Monday, August 17, 2009

What you get for your money

To continue my train of thought on the Wall Street Journal opinion piece from yesterday. The United States spends 17% of its GDP on health care but what do we get for it? I would bet we take care of more sick patients than any other industrialized country in the world. By sick I don't mean just acutely ill, but also chronically ill. We have the highest rate of obesity in the world. We probably have more people with coronary artery disease, diabetes, hypertension, cancer, congenital defects, renal and liver failure, alcoholism, and drug abuse than any other first world country. We take care of more extremely premature infants, and more centenarians than any other advanced nation. Just in the last month I saw an orthopedic surgeon put in a new hip on a 95 year old patient, a gastroenterologist perform an ERCP on a 103 year old, and another gastroenterologist put in a PEG on a demented 92 year old. All those patients got million dollar workups and consultations during their hospital stays. How many other countries in the world can boast that claim?

In this country, where every life, even the unborn, is considered precious, we are going to have to spend more money than anybody else. Our societal expectations, along with our legal obligations, ensures that we will spend top dollar to treat everybody equally. Nobody gets short shrift on health care regardless of their ability, or inability, to pay. Whether they are citizens, legal residents, or illegal immigrants, all patients who walk through the emergency room doors get treated equally.

So what if Japan only spends 8% of its GDP on health care. Or that South Korea spends 6%. I've been to hospitals in Asia. They spend less but they also get less. Most rooms are like the old hospital suites we used to have here, 2-4 patients per room or more. Sure you can have a private room, but you'll pay more for it. They are extremely understaffed. If you want a nurse's attention, you better hire your own private nurse. If the patient doesn't get better, they don't usually call the first malpractice lawyer they see on a TV commercial.

Perhaps spending 17% of our GDP for health care is commensurate with our quality of care for our given patient population. We spend more because we need more. We have sicker patients than most other industrialized countries. Other first world countries in general are healthier than us, with lower rates of obesity, alcoholism, and drug abuse. They can afford to spend less on their health care. If we want to improve the quality of our health care, given our country's health status, perhaps we need to spend even more, not less.

Sunday, August 16, 2009

We need to spend more on health care

An interesting editorial in the Wall Street Journal argues that we should be spending more money on health care. Health care currently makes up 17% of the GDP in this country. And what's wrong with that? Nobody argues that manufacturing, with 20% of GDP, is bad for us. In fact we want more manufacturing. When the housing bubble was inflating, nobody complained that construction jobs was consuming too much of the economy and needed to be refrained (though in retrospect it probably should have been). Imagine if information technology spending was growing as fast as health care spending; everybody would be singing the praises of the technology revolution advancing our nation into the 21st century.

Other countries want the medical products that are manufactured here, from pharmaceuticals to MRI's to artificial joints. Is it such a bad thing to invest 17% of GDP in such a robust industry? Why are we propping up the old fading industrial segments, with bailouts to the car companies and their suppliers, while trying to tear down the most innovative companies in the U.S., the drug companies, the biotechnology companies, the medical equipment companies?

The money spent for health care is not wasted money. That's like arguing that money spent on food is wasted. Health care is commonly referred to as a universal right, like having adequate food, clothing, and shelter. The government spends enormous amounts of money on food stamps and housing subsidies to make sure everybody has some sort of food and shelter. We don't mind spending more on those yet spending more for medicine is wrong. And there seems to be a common misconception that health care employees make less than manufacturing employees. I see all around me nurses, administrators, PA's, techs, etc. that make very good incomes. In fact many drive better cars and go on nicer and more frequent vacations than me. I bet there are just as many or more employees in health care who have nice incomes and benefits as there are in manufacturing. Why does the press keep denigrating the addition of employees in health care as if they are worthless jobs? That somehow they don't measure up to the romanticized benefits of manufacturing jobs?

So maybe the medical field just needs better PR. We need to get people over the perception that spending money on their own well being is money down the drain. It is money that will increase their longevity, make them healthier of mind and body, and expand one of the few world class industries still in the U.S.

Saturday, August 15, 2009

Porsche Panamera

I feel a mid-life crisis coming on.

I'm finally one of the cool guys.

According to the New York Times, the hipsters in the city this year all dress like slobs and sport round protruding guts. Hallelujah! Now I can stop worrying about my lack of gym time. They call this look the Ralph Kramden, after the Honeymooners character. According to Aaron Hicklin, editor of Out magazine, all that metrosexual manscaping and body sculpting got too precious. It was a sign that somebody had too much time on their hands.

I totally agree with that. In my frenetic world, I'm trying to juggle 12 hour work days, kids times, wifey times, and sleep times. I can't do much about the work hours, and I've already cut family time to the bare minimum, even less according to my exasperated wife. If I cut any more snooze time, I might get into an accident on the way to work. So the gym will just have to wait. And now I don't have to worry about my lack of six pack abs or the huge guns I see on all those ads. I'm finally with the In crowd, and I didn't even have to try that hard.

Thursday, August 13, 2009

Match Day

Just got my medical school alumni newsletter. It highlighted the momentous event in every medical student's school years, Match Day. It was wonderful seeing all those pictures of happy faces as they opened up their envelopes. I remember all the seniors would be gathered in a conference room that morning. Everybody was nervous but also anxious to find out their destiny. For the most part, people usually got into the field they sought, if not necessarily the location they desired. Then there were the surprises. Some people matched into fields that were totally unexpected. Then you realized you didn't know people as well as you thought.

I was happy to see that about four percent of this year's graduating class decided to pursue anesthesiology. Good luck to all of them. And I'm sure some of those who matched into surgery will switch into anesthesia, there usually are a few. But we'll welcome the late comers like everyone else as they cross over into the light from the dark side. But they will all start to work harder than they've ever worked, harder than they thought possible. They'll realize that even though medical school was tough, residency is even tougher. The hours, the responsibilities, the lack of personal time.

But maybe residencies have changed since I was in one. As I've previously written, residency hours are being drastically cut back. They may actually have a few free weekends to themselves now without any patient responsibilities. And the new graduates will be entering a medical field that may undergo changes greater than any seen in the last forty years. The great thing about youth is that they will adapt ably and competently while us old geezers complain about the good old days. Looking at all those smiling faces makes me realize how good my life has been, how I should be proud of the privileged life I've led as a physician. So in the last week, I've smiled a little bit more for my patients, tried to not let evil surgeons ruin my day. Yes it's good to be me.

Tuesday, August 11, 2009

I guess three out of four ain't bad

According to this LA Times article, citing the Archives of Internal Medicine, it takes just four lifestyle changes to decrease your risk of stroke, cancer, diabetes, and coronary artery disease by 80%. These four factors are: avoid smoking, avoid obesity, moderate exercise, and eating a healthy diet. Well duh. We physicians have been preaching this concept for decades. But decades of research into the benefits of diet and exercise hasn't really changed anybody's mind. In all the health care debates, America's higher mortality rate compared to other industrialized nations is repeatedly brought up, as if insuring more people and spending more money will make a big difference.

The article also states that even if you accomplish two of the four factors, avoid obesity and smoking, your risk of getting a chronic disease decreases by 72%. So I guess I'm doing pretty okay. Can I also add attempt to eat healthy? Will an occasional Big Mac worsen my risk improvement to 65%? I promise I'll do better at the exercise part but 72% is already pretty darn good and I'll have more time to spend with my kids instead of being at the gym.

Nowhere are the genes you inherit mentioned as a risk factor. We've all heard of the 45 year old marathon runner who collapses from a sudden MI. Or the college sports player who has sudden death from a cardiac arrhythmia. George Burns lived to be over 100 years old while smoking a cigar. So this has not been taken into account. Since you can't choose your parents, you might as well do what your doctors tell you and diet and exercise, as always.

Friday, August 7, 2009

Is the French system better?

Today's issue of the Wall Street Journal discusses universal health care in France. It talks about how France is now trying to move towards the U.S. model of health care, with higher copays and higher deductibles. France is also trying to cut back ever growing expenditures as health care now consumes 11% of their GDP. Of course people are up in arms about these changes despite an evergrowing financial burden on the country. But as long as somebody else is paying for it, why should their health care be cut back?

What strikes me the most is the chronology of France's system going back to 1976. If you go through the list, you'll see that taxes were raised in one form or another eight times since then. That doesn't include the extra fees and reduced reimbursements that were used to moderate cost inflation. So if other countries have been offering universal coverage for over fifty years and still can't get their costs under control, what makes the U.S. think we can do it here with one legislative session? Once again, we'll have to choose, universal health care or reduced costs. We can't have it both ways.

Thursday, August 6, 2009

These are a few of my favorite things

This monstrosity is called The Luther Rory. It is a one-third pound burger between two slices of cheese, four slices of bacon, peanut butter, and two Krispy Kreme doughnuts. YUM! I found this picture courtesy of a great website Other food creations featured include deep fried anythings and giant meat and carb creations. Check it out. I am no gastronome. My fanciest meal each year is the buffet line at the Bellagio for our annual Las Vegas vacation. But sometimes, when I'm on call in the middle of the night, I sure could go for a Luther Rory, or a Scooby Snack, or a Hamburger Helper Pizza Burger.

Since this is an anesthesia blog, I should say a little something about how this is medically related, right? Which leads me to the medical lecture I am about to give. Eating Luther Rories or Scooby Snacks will eventually lead to obesity which may require a gastric bypass to correct. For those who are not familiar with inducing anesthesia in morbidly obese patients, here is a video of an awake fiberoptic intubation. It is not pretty. And I have to say it is one of my least favorite and scariest things I have to do in the OR. Patients don't think it's such a great thrill ride either. Think about that next time you go to the country fair and order that fried Snickers.

So there you have it, a blog entry on two of my favorite subjects in the world: food (especially if it's bad for you) and anesthesia.

Sunday, August 2, 2009

A new breed of doctors

A patient complains to her anesthesiologist about her anesthesia bill. "Doctor, I can't believe you charge me this much money to put me to sleep." The anesthesiologist replies, "No madam. Putting you to sleep is free. This fee is for waking you up."

While talking with my colleagues, a complaint was voiced that medical, and anesthesia, residents sure have it good compared to when we were in training. While we had to walk six miles to work in hip deep snow and crafted Ambu bags out of the bladders of sacrificial virgin lambs, the current residents' hours are strictly capped at eighty hours per week. And the talk was of even stricter work rules next year. Their work week will be capped at 65 hours a week, with no 24 hour shifts and a required 10 hours of rest between shifts. When a resident's work day is finished, he or she must leave immediately by pulling his car out of the parking lot, swiping his ID card at the gate to signify he is no longer at work. Study at the hospital library after work? No can do. Postop checks? Not if it will violate the work hours limit.

But it is the clinical skills that will suffer the most. The 65 hour work week includes classroom time. So actual OR time will be much less. While the resident will put at least one patient to sleep during the day, he may not be around for the end of the case, the critical time when major decisions are made about extubation criteria, hemodynamic stability with awakening, need for intensive care postoperatively, and PACU complications. And of course the longer the case, the more critical the postoperative period, and the less likely the anesthesia resident will be present to make the important decisions. The residents will have the intellectual knowledge to pass the board examinations, but they will be lacking in the art of anesthesia, the little intangibles that are not taught in books but every anesthesiologist has learned in a successful practice.

These new anesthesiologists may actually be perfect for the future of medicine as envisioned by our politicians. With reimbursement threatening to be lowered even more and millions more patients flooding the health system, all physicians may eventually be forced into salaried positions. At that point, there is no reason to work past your scheduled shift. The evening shift will take over, even if it is in the middle of a case. There is no incentive to work any longer and every incentive to leave. The new residencies are the perfect training grounds for what's coming to the practice of medicine.

Saturday, August 1, 2009

Is the public this naive?

In today's Wall Street Journal, there is an article titled "Imagine Doctors, Patients Talking" that demonstrates the naivete of the public, or at least this journalist, on the doctor-patient relationship. The article implies that it is the doctor that is the sole reason for driving up health care costs.

It starts out with advocating more "intimate" office visits with your doctor, like having a dinner conversation. Sure it would be great to spend two hours with each of your patients to discuss their health care but if the new health care bill is allowing more patients to visit their doctors while lowering payments to doctors, those dinner conversations will instead become more like a drive through at the In N Out.

Then the article leads with snarky remarks like "If there's a history of mutual honesty and transparency" and "Doctors should be forthcoming about discussing the alternatives." I would say that in most if not nearly all less-than-honest relationships with patients, it is the patient that lies to the doctor. "Doctor, I'm agonizing. I need more pain meds." "Doctor, I don't have enough money to feed my children. I can't make the copay." "Of course I take all my meds as prescribed doctor but I still can't get my blood pressure (glucose level, acid reflux, INR, etc.) under control." So the writer is implying that doctors are not honest with their patients about available treatments. Has the writer ever heard of informed consents? Before starting any treatments, virtually all doctors discuss the medical plan along with alternatives. We physicians have not dictated to patients their health plans for at least the last twenty years.

Then we get to the laughably ridiculous line "In exchange, patients should signal that they don't necessarily want to act on all the possibilities." Are you kidding me? How many times have I seen patients or their family say "I want everything possible done." I've seen 95 year old demented patients get gastrostomy tubes placed because the family wants everything done. I've seen the whole blood bank transfused into exsanguinating cirrhotic Child-Pugh C patients because the family wants everything done. Walk into the ICU in any hospital and you'll find patients on multiple pressors, ventilated, with feeding tubes and on dialysis long past what is medically indicated because the family wants everything done.

The problem of course is that patients don't know or don't care about the costs of these treatments because somebody else is paying for it. The article states "patients may welcome these developments as they watch their wallets" but that is precisely the problem, the patients and families don't. Most people have insurance through their employer or the government so somebody else is paying for all this. If they had to pay for the real cost of medical treatment, like in Britain where dialysis is out of pocket after age fifty and transplants after age 55, we wouldn't have so much needlessly aggressive care. But of course that would be cruel to the "most vulnerable" people in society.

The article ends by saying it is the doctors who need to upgrade their communication skills to better inform their naive easily impressionable patients. And the patients should have bias free information to make an informed decision. Hello. Patients already have that. But medical care is a very emotional decision. If you read the entire text of Harrison's to these patients, they would still want what they want, regardless of the logic and price of the treatment. No wonder doctors are leaving the AMA in droves. If they can't educate the public about what's really going on, the public will just keep squeezing the doctors until we are all just slave labor for the government. But we doctors are not supposed to say the truth. We're supposed to be all about compassion, treating each and every patient regardless of the physical, emotional, and fiscal tolls on ourselves. Otherwise we're bad greedy doctors who only care about money.