want to be nurses, but instead non-doctor physicians; practicing medicine, without the training.

I have the utmost of respect for our nurses who take care of our patients in the office, on the floor, in the ICU, or the OR.  They truly do a phenomenal job and deserve far more credit than they often receive.  Unfortunately for them, many of their colleagues have waged war with medicine, using the patient as the battleground.

Even so, the care provided by NP or CRNA providers is often high quality.  I work with them on a daily basis, and the vast majority are great people and great providers.  They play an invaluable role in the medical care team.  Perhaps they are being coy, but most of the midlevel providers I speak with on a frank basis about their thoughts on independent practice do not feel the need to abandon the current model.

At the national level, the leadership for these organizations, however sing a different tune.  These advocating for an MD-lite practice model for NP/CRNA providers use studies relating a similar level of care provided by doctors and midlevels.  These studies have typical flaws such as MD supervision of the midlevel group as well as less acute or severe cases in the midlevel group.  Even so, the war-drums continue the march towards independent practice.

The VA has a nefarious reputation both in and out of the medical community as a place for poor care on all levels.  I am simply flabbergasted as to why, aside from purely financial reasons, the VA would advocate an anesthesiologist-less model for care.  Our veterans simply deserve the best we have to offer.  Indeed, many CRNA providers are exemplary in their care.  Even so, the current model of supervision by a doctor exists for a reason, a doctor is trained to handle significantly more and more severe scenarios than a CRNA.

The next 10-years of medicine will prove to be interesting.  The VA has launched the first salvo of the nursing provider interjection.  There will only be more to follow.

Thursday, May 26, 2016

Oh Microsoft!

Microsoft, Microsoft, Microsoft.  Why must you always torture me?  From the incessant driver issues with DOS and early Windows, to the terrible joke of Windows ME and 8.  Crippling my Windows or Office software because you believe it is stolen, despite buying it directly from your website.

I should have taken the hint with your prior flops as you foray in to hardware.  The original Xbox was a lovely device.  As was the Xbox 360.  Yet your response to the Red Ring of Death should have been a lesson to me.  Now, as I sit, Surface Pro 3 in hand, I remember our affairs of the past.

My poor Surface!  I babied you!  Not so much as a scratch.  That is until the strap on my bag broke and injured you.  A small crack coursing over the rostral end of your screen, visibly not effecting your performance, but the touch surface no longer functional in that region!

A marvel of engineering oh how I longed for you.  The cute little kick-stand.  The detachable, magnetic keyboard.  How happy I was when you were finally mine.  Such a tragedy we must end it like this.

The marvel of engineering makes it exceptionally difficult for semi-professional or amateur technicians to replace the screen on the Surface Pro 3.  As opposed to cell phones and ipads, the Surface must be sent back to Microsoft for its tender loving care.

Naturally, my warranty has expired.  As helpful as they were, the technicians on the phone for Microsoft quoted me $450 to replace the screen of my Surface Pro 3.  Perhaps it is simply a business model of planned obsolescence, as there is a new belle at the ball.  

The Surface Pro 4 is now the new kid in town.  Priced at $950 entry, it is not that far of a leap to upgrade to the latest and greatest.  Replacing my exact device would be a mere $800.  Surely, $450 for a screen replacement is a deal.  Otherwise, just get a brand new one!

Unfortunately for Microsoft, there are other devices on the market.  Google has introduced the Pixel C, with an entry price of $500.  This device has similar specs to the Surface Pro I would be replacing.

As opposed to Microsoft, my love affair with google has been nothing but mutually beneficial.  Google gives me loads of free stuff such as email, searching, cloud space, and an office suite.  Their phone apps as well are incredibly useful and used.

It may seem I only use Google for their free stuff.  Fear not, I have bought several google hardware devices including a Nexus 7 and several chromecasts.  Each has performed remarkably.  Further, when my Nexus 7 did take a hit, Google replaced my device, no questions asked.

While discussing with the Microsoft people, I made it clear that I was not asking for a free ride.  I offered $100 to repair my screen.  To me, that does not seem terribly outlandish.  Microsoft gets money, I get my screen fixed.  Everyone is happy.  I suppose they feel that the actual hardware may cost more than that, and they have to pay a technician to do the work.  I pointed out to the gentleman on the phone that $450 to replace my screen is remarkably close to the cost for a brand new Google device.  My cries fell on deaf ears.  Microsoft has a policy, and that is to take the set amount of money from the customer, regardless of the implications to the contrary.

While I do not anticipate migrating entirely from Microsoft in the near future, experiences such as this certainly give me reason for pause to think about and investigating the possibility.  Let us be honest here, as the consumer, we are also a product.  Microsoft collects the same (or more) information from its users as any other company in its role. Their forced updates to Windows 10, and nefarious reporting back to the mother ship that occurs is borderline unethical.  Why continue a relationship with this company when alternatives exist.  Likewise, why pay for products when a free version is perhaps better.

Fool me once Microsoft, shame on you.  Fool me twice, shame on me.  Looks like it is Pixel time.

Wednesday, May 25, 2016

Scammer Revenge

As a follow up to the post about Craigslist bots, I wanted to post about another recent experience I have had on CL.  Namely, as I am moving, and have way too many belongings, I am trying to sell some that still have value.

Never one to want to hassle with shipping, I have historically always turned to CL.  Yes, there are a lot of tire kickers or joy-riders when it comes to selling things on CL.  Likewise, I can not tell you how many times we agree to a price, only to have the purchaser claim they "only" had a significantly smaller amount.  Take it or leave it.  Well, gee, that seems fair and like you are an ethical business contact.  I will certainly sell you my already discounted belongings for less, because you evidently do not know how to count.

More recently, however, I have run in to a fair number of scammers.  The classic scam, as described previously, is to send out a cashier's check or money order for OVER the agreed price.  Then, request the difference, after cashing the check.  Inevitably, the check bounces and I am out the money that I sent to them.

While I have never fallen victim for this particular scam, I suspect there must be some who have.  Otherwise, why would they continue.  I  have, in the past,forwarded the contact information to the FBI and Secret Service for these scammers.  The FBI indicated unless it was for a significant amount (e.g. $10,000 or $50,000, I forget, it has been a while) it was not worth investigating.

Lately, the scam has taken a new twist.  The people claim to be able to add a zero, "0," to your amount.  Thus, if you send them $100, in a week, they will return $1,000.  Sound too good to be true?  Indeed, it is.

Initially, I tried to get them to deal with significant amounts, claiming I would send them $500,000.  Interestingly, they balked and said "we need to start out small,"  then requested $200.  This was all over text.  I had posted my phone number for respondents to reply to in order to facilitate a sale.

It seems these craigslist scam artists obtain a VoIP service that they can use software to pull information from CL and message people.  A quick reverse number search provided the name of the provider.  Visiting the VoIP provider website revealed they have both a technical support telephone number as well as a form to submit illegal activity.

I dutifully filled out the form, but suspected it would end up in the proverbial circular file.  So, I called the tech support and explained to them that the account was committing wire fraud, which is a federal felony.  The tech support individual was kind and provided further information regarding the account holder and so forth, and agreed to halt activity.  Needless to say, I forwarded this information along to the local law enforcement office as well.

While killing one VoIP text number feels like a small victory, I make no claim to have stopped them.  The scammer almost certainly has hundreds of other anonymous free email, CL, and VoIP accounts.  It is rather unfortunate that such a pervasive unwanted and illegal activity seems to dominate what once was a great marketplace for local sales.

Friday, May 20, 2016


Medical training is a very long, intensive, and expensive process.  The supply of well trained and proficient doctors is thus limited.  For surgical specialties, this is even more the case.

In the US, there has long been a discourse over the looming shortage of trained physicians.  The doctor deficit stems from a number of factors.

People are living longer, healthier lives.  When they do die, it tends to be a longer, more drawn out, medically intensive process.  Gone are the days where people would spend a day or two in bed at home and kick the bucket.  Any more, it takes days, to weeks, to months, sometimes even years, of hospitalization, intensive care, nursing home care, back to the hospital.  Add to this office visits and ambulance rides, titration of medications for chronic diseases.  Medicine in general is becoming big business.

Younger people tend to be healthier and require less medical attention.  For those in our 20s and 30s, it is not uncommon to go years without a doctors visit.  The aging population results in both an increase in the number of patients with health needs, as well as a decrease in doctors as they retire.  

People tend to want to live where they want to, and recently the trend has been towards urban centers.  The cost of living may be higher, but the salaries tend to be as well.  This results in a disparity of care for those in rural locations.

Further, for specialists, a catchment population of a particular size is generally required to sustain a practice.  That is to say, the lower the incidence of a disease that a doctor treats, the larger a population that is required to support him so that he has enough patients to continue practicing.

For surgeons, an infrastructure is also necessary.  As often as it happens on television, where a hero paramedic or surgeon in the field uses a power tool to decompress a head bleed, in real life we need an operating room.  Operating rooms are expensive to run, they require at a minimum circulating nurse, a scrub nurse, a surgeon, and an anesthesiologist.  Add to that any machinery e.g. the anesthesia machine or tools e.g. microscope, xray/c-arm, and it becomes increasingly expensive simply to have available.

Perhaps I am self centered, but for a surgery, my opinion is the surgeon is the most important facet.  It simply would not happen without a surgeon.  Thus, with a limited supply of surgeons available, innovations on how to maximize the utility and reach of the surgeons we have are important.

Advancements in both control mechanisms and telecommunications have reached the point where we are able to remotely control robots with high precision and accuracy.  Devices such as the Da Vinci Robot allow for a computerized robot control a camera and multiple arms.  Meanwhile, a surgeon sits at a control console and moves the camera and arm as needed.

With high speed internet connections, this control console is capable of being down the hall, in another building, or somewhere else in the world entirely.  The benefit of this is that, though currently expensive, we could build thousands of these robots and stock them in just about every hospital in the world.  When a patient needs surgery, a surgeon who is available goes to his console and performs the surgery.

For applications such as rural health, military medicine, or third world care this has phenomenal implications.  A specialist surgeon's reach is significantly extended, and those unable to reach a center for care are able to receive it nonetheless.

Indeed, there remain many obstacles to be overcome.  Namely, supportive care following surgery.  If a rural or third world hospital is unable to staff a surgeon, it is also likely they would have difficulty with an intensive care patient.  That being said, telemedicine is also advancing in these fields as well.
While the robot or remote surgeon may never fully displace the current hospital model, it may allow for rural communities to continue having community hospitals that address the local needs.  Likewise, for third world care, life and limb saving surgery can be offered with greater frequency.  I look forward to the day I can log in from home in my pajamas and decompress a subdural hematoma and go straight back to bed!

Thursday, May 19, 2016


The medical community has had an interesting relationship between doctors and pharmaceutical device and drug companies.  Stories of excessive honoraria, paid trips, and free lunches have resulted in regulation and increased transparency and reporting of these relationships.  Following the lead of the federal government reporting for government contracts, the Physician Payments Sunshine Act requires reporting for entities at teaching institutions that interact with the Centers for Medicare Services.

As a medical student, I can remember my outpatient rotations in clinics where routinely a drug company representative would provide a lunch for the office staff.  These meals came with a caveat that the rep would provide information on his or her drug and pitch them to the doctors making the decisions on prescribing.

While as a student, I rarely had much of a role in this decision making process, let alone even pronouncing some of the names of the drugs.  I do fondly remember the lunches, pens, books, and other materials provided by these companies.  Now, when I am in the role of making these decisions, I find the influence of these companies rarely influences my decision making process.

Though the companies have had to significantly curtail their practice of advertising directly to the physician, as the title indicates, is there such a thing as a free lunch?  As the economics lesson would suggest, there must be a benefit to the drug companies spending money to influence providers.

While I agree, direct money or kick backs to doctors for prescribing particular medications or using specific devices is unethical.  Hypothetically, though, how is this any different than a company lowering their bid for a contract to supply a practice or hospital?  While in the former scenario, the money goes to the doctor for using the companies products, in the latter, the doctor has less cost associated with using the product and thus a greater net profit.

To my knowledge, the advertising budget for these companies has not significantly changed, despite the restriction of lunches, dinners, or educational gifts for doctors.  Instead, the companies have turned to direct marketing to consumers.

Turn on the television during prime-time and during any commercial break I see various prescription medication for allergies, arthritis, men's or women's sexual health, or blood thinners being hocked.  These advertisements typically portray attractive people in serene settings, smiling, trying to convince people with these diseases that they will be healthier and happier if they talk their doctor in to switching their prescription.

The commercials are always ended with a laundry list of complications and contraindications, many of which the consumer has no idea about the tangible risk associated with their condition or benefit of staying with their current medication or changing.  Further, the advertisements are always for proprietary medicines that are still under patent by the manufacturer.  Namely, a generic alternative is not available, so the company stands to make a significant profit.

The internet has given the average person an incredible ability to research their ailments, to better understand the symptoms they are having, course of their disease, and management options.  While "doctor google" is becoming more and more common in the actual doctor's office, the average person, while intelligent, may not fully understand the human pathophysiology that is occurring.

Perhaps I am being naive in thinking that a free lunch had limited effect on my decision making process.  That being said, if every company with a competing product is buying me lunch, the amount of influence by one or the other is not particularly different.

Wednesday, May 18, 2016

Money for Time

The recent discourse about increasing the national minimum wage to $15/hr has been meet with some criticism.  Namely, employers of individuals at this pay scale question the sustainability of such a policy as well as the worth of the employees.

I have had the recent experience of having to pay various hourly wage workers at their going rate.  Be it the auto mechanic for $90/hr, the plumber for $100/hr, the accountant for $125/hr, or the attorney at $300/hr, they all set their fee based on the demand of their services, and what the market will support.

Factoring in overhead and other costs, it is unlikely the mechanic is taking home $90/hr, nor the the attorney $300/hr.  Likewise, that may be what they bill, and would ideally take home an hour, but they may not fill their entire schedule.

What is a reasonable rate?  As a doctor, moonlighting in the ER or the hospital ranges from $100 - $200/hr, depending on experience, location, and level of involvement of the position.  Indeed, that is the gross, take-home pay.  As opposed to the mechanic or attorney, the overhead for the doctor is taken care of by the employer.  Essentially, they bill the patients for whatever the case may be, an office or ER visit, another night in the hospital, and pay the overhead as well as the doctor out of that.

Medicine in general is transitioning from an independent practitioner model, wherein the doctor would bill the patient directly, to a managed care model.  True, depending on the arrangement, there may still be a professional fee assessed on behalf of the doctor, but in managed care, this is added to the pot, not the doctor's take.

As you can imagine, managed care has more managers involved.  They do often provide benefit, creating efficiencies and decreasing waste.  Further, if they are responsible for maintaining a level of care, e.g. scheduling, it takes any gaps of coverage out of the equation.  Nonetheless, they are another expense.  Moreover, in many practices, they value the bottom line over patient care.  Truly, they are just doing their job, which is to ensure the business functions and everyone profits.

That being said, healthcare is not particularly business oriented.  Many of our patients are unable to afford our care.  Yet we provide it, nonetheless.  A good organization has these loss centers built in to the model.  Unfortunately, as a surgeon, my experience with cost control has often been finding inferior, off-brand replacements for tools or supplies in a cost-saving attempt.  I try to be as conservative as possible, using as minimal technology and costly tools as needed.  Squeezing even more saving out of an already lean budget can prove difficult.

When it comes down to it, we are either labor or capital.  Those of us who lack the resources to employ others to do things for us, must exchange our time for money from those who have those resources.  Ideally, everyone is happy with the arrangement; those of us exchanging our time and expertise feel we are worth what we are being compensated, and those paying feel they are getting their money's worth.  Unfortunately, everyone wants more, no one is happy, and the other guy is to blame!