Thursday, August 27, 2009

Propofol sedation and Michael Jackson..

Okay, I like Happy's blog for the most part, we have been in MASSIVE disagreements over the utilization and deployment of PA's, and NP's, but I also for the most part respect his opinion....

HOWEVER, here, I think Happy has lost it.

Trying to assert that giving propofol in a persons bedroom, and leaving 10 minutes after administration to go to the restroom, is similar to administration in an outpatient healthcare setting is just crazy. That is truly, jumping the shark.

I give propofol frequently for shoulder and hip dislocations, fracture reductions, central line placement, chest tube placement, etc. I also use etomidate, versed, and other sedatives/anesthetics. But never, unless I have airway equipment at the ready, including a laryngoscope and ET tube, and never without proper monitoring. In fact, I had to take a course on concious sedation and prove competency prior to being able to use them. Which is a GOOD thing.

These are serious drugs, and one has to have a VERY healthy respect for them. Using them in someone's bedroom is crazy. Using them, and then leaving 10 min in (which, btw, is just about when they will be awakening with propofol) to go the restroom is criminal.

But that's my opinion.

Great description of elasticity modeling in healthcare

In economics, several of the words that you might hear, are elasticity, inelasticity, and contractility.

Jason over at Healthcare Economist does a great job describing price elasticity in medical services in a relatively straightforward manner.

Price elasticity estimates how consumer demand changes as prices change. For instance, the price elasticity of medical service is defined as the percentage change in quantity of medical care demanded divided by the percentage change in price of the same commodity. Most academics believe that the price elasticity for medical services is between 0 and -1. This means that if prices increase by 10%, the demand for medical services decreases, but by less than 10%. This means that medical goods are inelastic.

This is in large part, the reason we are seeing a failure of the medical markets to respond to the pressures of the current recession.

Wednesday, August 26, 2009

RIP Teddy

Senator Ted Kennedy died today.

Regardless of where you stood politically, there are very few politicians who have had the true passion for helping others that he had. He also may have been more involved over the course of his career in pursuing healthcare reform, than any other politician in US history.

So the last brother passes.

Tuesday, August 25, 2009

Football is upon us....

It's the first sign of the coming autumn. Football is here. THANK god, I love football, I love everything about football. My beloved Cleveland Browns will hopefully not suck TOO badly, and my fantasy team seems decent.

Can't wait, for brats, beer, and chips/pretzels. But what I really miss.....

I really miss playing football. I was discussing this the other night with a nurse at work, and she asked me why. That's easy, I miss the pain. I miss the contact. There was nothing better in this world than watching a wide receiver come across the middle and go up for a ball...I was a free safety...and then to make the hit, and make it so hard, to stick it, to actually feel his wind being expelled from his lungs and watch him hit the ground hard is a feeling that is hard to replace.

I never wanted to injure anyone, and no one I knew, or played for wanted to see that either. But to smack someone REALLY hard, and make them think twice about where you were the next time they were running a route was a great feeling. I even liked getting smacked myself. I remember once getting ready to nail a wide reciever coming across the middle from the right side, and I didn't see the tight end coming from the other side. I got smacked...knocked about 10 yards..I loved it.

I really miss the contact....the only thing that might compare is drunken kickboxing, but that is a WHOLE nother story.

The Drug Seeker Dance

I love drug seekers, I love everything about them. I actually get a BIG smile when I see the complaint, and recognize the name. It wasn't always that way, I used to despise them. I used to groan, and complain about seeing them, and I would dread the coming confrontation. Not anymore. Now I've dealt with them so many times, that I actually enjoy it. I'm not known as being a "dispenser", in fact quite to the contrary, there have been times working at some of my locations where I have watched a familiar patient walk in, see me working, and watch their mouth open and sigh, and watch them walk right out the door. It's an unusual thing.

However, after seeing so many, there seems to be a common dance that they all do...regardless of whatever flavor they may be seeking.

Step 1, As you enter the room, the patient greets you with a smile, and an enthusiastic expression. (the first part of the buttering up phase), and seems to be comfortably sitting there...BUT wait, something is amiss....they are complaining of 10 out of 10 pain.....Hmm, now that's odd.

Step 2, As the interview progresses they repeatedly ask about your personal life and family, IE; do you have kids?, how old are they?, etc. (the second part of the buttering up phase).

Step 3, Now for the exam, this is almost always benign, and usually completely unremarkable, yet they might try to grimace, or act as though something is really wrong. The trick is to get them to repeat the motions, or pressure without them thinking it is an exam. IE; ask them if they need help sitting up, and press on the tender point in their back.

Step 4, the dreaded confrontation, I used to hate this, but now I don't mind at all. You calmly confront them about their frequent visits for narcotics, and how they should be obtaining ALL narcotics from one solitary primary care provider. This is where the patient goes almost invariably through several stages. First there is disbelief, and subsequently a defensive posturing. Then there is usually an excuse or story, IE; my meds got stolen, I lost them, my doctor is out of town, etc, followed by an attempt at bargaining.

Too bad it rarely works. I have no problem treating real pain, and I might be more liberal than some when treating fractures, occasional isolated migraines, pain related to cancer, etc. However, when I see a frequent flyer in the ED, with chronic pain, who is chronically drug seeking, and doctor shopping, well.....Not so much.

Eight Stages of American Medicine

From Happy's blog:

Phase VII: Destruction of the Tax Base, and With It, Government Health Care

Believing they could continue to soak the rich for all their needs; With massive deficits that must be repaid; With 50% of the population paying just 3% of the tax base; The government finally killed off the productivity that drives American growth. With a tax base massively skewed to the productive members of society, the ones that take all the risk of capital, the tax burden became too much. No longer were folks willing to take risks to see rewards which were confiscated to the tune of 90% or more in federal tax rates. Tax rates that continued its northward spiral in a misguided attempt to pay spiraling entitlement programs. Programs that bought off the populace years prior.

As growth plummeted so did jobs and productivity. And with that came the lose of tax revenues to fund the already shrinking and rationed government health care entitlements. Ultimately what the government realized was the wisdom of their ways. They realized they could not continue to promise FREE=MORE to a poor and middle class population while also funding that obligation from a small and shrinking rich population burdened under the weight of massive tax hikes and anti growth programs.

At this point the government made an amazing proposition to its entitled masses. Either the poor and middle class would now have to cough up more than 3% of the federal tax revenue, or they would have to dismantle the entitlement programs funded almost entirely on the backs of the rich, a population who's numbers have dwindled drastically since the tax and spend policies were initiated two decades prior.

The people now had a choice. Pay their share or go without. One hundred years on the road to socialism was finally meeting its demise.

I especially liked stage VII, how apropos. I have been stating similar things on here for awhile, but perhaps, not so eloquently (who knew a hospitalist could write?)

Folks, if we don't dramatically reduce costs, and realize that we might need to raise taxes on more than just the rich, than this will fail. It will fail epically.

BTW- this is why I support Zeke's plan. A national VAT tax rate of 10% to fund a single payor system. EVERYONE PAYS.

10.5% increase in health care premiums..

Nice, but this is economically part of the problem.

Found THIS in the Washington Post today.

So, it begins, employees will likely begin to see wage stagnation, a decrease in real purchasing power (ESPECIALLY if the newly minted deficit of 1.6 trillion causes devaluation of the dollar, and subsequent inflation), and possibly an increase in healthcare deductions.

Not only that, but prescription drug prices are expected to rise 9.3%.....I mean REALLY????

We need real cost controls, and a real effort to reduce healthcare expenditures.

Monday, August 24, 2009

Wake Forest fires the first shot....

Here we go, Wake Forest University fires the first shot. Found this over on the forums.


Wake Forest University School of Medicine
Winston-Salem, North Carolina
Applications are invited for the position of chair of the Department of PA Studies at Wake Forest University School of Medicine. The chair has overall responsibility for all activities of the department and reports directly to the dean of the School of Medicine.
The Department of PA Studies was one of the first PA programs in the country. It is a pioneer in the use of problem-based learning (PBL) and had over 700 applicants for the 56 positions available in the class starting in 2009. Wake Forest will be the first institution in the country to offer a combined Master of Medical Science (MMS) and PhD program, pending final approval by the University’s Board of Trustees.
The successful candidate will have an established record of leadership in PA education (including exposure to PBL) and extensive administrative experience. A doctoral degree (or one in progress) and research experience are highly desirable. We seek a leader who is well grounded in all aspects of PA education and who also has a vision for the continued growth and development of the field.
To apply, send a curriculum vitae and letter of interest to

Burton V. Reifler MD, MPH
Chair of the Search Committee, at

Wake Forest University School of Medicine is an affirmative action, equal opportunity employer. Women and minorities are encouraged to apply.

So, it sounds like an entry level PhD program for PA's....Which is groundbreaking, this has the potential to really, and dynamically affect PA education, although not necessarily for the better. The proof is in the details, and still remains to be seen.


Sunday, August 23, 2009

Mandatory PA Residencies...

Now, for something not so popular with some of my colleagues. PA residencies. They've been around for years, and I believe there are now 48 or 49 programs. The Baylor/Army EM residency program is 18 months and awards a doctoral of science degree, or a DSc at it's completion. I think someone mentioned that it contains 5600 clinical residency hours, and 516 didactic hours.

The point of this discussion, is that the PA profession is changing. Our roots were based in experienced health care workers, at the beginning, military medics, who could recieve additional training and be a complement to the physician. Medicine, and PA training have changed however. Physicians, healthcare policy wonks, and even the market itself is starting to see more and more PA's practicing with more indirect physician supervision. PA's are increasingly becoming practice owners, and hiring supervising docs to work with them. We have branched far from our initial purpose, which was to provide primary care in rural and underserved areas, and are now working in almost every single specialty, including interventional radiology.

Concomitantly, programs have transitioned from a certificate or associates based training, to the majority being held at a Master's degree level. This has meant more and more younger students coming straight from undergraduate into PA school with nominal, if any prior healthcare experience.

Should we mandate mandatory residency training? I am thinking this is an idea whose time may be upon us. Not all of them need to, or should offer a Doctoral degree. But I think any PA who wishes to practice outside of primary care, should complete a residency.

BTW-this is not a very popular idea with a lot of PA's

Here's a link to an article about the Baylor/Army program.

Here's another that needed to be resurrected.

Bill Maher is my hero....


From his show the other night...

And finally, New Rule: Just because a country elects a smart president doesn't make it a smart country. Now, a couple of weeks ago, I was asked on CNN if I thought Sarah Palin, and I said, "I hope not, but I wouldn't put anything past this stupid country." Well, the station was flooded with emails and the Twits hit the fan. And you could tell these people were really mad because they wrote entirely in capital letters!

Worst of all, Bill O'Reilly refuted my contention that this is a stupid country by calling me a "pinhead." Which, a) proves my point and b) is really funny coming from a "doody-face" like him!

Now, before I go about demonstrating how sadly easy it is to prove the dumbness that is dragging us down, let me just say that ignorance has life and death consequences. On the eve of the Iraq war, 70% of Americans thought Saddam Hussein was personally involved in 9/11. Six years later, 34% still do.

Or, look at the healthcare debate going on now. At a recent town hall meeting in South Carolina, a man stood up and told his congressman to "keep your government hands off my Medicare." Which is kind of like driving cross-country to protest highways.

This country is like a college chick after two Long Island ice teas. We can be talked into anything. Like wars. And we can be talked out of anything. Like healthcare.

We should forget the town halls and replace them with study halls.

Listen to some of these statistics. A majority of Americans cannot name a single branch of government, or explain what the Bill of Rights is. Twenty-four percent could not name the country America fought in the Revolutionary War. More than two-thirds of Americans don't know what's in Roe v. Wade; two-thirds don't know what the Food and Drug Administration does.

Some of this stuff you should be able to pick up simply by being alive. You know, the way the "Slumdog" kid knew about cricket?

But, not here. Nearly half of Americans don't know that states have two senators. And more than half can't name their congressman. And, among Republican governors, only three got their wife's name right on the first try.

People b*tch and moan about taxes and spending. They have no idea what their government spends money on. The average voter thinks foreign aid consumes 24% of our federal budget. It's actually less than one percent. A third of Republicans believe Obama is not a citizen. And a third of Democrats believe that George Bush had prior knowledge of the 9/11 attacks. Which is an ABSURD sentence, because it contains the words "Bush" and "knowledge."

Sleep tight, bat-****. Sarah Palin says she would never apologize for America, even though a Gallup Poll says 18% of us think the sun revolves around the earth. No, they're not stupid; they're "interplanetary mavericks."

And I haven't even brought up religion. But, here's one fun fact I'll leave you with: Did you know only about half of Americans are aware that Judaism is an older religion than Christianity? That's right. Half of America looks at books called the Old Testament and the New Testament, and cannot figure out which one came first.

I rest my case.

The stupidity of the average american just never ceases to amaze me.

BTW, those statistics are should be enough to scare anyone. More than 2/3 don't know what's in Roe V Wade???

I'm seriously starting to think that we need to start curbing the growth of the stupid in this country.....

This goes in the "duh" category....

This is so astronomically obvious, that it might even eclipse the sun. Unfortunately, our country is exceedingly stupid, and what is blatantly obvious seems to escape many.


SO, let's see, premiums are rising faster than income. Well, golly, I'm shocked, SHOCKED I tell you.

Until half of this country begins to take their collective heads out of their collective asses, we are in real trouble.

PA name change.

This has been an issue for a long time, and has been debated in PA circles ad nauseum. When our profession was first created. Dr Eugene Stead, the professions founder, wanted to name us Physician Associates. The AMA at them time, in their infinite paranoia (think of the DO profession, and pretty much the AMA reaction to anyone else in healthcare) thought that the name "associate" was misleading, and could lead people to think of PA's as physicians, or physicians in training. What a crock. The Yale program (Yes we have Ivy league programs), still to this day calls their graduates Physician Associates, and at the hospital there, they are titled as such.

There are many in our profession who think of the "assistant" title as denigrating, and demeaning. Count me among them. Patients and the public frequently misconstrue us as "medical assistants", and while I have nothing against medical assistants, that implication is insulting. Assistant implies that I have nothing to offer besides helping a physician with a specific task. It implies a lack of training.

PA's own their own practices. They serve as FLAG officers (yes, admirals, etc.) in the military, when VP Cheney was sick, he wasn't cared for by an MD initially, he was cared for by a PA. In most specialties, PA's function with a HIGH level of independence, and autonomy. In one of the ED's I work in, specifically, Waseca Medical Center, the ED is solely staffed by PA's. There are NO MD's in the ED. Overnight, we cover the floors as well. Guess what, in the fall of 2008, the ED had the HIGHEST patient satisfaction scores in the COUNTRY..not just the state, the COUNTRY. Does that sound like what an "assistant" does?

More here

It is time to return to our roots, it is time to return to the name that Dr Stead initially intended for our profession. We have outgrown the old one.


Thought I would resurrect this, as I like this discussion, and my desire for a name change has only become MORE resolute

Thursday, August 20, 2009

Rationing of Care

This is an editorial that I just published in the latest issue of PA Professional, as many of you likely do not GET that journal, I thought I would also post here.

Rationing of care, yep, it’s a scary term I know. Yet, while it’s an emotionally charged and difficult topic to discuss, it remains one of the most complex and pressing issues for a society heading rapidly towards health reform.
We ration care now. However, now it’s rationed simply on a financial basis, i.e. those who cannot afford insurance, and do not qualify for state assistance have little in the way of options for chronic medical treatment. Even those with Medicare and Medicaid can sometimes find it difficult to obtain appointments or a provider, as many do not accept those insurance plans.
I have had my more conservative friends tell me, that those without insurance can simply obtain care “in the ER”. Sadly, this observation plays itself out in reality more times than not. However, the care that is provided in the emergency department (ED) setting should, in no way, be compared to the comprehensive care, and management that an experienced and competent primary care provider could provide for chronic disease management.
I discuss health policy on a daily basis, and one of the frequent things that I try to tell people is that, discussing health care reform without discussing how to provide care for an increased number of people, while lowering costs at the same time, and not discussing rationing, is ignoring the 800 pound gorilla sitting in the corner of the room. It’s a difficult discussion because – unlike our European counterparts – there are cultural forces at work in the United States.
Many patients have a rather defiant attitude towards death. This is problematic when we realize that the majority of patient health care expenditures occur in the last months of life. For example, Taxol is used in the United Kingdom in the treatment of ovarian neoplasms, but it’s often withheld in advanced ovarian cancer. Elderly patients, who have multiple co-morbidities and develop conditions like renal failure, may not be eligible for services like dialysis. Their system has decided that the cost/benefit ratio is simply not acceptable.
Other industrialized countries, with more governmental control of health care, use similar methods to ration care. Now, ask yourself how you would feel if it were your loved one? Does that change your response? These are important questions, and I am not going to pretend to know the answers, but this is a necessary discussion, and there is a definite fiscal reality that we as a nation, are going to have to confront.
As provider’s, we all have the ability to influence the health care reform debate to some degree, and if we want to have any sort of real honest discussion about health reform, or universal coverage, we need to first be honest with ourselves, because it’s still the 800 pound gorilla, sitting there in the corner, staring at you.

For those interested, it is in Vol. 1, No. 2 of the PA Professional.

Clinician One

Dave Mittman from Clinician One has asked me to, and I will begin to post this blog on the Clinician One site. I will try to crosspost here as much as possible as well, but thought that I should inform you.

I will post the direct link, once I have it.


MORE on Prometheus....

I've posted about this before, but here is an article from the NEJM, which is a bit more substantive.

Prometheus....NO, not the god who was forever condemned to watch his liver being eaten every day, but a healthcare payment system that was first implemented in Rockford, Ill.


Prometheus in Practice

A 63-year-old white man with chest pain and a history of unstable angina is admitted to a teaching hospital. The patient has hypertension and diabetes. An electrocardiogram reveals ST-segment elevation in the lateral leads. The man is taken to the cardiac catheterization laboratory, where coronary angiography reveals severe triple-vessel disease as well as 60% stenosis of the left main coronary artery. A left ventriculogram shows mitral regurgitation (grade 2 to 3) with papillary muscle dysfunction. The patient is then taken urgently to the operating room, where he receives two venousgrafts and a left-internal-thoracic-artery graft. In addition, a mitral-valve reconstruction procedure is performed to correct the mitral regurgitation. The surgery is a success, and the patient returns to the intensive care unit in stable condition. However, his blood sugar is out of control, and he requires an insulin drip. His stay in the intensive care unit is prolonged by 2 days, and he must stay another day in the step-down unit. He is discharged 8 days after surgery in stable condition. One week after discharge, he is readmitted for a wound infection in his leg from the vein harvest site. He requires wound d├ębridement and a course of antibiotics.

Under fee-for-service payment, the hospital would receive $47,500 for the bypass surgery, and the surgeon would receive $15,000 for performing the procedure. The extended hospital stay that was necessitated by the uncontrolled diabetes would result in an additional $12,000 for the hospital and $2,000 for the physician, and the readmission costs would total $25,000, for a grand total of $101,500.

Under Prometheus, the case-payment rate for this patient would include a severity-adjusted budget for typical costs of $61,000 for the hospital and $13,000 for the physician. The severity-adjusted allowance for PACs would be $15,300, for a total budget of $89,300. Had the readmission been prevented, the hospital and physician would effectively have earned a bonus of $12,800 ($101,500 – $25,000 = $76,500, which is $12,800 less than the Prometheus budget).

BTW, Doctors HATE this concept. But they pretty much hate anyone telling them what to do.....